Hot off the Press August 2023

We have collated some great articles and material published over the last month. Click on the links below to read the  abstract or download the full paper.

Anatomy / Physiology /Pathophysiology

Variable Anatomy of the Lateral Upper Arm Lymphatic Channel: An Anatomical Risk Factor for Breast Cancer–Related Lymphedema - click for abstract

Variable Anatomy of the Lateral Upper Arm Lymphatic Channel: An Anatomical Risk Factor for Breast Cancer–Related Lymphedema

Granoff, Melisa D. BA1; Pardo, Jaime MD1; Shillue, Kathy DPT, OCS, CLT2; Fleishman, Aaron MPH3; Teller, Paige MD4; Lee, Bernard T. MD, MBA, MPH1; James, Ted MD3; Singhal, Dhruv MD1. Plastic and Reconstructive Surgery 152(2):p 422-429,August 2023. 


The lateral upper arm channel is an accessory lymphatic pathway that drains the upper extremity by means of the deltopectoral groove and supraclavicular nodes, thereby bypassing the axilla. Its variable connectivity to the forearm has not been studied in vivo.


Indocyanine green (ICG) lymphography was performed preoperatively to map the superficial and functional arm lymphatics in breast cancer patients without clinical or objective evidence of lymphedema. A retrospective review was performed to extract demographic, ICG imaging, and surgical data.


Sixty patients underwent ICG lymphography before axillary lymph node dissection between June of 2019 and October of 2020. In 59%, the lateral upper arm lymphatic channel was contiguous with the forearm (long bundle). In 38%, the lateral upper arm lymphatic channel was present but not contiguous with the forearm (short bundle). In 3%, the lateral upper arm pathway was entirely absent. Seven patients developed at least one sign of lymphedema during postoperative surveillance, of which 71% demonstrated the short bundle variant.


Although the lateral upper arm pathway is most often present, its connections to the forearm are frequently absent (short bundle), which, in this pilot report, appears to represent a potential risk factor for the development of lymphedema.

Intracellular and Extracellular Water Balance in Patients with Lipedema. –Related Lymphedema - click for abstract

Intracellular and Extracellular Water Balance in Patients with Lipedema.

Esmer M, Schingale FJ. Lymphat Res Biol. 2023 Aug 2. doi: 10.1089/lrb.2023.0007. Epub ahead of print. PMID: 37530741.

Background: The presence of edema in patients with lipedema has been investigated in many studies. However, no study has been found that examines the amount of intracellular (ICF) and extracellular fluid (ECF) in these patients together. The aim of this study is to examine the amount of ICF and ECF in patients with stage 2 lipedema. Methods and Results: Twenty-four patients diagnosed with stage 2 lipedema were included in the study. Bioimpedance spectroscopy was applied to measure extracellular and intracellular water levels. The mean age of the participants was 44.58 ± 2.95 years. The mean body mass index (BMI) of the participants was 33.9 ± 1.84 kg/m2. It was observed that the amount of ECF in the patients was above the normal values (p < 0.001), whereas the amount of ICF was within the normal range (p = 0.801). In addition, it was observed that there was a moderate relationship between BMI and the amount of ECF. Conclusion: Although the amount of ICF is within the normal range in patients with lipedema, an increase in ECF is observed. The reason why edema is not observed in these patients despite the increase in ECF may be the increase in glycosaminoglycan and proteoglycan synthesis. In addition, the attention of these patients to weight control may contribute to slowing the course of the disease by preventing the increase in the amount of ECF. For a better diagnosis of lipedema, it is considered important to evaluate the amount of ECF in addition to routine evaluations.

Lymphatic Vessels Insufficiency and Focal Edema in Early Stages Noncancer-Related Lymphedema. –Related Lymphedema - click for abstract

Lymphatic Vessels Insufficiency and Focal Edema in Early Stages Noncancer-Related Lymphedema
Marzanna T. Zaleska and Natalia E. Krzesniak. Lymphatic Research and Biology 2023

Introduction: Lymph flows along the lymphatics due to spontaneous contraction. However, injury and inflammation may deteriorate lymphatic’ s endothelial and muscle cells and valves. In consequence, lymphatic vessels (LVs) become insufficient. Their contraction strength and rate slow down, and then lymph flow stops. Our study aimed to investigate the changes in lymph flow in early lymphedema cases.

