Hot off the Press September 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
Lymphangiogenesis and lymphatic zippering in skin associated with the progression of lymphedema- click for abstract
Lymphangiogenesis and lymphatic zippering in skin associated with the progression of lymphedema
Secondary lymphedema often develops after lymph node dissection or radiation therapy for cancer treatment, resulting in marked skin fibrosis and increased stiffness due to insufficiency of the lymphatic system caused by abnormal structure and compromised function. However, little is known about the associated changes of the dermal lymphatic vessels. Here, using the lower limb skin of secondary lymphedema patients, classified as types 1-4 by lymphoscintigraphy, we first confirmed the presence of epidermal thickening and collagen accumulation in the dermis, closely associated with the progression of lymphedema. Three-dimensional characterization of lymphatic capillaries in skin revealed prominent lymphangiogenesis in types 1 and 2 lymphedema. In contrast, increased recruitment of smooth muscle cells accompanied by development of the basement membrane in lymphatic capillaries was observed in types 3 and 4 lymphedema. Remarkably, the junctions of dermal lymphatic capillaries were dramatically remodeled from a discontinuous button-like structure to a continuous zipper-like structure. This finding is consistent with previous findings in an infection-induced mouse model. Such junction tightening (zippering) could reduce fluid transport and cutaneous viral sequestration during the progression of lymphedema, and might explain the aggravation of secondary lymphedema. These findings may be helpful in developing stage-dependent treatment of lymphedema patients.
Association of clinical manifestations of secondary lymphedema and lymph node dissection sites in the lower extremities of patients with melanoma - click for abstract
Association of clinical manifestations of secondary lymphedema and lymph node dissection sites in the lower extremities of patients with melanoma
BACKGROUND: Lymphedema is a chronic, debilitating disease that often requires life-long management. Predicting clinical manifestations and prognosis is crucial in clinical practice because the treatment of lymphedema should be individualized for best clinical outcome. The aim of this study is to explore the location and severity of lymphedema secondary to inguinal and/or iliac lymph node dissection (LND) in patients with melanoma.
METHODS: Patients with melanoma who received LND at a single tertiary medical center between 1 January 2010 and 31 September 2022 were retrospectively reviewed. Patient who received inguinal LND only were designate as the inguinal group while those who received both ilioinguinal LND were included in the ilioinguinal group. Volumetric measurement was used to objectify the severity and location of lymphedema. Clinical data was acquired for 12-15 months of follow-up.
RESULTS: Among 81 patients, 43 (53%) had developed lymphedema in the lower extremities at an average of 33 days after the surgery. Initially, patients manifested with medial thigh lymphedema in the inguinal group while patients were presented with whole leg lymphedema in the ilioinguinal group. Lower leg volume of the ilioinguinal group was significantly higher than the inguinal group. After more than 12 months of lymphedema treatment, upper leg volume was higher in the ilioinguinal group than the inguinal group (12.7% vs 5.4%, p < 0.05). CONCLUSION: Lymphedema developed in early post-op period. The ilioinguinal group presented with a larger volume of lymphedema in the distal area of the legs. Even after sufficient treatment, predominant lymphedema remained in the proximal leg for the ilioinguinal group. Patients with both inguinal and iliac LND were associated with more severe lymphedema. Based on the dissection sites, the clinical manifestations and prognosis of leg lymphedema can vary widely. Thus, clinicians should consider the dissection site when approaching melanoma patients with lymphedema [/av_toggle] [/av_toggle_container] [av_hr class='invisible' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' font='entypo-fontello'] [/av_one_full] [av_hr class='short' height='40' shadow='no-shadow' position='left' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' font='entypo-fontello' admin_preview_bg=''] [av_one_full first min_height='' vertical_alignment='' space='' custom_margin='' margin='0px' padding='0px' border='' border_color='' radius='0px' background_color='' src='' background_position='top left' background_repeat='no-repeat' animation='' mobile_breaking='' mobile_display=''] [av_textblock size='' font_color='' color='' av-medium-font-size='' av-small-font-size='' av-mini-font-size='' admin_preview_bg='']
Assessment
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Timescaled monitoring to manage venous leg ulcers and chronic oedema - click for abstract
Timescaled monitoring to manage venous leg ulcers and chronic oedema
Jeanette Muldoon, Br J Community Nurs. 2023 Sep 1;28(Sup9):S24-S30. doi: 10.12968/bjcn.2023.28.Sup9.S24.
