Hot of the Press October 2025

Article to ponder

Latest BLS & LSN Cellulitis Guidelines: Cellulitis in lymphoedema requires urgent attention. A 14-day course of antibiotics is recommended, oral initially, with IV for severe cases. Preventing recurrence involves good skin care, consistent compression therapy, and treating fungal infections. For patients with two or more episodes in 12 months, prophylactic antibiotics should be considered. Educating patients to recognise early signs and begin treatment promptly is essential.

BLS and LSN, 2025. Guidelines on the management of cellulitis in lymphoedema

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Key Takeaway: Treat cellulitis in lymphoedema urgently and completely to prevent recurrence.

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 pattern of arm lymphatic drainage and subclinical lymphedema progression after axillary lymph node dissection: a prospective cohort study

Bayu Brahma, Takumi Yamamoto, Sonar S. Panigoro, Samuel J. Haryono, Prasandhya A. Yusuf, Purnomo S. Priambodo, Kuntjoro Harimurti, Rizky I. Putri, Akmal Taher. Int J Surg. 2025 Aug 25

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Identification of novel hub genes and pathways predictive of fibrosis progression in cancer-related lymphedema through integrated multi-omics

Junzhe Chen, Yuezhong Chen, Liangliang Wang, Yaping Deng, Yan Zhou, Yun Wang, Shune Xiao, Chengliang Deng. Front Immunol. 2025 Aug 13

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Lymphedema is a rare manifestation of lymphoma: A case series and literature review

Kun Hao, Xingpeng Li, Jie Ren, Chunkai Yu, Li Zhang, Bin Li, Rengui Wang, Wenbin Shen, Yuguang Sun. Oncol Lett. 2025 Sep 9

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Time-Dependent Changes in the Skin Hardness in Taxane-Induced Swollen Arms

Kotaro Suehiro, Saiko Honda, Takasuke Harada, Yuriko Takeuchi, Takahiro Mizoguchi, Ryunosuke Sakamoto, Ryo Suzuki, Hiroshi Kurazumi, Kimikazu Hamano. Lymphat Res Biol. 2025 Sep 12.

Background: We aimed to clarify the time-dependent changes in skin hardness in taxane-induced arm swelling.
Methods and Results: Fifteen patients with unilateral arm swelling that developed during or within 3 months from the termination of postoperative taxane-containing chemotherapy were studied. The patients were followed up every 3-6 months for 24 months from the initial visit. During each visit, arm circumference and skin hardness were assessed using a scale ranging from 1 (softest) to 7 (hardest). Ultrasonography of the skin and subcutaneous tissues was performed at 0, 6, 12, and 24 months from the initial visit. In the initial visit, the mean skin hardness in the affected and contralateral arms was 3.8 versus 2.8 (p < 0.05) in the medial/lateral upper arm, 5.0 versus 2.8 (p < 0.01) in the medial forearm, and 4.3 versus 2.8 (p < 0.05) in the lateral forearm. In 12 patients whose arm swelling resolved, the difference in skin hardness between the arms disappeared in 9 patients until 9 months from the initial visit, whereas a mild difference in skin hardness persisted in the remaining 3 patients. Even in three patients whose arm swelling persisted, a certain improvement was observed until 9-12 months from the initial visit.
Conclusions: We found that the majority of skin hardening associated with taxane-induced arm swelling improved until approximately 9-12 months from the initial visit, including complete resolution in 60% of patients.:10.1177/15578585251378108

Prevalence and Risk Factors

Head and neck lymphedema after radiotherapy – Prevalence, changes and associated factors – a prospective observational cohort study

A Hagren, J Sjövall, C Brogårdh, Karin Johansson, E. Ekvall Hansson. Oral Oncol. 2025 Sep 12

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Analysis of the Influencing Factors of Postoperative Lymphedema of Breast Cancer and the Influence of Axillary Reverse Mapping on Edema and Postoperative Quality of Life

HuanLi Zeng, Xiu Wang, Yi Xiao, ShangYu Xie, ChuanRen Zhuang. Ann Ital Chir. 2025 Sep 10.-1233.