Methods and Results: In 36 patients with unilateral lymphedema stages 0 and I, we performed indocyanine green (ICG) lymphography, lymphoscintigraphy, skin water concentration, and stiffness measurement. We compared lymph flow velocity, LVs’ appearance, contraction pattern, and rate between swollen and healthy limbs. ICG lymphography revealed (1) slower lymph flow after 3 minutes of foot movement; in lower calf level, lymphatics are seen in 22 (61.1%) swollen limbs compared with 36 (100%) healthy limbs (p < 0.0001); (2) dye spots in the foot (47.1%) and calves (13.9%) in swollen limbs; (3) dilated foot (41.7%) and calves' lymphatics (52.8%); (4) different patterns of lymphatics contractility with slower contractions rate and (5) higher fluorescent intensity in edema limbs. There was higher skin water concentration at foot and ankle level and higher skin stiffness in the foot. Conclusions: Our studies have shown the distortion in lymphatic function as dilatation, slower lymph flow, slower contraction rate, presence of areas with occluded lymphatics (dermal backflow in foot and calves-focal edema), and higher skin water concentration in these regions in limbs with early lymphedema. ICG lymphography can be used for the early detection of LV insufficiency, which allows early prophylactic implementation.

Non-Linear Lymphatic Anatomy in Breast Cancer Patients Prior to Axillary Lymph Node Dissection: A Risk Factor For Lymphedema Development.

Kinney JR, Friedman R, Kim E, Tillotson E, Shillue K, Lee BT, Singhal D. J Mammary Gland Biol Neoplasia. 2023 Jul 22;28(1):20. doi: 10.1007/s10911-023-09545-x. PMID: 37480365; PMCID: PMC10363047.

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Chronic Venous Insufficiency With Emphasis on the Geriatric Population.

Mayrovitz H N, Aoki K C, Colon J (June 20, 2023). Cureus 15(6): e40687. doi:10.7759/cureus.40687

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Prevalence and Risk Factors

Factors associated with lymphedema self-management behaviours among breast cancer survivors: A cross-sectional study. - click for abstract

Factors associated with lymphedema self-management behaviours among breast cancer survivors: A cross-sectional study

Shen, A.Wu, P.Qiang, W.Fu, X.Zhu, F.Pang, L.Wang, F., & Lu, Q. (2023).Journal of Clinical Nursing00116.

Aims and Objectives

The purpose of this empirical study was to explore the current status and associated factors of lymphedema self-management behaviours among Chinese breast cancer survivors.


Breast cancer-related lymphedema is a lifetime concern for survivors and is currently incurable. Lifetime lymphedema self-management takes a significant role in preventing development and progression of lymphedema. Understanding influencing factors of lymphedema self-management behaviours can help to develop targeted intervention programs.


A multicentre cross-sectional study.


From December 2021 to April 2022, a convenience sample of 586 participants were recruited at four tertiary hospitals in four cities in China. Self-reported questionnaires were used to measure socio-demographic characteristics, disease-and treatment-related characteristics, lymphedema self-management behaviours, lymphedema knowledge, illness perception, self-efficacy, self-regulation and social support. Descriptive analysis, bivariate analysis and hierarchical multiple regression were conducted. This study was registered at Chinese Clinical Trial Registry (ChiCTR2200057084), and was reported followed the STROBE checklist.


Breast cancer survivors reported moderate level of lymphedema self-management behaviours. Promotion of lymph reflux management was ranked the least performed self-management behaviours, while the affected limb protection management ranked the most. 36.2% of self-management behaviours was explained by exercise regularly, level of attention on lymphedema prevention, unclear about the tumour stage (vs. stage I), knowledge, self-efficacy, emotional illness representation and social support.


Lymphedema self-management behaviours of breast cancer survivors was insufficient. Performance of lymphedema self-management varied with different socio-demographic characteristics, along with different levels of knowledge, self-efficacy, perception and social support. All these identified predictors should be reckoned in assessment and intervention of lymphedema self-management behaviours.

