Hot off the Press February 2024

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

The VASCERN PPL working group patient pathway for primary and paediatric lymphoedema

Nele Devoogdt, Sarah Thomis, Florence Belva, Janine Dickinson-Blok, Caroline Fourgeaud, Guido Giacalone, Tonny Karlsmark, Heli Kavola, Vaughan L. Keeley, Manuela Lourenço Marques, Sahar Mansour, Christoffer V. Nissen, Susan Nørregaard, Michael Oberlin, Tanja Planinšek Ručigaj, Gloria Somalo-Barranco, Sinikka Suominen, Kirsten Van Duinen, Stéphane Vignes, Robert J. Damstra. Eur J Med Genet. 2023 Dec 22

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Factors associated with cellulitis in lymphoedema of the arm – an international cross-sectional study (LIMPRINT)

Ewa Anna Burian, Peter J. Franks, Pinar Borman, Isabelle Quéré, Tonny Karlsmark, Vaughan L. Keeley, Junko Sugama, Marina Cestari, Christine J. Moffatt. BMC Infect Dis. 2024 Jan 18

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The Arteria Lymphatica and Lymphatic Microperforators: A Dedicated Blood Supply to Collecting Lymphatics and Their Potential Implications in Lymphedema: Anatomical Description

Charlotte L. Bendon, Eric Hanssen, Cameron Nowell, Tara Karnezis, Ramin Shayan. Plast Reconstr Surg Glob Open. 2024 Jan 24. Jan.

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Prevalence and Risk Factors

Impact of neoadjuvant chemotherapy on breast cancer-related lymphedema after axillary lymph node dissection: a retrospective cohort study- click for abstract

Impact of neoadjuvant chemotherapy on breast cancer-related lymphedema after axillary lymph node dissection: a retrospective cohort study

Miaomiao Jia, Lihui Pan, Haibo Yang, Jinnan Gao, Fan Guo. Breast Cancer Res Treat. 2023 Dec 15.

PURPOSE: We aimed to evaluate whether neoadjuvant chemotherapy (NAC) could be a risk factor for breast cancer-related lymphedema (BCRL) associated with axillary lymph node dissection (ALND).
PATIENTS AND METHODS: A total of 596 patients with cT0-4N0-3M0 breast cancer who underwent ALND and chemotherapy were retrospectively analyzed between March 2012 and March 2022. NAC was administered in 188 patients (31.5%), while up-front surgery in 408 (68.5%). Univariate and multivariable Cox regression analyses were performed to determine whether NAC was an independent risk factor for BCRL. With propensity score matching (PSM), the NAC group and up-front surgery group were matched 1:1 by age, body mass index (BMI), molecular subtypes, type of breast surgery, and the number of positive lymph nodes. Kaplan-Meier survival analyses were performed for BCRL between groups before and after PSM. Subgroup analyses were conducted to explore whether NAC differed for BCRL occurrence in people with different characteristics.
RESULTS: At a median follow-up of 36.3 months, 130 patients (21.8%) experienced BCRL [NAC, 50/188 (26.60%) vs. up-front surgery, 80/408 (19.61%); P = 0.030]. Multivariable analysis identified that NAC [hazard ratio, 1.503; 95% CI (1.03, 2.19); P = 0.033] was an independent risk factor for BCRL. In addition, the hormone receptor-negative/human epidermal growth factor receptor 2-negative (HR-/HER2-) subtype, breast-conserving surgery (BCS), and increased positive lymph nodes significantly increased BCRL risk. After PSM, NAC remained a risk factor for BCRL [hazard ratio, 1.896; 95% CI (1.18, 3.04); P = 0.007]. Subgroup analyses showed that NAC had a consistent BCRL risk in most clinical subgroups.
CONCLUSION: NAC receipt has a statistically significant increase in BCRL risk in patients with ALND. These patients should be closely monitored and may benefit from early BCRL intervention

Prevalence of Fibromyalgia Syndrome in Women with Lipedema and Its Effect on Anxiety, Depression, and Quality of Life - click for abstract

Prevalence of Fibromyalgia Syndrome in Women with Lipedema and Its Effect on Anxiety, Depression, and Quality of Life

Ayla Cagliyan Turk, Ender Erden, Dilek Eker Buyuksireci, Mutlu Umaroglu, Pinar Borman. Lymphat Res Biol. 2023 Dec 22.

