Hot off the Press September 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.
Anatomy / Physiology /Pathophysiology
Early Blood Flow Abnormalities in Axillary and Brachial Arteries Precede the Onset of Persistent Lymphedema in Women Treated Surgically for Breast Cancer- click for abstract
Early Blood Flow Abnormalities in Axillary and Brachial Arteries Precede the Onset of Persistent Lymphedema in Women Treated Surgically for Breast Cancer
Lymphat Res Biol. 2022 Aug 11.
urgery to treat breast cancer (BC) is associated with upper limb (UL) lymphedema, which in some cases may become permanent. It is uncertain whether lymphedema results from injury to either lymphatic or blood vessels, or to both. Methods and Results: a cohort of 200 BC patients was examined 1, 3, 6, 12, and 24 months after surgery. Axillary and brachial blood vessels were evaluated using Doppler Ultrasound, and patients had their UL examined for lymphedema at each visit. Patients who developed lymphedema 24 months after surgery presented with higher mean flow velocity (MFV) and end diastolic velocity (EDV) in both axillary (MFV = 13.57 vs. 10.7 cm/s, p = 0.02; EDV = 5.62 vs. 3.47 cm/s; p = 0.004) and brachial (MFV = 11.44 vs. 8.74 cm/s; p = 0.03; EDV = 5.08 vs. 3.04; p = 0.04) arteries as early as 1 month after surgery. Similar associations were found 3, 6, and 12 months after surgery. Early abnormalities of the resistive and pulsatility indexes were also significantly associated with persistent lymphedema. EDV measured 1 month after surgery had the best performance to detect patients who will later develop long-term lymphedema, (sensitivity = 73.7%; specificity = 71.2%; negative predictive value = 57.6%). Conclusion: vascular abnormalities precede and are possible causal factors for UL lymphedema in BC patients.
Evaluation of Abdominal Fat Ratio in Patients with Breast Cancer-Related Lymphedema: A Controlled Study- click for abstract
Evaluation of Abdominal Fat Ratio in Patients with Breast Cancer-Related Lymphedema: A Controlled Study
This study aimed to investigate the possible relationship between breast cancer-related lymphedema and central obesity, which is known to be effective in metabolic syndrome and chronic inflammation. Methods and Results: Thirty-six patients (18 lymphedemas, 18 control) enrolled in the study. There was no statistically significant difference in demographic data between the two groups except body mass index (BMI) distribution (p = 0.008). Although 50% of the patients in the study group were obese, this rate was 5.6% in the control group. Although there was a significant difference between the study and control groups in terms of abdominal circumference measurement, there was no significant difference between total and abdominal fat amount and ratios. When BMI and abdominal circumference measurements were evaluated together to predict lymphedema, the area under the curve in abdominal circumference measurement was higher than BMI (0.715 vs. 0.659). In receiver operating characteristic curve analysis, 107 cm of abdominal circumference measurement was determined as cut off value for lymphedema, with 55% sensitivity and 89% specificity (Youden index: 0.44). Conclusion: Abdominal circumference measurement can be evaluated together with BMI in determining the risk of lymphedema
Temporal Changes in Subcutaneous Fibrosis in Patients with Lower Extremity Lymphedema Following Surgery for Gynecologic Cancer: A Computed Tomography-Based Quantitative Analysis- click for abstract
Evaluation of Abdominal Fat Ratio in Patients with Breast Cancer-Related Lymphedema: A Controlled Study
This study aimed to investigate the possible relationship between breast cancer-related lymphedema and central obesity, which is known to be effective in metabolic syndrome and chronic inflammation. Methods and Results: Thirty-six patients (18 lymphedemas, 18 control) enrolled in the study. There was no statistically significant difference in demographic data between the two groups except body mass index (BMI) distribution (p = 0.008). Although 50% of the patients in the study group were obese, this rate was 5.6% in the control group. Although there was a significant difference between the study and control groups in terms of abdominal circumference measurement, there was no significant difference between total and abdominal fat amount and ratios. When BMI and abdominal circumference measurements were evaluated together to predict lymphedema, the area under the curve in abdominal circumference measurement was higher than BMI (0.715 vs. 0.659). In receiver operating characteristic curve analysis, 107 cm of abdominal circumference measurement was determined as cut off value for lymphedema, with 55% sensitivity and 89% specificity (Youden index: 0.44). Conclusion: Abdominal circumference measurement can be evaluated together with BMI in determining the risk of lymphedema
Prevalence and Risk Factors
Breast cancer-related lymphedema correlated with incidence of cellulitis and mortality - click for abstract
Breast cancer-related lymphedema correlated with incidence of cellulitis and mortality
BACKGROUND: This study investigated breast cancer-related lymphedema (BCRL) and its correlation with the incidence of cellulitis and mortality in the National Health Insurance (NHI) database in Taiwan.