Relevance To Clinical Practice

This study addressed that breast cancer survivors’ lymphedema self-management behaviours should be promoted. Focusing on identified predictors, further lymphedema surveillance, knowledge education or social facilitation programs are recommended to enhance their self-management performance and adherence.

Correlation Of Kinesiophobia And Upper Extremity Parameters In Post Mastectomy Patients.

Aleem H, Qazi R, Azim ME, Ismail M, Amer H, Ashfaq M. J Pak Med Assoc. 2023 Jul;73(7):1498-1501. doi: 10.47391/JPMA.7170. PMID: 37469066.

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Breast Cancer-Related Lymphedema (BCRL) and Bioimpedance Spectroscopy: Long-Term Follow-Up, Surveillance Recommendations, and Multidisciplinary Risk Factors - click for abstract

Breast Cancer-Related Lymphedema (BCRL) and Bioimpedance Spectroscopy: Long-Term Follow-Up, Surveillance Recommendations, and Multidisciplinary Risk Factors

Elizabeth J. Jeffers MD, Jamie L. Wagner DO, MBA, Sabrina S. Korentager MSN, CLT-UE, Kelsey E. Larson MD, Christa R. Balanoff MD, Jordan Baker MS, Lynn Chollet-Hinton PhD, MSPH & Lyndsey J. Kilgore MD Annals of Surgical Oncology (2023)


Early detection and intervention for breast cancer-related lymphedema (BCRL) significantly decreases progression to persistent BCRL (pBCRL). We aimed to provide long-term follow-up on our early detection with bioimpedance spectroscopy (BIS) and early home intervention demonstrating reduced pBCRL to guide surveillance recommendations.

Patients and Methods

In total, 148 female patients with breast cancer who had axillary lymph node dissection (ALND) from November 2014 to December 2017 were analyzed. Baseline BIS measurements and postoperative follow-up occurred every 3 months for 1 year, biannual for 1 year, and then annually. An elevated BIS triggered evaluation and initiation of at-home interventions with reassessment for resolution versus persistent BCRL (pBCRL). High-risk factors and timing were analyzed.


Mean follow-up was 55 months, and 65 (44%) patients had an abnormal BIS. Of these, 54 (82%) resolved with home intervention. The overall pBCRL rate was 8%. Average time to first abnormal BIS was 11.7 months. None of the stage 0 patients (0/34) and only 5/25 (20%) of stage 1 patients had pBCRL. All of stage 2 and stage 3 patients (7/7) had pBCRL. pBCRL correlated with number of positive nodes, percentage of positive nodes, stage of lymphedema at diagnosis, and recurring abnormal BIS measurements (p < 0.05).


We have shown that patients undergoing ALND with early BCRL identified by BIS who performed home interventions had an 8% pBCRL rate. Patients at high risk for pBCRL should have routine surveillance starting at 9 months postoperatively to identify an opportunity for early intervention.

Coping Mechanisms for Lymphedema: An Analysis of Patient Experiences

Claudia Admoun, Harvey N. Mayrovitz. Cureus. 2023 Jul 8.

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A Practical Approach to the Diagnosis of Lymphedema: A Narrative Review

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The Use of Wearable Activity Monitors to Measure Upper Limb Physical Activity After Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy.

Che Bakri NA, Kwasnicki RM, Giannas E, Tenang L, Khan N, Moenig C, Imam Z, Dhillon K, Ashrafian H, Darzi A, Leff DR. Ann Surg Oncol. 2023 Jul 28. doi: 10.1245/s10434-023-13966-7. Epub ahead of print. PMID: 37507555.

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Management Strategies

Practical Approach to Establishing a Lymphedema Screening Program: Tips and Tricks - click for abstract

Purpose of Review

Breast cancer-related lymphedema (BCRL) affects approximately 1 in 5 women diagnosed with breast cancer. Improvements in overall survival cultivate a focus on breast cancer survivorship and quality of life. While personalized cancer care has allowed us to optimize oncologic outcomes and minimize treatment-related morbidity, treatments rendered for cancer cure continue to place our patients at risk for BCRL.

