Hot off the Press November 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

A Review of Histopathological Modifications in Lymphedema.

Elisabetta Weber MA, Eugenio Bertelli, Guido Gabriele, Paolo Gennaro, and Virginia Barone. Lymphatic Collecting Vessels in Health and Disease. Lymphatic research and biology 2022; 20: 468-477.

Secondary lymphedema of the extremities affects millions of people in the world as a common side effect of oncological treatments with heavy impact on every day life of patients and on the health care system. One of the surgical techniques for lymphedema treatment is the creation of a local connection between lymphatic vessels and veins, facilitating drainage of lymphatic fluid into the circulatory system. Successful results, however, rely on using a functional vessel for the anastomosis, and vessel function, in turn, depends on its structure. The structure of lymphatic collecting vessels changes with the progression of lymphedema. They appear initially dilated by excess interstitial fluid entered at capillary level. The number of lymphatic smooth muscle cells in their media then increases in the attempt to overcome the impaired drainage. When lymphatic muscle cells hyperplasia occurs at the expenses of the lumen, vessel patency decreases hampering lymph flow. Finally, collagen fiber accumulation leads to complete occlusion of the lumen rendering the vessel unfit to conduct lymph. Different types of vessels may coexist in the same patient but usually the distal part of the limb contains less affected vessels that are more likely to perform efficient lymphatic–venular anastomosis. Here we review the structure of the lymphatic collecting vessels in health and in lymphedema, focusing on the histopathological changes of the lymphatic vessel wall based on the observations on segments of the vessels used for lymphatic–venular anastomoses.

Evaluation of Circulating MicroRNAs and Adipokines in Breast Cancer Survivors with Arm Lymphedema

Khairunnisa’ Md Yusof, Kira Groen, Rozita Rosli, Maha Abdullah, Rozi Mahmud, Kelly A Avery-Kiejda. Int J Mol Sci. 2022 Sep 26;23(19):11359. doi: 10.3390/ijms23191135

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Prevalence and Risk Factors

Prediction models for breast cancer-related lymphedema: a systematic review and critical appraisal

Qiu Lin, Tong Yang, Jin Yongmei, Ye Mao Die. Syst Rev. 2022 Oct 13;11(1):217. doi: 10.1186/s13643-022-02084-2

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Assessment

Lymphedema after pelvic and para-aortic lymphadenectomy-results of a systematic evaluation in patients with cervical and endometrial carcinoma

R Armbrust, V Auletta, G Cichon, G Vercellino, K Yost, J Sehouli. Arch Gynecol Obstet. 2022 Oct 12. doi: 10.1007/s00404-022-06779-8
BACKGROUND: Lymphedema is a frequent complication after surgical treatment in gynecological oncology with substantial impact on patients´ Quality of Life (QoL). Little is known about screening instruments and prevention. Primary objective was to develop and validate the German version of a 13 items screening questionnaire (SQ) developed by Yost et al. to provide a valid instrument for early diagnosis of lower extremity lymphedema (LEL).
METHODS: After translation the SQ was used in pt. with cervical or endometrial cancer who underwent pelvic/paraaortic Lymphadenectomy. Sensitivity and specifity were analysed regarding possible prediction and influencing factors of LEL.
RESULTS: 67 pt. had LEL (N = 128). Nearly 50% of women in each group (38 in LEL + e 30 in LEL – ) had a body mass index (BMI) > 30 kg/m2. Number of removed lymphnodes, radiotherapy and were significantly associated with development of LEL. Translated Mayo Clinic questionnaire can be used with reliable specifity and sensitivity. Four additional questions improved the diagnostic accuracy of the SQ.
CONCLUSIONS: The translated SQ is a valuable and predictive tool for screening and early detection of LEL in Gynecological cancer surgery and can even improved by adding simple questions.