Background/Aim: The aim of this study was to determine the frequency of fibromyalgia syndrome (FMS) in patients with lipedema and to evaluate the effects of FMS on anxiety, depression, and quality of life (QoL) in this patient group.
Methods: Patients with lipedema were invited to participate in a Survey-Monkey questionnaire (according to inclusion and exclusion criteria) that was announced on the facebook page of the lipedema patient community. The demographic and clinical properties, including age, body mass index (BMI), education, marital status, and types and stage of lipedema, were collected. Presence of fibromyalgia was assessed by the questions based on American College of Rheumatology 2016 FMS diagnostic criteria. The Hospital Anxiety and Depression Scale and Short Form-12 (SF-12) were used to assess the anxiety and depression, and QoL respectively. The demographic and clinical characteristics, as well as anxiety/depression level and QoL of lipedema patients were evaluated in regard to the presence (Group 1) and absence (Group 2) of FMS.
Results: A total of 354 participants with a mean age of 43.18 ± 9.53 years and BMI of 30.61 ± 6.86 were included. The majority of them were married and had university education. Most of the patients had types 1, 2 and commonly stages 1 and 2 lipedema. One hundred twenty-four patients (35%) satisfied FMS criteria. The demographic characteristics except pain intensity were similar between the groups. The mean anxiety and depression scores of Group 1 were significantly higher compared with Group 2 (13.11 ± 4.2 vs. 9.87 ± 4.65, 10.23 ± 3.79 vs. 8.26 ± 4.15, respectively, p < 0.001). The mental and physical subgroup scores of SF-12 (35.37 ± 8.59 vs. 42.55 ± 10.15, 35.27 ± 8.49 vs. 40.38 ± 11.36, respectively) were significantly lower in Group 1 than in Group 2 (p < 0.001).
Conclusion: More than every 3 lipedema patient may have FMS. This comorbidity may increase depression and anxiety, and impair QoL. Therefore, FMS must be kept in mind especially in the assessment of painful lipedema patients to decrease anxiety/depression and enhance the QoL of them.:10.1089.0038

Relationship between kinesiophobia and quality of life among patients with breast cancer-related lymphedema: Chain-mediating effect of self-care and functional exercise compliance

Qi Wang, Na Du. Asia Pac J Oncol Nurs. 2023 Nov 18. Jan.

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Prevention of Breast Cancer-Related Lymphedema: An Up-to-Date Systematic Review of Different Surgical Approaches

Domenico Pagliara, Federica Grieco, Silvia Rampazzo, Nicola Pili, Pietro Luciano Serra, Roberto Cuomo, Corrado Rubino. J Clin Med. 2024 Jan 18.

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Breast lymphedema following breast‑conserving treatment for breast cancer: current status and future directions - click for abstract

Breast lymphedema following breast-conserving treatment for breast cancer: current status and future directions

Cheryl L. Brunelle, John Boyages, Amanda W. Jung, Hiroo Suami, Brooke C. Juhel, Asha Heydon-White, Helen Mackie, Shinn-Huey Shirley Chou, Vincent S. Paramanandam, Louise Koelmeyer, Alphonse G. Taghian Breast Cancer Res Treat. 2023 Dec 15.

PURPOSE: To examine the current evidence on breast lymphedema (BL) diagnosis and treatment after breast-conserving surgery, identify gaps in the literature, and propose future research directions.

METHODS: A comprehensive literature review was conducted using Ovid, PubMed, and Cochrane, including studies published between 2000 and 2023. References were reviewed manually for eligible studies. Inclusion criteria were as follows: patients who underwent breast conserving treatment (surgery ± radiation) for breast cancer, goals of the paper included analyzing or reviewing BL measurement with ultrasound or tissue dielectric constant, or BL treatment. Twenty-seven manuscripts were included in the review.

RESULTS: There is variation in incidence, time course, and risk factors for BL. Risk factors for BL included breast size, primary and axillary surgery extent, radiation, and chemotherapy but require further investigation. Diagnostic methods for BL currently rely on patient report and lack standardized criteria. Tissue dielectric constant (TDC) and ultrasound (US) emerged as promising ambulatory BL assessment tools; however, diagnostic thresholds and validation studies with ICG lymphography are needed to establish clinical utility. The evidence base for treatment of BL is weak, lacking high-quality studies.

CONCLUSION: The natural history of BL is not well defined. TDC and US show promise as ambulatory assessment tools for BL; however, further validation with lymphatic imaging is required. BL treatment is not established in the literature. Longitudinal, prospective studies including pre-radiation measurements and validating with lymphatic imaging are required. These data will inform screening, diagnostic criteria, and evidence-based treatment parameters for patients with BL after breast-conserving surgery and radiation

A new lymphography protocol and interpretation principles based on functional lymphatic anatomy in lower limb lymphedema - click for abstract

A new lymphography protocol and interpretation principles based on functional lymphatic anatomy in lower limb lymphedema

Akira Shinaoka. Anat Sci Int. 2023 Dec 22.