AIM: Postoperative lymphedema was a common and debilitating complication following breast cancer surgery, which significantly affects quality of life. This study analyzes the risk factors associated with lymphedema and evaluates the effectiveness of axillary reverse mapping (ARM) in reducing its incidence and improving quality of life.
METHODS: For this retrospective cohort study, 232 breast cancer patients who underwent axillary dissection between January 2022 and January 2023 were recruited. Patients were classified into the lymphedema group (n = 54) and the control group (n = 178) based on edema occurrence. Influencing factors such as body mass index, surgical techniques, and adjuvant therapies were analyzed. To assess ARM’s impact on lymphedema and quality of life, patients were also divided into a mapping group (n =133) and the control group (n = 99). Lymphedema stages were evaluated according to the International Lymphatic Society consensus, and quality of life was assessed using the Quality of Working Life Questionnaire for Cancer Survivors (QWLQ-CS), Breast Cancer Survivors Resilience Scale (BCRS), and Strategies Used by People to Promote Health (SUPPH) scale.
RESULTS: The results showed that chemotherapy (odds ratios [OR]: 4.063; p < 0.001) and radiotherapy (OR: 3.358; p < 0.001) were significant risk factors for lymphedema. ARM was associated with a reduced risk of lymphedema (OR: 0.322, p = 0.004). A higher proportion of patients in the mapping group were classified as having Stage 0 lymphedema (86.46%) compared to the control group (63.67%). For the mapping group, the QWLQ-CS was 71.04 ± 12.31 (p = 0.041), BCRS was 23.89 ± 6.32 (p = 0.003), and SUPPH was 85.65 ± 12.57 (p = 0.001), which were significantly higher than the control group.
CONCLUSIONS: Postoperative lymphedema risk in breast cancer patients is influenced by chemotherapy and radiotherapy, with ARM proving beneficial in reducing incidence and enhancing postoperative quality of life.:10.62713

The impact of breast reconstruction compared with no reconstruction on breast cancer-related lymphedema: A systematic review and meta-analysis

Cecilie Mullerup Laustsen-Kiel, Laura Hansen, Mathias Ørholt, Sofie Meng Zhang, Nicco Krezdorn, Peter Viktor Vester-Glowinski, Tine Engberg Damsgaard. Surgery. 2025 Sep 14.

INTRODUCTION: Breast cancer-related lymphedema affects 21.9% of patients. The role of breast reconstruction in lymphedema prevention remains unclear. This review aimed to assess the relative risk of breast cancer-related lymphedema after breast reconstruction compared with mastectomy and breast-conserving surgery, which has thus far been inconclusively assessed.
METHODS: We conducted a systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. PubMed, EMBASE, Cochrane Central, and gray literature searches identified studies reporting lymphedema outcomes after mastectomy, breast-conserving surgery, and breast reconstruction. We calculated incidence rate ratios using random-effects models. Subgroup analyses compared reconstruction timing (immediate compared with delayed), types (autologous compared with implant-based), and immediate implant stages (1-stage compared with 2-stage).
RESULTS: Twenty-three studies with 15,670 patients were included in the qualitative analysis, and 14 were included in the meta-analysis. Patients with breast reconstruction had a significantly lower risk of lymphedema than those without reconstruction (incidence rate ratio, 0.58; 95% confidence interval, 0.38-0.87, P < .001). However, this effect was less pronounced when only studies with baseline lymphedema measurements were included. We found no significant differences between autologous and implant-based reconstructions, immediate and delayed reconstruction, or 1- and 2-stage implant-based reconstruction.
CONCLUSION: Breast reconstruction does not increase the risk for breast cancer-related lymphedema, and the risk of lymphedema is similar across different types of breast reconstruction. Breast reconstruction may reduce the risk of breast cancer-related lymphedema compared with mastectomy alone. The lack of baseline lymphedema measurements in most studies and studies with follow-up less than 4 years limits the strength of these findings.:10.1016/j.surg.2025.109649

Association Between Objectively Measured Physical Activity and Lower-Limb Lymphedema Markers in Patients with Lymphedema Secondary to Gynecological Cancer: A Cross-Sectional Study

Yuriko Matsunaga-Myoji, Kimie Fujita, Satomi Tanaka, Miyuki Izumi, Urara Hirata, Kiyoko Kato. Lymphat Res Biol. 2025 Sep 11.

