Hot off the Press March 2023

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

Seasonal Variation in Upper Limb Size, Volume, Fluid Distribution, and Lymphedema Diagnosis, Following Breast Cancer Treatment

Jennifer Phillips, Susan Witt, Neil B. Piller, Susan Gordon. Lymphat Res Biol. 2023 Feb 22. 
Breast cancer-related lymphedema (BCRL) is a common complication of breast cancer treatment. Anecdotal and qualitative research suggests that heat and hot weather cause an exacerbation of BCRL; however, there is little quantitative evidence to support this. The aim of this article is to investigate the relationship between seasonal climate variation and limb size, volume, fluid distribution, and diagnosis in women following breast cancer treatment. Methods and Results: Women older than the age of 35 years who had undergone treatment for breast cancer were invited to participate. Twenty-five women aged between 38 and 82 years were recruited. Seventy-two percent received surgery, radiation therapy, and chemotherapy as part of their breast cancer treatment. Participants completed anthropometric, circumferential, and bioimpedance measures and a survey on three occasions: November (spring), February (summer), and June (winter). Diagnostic criteria of >2 cm and >200 mL difference between the affected and unaffected arm, and a positive bioimpedance ratio of >1.139 for a dominant arm and >1.066 for nondominant arm was applied across the three measurement occasions. No significant correlation between seasonal variation in climate and upper limb size, volume, or fluid distribution were found in women diagnosed with or at risk of developing BCRL. Lymphedema diagnosis depends on the season and diagnostic measurement tool utilized. Conclusion: There was no statistically significant variation in limb size, volume, or fluid distribution in this population across spring, summer, and winter, although there were linked trends in these values. The diagnosis of lymphedema, however, varied between individual participants throughout the year. This has important implications for the implementation/commencement of treatment and management. Further research with a larger population in different climates is required to explore the status of women with respect to BCRL. The use of common clinical diagnostic criteria did not result in consistent diagnostic classification of BCRL for the women involved in this study.

Near-Infrared Imaging of Indocyanine Green Identifies Novel Routes of Lymphatic Drainage from Metacarpophalangeal Joints in Healthy Human Hands

H Mark Kenney, Gregory Dieudonne, Seonghwan Yee, Jeffrey H Maki, Ronald W Wood, Edward M Schwarz, Christopher T Ritchlin, Homaira Rahimi. Lymphat Res Biol. 2023 Feb 20.
Collecting lymphatic vessel (CLV) dysfunction has been implicated in various diseases, including rheumatoid arthritis (RA). RA patients with active hand arthritis exhibit significantly reduced lymphatic clearance of the web spaces adjacent to the metacarpophalangeal (MCP) joints and a reduction in total and basilic-associated CLVs on the dorsal surface of the hand by near-infrared (NIR) imaging of indocyanine green (ICG). In this pilot study, we assessed direct lymphatic drainage from MCP joints and aimed to visualize the total lymphatic anatomy using novel dual-agent relaxation contrast magnetic resonance lymphography (DARC-MRL) in the upper extremity of healthy human subjects. Methods and Results: Two healthy male subjects >18 years old participated in the study. We performed NIR imaging along with conventional- or DARC-MRL following intradermal web space and intra-articular MCP joint injections. ICG (NIR) or gadolinium (Gd) (MRL) was administered to visualize the CLV anatomy of the upper extremity. Web space draining CLVs were associated with the cephalic side of the antecubital fossa, while MCP draining CLVs were localized to the basilic side of the forearm by near-infrared indocyanine green imaging. The DARC-MRL methods used in this study did not adequately nullify the contrast in the blood vessels, and limited Gd-filled CLVs were identified. Conclusion: MCP joints predominantly drain into basilic CLVs in the forearm, which may explain the reduction in basilic-associated CLVs in the hands of RA patients. Current DARC-MRL techniques show limited identification of healthy lymphatic structures, and further refinement in this technique is necessary.