Indirect lymphatic system imaging is essential for diagnosing lymphatic diseases. The basic methodology involves intradermal or subcutaneous injection of a contrast agent into the surrounding lymphatic capillary, and the flow of the contrast agent is identified using a detector. Many contrast agents that use near-infrared dye, including indocyanine green (ICG) fluorescent lymphography, are available. ICG is rapidly spreading as a convenient and safe lymphedema diagnostic method, because it does not involve radiation exposure, and the imaging equipment is more compact than other devices. The lymphatic system is a semi-open circulatory system with numerous lymphatic capillaries acting as blind ends. Anatomical information on the injection site and observation of specific lymphatic vessels and nodes is important. However, this anatomical information is lacking. Recent reports suggest that ICG fluorescent lymphography can be applied to cadavers in the same manner as living bodies. Furthermore, these reports have demonstrated the functional aspects of the capillary lymph vessel networks as well as their relationship with lymphatic vessels and lymph nodes. This review article describes the historical progression from the old to the new functional lymphatic anatomy and introduces a new functional lymphography technique for the lower limbs.:10.1007

Sleep quality and lymphedema in breast cancer survivors: a mixed method analysis - click for abstract

Sleep quality and lymphedema in breast cancer survivors: a mixed method analysis

Karen Bock, Jill Peltzer, Wen Liu, Yvonne Colgrove, Irina Smirnova, Catherine Siengsukon. J Cancer Surviv. 2024 Jan 6.

PURPOSE: The purpose of this convergent mixed methods study was to assess the perceptions and characteristics of sleep in breast cancer survivors (BCSs) and elucidate perceptions of sleep among BCS with lymphedema.
METHODS: Participants were BCS with and without lymphedema. Both groups completed the Pittsburgh Sleep Quality Index (PSQI), PROMIS® Sleep Disturbance (8a short form), and wore an actigraph on their wrist to capture sleep/wake cycles for 7 days/nights while logging their sleep using a sleep diary. The coefficient of variation of sleep efficiency was calculated from the sleep diary to assess intraindividual variability. In addition, a subsample of BCS with lymphedema participated in a semi-structured qualitative interview. The qualitative data was analyzed separately, and the themes were applied to provide a more nuanced explanation of the quantitative outcomes.
RESULTS: The BCS with lymphedema (n=23) had a significant difference in PSQI (p=0.002), PROMIS® Sleep Disturbance (p=0.084), and sleep efficiency coefficient of variation (p=0.014) compared to BCS without lymphedema (n=23). There were no statistically significant differences between groups in the actigraphy results. BCS with lymphedema perceived that lymphedema management contributed to their sleep disturbance, further exacerbating their mind/body fatigue.
CONCLUSION: This study provides the foundation for future research to investigate the integration of sleep interventions with lymphedema management for holistic survivorship care for BCS with lymphedema.
IMPLICATIONS FOR CANCER SURVIVORS: An innovative sleep health intervention designed to consider the unique factors contributing to sleep disturbance in BCS with lymphedema will fill a gap in their post-cancer treatment quality of life.:10.1007

Lymphedema self-assessment among endometrial cancer survivors - click for abstract

Lymphedema self-assessment among endometrial cancer survivors

Jordyn A. Brown, Andrew F. Olshan, Victoria L. Bae-Jump, Adeyemi A. Ogunleye, Shawn Smith, Stephenie Black-Grant, Hazel B. Nichols Cancer Causes Control. 2024 Jan 4.

PURPOSE: Lower extremity lymphedema (LEL), which causes ankle, leg, and feet swelling, poses a significant challenge for endometrial cancer survivors, impacting physical functioning and psychological well-being. Inconsistent LEL diagnostic methods result in wide-ranging LEL incidence estimates.
METHODS: We calculated the cumulative incidence of LEL based on survivor-reported Gynecologic Cancer Lymphedema Questionnaire (GCLQ) responses in addition to survivor- and nurse-reported leg circumference measurements among a pilot sample of 50 endometrial cancer survivors (27 White, 23 Black) enrolled in the ongoing population-based Carolina Endometrial Cancer Study.
RESULTS: Self-leg circumference measurements were perceived to be difficult and were completed by only 17 survivors. Diagnostic accuracy testing measures (sensitivity, specificity, positive and negative predictive value) compared the standard nurse-measured [Formula: see text]10% difference in leg circumference measurements to GCLQ responses. At a mean of ~11 months post-diagnosis, 54% of survivors met established criteria for LEL based on [Formula: see text]4 GCLQ cutpoint while 24% had LEL based on nurse-measurement. Percent agreement, sensitivity, and specificity approximated 60% at a threshold of [Formula: see text]5 GCLQ symptoms. However, Cohen’s kappa, a measure of reliability that corrects for agreement by chance, was highest at [Formula: see text]4 GCLQ symptoms (κ = 0.27).
CONCLUSION: Our findings emphasize the need for high quality measurements of LEL that are feasible for epidemiologic study designs among endometrial cancer survivors. Future studies should use patient-reported survey measures to assess lymphedema burden and quality of life outcomes among endometrial cancer survivors.:10.1007

