Hot off the Press June 2022
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.
Prevalence and Risk Factors
Patient-reported outcomes one year after positive sentinel lymph node biopsy with or without axillary lymph node dissection in the randomized SENOMAC trial
Risk Factors Associated With Postmastectomy Breast Cancer Lymphedema: A Multicenter Retrospective Analysis - Click for abstract
Risk Factors Associated With Postmastectomy Breast Cancer Lymphedema: A Multicenter Retrospective Analysis
BACKGROUND: Lymphedema is an edematous condition that afflicts the postmastectomy breast cancer population, with diminished quality of life with substantial financial costs. The factors predictive of postmastectomy lymphedema development in breast cancer patients are unknown. The objective was to evaluate the trends over time in lymphedema development and the risk factors predictive of lymphedema-related events within 2 years of mastectomy.
METHODS: Using the New York Statewide Planning and Research Cooperative System multicenter deidentified database from 2010 to 2016, a total of 65,543 breast cancer postmastectomy female patients (mean age, 59 ± 20 years) were identified across 177 facilities. The breast cancer patients were followed for any 2-year postmastectomy lymphedema-related events. A multivariable model identified predictors of 2-year lymphedema using eligible variables involving demographics, comorbidities, and complications. Elixhauser score was defined as a comorbidity index based on International Classification of Diseases codes used in hospital settings.
RESULTS: Overall, 5.2% (n = 3409) of the breast cancer postmastectomy patients experienced a lymphedema-related event within 2 years of initial surgery. Over time, 2-year postmastectomy lymphedema rates have more than doubled from 4.62% in 2010 to 9.75% in 2016 (P < 0.001). Two-year postmastectomy lymphedema rates varied significantly by mastectomy procedure type: 5.69% of the mastectomy-only procedures, 5.96% of the mastectomies with lymph node biopsies, and 7.83% of the mastectomies with lymph node dissections (P < 0.0001). Full mastectomies had a greater 2-year lymphedema rate of 7.31% when compared with partial mastectomies with 2.79% (P < 0.0001). The top predictive risk factors for a lymphedema-related event included higher Elixhauser score, prolonged hospitalization for mastectomy, more recent mastectomy procedure, obesity, younger age, non-Asian race, Medicaid insurance, and hypertension (all P's < 0.01).
CONCLUSIONS: Although more recent postmastectomy lymphedema rates may not be as high as historical estimates, the 2-year postmastectomy lymphedema rates have more than doubled from 2010 to 2016 requiring further elucidation as well as continued focus on treatment. Furthermore, risk factors were identified that predispose postmastectomy breast cancer patients to developing lymphedema. Given these findings, perioperative screening seems warranted to proactively identify, educate, and monitor postmastectomy patients at greatest risk of future lymphedema development.
The Association Between the Number of Retrieved Pelvic Lymph Nodes and Ipsilateral Lower Limb Lymphedema in Patients With Gynecologic Cancer- Click for abstract
The Association Between the Number of Retrieved Pelvic Lymph Nodes and Ipsilateral Lower Limb Lymphedema in Patients With Gynecologic Cancer
Sang Geun Jung, Sang Hee Im, Migang Kim, Min Chul Choi, Won Duk Joo, Seung Hun Song. Gynecologic Cancer, Journal of Investigative Surgery, 35:5, 978-983.
Purpose To identify currently used patient-reported outcome measures (PROMs) to evaluate disability in breast cancer survivors (BC) and critically evaluate their content and measurement properties.
Methods Four electronic databases (PubMed, EMBASE, CINAHL, Scopus and Google Scholar) were searched from 2001 to February 2021. PRISMA guidelines were followed. The content of the included PROM was evaluated by linking the items of the questionnaires to the International Classifcation of Functioning, Disability and Health (ICF) Core Set for BC using standard linking rules. Methodological quality and measurement properties were assessed using the COSMIN checklist. Qualitative synthesis was used to summarize the evidence on content validity and measurement properties. The overall quality of evidence on each measurement property was provided using GRADE principles.
Methods Four electronic databases (PubMed, EMBASE, CINAHL, Scopus and Google Scholar) were searched from 2001 to February 2021. PRISMA guidelines were followed. The content of the included PROM was evaluated by linking the items of the questionnaires to the International Classifcation of Functioning, Disability and Health (ICF) Core Set for BC using standard linking rules. Methodological quality and measurement properties were assessed using the COSMIN checklist. Qualitative synthesis was used to summarize the evidence on content validity and measurement properties. The overall quality of evidence on each measurement property was provided using GRADE principles.