METHODS: Between 2004 and 2014, the NHI database of patients with breast cancer who underwent surgical procedures, adjuvant therapies, BCRL, cellulitis, and mortality were retrospectively reviewed. Cox regression was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for incidence of BCRL and cellulitis in different treatment groups. The associations of BCRL with the incidence of cellulitis and mortality were further analyzed using the Kaplan-Meier curve.
RESULTS: Among 100 301 patients, 5464 (5.4%) developed BCRL with a median onset of 1.3 years. At a mean follow-up of 4.77 years, the incidence of cellulitis in the BCRL group (12.7%, 694/5464 patients) was significantly higher than in the no-BCRL group (2.73%, 2589/94 837 patients) (HR: 3.74; 95% CI: 3.43-4.08; p < 0.0001). At a mean follow-up of 5.77 years, the mortality rate in the cellulitis group (34.21%, 1123/3283 patients) was significantly greater than in the no-cellulitis group (16.29%, 15 804/97 018 patients) (HR: 1.17; 95% CI: 1.1-1.24; p < 0.0001).
CONCLUSIONS: BCRL had a significantly higher incidence of cellulitis and mortality.
Higher Rate of Lymphedema with Inguinal versus Axillary Complete Lymph Node Dissection for Melanoma: A Potential Target for Immediate Lymphatic Reconstruction? - click for abstract
Higher Rate of Lymphedema with Inguinal versus Axillary Complete Lymph Node Dissection for Melanoma: A Potential Target for Immediate Lymphatic Reconstruction?
BACKGROUND: The present study was conducted to define the lymphedema rate at our institution in patients undergoing axillary (ALND) or inguinal (ILND) lymph node dissection (LND) for melanoma. It aimed to examine risk factors predisposing patients to a higher rate of lymphedema, highlighting which patients could be targeted for immediate lymphatic reconstruction (ILR).
METHODS: A retrospective chart review was conducted between October 2015 and July 2020 to identify patients who had undergone ALND or ILND for melanoma. The main outcome measures were rates of transient and permanent lymphedema. Univariate and multivariate analyses were performed to assess the relationship between lymphedema rate and factors related to patient characteristics, surgical procedure, pathology findings, and adjuvant treatment.
RESULTS: Between October 2015 and July 2020, 66 patients underwent LND for melanoma: 34 patients underwent ALND and 32 patients underwent ILND. At a median follow-up of 29 months, 85.3% (n = 29) of patients having had an ALND did not experience lymphedema, versus 50.0% (n = 16) of ILND (p = 0.0019). The rates of permanent lymphedema for patients having undergone ALND and ILND were 11.8% (n = 4) and 37.5% (n = 12) respectively (p = 0.016, NS). The rate of transient lymphedema was 2.9% (n = 1) for ALND and 12.5% (n = 4) for ILND (p = 0.13, NS). On univariate analysis, the location of LND and wound infection were found to be significant factors for lymphedema. On multivariate analysis, only the location of LND remained a significant predictor, with the inguinal location predisposing to lymphedema.
CONCLUSION: This study highlights the high rate of lymphedema following ILND for melanoma and is a potential target for future patients to be considered for ILR.
Barriers and enablers of weight management after breast cancer: a thematic analysis of free text survey responses using the COM-B model
BMC Public Health. 2022 Aug 20;22(1):1587
Assessment
Health-related quality of life and assessment in patients with lower limb lymphoedema: a systematic review- click for abstract
Health-related quality of life and assessment in patients with lower limb lymphoedema: a systematic review
OBJECTIVE: To determine the impact of lower limb lymphoedema (LLL) on health-related quality of life (HRQoL), and to identify the methodologies used to assess HRQoL and their adherence to the World Health Organization (WHO)-recommended HRQoL dimensions.
METHOD: A systematic review was used following the PRISMA guidance. Studies were eligible if they assessed HRQoL in adult patients with LLL. The search was conducted between September 2019 and February 2020 using CINAHL, PubMed, Scopus, EMBASE and the Cochrane Library database. Data were placed onto a pre-developed data extraction table and analysed using a narrative synthesis. Evidence-based Librarianship (EBL) was used for quality appraisal.
RESULTS: A total of 18 studies were identified, among which 10 were cross-sectional and eight were longitudinal studies. Twelve HRQoL questionnaires were identified and the Lymphoedema Quality of Life tool (LYMQoL) was the most commonly used. All of the studies except one had an EBL validity score of ≥75%. Although LLL causes a considerable impairment in HRQoL, the findings varied across the studies. All the studies considered at least four of the six WHO recommended dimensions, with none considering the spirituality dimension. Furthermore, physical functioning and wellbeing were discovered to be the worst affected HRQoL dimensions.