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Variable Anatomy of the Lateral Upper Arm Lymphatic Channel: A Potential Anatomic Risk Factor for the Development of Breast Cancer Related Lymphedema

Melisa D Granoff, Jaime Pardo, Kathy Shillue, Aaron Fleishman, Paige Teller, Bernard T Lee, Ted James, Dhruv Singhal
Plast Reconstr Surg. 2023 Jan 24
BACKGROUND: The lateral upper arm channel is an accessory lymphatic pathway that drains the upper extremity via the deltopectoral groove and supraclavicular nodes, thereby bypassing the axilla. Its variable connectivity to the forearm has not been studied in vivo.
METHODS: Indocyanine green (ICG) lymphography was performed pre-operatively to map the superficial and functional arm lymphatics in breast cancer patients without clinical or objective evidence of lymphedema. A retrospective review was performed to extract demographic, ICG imaging, and surgical data.
RESULTS: Sixty patients underwent ICG lymphography prior to axillary lymph node dissection between June 2019 and October 2020. In 59%, the lateral upper arm lymphatic channel was contiguous with the forearm (long bundle). In 38%, the lateral upper arm lymphatic channel was present but not contiguous with the forearm (short bundle). In 3%, the lateral upper arm pathway was entirely absent. Seven patients developed at least one sign of lymphedema during post-operative surveillance, of which 71% demonstrated the short bundle variant.
CONCLUSIONS: While the lateral upper arm pathway is most often present, its connections to the forearm are frequently absent (short bundle) and, in this pilot report, appears to represent a potential risk factor for the development of lymphedema.

A retrospective analysis of Stewart-Treves syndrome in the context of chronic lymphedema

Kun Hao, Yuguang Sun, Yan Zhu, Jianfeng Xin, Li Zhang, Bin Li, Wenbin Shen
An Bras Dermatol. 2023 Feb 4:

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Differentiation of lipoedema from bilateral lower limb lymphoedema by imaging assessment of indocyanine green lymphography

Helen Mackie, Belinda M Thompson, Hiroo Suami, Asha Heydon-White, Robbie Blackwell, Fiona Tisdall Blake, Louise A Koelmeyer. Clin Obes. 2023 Feb 22:e12588. doi: 10.1111/cob.12588.

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Magnetic resonance findings of Stewart-Treves Syndrome in primary limb lymphedema compared with pathology: A retrospective single-center study

Bin Li, Jiyuan Li, Kun Hao, Yanfang Jin, Jun Ma, Xuemei Du. Front Oncol. 2023 Feb 9;13:953524

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Prevalence and Risk Factors

The influence of axillary surgery and radiotherapeutic strategy on the risk of lymphedema and upper extremity dysfunction in early breast cancer patients

Si-Yue Zheng, Chu-Ying Chen, Wei-Xiang Qi, Gang Cai, Cheng Xu, Rong Cai, Xiao-Fang Qian, Kun-Wei Shen, Lu Cao, Jia-Yi Chen. Breast. 2023 Feb 4;68:142-148.

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Development and validation of a normal tissue complication probability model for lymphedema after radiotherapy in breast cancer

Ye-In Park, Jee Suk Chang, Heejoo Ko, Sang Hee Im, Jin Sung Kim, Hwa Kyung Byun, Yong Bae Kim, Wonguen Jung, Kyubo Kim, Chae-Seon Hong. Int J Radiat Oncol Biol Phys. 2023 Feb 3:S0360-3016(23)00106-2
 

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Assessment

Indirect partial volumetry in breast cancer-related lymphoedema: Distribution of oedema and clinical-diagnostic implications

E Cuello Villaverde, E Rambla Tirado, B Cardells Beltrán, N Guerola Soler. Rehabilitacion (Madr). 2023 Feb 3;57(3):10077

INTRODUCTION AND OBJECTIVES: Currently, the assessment of lymphoedema related to breast cancer (BCRL) is performed through the global perimeter volumetry. We implemented an additional system with partial measures (hand, forearm, and upper arm) that allows us to approximate the segmental distribution of oedema. We used this measurement tool to determine the oedema distribution and its evolution, as well as its possible impact on clinical assessment.