Results Ten eligible studies reported measurement properties of seven PROMs. The content of included PROMs mostly focused on disability (70% of items), and less on body function and structure (23%) or environmental factors (6%). There was high linkage to The Comprehensive Core Set for BC, Q-DASH (100%), UEFI (95%) and DASH (92%). The Core Set Unique Disability Representation for DASH, and WHODAS2 was 39% and BCSQ-BC, Lymph-ICF was 34%. BCSQ-BC, and Lymph-ICF represented 32, and 20% of the content of the Core Set for BC, respectively, however, the other questionnaires covered less than 20% of the content of the Core Set. High quality of evidence supports sufficient results for internal
consistency, testretest, and measurement error for BCSQ-BC, Lymph-ICF, DASH and WHODAS2.
Conclusions Despite a lack of evidence on all-important clinical measurement, two generic (DASH and WHODAS2) and two disease-specifc (BCSQ-BC, Lymph-ICF) PROM demonstrated emerging evidence of adequate measurement properties. The stronger alignment of the BCSQ-BC to the breast cancer ICF core set makes it preferable is a disease-specifc measure. The Lymph-ICF is recommended where lymphedema is a specifc focus. The DASH and WHODAS2 might be most useful where patients with a variety of upper extremity conditions, including breast cancer survivors, are being evaluated in the clinic or research study.
consistency, testretest, and measurement error for BCSQ-BC, Lymph-ICF, DASH and WHODAS2.
Conclusions Despite a lack of evidence on all-important clinical measurement, two generic (DASH and WHODAS2) and two disease-specifc (BCSQ-BC, Lymph-ICF) PROM demonstrated emerging evidence of adequate measurement properties. The stronger alignment of the BCSQ-BC to the breast cancer ICF core set makes it preferable is a disease-specifc measure. The Lymph-ICF is recommended where lymphedema is a specifc focus. The DASH and WHODAS2 might be most useful where patients with a variety of upper extremity conditions, including breast cancer survivors, are being evaluated in the clinic or research study.
Assessment
A systematic review comparing lymphoscintigraphy and magnetic resonance imaging techniques in the assessment of peripheral lymphedema - click for abstract
A systematic review comparing lymphoscintigraphy and magnetic resonance imaging techniques in the assessment of peripheral lymphedema
Curr Med Imaging. 2022 May 25.
BACKGROUND: Peripheral lymphedema represents a disabilitating condition affecting the lymphatic system of the limbs resulting from impaired drainage and excessive lymphatic fluid accumulation in the interstitial spaces. Lymphoscintigraphy stands as the imaging modality of the first choice to investigate patients with peripheral lymphedema. Nevertheless, in recent times, magnetic resonance imaging (MRI) techniques have also been applied to assess patients with lymphedema.
OBJECTIVE: The present systematic review aimed to appraise the available evidence providing a head-to-head comparison between lymphoscintigraphy and MRI techniques in peripheral lymphedema.
METHOD: A systematic literature search was performed using the PubMed database and Cochrane Central Register of Controlled Trials (CENTRAL). The eligibility criteria for the articles to be included in the qualitative synthesis were: 1) a study cohort or a subset of patients with a clinical diagnosis of peripheral lymphedema (either upper or lower limb); 2) execution of both MR imaging and lymphoscintigraphy in the same subset of patients. The methodological quality of the studies was assessed by an investigator using the “Quality Assessment of Diagnostic Accuracy Studies” tool, v. 2 (QUADAS-2).
RESULTS: Overall, 11 studies were ultimately included in the quantitative analysis. No meta-analysis was performed due to the heterogeneous patient samples, the different study aims of the retrieved literature, and the limited number of available articles. In the diagnosis of upper limb extremity lymphedema, the sensitivity of MRI techniques appears superior to that of lymphoscintigraphy. Comparative studies in the lower limbs are still scarce but suggest that MRI may increase the diagnostic accuracy for lymphedema.
CONCLUSION: The available literature on patients with lymphedema evaluated with both lymphoscintigraphy and MRI does not allow definite conclusions on the superiority of one imaging technique over the other one. Further studies including well-selected patient samples are still necessary to compare the accuracy of these imaging modalities. Since MRI techniques seem to provide complementary findings to lymphoscintigraphy, it would be conceivable to acquire both imaging exams in patients with peripheral lymphedema. Furthermore, studies evaluating the clinical impact of adding MRl to the diagnostic workup are warranted.