CONCLUSION: LLL adversely affects physical function, wellbeing and thus the HRQoL. The LYMQoL is the most commonly used questionnaire; despite this, all elements of the WHO recommendations were not captured in the included studies. However, accurate information on HRQoL indicating the impact of the disease on survivors’ lives and complete wellbeing is needed to inform evidence-based decision-making. Furthermore, having a universally accepted, disease-specific methodology will facilitate comparison and contrasting of HRQoL
Reducing rates of chronic breast cancer-related lymphedema with screening and early intervention: an update of recent data - click for abstract
Reducing rates of chronic breast cancer-related lymphedema with screening and early intervention: an update of recent data
PURPOSE: Breast cancer-related lymphedema (BCRL) represents a dreaded complication of breast cancer treatment that can lead to morbidity, diminished quality of life, and psychosocial harm and is associated with increased costs of care. Increasingly, data has supported the concept of prospective BCRL surveillance coupled with early intervention to mitigate these effects.
METHODS: We performed a systematic review of the literature searching for published randomized and prospective data evaluating prospective BCRL surveillance with early intervention.
RESULTS: We identified 12 studies (2907 patients) including 4 randomized trials (1203 patients) and 8 prospective studies (1704 patients). Randomized data consistently demonstrate that early intervention reduces rates of progression to chronic BCRL with multiple paradigms and diagnostic modalities utilized; the strongest data comes from the randomized PREVENT trial, which demonstrated early detection with bioimpedance spectroscopy (BIS), coupled with early intervention with a compression garment applied for 12 h a day over 4 weeks, significantly reduced the rate of chronic BCRL compared to tape measurement coupled with early intervention.
CONCLUSIONS: Current data support the role of prospective BCRL surveillance with early detection and intervention to reduce rates of chronic BCRL. Breast cancer patients at risk for BCRL should undergo prospective surveillance as part of survivorship. Because level 1 data demonstrate that BIS is superior to conventional tape measure, it should be included as the standard BCRL diagnostic modality unless an equally effective modality is employed.
IMPLICATIONS FOR CANCER SURVIVORS: Breast cancer survivor should undergo prospective BCRL screening with BIS
Circumferential and Depth Variations in Tissue Dielectric Constant Values as Indices of Lower Leg Localized Skin Water - click for abstract
Circumferential and Depth Variations in Tissue Dielectric Constant Values as Indices of Lower Leg Localized Skin Water
The primary goal of this study was to quantify circumferential (medial, anterior, lateral) and measurement depth variations (0.5 mm, 1.5 mm, 2.5 mm) in tissue dielectric constant (TDC) values as an aid to their use to assess the presence and progression of lower extremity edema and lymphedema. Measurements were done in 30 healthy non-edematous women to provide reference data to estimate expected values and thresholds when evaluating clinical edematous or lymphedematous conditions. A second goal was to determine the extent to which TDC values evaluated at lower leg sites depend on body mass index (BMI). The study protocol (#12180901) was approved by the university’s institutional review board and subjects were evaluated after signing an approved informed consent. The study group had an age range of 19-54 years with a mean age and SD of 30.6 ± 10.1 years and had a BMI between 18.1-44.1 Kg/m2 with a mean BMI and SD of 24.5 ± 5.4 Kg/m2. The main findings show that at the three circumferential sites (medial, anterior, and lateral) located eight cm from the mid-malleolus, there are small but statistically significant differences in TDC values at every measurement depth (0.5 mm, 1.5 mm and 2.5 mm). For each depth, the maximum difference occurs between the medial and lateral locations with lateral locations having a greater TDC value at all depths. Despite the wide range of BMI values of the subjects evaluated, no significant relationship between TDC value and BMI was detected. It is concluded that TDC measurements in the lower leg reveal statistically significant differences among circumferential sites and measurement depths that should be considered when evaluating or tracking lower extremity tissue water changes associated with edema, lymphedema or other conditions related to skin water. The absolute values of these non-edematous TDC values herein determined may provide a basis for calculating TDC thresholds applicable to edematous or lymphedematous lower leg conditions.
Management Strategies
Real-time image-sharing to educate a patient with lymphoedema on self-care: a case study - click for abstract
Real-time image-sharing to educate a patient with lymphoedema on self-care: a case study
Br J Nurs. 2022 Aug 11;31(15):S22-S29.
INTRODUCTION: Compression therapy is important in oedema control in lymphoedema. However, some patients have difficulties starting compression therapy because standard self-care education does not enable them to fully understand lymphoedema and recognise it as their problem. To overcome this, real-time image-sharing education, using a combination of indocyanine green lymphography (ICG) and ultrasonography, may be used to educate patients. In this case study, real-time image-sharing education promoted decision-making and behaviour change in a patient with lower extremity lymphoedema so she would wear elastic stockings.