Venous leg ulcers and chronic oedema including lymphoedema are lifelong conditions that cause great distress to sufferers due to psychophysical symptoms. Time and resources spent on managing chronic wounds place an economic burden on healthcare providers, particularly with an anticipated increase in an ageing population and diminishing numbers of those providing long-term care. Resources are further challenged if wounds remain unhealed. The human costs are even greater, with patients often facing a lifetime of discomfort due to low awareness of venous disease, despite epidemiological studies. Possible causes of persistent venous disease may be misdiagnosis, mismanagement, or simply, no management if help is not sought. Therefore, it is important that chronic leg ulcers are managed with clinically effective regimes, reassessment, monitoring and appropriate referrals for adjunct management, alongside patient education. This article provides simple timescaled measurements to ensure timely interventions and appropriate care at each stage.
The Efficacy of Axillary Reverse Mapping for the Prevention of Lymphedema - click for abstract
The Efficacy of Axillary Reverse Mapping for the Prevention of Lymphedema
BACKGROUND: Lymphedema (LE) is the most notable complication of axillary surgery. The axillary reverse mapping (ARM) technique was created to decrease LE. This study aims to evaluate a single surgeon’s experience with ARM in patients undergoing sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) for breast cancer.
METHODS: We retrospectively analyzed patients who underwent SLNB or ALND. Tumor characteristics and treatments received were evaluated. Surgical intervention and use of ARM were compared to assess LE rates. A subgroup analysis was also performed of patients who underwent NAC.
RESULTS: LE was initially reported in 7.1% (n = 10) of patients; 3.3% (n = 4) with SLNB and 35% (n = 6) with ALND. At initial follow-up, LE was reported 16.4% more often in patients who underwent ALND with no ARM, and 38.8% more often in patients who underwent ALND plus ARM. An increased risk of LE was found in patients treated with ALND (OR = 16.0, P < .001). All patients who underwent ARM were 12.75% more likely to develop LE if they received NAC (P < .05). Patients in the ALND group who also received NAC were more likely to undergo ARM as compared with patients in the SLNB group (P < .01). DISCUSSION: Our study showed that ARM failed to decrease the incidence of LE. Until better surgical outcomes are shown for the prevention of LE using ARM, other approaches should be utilized. However, larger prospective studies are needed to evaluate ARM [/av_toggle] [/av_toggle_container] [av_toggle_container initial='0' mode='accordion' sort='' styling='' colors='' font_color='' background_color='' border_color=''] [av_toggle title='Attaining consensus on a core dataset for upper limb lymphoedema using the Delphi method: A foundational step in creating a clinical support system- click for abstract' tags='']
Attaining consensus on a core dataset for upper limb lymphoedema using the Delphi method: A foundational step in creating a clinical support system
Background: Lymphoedema is a condition of localised swelling caused by a compromised lymphatic system. The protein-rich fluid accumulating in the interstitial tissue can create inflammation and irreversible changes to the skin and underlying tissue. An array of methods has been used to assess and report these changes. Heterogeneity is evident in the clinic and in the literature for the domains assessed, outcomes and outcome measures selected, measurement protocols followed, methods of analysis, and descriptors used to report change. Objective: This study seeks consensus on the required items for inclusion in a core data set for upper limb lymphoedema to digitise the monitoring and reporting of upper limb lymphoedema.
Methods: The breadth of outcomes and descriptors in common use were captured in prior studies by this research group. This list was refined by frequency and proposed to experts in the field (n = 70) through a two-round online modified Delphi study. These participants rated the importance of each item for inclusion in the dataset and identified outcomes or descriptors they felt were missing in Round 1. In Round 2, participants rated any new outcomes or descriptors proposed and preference for how numeric data is displayed.
Results: The core dataset was confirmed on completion of Round 2. Interlimb difference as a percentage, and limb volume were preferred for graphed display over time; and descriptors for observed and palpated change narrowed from 42 to 20.
Conclusion: This dataset provides the foundation to create a clinical support system for upper limb lymphoedema.