The Role of Imaging of Lymphatic System to Prevent Cancer Related Lymphedema

Vincenzo Cuccurullo, Marco Rapa, Barbara Catalfamo, Gianluca Gatta, Graziella Di Grezia, Giuseppe Lucio Cascini. Bioengineering (Basel). 2023 Dec 10

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Medical Applications of Skin Tissue Dielectric Constant Measurements

Harvey N. Mayrovitz. Cureus. 2023 Dec 14

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Analysis of the effect of nursing care based on action research method on the prevention of postoperative lymphedema in breast cancer patients

Weijuan Yang, Li Yang, Shuangwei Mao, Dandan Liu, Lili Wang. Medicine (Baltimore). 2023 Dec 29

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Management Strategies

Effect of various photobiomodulation regimens on breast cancer-related lymphedema: A systematic review and meta-analysis - click for abstract

Effect of various photobiomodulation regimens on breast cancer-related lymphedema: A systematic review and meta-analysis

Shao-Tang Chiu, U-Hin Lai, Yu-Chi Huang, Chau-Peng Leong, Po-Cheng Chen. Lasers Med Sci. 2023 Dec 22.

Breast cancer-related lymphedema (BCRL) is common among patients who have completed their cancer treatment. Although low-level laser therapy (LLLT) has been explored as a treatment option for BCRL, we could not find a regimen that is more effective than others. This meta-analysis aimed to organize existing research and determine the optimal combination of LLLT parameters for BCRL treatment. Studies were collected from four online databases: Embase, Ovid Medline, Cochrane, and Cinahl. The collected studies were reviewed by two of the authors. We focused on the aspects of the treatment area, treatment regimen, and total treatment sessions across the included studies. The comparisons between LLLT and non-LLLT were performed through a meta-analysis. Post-treatment QOL was significantly better in the axillary group. The group treated “three times/week with a laser density of 1.5-2 J/cm2” had significantly better outcomes in terms of swelling reduction, both immediately post-treatment and at 1-3 months follow-ups. The group with > 15 treatment sessions had significantly better post-treatment outcomes regarding reduced swelling and improved grip strength. According to these results, LLLT can relieve the symptoms of BCRL by reducing limb swelling and improving QOL. Further exploration found that a treatment approach targeting the axilla, combined with an increased treatment frequency, appropriate laser density, and extended treatment course, yielded better outcomes. However, further rigorous, large-scale studies, including long-term follow-up, are needed to substantiate this regimen.:10.1007

Impact of text reminders on pneumatic compression device (PCD) compliance in patients with breast cancer-related lymphedema

Shail Maingi, Ellen M. O’Malley. Support Care Cancer. 2023 Dec 16.

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Black Holes in compression therapy – A quest for data

Giovanni Mosti, Cees Wittens, Alberto Caggiati. J Vasc Surg Venous Lymphat Disord. 2023 Dec 11

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The Top 100 Most-Cited Articles on the Treatment of Lymphedema

Abdullah M. Alahwal, Hattan Aljaaly. Cureus. 2023 Dec 21. Dec

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Preventing lower limb lymphedema after pelvic lymphadenectomy with progressive resistance exercise training: A randomized controlled trial

Jiajia Zhang, Changming Zhou, Qin Ma, Yi Zhang, Xiaoju Zhang. Asia Pac J Oncol Nurs. 2024 Jan.

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Postoperative lymphedema after primary total hip arthroplasty: prospective analysis of bikini incision-type direct anterior approach versus established standard approaches

Sylwia Banasiak, Maximilian Hartel, Karl-Heinz Frosch, Josephine Berger-Groch. J Orthop Surg Res. 2024 Jan 11

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Is the Absence of Manual Lymphatic Drainage-Based Treatment in Lymphedema after Breast Cancer Harmful? A Randomized Crossover Study

Iria Da Cuña-Carrera, Mercedes Soto-González, Rocío Abalo-Núñez, Eva M. Lantarón-Caeiro. J Clin Med. 2024 Jan 11.

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Initiating and Maintaining Complete Decongestive Therapy Self-Management of Lymphedema Among Breast Cancer Survivors: Descriptive Qualitative Study

Yuanlu Sun, Mei Rosemary Fu, Yun Jiang, Amy S. Little. Integr Cancer Ther. 2024 Jan 28.

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