MRI of Lymphedema

Betsa Parsai Salehi, Robert Carson Sibley, Rosie Friedman, Geunwon Kim, Dhruv Singhal, Andreas Markus Loening, Leo L Tsai. J Magn Reson Imaging. 2022 Oct 22. doi: 10.1002/jmri.28496
Lymphedema is a devastating disease that has no cure. Management of lymphedema has evolved rapidly over the past two decades with the advent of surgeries that can ameliorate symptoms. MRI has played an increasingly important role in the diagnosis and evaluation of lymphedema, as it provides high spatial resolution of the distribution and severity of soft tissue edema, characterizes diseased lymphatic channels, and assesses secondary effects such as fat hypertrophy. Many different MR techniques have been developed for the evaluation of lymphedema, and the modality can be tailored to suit the needs of a lymphatic clinic. In this review article we provide an overview of lymphedema, current management options, and the current role of MRI in lymphedema diagnosis and management.

Development and psychometric evaluation of a lymphoedema self-management behaviour questionnaire for breast cancer patients

Xiaoxia Wei, Qian Lu, Aomei Shen, Xin Fu, Lichuan Zhang, Yujie Wang, Yingxin Wang. Eur J Cancer Care (Engl). 2022 Oct 19:e13743. doi: 10.1111/ecc.13743
OBJECTIVES: The study was aimed to develop and evaluate a lymphoedema self-management behaviour questionnaire (LSMBQ) for breast cancer patients.
METHODS: The initial version of the behaviour questionnaire was developed based on the framework of self-management and the evidence summary of lymphoedema self-management. Two rounds of expert consultation were conducted to validate the questionnaire’s content validity. A cross-sectional survey was then conducted in breast wards of two hospitals in China to evaluate the reliability and validity of this scale. Exploratory structural equation model was used to test the construct validity. T-test was used to analyse the known group validity. Structural equation model was applied to verify the relationship between self-efficacy, social support, and lymphoedema self-management behaviour to test the convergent validity. Also, the internal consistency reliability and test-retest reliability were evaluated.
RESULTS: The questionnaire’s content validity was satisfactory. There were 22 items included in the LSMBQ for validation and 260 completed the survey. A six-factor structure with good construct validity was identified. The result of t-test verified that patients who knew the risk of lymphoedema and those who received lymphoedema health education had higher scores of lymphoedema self-management behaviours (P < 0.05), indicating that the questionnaire has good known group validity. The fitting results of the structural equation model indicated that the 22-item questionnaire had good convergent validity. Cronbach's alpha coefficients and test-retest reliability for the total questionnaire were 0.910 and 0.875, respectively.
CONCLUSIONS: The 22-item LSMBQ appears to have adequate reliability and validity to assess the lymphoedema self-management behaviours for breast cancer patients

A new indocyanine green fluorescence lymphography protocol for diagnostic assessment of lower limb lymphoedema

Hiroo Suami, Belinda Thompson, Helen Mackie, Robbie Blackwell, Asha Heydon-White, Fiona Tisdall Blake, John Boyages, Louise Koelmeyer
J Plast Reconstr Aesthet Surg. 2022 Aug 24:S1748-6815(22)00460-0

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Management Strategies

Patient education for breast cancer-related lymphedema: a systematic review

Marisa Perdomo, Claire Davies, Kimberly Levenhagen, Kathryn Ryans, Laura Gilchrist. J Cancer Surviv. 2022 Oct 8. doi: 10.1007/s11764-022-01262-4.

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Effects of preoperative personal education on shoulder function and lymphedema in patients with breast cancer: A consort

Hayoung Byun, Yunjeong Jang, Ju-Yeon Kim, Jae-Myung Kim, Chang Han Lee
Medicine (Baltimore). 2022 Sep 23;101(38):e30810. 

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Effect of early interventions with manual lymphatic drainage and rehabilitation exercise on morbidity and lymphedema in patients with oral cavity cancer

Kuo-Yang Tsai, Su-Fen Liao, Kuan-Lin Chen, Hao-Wei Tang, Hsin-Ya Huang
Medicine (Baltimore). 2022 Oct 21;101(42):e30910

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Does Manual Lymphatic Drainage Add Value in Reducing Arm Volume in Patients With Breast Cancer-Related Lymphedema?

Tessa De Vrieze, Nick Gebruers, Ines Nevelsteen, Sarah Thomis, An De Groef, Wiebren A A Tjalma, Jean-Paul Belgrado, Liesbeth Vandermeeren, Chris Monten, Marianne Hanssens, Anne Asnong, Lore Dams, Elien Van der Gucht, An-Kathleen Heroes, Nele Devoogdt. Phys Ther. 2022 Oct 9:pzac137.