Development of Pressure Sensors to Help Support Community Lymphedema Monitoring: A Scoping Review- click for abstract
Development of Pressure Sensors to Help Support Community Lymphedema Monitoring: A Scoping Review
Lymphat Res Biol. 2023 Aug 14
Breast cancer-related lymphedema is a condition occurring after a partial or full mastectomy, where there is a buildup of interstitial fluid in the body, particularly in the upper limb. There is a lack of at-home sensors that can help monitor the progression of lymphedema. The purpose of this scoping review is to gather relevant information on sensors for remote lymphedema monitoring. A literature search of Medline, PubMed, Scopus, Web of Science, and BMC databases yielded 96 studies. A total of six studies were selected for data extraction. Data were extracted from each study and organized into tables for analysis. A total of six different devices were mentioned in the six studies included in the scoping review, divided into wearable and nonwearable sensors. Nonwearable sensors were more likely to be adaptable for remote sensing as they were further along in development and commercially available on the market. Nonwearable sensors are more developed than wearable sensors for the purpose of remote lymphedema monitoring. This review advocates further development and validation of sensors for lymphedema management, particularly for remote monitoring and health assessments.
Body image and cancer-related lymphoedema: A systematic review
Management Strategies
Venous and lymphovenous lower limb wound outcomes in specialist UK wound and lymphoedema clinics- click for abstract
Venous and lymphovenous lower limb wound outcomes in specialist UK wound and lymphoedema clinics
This article explores the impact of combining tissue viability and lymphoedema techniques on optimising time to healing.AIM: To investigate the healing rates observed in patients who presented to wound and lymphoedema specialist clinics, located in the south eastern region of England, with venous/lymphovenous ulceration of the lower limb during the COVID-19 pandemic in 2020-2022 (30 months in all). METHODOLOGY: A retrospective analysis of patient outcomes. RESULTS: 1041 patients were referred to the service, with a healing rate of 88.5% over 78 days. DISCUSSION: When comparing 2013-2019 healing rates/time to healing vs 2020-2022 there was a decrease of 1.5% in the rate of healing and a mean reduction in time to healing of 40 days. CONCLUSION: Despite the pandemic the service was able to maintain previous levels of outcomes and observed a decrease in the mean time to healing.
Impact of lymphedema in the management of venous leg ulcers - click for abstract
Venous and lymphovenous lower limb wound outcomes in specialist UK wound and lymphoedema clinics
This article explores the impact of combining tissue viability and lymphoedema techniques on optimising time to healing.AIM: To investigate the healing rates observed in patients who presented to wound and lymphoedema specialist clinics, located in the south eastern region of England, with venous/lymphovenous ulceration of the lower limb during the COVID-19 pandemic in 2020-2022 (30 months in all). METHODOLOGY: A retrospective analysis of patient outcomes. RESULTS: 1041 patients were referred to the service, with a healing rate of 88.5% over 78 days. DISCUSSION: When comparing 2013-2019 healing rates/time to healing vs 2020-2022 there was a decrease of 1.5% in the rate of healing and a mean reduction in time to healing of 40 days. CONCLUSION: Despite the pandemic the service was able to maintain previous levels of outcomes and observed a decrease in the mean time to healing.
Decompression of Axillary vein - An essential adjunct for advanced lymphedema - click for abstract
Decompression of Axillary vein – An essential adjunct for advanced lymphedema
INTRODUCTION: In advanced lymphedema, lymphovenous anastomosis (LVA) can be a solution based on utilizing the pressure gradient between the high pressure lymphatics and low pressure veins. If the vein pressure in high, the effect affect surgery will be less optimal. This study evaluated the effect of axillary vein perivascular scar release on LVA.
MATERIALS AND METHODS: This is a retrospective study of 40 upper limb stage 2 and 3 lymphedema patients divided into 2 groups with an average follow-up of 33 months (minimal of at least 12 months); scar-released group (n=25) and control group (n=15). All patients underwent LVA with or without lymph node transfer. Demographic data, outcome (volumetric change and bioimpedence analysis (BIA)), and major veins (axillary, basilic and cephalic) diameter changes were evaluated.
RESULTS: Both groups showed significant reduction in volume and BIA parameters after LVA. The scar-released groups (24/25 with lymph node transfer and 1 without) showed statistically higher reduction of BIA analysis compared to the control group at 1, 6 and 12 months after LVA. The changes in the major veins after axilla scar release showed significant changes in all 3 veins. There was a significant correlation between cephailic vein dimeter reduction and BIA measurement.
CONCLUSION: The release of perivascular scar in the axially vein may result in better outcome after LVA. This is based on the finding that scar release shows correlation between cephailic vein dimeter reduction and BIA measurement suggesting reduction of venous pressure in the peripheral vein increasing the pressure gradient between the lymphatic and venous system allowing better outflow after LVA
Evaluating the effects of lymphoedema management strategies on functional status and health-related quality of life following treatment for head and neck cancer: a systematic review
Kankariya Nimesh *, TexMat Research Journal. 2023: Volume 1, Issue 1; pp. 1-17