Background: Lower-limb lymphedema (LLL) secondary to gynecological cancer is a serious health condition that negatively affects physical activity (PA). We investigated the association between objectively measured PA and lymphedema markers in patients with LLL after gynecological cancer treatment.
Methods and Results: This cross-sectional study included 56 patients (mean age: 62.0 years) with LLL attending a lymphedema center. The degree of lymphedema was evaluated based on lower-limb water content (extracellular water content/whole body water content: ECW/TBW). The amount and intensity of PA were measured using an accelerometer. Thirty-three patients (61.1%) with ECW/TBW ≥0.4 were older, had significantly more sedentary time, and spent lesser time on moderate-to-vigorous activity than patients with ECW/TBW <0.4 (p < 0.05). A generalized linear model using the rate of change in ECW/TBW showed an association with older age, longer time since cancer diagnosis, and lower activity level. The severity of subjective symptoms measured using a visual analog scale did not differ between patients with high and low ECW/TBW.
Conclusions: Patients with LLL spent approximately half of the time in sedentary behavior, with more severe cases exhibiting longer sedentary durations. In older patients who have a long-standing cancer diagnosis, medical professionals should evaluate their activity and self-care status in addition to evaluating LLL and use this information to provide individualized interventions.:10.1177/15578585251376172

A dynamic nomogram predicting persistent breast cancer-related lymphedema: a retrospective cohort study in China

Wenting Jiang, Yuanqiang Li. Breast Cancer. 2025 Sep 22.

BACKGROUND: Once developed, persistent lymphedema (PLE) is irreversible and imposes multiple adverse challenges and a heavy economic burden on patients and the healthcare industry. This study aims to develop a risk nomogram model for PLE in breast cancer-related lymphedema (BCRL) patients and visualize it as a free online prediction website to guide individualized risk stratification and graded management.
METHODS: 418 BCRL patients who underwent axillary lymph node dissection (ALND) among 2176 postoperative breast cancer patients from January 2020 to December 2022 were retrospectively enrolled as research subjects. Univariate and logistic regression models were performed to identify risk factors. A visual dynamic nomogram was constructed using R and Shinyapps software, followed by validation of its discrimination, calibration, and clinical validity.
RESULTS: PLE incidence was 32.78%. Age, ALND level, severity of lymphedema, dominant side, and lymph node metastasis were significant risk factors for PLE (P < 0.05). The nomogram's C index was 0.827 (95%CI 0.774-0.880) in the training cohort and 0.849 (95%CI 0.782-0.916) in the validation cohort. Calibration curves showed good consistency across both cohorts. Decision curve analysis confirmed the good clinical validity, identifying 36% as the optimal threshold probability.
CONCLUSION: The dynamic nomogram, leveraging readily available clinical parameters, offers a clinically applicable web-based platform for dynamic risk quantification of PLE, facilitating early prediction, resource allocation, and prognosis management for high-risk PLE patients.:10.1007

Are We Underestimating Breast Cancer-Related Lymphedema? The Impact of Diagnostic Thresholds and Compression Therapy

Benjamin D. Wagner, Jonathan Rubin, Lillian A. Boe, Richard Diwan, Emily Bloomfield, Caitlin Giles, Danielle H. Rochlin, Hidehiko Yoshimatsu, Babak J. Mehrara, Michelle R. Coriddi. Ann Surg Oncol. 2025 Sep 19.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is commonly diagnosed using limb volume criteria; however, diagnostic thresholds vary and lack empirical validation. This variability may lead to underdiagnosis, particularly in patients using compression garments that can reduce limb size.
OBJECTIVE: This study evaluated how different diagnostic criteria and compression therapy influence the reported incidence of BCRL.
METHODS: A single-institution analysis was conducted on 165 female patients with breast cancer originally enrolled in a randomized controlled trial comparing axillary lymph node dissection with and without immediate lymphatic reconstruction from 2020 to 2025. Limb volumes were measured preoperatively and at 12, 18, and 24 months postoperatively. BCRL incidence was assessed using 5%, 10%, and 15% thresholds for relative volume change (RVC) and interlimb volume difference. The Upper Limb Lymphedema-27 (ULL-27) questionnaire evaluated symptoms. Compression use was evaluated to determine the effect on BCRL incidence.
RESULTS: BCRL incidence varied by threshold, from 55.8% at 5% RVC to 12.1% at 15% RVC. ULL-27 scores indicated comparable symptom burdens between patients meeting volume-based diagnostic criteria and those wearing compression garments but not meeting volume criteria. Both groups had significantly worse physical domain scores than patients without volume changes or compression use (P < 0.001). Including compression users who did not meet volume criteria increased the incidence of BCRL across all thresholds (e.g., 23.6% to 41.8% at 10% RVC).
CONCLUSIONS: BCRL incidence varied markedly by volume-based diagnostic thresholds, and inclusion of compression users significantly increased reported rates. Relying solely on volume thresholds may miss symptomatic patients. Integrating compression use and patient-reported outcomes can better identify clinically meaningful BCRL.:10.1245