CASE: A 51-year-old woman with a BMI of 31.7 kg/m2 and secondary lower extremity lymphoedema following cervical cancer surgery did not adhere to self-care instructions regarding wearing elastic stockings for 5 years. The oedema worsened, her limb circumference increased and she had two episodes of cellulitis within a year. Because the patient had a negative attitude towards elastic stockings, real-time image-sharing education was used to promote recognition of illness using ICG and an understanding of the condition of lymphoedema using ultrasonography. After the images were shared and explained, the patient discussed her recognition and understanding of lymphoedema, then decided to use compression stockings. She continued to wear them for 4 months, and her limb circumference decreased.
CONCLUSION: Real-time image-sharing education using ICG and ultrasonography as self-care support for a lymphoedema patient who would not start compression therapy could result in behavioural changes and the patient starting and continuing to wear elastic stockings
Water-based exercise for upper and lower limb lymphoedema treatment - click for abstract
Water-based exercise for upper and lower limb lymphoedema treatment
J Vasc Surg Venous Lymphat Disord. 2022 Aug 19:S2213-333X(22)00354-7. doi: 10.1016/j.jvsv.2022.08.002.
INTRODUCTION: Lymphedema is a debilitating illness caused by insufficient lymph drainage, which can have serious physical and psychological consequences. Although water-based exercise can be useful, there is currently little evidence on the outcomes of aquatic treatment for patients with lymphoedema. Therefore, the aim of this scoping review is to evaluate, based on current literature, the impact of water-based exercise on pain, limb motor function, Quality of Life (QoL), and limb volume among patients affected by primary and secondary upper and lower limb lymphedema.
MATERIALS AND METHODS: A scoping review examining clinical studies and Randomized Controlled Trials (RCTs) published in English from 2000 to 2021 was conducted screening MEDLINE (Pubmed) and PEDro databases.
RESULTS: The search produced a total of 88 studies. 8 RCTs and one clinical study including patients with primary or secondary lymphedema of upper or lower limbs who benefited from water-based treatment were finally included. Most trials were focused on breast cancer related lymphedema. Shoulder range of flexion, external rotation and abduction have been shown to improve after performing a water-based exercise protocol. Some evidence demonstrated that also the lymphedematous limb strength can improve. Moreover, water-based exercise seemed to improve pain perception and QoL in patients with upper or lower limb lymphoedema, whereas in the control groups QoL tended to worsen over time. While some studies did not show a beneficial effect on the lymphedematous limb volume, most of the studies examined showed a reduction in volume, especially in the short term. No studies reported adverse events.
CONCLUSION: This review shows the potentials of aquatic exercise in lymphedema management, but at the same time it underlines multiple limitations due to the heterogeneity in study population and related physical activity protocols. The aquatic exercise role in the conservative treatment of lymphoedema will need to be further investigated in the future in order to define specific protocols of application
The effect of the combined use of complex decongestive therapy with electrotherapy modalities for the treatment of breast cancer-related lymphedema: a randomized clinical trial - click for abstract
The effect of the combined use of complex decongestive therapy with electrotherapy modalities for the treatment of breast cancer-related lymphedema: a randomized clinical trial
BMC Musculoskelet Disord. 2022 Sep 3;23(1):837. doi: 10.1186/s12891-022-05780-1
BACKGROUND: We evaluated the effects of combined complex decongestive therapy (CDT) with electrotherapy modalities (ultrasound and faradic currents) in patients with breast cancer-related lymphedema (BCRL), investigating upper extremity circumference, volume, pain, and functional disability.
METHODS: Thirty-nine patients with unilateral BCRL were randomly allocated to three groups (n = 13) as the following: The control group received CDT, the ultrasound group received CDT and therapeutic ultrasound, and the faradic group received CDT and faradic current. All the participants underwent treatment for 10 sessions. The outcomes including volume, circumference (measured at five points), pain intensity, and functional disability of the affected upper extremity were evaluated at baseline and after the treatment.
RESULTS: Following the treatment, an improvement was noted in lymphedema volume, pain, and functional disability in all the three groups and there was a significant difference between the groups (P < 0.05). However, changes in limb circumference at the end of the treatment were not significantly different among the three groups in any sites (P > 0.05).
CONCLUSION: The combination of electrotherapy modalities, faradic current or ultrasound, with CDT can result in a greater reduction in lymphedema volume, pain, and functional disability in patients with BCRL.
Safety and Effectiveness of a Novel Non-Pneumatic Active Compression Device for Treating Breast Cancer-Related Lymphedema, a Multi-center Randomized, Crossover Trial (NILE)
J Vasc Surg Venous Lymphat Disord. 2022 Aug 8:S2213-333X(22)00338-9