Recent Findings

Although there is no definitive cure for BCRL, prospective screening has demonstrated lower rates of BCRL and lower rates of progression to late-stage disease. Prevention of late-stage BCRL in turn improves quality of life and results in overall cost advantage to patients and the health care system. Establishment of BCRL screening requires a multidisciplinary team approach. Understanding diagnostic tools and criteria for BCRL detection is imperative, and the development of an institutional protocol is essential for success.


With continued advances in breast cancer outcomes, a focus on breast cancer survivorship must be fostered. Institution of BCRL screening is imperative to continue improving our patients’ survivorship. We hope that education on the importance for BCRL screening, tools for detection and diagnosis, along with the impact of a multidisciplinary approach, can further advance BCRL detection, prevention, and treatment.

The Utilization of e-Health in Lymphedema Care: A Narrative Review - click for abstract

The Utilization of e-Health in Lymphedema Care: A Narrative Review
Andrea Mangion, Bruno Ivasic, and Neil Piller. Telemedicine and e-Health, 2023

Background:Electronic health (e-Health), refers to technologies that can be utilized to enhance patient care as well as collect and share health information. e-Health comprises several umbrella terms, including telehealth, mobile health, e-Health, wearables, and artificial intelligence. The types of e-Health technologies being utilized in lymphedema (LE) care are unknown.

Method:In this narrative review, a search of published research on the utilization of e-Health technologies in LE-related care was conducted.

Results:Five different types of e-Health modalities were found (robotics, artificial intelligence, electronic medical records, smart wearable devices, and instructive online information) spanning 14 use cases and 4 phases of care (preventative, diagnostic, assessment, and treatment phases). Broad e-Health utilization examples were found including robotic-assisted surgery to reduce the likelihood of LE after lymphadenectomy, machine learning to predict patients at risk of filarial-related LE, and a novel wearable device prototype designed to provide lymphatic drainage.

Conclusions:e-Health has reported merit in the prevention, diagnoses, assessment, and treatment of LE with utilization demonstrating cutting edge applicability of e-Health for achieving optimal patient care and outcomes. As technology continues to advance, additional research into the utilization of e-Health in LE care is warranted.

Lymphedema self-care: economic cost savings and opportunities to improve adherence.

Karaca-Mandic, P., Solid, C.A., Armer, J.M. et al. Cost Eff Resour Alloc 21, 47 (2023).

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The effectiveness and safety of heat/cold therapy in adults with lymphoedema: systematic review.

J. E. Hill, J. C. Whitaker, N. Sharafi, O. Hamer, A. Chohan, C. Harris & A. Clegg (2023). Disability and Rehabilitation, DOI: 10.1080/09638288.2023.2231842

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Complete Decongestive Therapy Effect on Breast Cancer Related to Lymphedema: A Systemic Review and Meta-Analysis of Randomized Controlled Trials.

Shamoun S, Ahmad M. Asian Pac J Cancer Prev. 2023 Jul 1;24(7):2225-2238. doi: 10.31557/APJCP.2023.24.7.2225. PMID: 37505751.

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Compression therapy in dermatology.

Dissemond J, Protz K, Stücker M. J Dtsch Dermatol Ges. 2023 Aug 10. doi: 10.1111/ddg.15161. Epub ahead of print. PMID: 37565365.

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Effect of Home-Based Exercise on Lymphedema among Post-mastectomy Patients: an Integrative Review

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Clinical Practice Skills and Educational Resources for Managing Lymphedema.

Grimes-Williams Lacinda. 2023. Capstone. Nova Southeastern University. Retrieved from NSUWorks, . (132)

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Compression wraps as adjuvant therapy in the management of
acute systolic heart failure

Raef Ali Fadel a,*, Renato Cerna Viacava b, Tarek Makki a, Carina Dagher Fadel c,Kelly Malette d, Zachary D. Demertzis d, Guneet Ahluwalia e, Joseph Millerf,Cori Russell a. Heliyon 9 (2023) e19008

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The effects if high-intensity interval training on body composition and quality of life in women with lipedema

Hedda Eidet. Master’s thesis in Clinical health science. May 2023

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