METHODS: We carried out a retrospective observational study of the patients referred to our service with suspected BCRL.

INCLUSION CRITERIA: Unilateral breast cancer, availability of global and partial digital medical record, and follow-up for a minimum of 24 months. Of the 210 selected patients, 190 were considered affected (≥10% excess volume). We analysed at three time points (initial, final, and peak involvement) the oedema distribution and segmental predominance and its relationship with the evolutionary course and the severity of the process. We subsequently examined, at the initial timepoint, the concordance of the global assessment with the partial assessment for the clinical classification of the 210 patients in the initial sample.

RESULTS: The BCRL oedema was characteristically irregular, with the forearm being the most affected segment and the hand the least affected (RM ANOVA: p<0.001). The irregularity was related to its severity (χ2: p<0.001) and the evolutionary course (Student t-test: p<0.005 for the hand). Overall, disagreement of 46.67% was observed between the clinical classification of the global and partial assessment. CONCLUSIONS: This work supports the need to add partial volumetry to the commonly used global assessment. [/av_toggle] [/av_toggle_container] [av_hr class='invisible' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' font='entypo-fontello' av_uid='av-82fm03a'] [av_toggle_container initial='0' mode='accordion' sort='' styling='' colors='' font_color='' background_color='' border_color='' av_uid='av-rnal3q'] [av_toggle title='Prospective, early longitudinal assessment of lymphedema-related quality of life among patients with locally advanced breast cancer: The foundation for building a patient-centered screening program - click for abstract' tags='' av_uid='av-76n6l2u']

Prospective, early longitudinal assessment of lymphedema-related quality of life among patients with locally advanced breast cancer: The foundation for building a patient-centered screening program

Anusha Gandhi, Tianlin Xu, Sarah M DeSnyder, Grace L Smith, Ruitao Lin, Carlos H Barcenas, Michael C Stauder, Karen E Hoffman, Eric A Strom, Susan Ferguson, Benjamin D Smith, Wendy A Woodward, George H Perkins, Melissa P Mitchell, Desmond Garner, Chelain R Goodman, Melissa Aldrich, Marigold Travis, Susan Lilly, Isabelle Bedrosian, Simona F Shaitelman. Breast. 2023 Feb 24;68:205-215. doi: 10.1016/j.breast.2023.02.011.
BACKGROUND: We examined how breast cancer-related lymphedema (BCRL) affects health-related quality of life (HRQOL), productivity, and compliance with therapeutic interventions to guide structuring BCRL screening programs.
METHODS: We prospectively followed consecutive breast cancer patients who underwent axillary lymph node dissection (ALND) with arm volume screening and measures assessing patient-reported health-related quality of life (HRQOL) and perceptions of BCRL care. Comparisons by BCRL status were made with Mann-Whitney U, Chi-square, Fisher’s exact, or t tests. Trends over time from ALND were assessed with linear mixed-effects models.
RESULTS: With a median follow-up of 8 months in 247 patients, 46% self-reported ever having BCRL, a proportion that increased over time. About 73% reported fear of BCRL, which was stable over time. Further in time from ALND, patients were more likely to report that BCRL screening reduced fear. Patient-reported BCRL was associated with higher soft tissue sensation intensity, biobehavioral, and resource concerns, absenteeism, and work/activity impairment. Objectively measured BCRL had fewer associations with outcomes. Most patients reported performing prevention exercises, but compliance decreased over time; patient-reported BCRL was not associated with exercise frequency. Fear of BCRL was positively associated with performing prevention exercises and using compressive garments.
CONCLUSIONS: Both incidence and fear of BCRL were high after ALND for breast cancer. Fear was associated with improved therapeutic compliance, but compliance decreased over time. Patient-reported BCRL was more strongly associated with worse HRQOL and productivity than was objective BCRL. Screening programs must support patients’ psychological needs and aim to sustain long-term compliance with recommended interventions.