Management Strategies
A novel air microfluidics-enabled soft robotic sleeve: Toward realizing innovative lymphedema treatment - click for abstract
A novel air microfluidics-enabled soft robotic sleeve: Toward realizing innovative lymphedema treatment
A proof of concept of a novel air microfluidics-enabled soft robotic sleeve to enable lymphedema treatment is presented. Compression sleeves represent the current, suboptimal standard of care, and stationary pumps assist with lymph drainage; however, effective systems that are truly wearable while performing daily activities are very scarce. This problematic trade-off between performance and wearability requires a new solution, which is addressed by an innovative microfluidic device. Its novelty lies in the use of light, small, and inexpensive air microfluidic chips (35 × 20 × 5 mm3 in size) that bring three major advantages compared to their traditional counterparts. First, each chip is designed with 16 fluidic channels with a cross-sectional area varying from 0.04 to 1 mm2, providing sequential inflation and uniform deflation capability to eight air bladders, thereby producing intentional gradient compression to the arm to facilitate lymph fluid circulation. The design is derived from the fundamentals of microfluidics, in particular, hydraulic resistance and paths of least resistance. Second, the air microfluidic chip enables miniaturization of at least eight bulky energy-consuming valves to two miniature solenoid valves for control increasing wearability. Third, the air microfluidic chip has no moving parts, which reduces the noise and energy needed. The cost, simplicity, and scale-up potential of developing methods for making the system are also detailed. The sequential inflation, uniform deflation, and pressure gradient are demonstrated, and the resulted compression and internal air bladder pressure were evaluated. This air microfluidics-enabled sleeve presents tremendous potential toward future improvements in self-care lymphedema management.
Association of lymphatic flow velocity with surgical outcomes in patients undergoing lymphovenous anastomosis for breast cancer-related lymphedema - click for abstract
Association of lymphatic flow velocity with surgical outcomes in patients undergoing lymphovenous anastomosis for breast cancer-related lymphedema
Breast Cancer. 2022 May 12.
PURPOSE: Lymphovenous anastomosis (LVA) is primarily used for treating early-stage lymphedema. Here, we aimed to investigate the relationship between lymphatic flow velocity and the efficacy of LVA in breast cancer-related lymphedema patients. To this end, we assessed the transit velocity of lymphatic fluid using indocyanine green (ICG) lymphography and radioisotope lymphoscintigraphy.
METHODS: We retrospectively examined patients diagnosed with breast cancer-related lymphedema who underwent LVA from January to December 2020. Patient data, including demographics, clinical stage, and postoperative surgical outcomes, were collected from electronic medical records. ICG lymphography results and dynamic lymphoscintigrams were analyzed to measure the lymphatic flow velocity and to determine the grade of the limb lymphedemas.
RESULTS: Eighty patients (all female, mean age of 53.6 years) were included. The lymphatic flow velocity ranged between 0.58 and 21.5 cm/min (average, 7.61 cm/min); 37 (46.3%), 18 (22.5%), 15 (18.8%), and 10 (12.5%) arm lymphedemas were classified as lymphoscintigraphy grade 0, 1, 2, and 3, respectively. A significant association was observed between lymphatic flow velocity and lymphedema grade determined using lymphoscintigraphy and between the amount of volume reduction after LVA and preoperative lymphatic flow velocity (P < 0.05).CONCLUSIONS: Our findings suggest that lymphatic flow velocity is positively correlated with surgical outcomes in patients undergoing LVA. Therefore, surgical treatment plans for lymphedema should not be based only on the International Society of Lymphedema stage, because advanced-stage lymphedema patients with high ICG velocities can benefit from LVA alone.
Intensive complex physical therapy combined with intermittent pneumatic compression versus Kinesio taping for treating breast cancer-related lymphedema of the upper limb: A randomised cross-over clinical trial- click for abstract
Intensive complex physical therapy combined with intermittent pneumatic compression versus Kinesio taping for treating breast cancer-related lymphedema of the upper limb: A randomised cross-over clinical trial
OBJECTIVE: The objective of this study is to compare the effectiveness of complex physical therapy combined with intermittent pneumatic compression (CPT + IPC) versus Kinesio taping (KT) for breast cancer-related lymphedema.
METHODS: A cross-over clinical trial was conducted in 43 women with lymphedema. All participants received two interventions: CPT + IPC and KT, both lasting 3 weeks and a washout period. The main outcome variable was the relative volume change (RVC). The secondary variables were Satisfaction Questionnaire about Textile Therapeutic Devices used for Breast Cancer-Related Lymphedema, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, motion range of upper limb and lymphedema-related symptoms.
RESULTS: The RVC reduction was greater with CPT + IPC (-2.2%, SD = 4.7) versus KT (-0.9%, SD = 1.7) (P = 0.002). KT was more satisfactory than multilayer bandaging (8.9 points difference, P < 0.001) and improved DASH score more than CPT + IPC (14.3 points difference, P = 0.002). Regarding motion ranges, only shoulder movements showed significant improvement with CPT + IPC compared with KT (differences between 5.6° and 11.4°). Of the symptoms assessed, only pain reduction showed a significant improvement with KT versus CPT + IPC (0.5 points, P = 0.035).
CONCLUSIONS: CPT + IPC achieved higher RVC and greater improvement in th shoulder motion range than KT. Conversely, KT was more satisfactory than multilayer bandaging, obtained better DASH scores and relieved pain more than CPT + IPC.
CLINICAL REGISTRATION: ClinicalTrial registration number
Early intervention with compression garments prevents progression in mild breast cancer-related arm lymphedema: a randomized controlled trial