OBJECTIVE: The purpose of this study was to investigate the effectiveness of fluoroscopy-guided manual lymph drainage (MLD) versus that of traditional and placebo MLD, when added to decongestive lymphatic therapy (DLT) for the treatment of breast cancer-related lymphedema (BCRL), on the suprafascial accumulation of lymphatic fluid and skin elasticity.

METHODS: In this multicenter, 3-arm, double-blind randomized controlled trial (EFforT-BCRL trial), 194 participants (mean age = 61 [SD = 10] years) with unilateral BCRL were recruited. All participants received standardized DLT (education, skin care, compression therapy, exercises) and were randomized to fluoroscopy-guided, traditional, or placebo MLD. Each day participants received 60 minutes of treatment during the 3-week intensive phase and 18 sessions of 30 minutes during the 6-month maintenance phase. Participants were instructed to wear a compression garment, to perform exercises, and to perform a self-MLD procedure once daily. This study comprises secondary analyses of the EFforT-BCRL trial. Outcomes were the amount of fluid accumulation in the suprafascial tissues (local tissue water, extracellular fluid, and thickness of the skin and subcutaneous tissue) and skin elasticity at the level of the arm and trunk. Measurements were performed at baseline; after intensive treatment; after 1, 3, and 6 months of maintenance treatment; and after 6 months of follow-up.

RESULTS: At the level of the arm, there was a significant improvement over time in the 3 groups for most of the outcomes. At the level of the trunk, no remarkable improvement was noted within the individual groups. No significant interaction effects (between-group differences) were present. Only skin elasticity at the level of the arm, evaluated through palpation, showed a significant interaction effect.

CONCLUSIONS: All 3 groups showed similar improvements in response to DLT, regardless of the type of MLD that was added. The effect of the addition of MLD to other components of DLT for reducing local tissue water and extracellular fluid or skin thickness and for improving skin elasticity and fibrosis in participants with chronic BCRL was limited.

The All-Ireland Guidelines for the diagnosis, assessment and management of lymphoedema

Jane Rankin, Kay Morris, Aoife Reilly. Br J Community Nurs. 2022 Oct 1;27(Sup10):S22-S26. doi: 10.12968/bjcn.2022.27.Sup10.S22
The last decade has produced a plethora of lymphoedema-based research. As such, a new All-Ireland Guideline for lymphoedema diagnosis, assessment and management was required to replace the 2008 CREST Guideline. A research team was commissioned to work with healthcare staff and service users following international research standards practice. An evidence-based clinical practice guideline was developed to aid clinicians in the diagnosis, assessment, and management of lymphoedema. Recommendations were formulated based on the evidence available to answer each clinical question and were assigned a grade based on the strength of the evidence. In the absence of sufficient evidence and in an effort to maximise clinical applicability, recommendations were also based on expert opinion, which was gathered via guideline member consensus. The recommendations from the guideline, which aim to provide healthcare professionals with clear, evidence-based guidance on the diagnosis, assessment and management of patients with all types of lymphoedema, should be communicated at all levels regarding responsibility for implementation in clinical care and service development. Audit should be a core component of the implementation. A budget impact analysis should be completed to determine additional costs required to fully implement the guideline

Current Concepts in Surgical Management of Lymphedema

Rebecca Knackstedt, Wei F Chen. Phys Med Rehabil Clin N Am. 2022 Nov;33(4):885-899. doi: 10.1016/j.pmr.2022.06.003. Epub 2022 Sep 28.
The decision on whom to offer surgical interventions for lymphedema requires collaboration and input from all involved specialists and should address patients’ expectations, invasiveness of procedures, and disease severity. There is no consensus on what constitutes success or failure of complex decongestive therapy and when to pursue surgical intervention. Surgery has the potential to fundamentally affect the pathophysiology of the disease state and can be a powerful tool when used correctly. The dogma of which surgery to offer for a given clinical situation has been undergoing revision and is an area of ongoing research.PMID:36243478 | DOI:10.1016/j.pmr.2022.06.003
Hot off the Press October 2022Lymphatic Education & Research Network Videos