Assessment

Sentinel symptoms of breast cancer-related lymphedema across different lymphedema severity classes

Aomei Shen, Wanmin Qiang, Peipei Wu, Zijuan Zhang, Qian Hu, Nada Lukkahatai, Qian Lu. Eur J Oncol Nurs. 2025 Aug 23.

PURPOSE: Twenty percent of post-surgery breast cancer patients exhibited lymphedema, which is typically classified into various severity classes. Sentinel symptoms that are crucial for identifying each lymphedema class remain unclear. This study aims to examine the sentinel symptoms of patients at different classes of lymphedema.

METHODS: This secondary data analysis examined two cross-sectional studies of post-surgery breast cancer patients. Participants’ symptoms occurrence and distress were assessed using the Breast Cancer and Lymphedema Symptom Experience Index. Lymphedema severity classes were defined based on interarm circumference differences. Apriori algorithms combined with the symptom occurrence was employed to determine the sentinel symptoms for each lymphedema class.

RESULTS: A total of 894 participants, aged 54.32 ± 11.28 years (range 26-85) were included. The prevalence of lymphedema was 28.64 %. The top three most frequent limb symptoms were arm-swelling heaviness, and fatigue. Based on interarm circumference difference, participants were classified into non-lymphedema (n = 371), subclinical (n = 267), mild (n = 135), or moderate-to-severe (n = 121) lymphedema. Sentinel symptoms for each class were as follows: fatigue, heaviness, and arm-swelling for the subclinical lymphedema; arm-swelling, limited-elbow-movement, limited-arm-movement, and firmness for the mild lymphedema; and fibrosis, stiffness, and limited-wrist-movement for the moderate-to-severe lymphedema (Support >. %, Confidence >. %, Lift >.

CONCLUSIONS: This evidence supported that sentinel symptoms are associated with different lymphedema classes. It emphasizes prompt identification and management of sentinel symptoms during follow-up care for breast cancer patients. Future research should validate these sentinel symptoms, explore the underlying mechanisms, and develop targeted interventions to alleviate them.:10.1016.102967

Long-term lymphedema and quality of life following lymph node staging in early cervical cancer: 3 years follow-up in the prospective multicenter SENTIREC CERVIX study

Eva B. Ostenfeld, Sarah M. Bjørnholt, Sara E. Sponholtz, Ligita P. Frøding, Katrine Fuglsang, Algirdas Markauskas, Erik Parner, Pernille T. Jensen. Am J Obstet Gynecol. 2025 Sep 1.