Functional and psychosocial quality of life in gynecologic Cancer survivors with and without lymphedema symptoms

Linda Koehler, Lauren Elyse Penz, Florence John, Ashley Stenzel, Patricia Jewett, Deanna Teoh, Anne Blaes, Colleen Rivard, Rachel Vogel
Gynecol Oncol. 2023 Feb 2;170:254-258.
OBJECTIVE: The goal of this study was to compare function, quality of life, body image and distress levels between gynecologic cancer survivors with and without lymphedema symptoms as well as to determine how many individuals received rehabilitation treatment following treatment for gynecological malignancy.
METHODS: This prospective longitudinal cohort study sought to examine long-term physical and psychosocial outcomes among gynecologic cancer survivors.
RESULTS: Participants in the symptomatic group reported lower quality of life, lower function scores, and greater cancer-related, with greater rates of clinically significant levels of distress. These results remained largely consistent in multivariable models.
CONCLUSIONS: We found lower extremity lymphedema to be associated with lower quality of life, lower limb function, greater distress, and negative body image.

Cross-sectional validity and specificity of comprehensive measurement in lymphedema and lipedema of the lower extremity: a comparison of five outcome instruments

Angst F, Lehmann S, Aeschlimann A, Sandòr PS, Wagner S. Health Qual Life Outcomes. 2020 Jul 22;18(1):245

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A systematic review of validated assessments methods for head and neck lymphedema

Coralie R Arends, Josephine E Lindhout, Lisette van der Molen, Erica A Wilthagen, Michiel W M van den Brekel, Martijn M Stuiver. Eur Arch Otorhinolaryngol. 2023 Feb 10

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Management Strategies

Effects of scapulothoracic stabilization exercises on scapular function, posture, and balance in lymphedema after mastectomy: a randomized controlled trial

Cansu Sahbaz Pirincci, Meltem Dalyan, Sibel Unsal Delialioglu, Seyda Toprak Celenay. Women Health. 2023 Feb 22:1-15. 
This study aimed to investigate the effects of scapulothoracic stabilization exercises (SSE) on scapular function, posture, and balance in women with lymphedema after mastectomy. The patients were randomly divided into two groups as complex decongestive physiotherapy (CDP) (n: 12; age: 55.25 ± 8.17 years) and CDP+SSE (n: 13; age: 54.38 ± 9.08 years). While only CDP was applied in the CDP group, CDP and SSE were applied in the CDP+SSE group. Scapulothoracic muscle strength with dynamometer, scapular endurance with Scapular Isometric Compression Test, scapular dyskinesia with Lateral Scapular Slide Test, thoracic posture with inclinometer, general posture with New York Posture Scale, and balance with Mini-BESTest were evaluated before the 3-week treatment phase (TP), after the TP, and after the fifth week of the maintenance phase (MP). Improvements in the lower trapezius muscle strength were found in both groups after the TP (p < .05). In addition, the middle trapezius muscle strength and general posture improved more in the CDP+SSE group than in the CDP group after the TP (p < .05). In the MP, scapulothoracic muscle strength, scapular endurance, and general posture improved more in CDP+SSE group compared to the CDP group (p < .05). In upper extremity lymphedema patients, incorporating additional SSE in CDP may contribute to the improvement of posture and scapular functions

Efficacy of kinesio taping on upper limb volume reduction in patients with breast cancer-related lymphedema: a systematic review of randomized controlled trials

Nicola Marotta, Lorenzo Lippi, Valerio Ammendolia, Dario Calafiore, Maria T Inzitari, Monica Pinto, Marco Invernizzi, Alessandro de Sire. Eur J Phys Rehabil Med. 2023 Feb 27

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Simultaneous upper limb melanoma and breast cancer related lymphedema management

Dimitrios Dionyssiou, Athanasios Papas, Avra Drougou, Athanasios Tsamaldoupis, Georgios Arsos, Efterpi Demiri. Case Reports Plast Surg Hand Surg. 2023 Feb 24;10(1):2182308

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Let’s Face the Elephant in the RoomTreatment of head and neck lymphedema