BACKGROUND: Pelvic lymphadenectomy (PL) is the gold standard in nodal staging in cervical cancer but increases risk of leg lymphedema (LL). Sentinel lymph node (SLN) mapping is a less invasive technique enabling accurate detection of nodal metastases, although evidence confirming its oncological safety has yet to be established. Knowledge on chronic LL and quality of life (QOL) following PL or SLN mapping is essential for qualifying treatment and survivorship strategies in women with cervical cancer but current evidence is limited
OBJECTIVES: To evaluate long-term LL after SLN mapping alone and SLN mapping + PL in women with cervical cancer. Further, to examine risk factors for LL and the condition-specific QOL among patients with LL at 12 months follow-up.
STUDY DESIGN: This national prospective cohort study included patients with early-stage cervical cancer who underwent radical surgery including SLN mapping (2017-2021). In case of tumors >20 mm, back-up PL was performed. Patients completed validated patient-reported outcome questionnaires before surgery and 3, 12, 24, and 36 months postoperatively. LL was assessed by the European Organization of Research and Treatment of Cancer (EORTC) cervix cancer module (QLQ-CX24), supplemented by eight single items from the EORTC item library addressing lymphedema of the legs, genitals, and groins. QOL was reported according to the Lymphedema Quality of Life (LYMQOL) tool, the EORTC QLQ-C30 and the QLQ-CX24 modules. Mean difference scores from baseline to each follow-up were estimated with 95% confidence intervals (CIs), defining a change of 8 points or more as clinically significant. Linear regression models were used to examine predictors of LL 12 months postoperatively. We evaluated QOL within LYMQOL domains in patients with lymphedema and analyzed domain trends using multiple linear regression. We compared QOL in patients with and without LL using guidelines for interpretation of clinically important differences.
RESULTS: Among 109 women who underwent SLN mapping alone, LL mean score differences from baseline to 3, 12, and 36 months were 6 (95% CI: 2-10), 10 (95% CI: 5-15), and 15 (95% CI: 7-22), respectively. At similar time points, 77 women reported substantial LL after SLN mapping + PL, with mean score differences of 18 (95% CI: 11-25), 29 (95% CI: 21-37), and 21 (95% CI: 11-32). Three-month LL scores were positively associated with LL scores at 12-months regardless of the extent of lymph node removal. BMI predicted LL after SLN mapping alone, whereas chemoradiotherapy was associated with lymphedema following back-up PL. Reporting lymphedema at 12-month follow-up was associated with impairment in several QOL aspects including fatigue, pain, physical, cognitive, social and sexual functioning.
CONCLUSION: Patients with cervical cancer reported long-term LL, most pronounced after SLN mapping + PL, and to a lesser extent after SLN mapping alone. Three months LL score predicted persistent lymphedema which was significantly associated with deterioration in several QOL symptoms and functioning. Our findings contribute with new knowledge in the field and support less invasive surgical approaches and may qualify shared decision making and survivorship intervention.:10.1016/j.ajog.2025.09.020

Management Strategies

Targeting Lymphedema in Overweight Breast Cancer Survivors: A Pilot Randomized Controlled Trial of Diet and Exercise Intervention

Yolanda Ruiz-Molina, Marina Padial, María Del Mar Martín-Bravo, María García-Olivares, Nuria Porras, Alejandro Chicharro, Javier Mora-Robles, Andrés González-Jiménez, Corina Verónica Sasso, Gabriel Olveira. Nutrients. 2025 Aug 27

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What we cannot miss in clinical trials on compression therapy

Giovanni Mosti, Serge Bohbot, Christine Bongards, J.P. Benigni, Nele Devoogdt, Isabel Forner-Cordero, Sergio Gianesini, Ravul Jindal, Fedor Lurie, Eduardo da Matta, Makoto Mo, Didier Rastel, Claas Roes, Wassila Taha, Sarah Thomis, Cees Wittens. Phlebology. 2025 Sep 3:2683 555 25.

Background
Compression therapy (CT) is widely prescribed for chronic venous disease (CVD), lymphedema, and lipedema despite robust evidence supporting its effectiveness only in a minority of clinical scenarios.
Aim
Provide an overview of the methodological parameters essential for obtaining a high-quality scientific trial. MethodsThe International Compression Club (ICC) chairman prepared a preliminary list of the main methodological flaws in publications on CT, and a list of parameters to be included in high-quality randomized controlled trials (RCTs). This list was circulated among ICC board members, who provided their comments and suggestions. The document was then presented and discussed at an ICC consensus meeting with various professionals in May 2024 in London. Meeting minutes were distributed to ICC members, and the final document reflecting all additional comments and suggestions was compiled. In summary, the following recommendations represent the consensus of the ICC members.
Results
The ICC recommends that the following parameters be reported in randomized clinical trials (RCTs): appropriate patient selection, adequate sample size, detailed classification of venous and lymphatic diseases, detailed description of CT modality, adherence to CT, and reasons for non-adherence. Tailored recommendations for specific scenarios and the use of standardized quality-of-life (QoL) tools are emphasized. Despite their value, RCTs face limitations and do not reflect real-world clinical practice. Real-world evidence (RWE) can complement RCTs by providing insights into routine applications, safety, compliance, and cost-effectiveness across diverse patient populations by standardized methodologies, large cohorts, and reliable validated registries to ensure validity. ConclusionsCombining data from RCTs and RWS allows for a comprehensive understanding of CT. RCTs provide evidence of effectiveness in a controlled scenario, while RWE offers real-world perspectives on compliance and economic outcomes in clinical practice. Together, these approaches enable a more holistic evaluation of CT, addressing current gaps in knowledge and guiding its optimal use.:10.1177/02683555251377228