A comprehensive review of bioimpedance spectroscopy as a diagnostic tool for the detection and measurement of breast cancer-related lymphedema

Three-dimensional non-contrast magnetic resonance lymphography severity stage for upper extremity lymphedema

PURPOSES

Non-contrast magnetic resonance lymphography (NMRL) has recently shown the capability of evaluating anatomical fluid distribution in upper extremity lymphedema (UEL). However, there is still a lack of knowledge about the correlation between the characteristic three-dimensional (3D) NMRL findings and the indocyanine green lymphography (ICG-L) findings. Our goal was to clarify the relationship between the 3D NMRL findings and the ICG-L findings.

METHODS

Medical charts of patients with secondary UEL who underwent NMRL and ICG-L between January 2018 to October 2021 were reviewed. The upper extremities were divided into 6 regions; the hand, elbow, and the radial and ulnar aspects of the forearm and the upper arm. We investigated the prevalence of characteristic 3D NMRL patterns (Mist/Spray/Inky) in each region based on the ICG-L stage. We also examined the association between the 3D NMRL stage which we proposed and the ICG-L stage, and other clinical factors.

RESULTS

A total of 150 regions of 25 patients with upper extremities lymphedema were enrolled in the study. All of the characteristic patterns increased significantly as the ICG-L stage advanced (p < 0.001, < 0.001, and < 0.001, respectively). The predominant NMRL patterns changed significantly from the Early pattern (Mist pattern) to the Advanced pattern (Inky/Spray pattern) as the ICG-L stage progressed (p < 0.001). The higher Stage of 3D NMRL was significantly associated with the progression of the ICG-L stage (rs = 0.80, p < 0.001).

CONCLUSIONS

Characteristic 3D NMRL patterns and the 3D NMRL Stage had a significant relationship with the ICG-L stage and other clinical parameters. This information may be an efficient tool for a more precise and objective evaluation of various treatments for UEL patients.

Breast Cancer-Related Lymphedema Assessed via Tissue Dielectric Constant Measurements

This review describes the use of tissue dielectric constant (TDC) measurements mainly in the assessment of breast cancer-related lymphedema (BCRL). PubMed, Web of Science, and EMBASE databases were initially searched using criteria that included the terms "dielectric" and "lymphedema." The initial search yielded a total of 131 titles. After removing studies not focused on upper extremity lymphedema, 56 articles remained. These articles, together with relevant articles from their bibliographies, formed the basis of the review. The findings show the potential utility and applications of TDC measurements to help detect and track BCRL, whether present in limbs, breasts, or trunks. It is reported as a non-invasive, simple-to-use method, with each measurement requiring less than 10 seconds, suggesting its practicality and useability as an in-office or in-clinic screening and tracking method. Although there are various ways to quantitatively evaluate lymphedema, most, if not all, are restricted to measurements on limbs. Thus, one significant advantage of the TDC approach is that almost any local region of interest can be effectively measured and tracked, which, for BCRL, could include specific regions of arms or hands, breasts, and truncal areas.

Evaluation of upper limb lymphoedema and diagnostic accuracy of bioimpedance spectroscopy. A comprehensive validation in a Brazilian population

Lymphoedema is a complication of breast cancer treatment. Its early diagnosis is related to a good prognosis for lymphoedema treatment. The bioimpedance spectroscopy (BIS) evaluates changes in extracellular fluid. The objective of our study was to evaluate the validity, agreement and accuracy of BIS in the diagnosis of breast cancer-related lymphoedema in a Brazilian population.

Methods

This is a prospective, cross-sectional study of a convenience sample of 462 women who underwent surgical treatment for breast cancer (mastectomy or breast-conserving treatment). The validity, agreement and accuracy were performed comparing BIS (lymphoedema index (L-DEX) ≥ 6.5 or 10) with volumetry by water displacement, which is the gold standard for evaluating lymphoedema. Receiver operating characteristic curve was performed. Additionally, other methods like perimetry and indirect volumetry of the upper limbs were compared with water displacement volumetry (direct volumetry), and the BIS were compared with subjective evaluation.

Results

Considering L-DEX ≥ 10 the sensitivity of the BIS was 44.1%, specificity 95.4%, positive predictive value (PPV) was 70.7%, negative predictive value (NPV) was 87% and kappa was 0.459. The BIS with L-DEX ≥ 6.5, the sensitivity, specificity, PPV, NPV and kappa were 57%, 88.5%, 55.8%, 89% and 0.452, respectively. Area under curve was 0.724 and a possible cut-off point of L-DEX ≥ 7.35 with sensitivity of 57%, specificity of 90.7% and kappa value = 0.489.

Conclusion

Although BIS was significantly associated with the subjective evaluation of lymphoedema, it showed low sensitivity and agreement and moderate correlation when used as a method for diagnosing the condition. Thus, it is not the most valid method for evaluating lymphoedema. In addition, it was not the most accurate method when compared with other objective evaluation tools. Public health resources are scarce and must be used consciously. The knowledge that BIS is not a more accurate method than other, lower-cost instruments allows for better targeting of these resources.

Segmentation of Arm Ultrasound Images in Breast Cancer-Related Lymphedema: A Database and Deep Learning Algorithm

OBJECTIVE

Breast cancer treatment often causes the removal of or damage to lymph nodes of the patient's lymphatic drainage system. This side effect is the origin of Breast Cancer-Related Lymphedema (BCRL), referring to a noticeable increase in excess arm volume. Ultrasound imaging is a preferred modality for the diagnosis and progression monitoring of BCRL because of its low cost, safety, and portability. As the affected and unaffected arms look similar in B-mode ultrasound images, the thickness of the skin, subcutaneous fat, and muscle have been shown to be important biomarkers for this task. The segmentation masks are also helpful in monitoring the longitudinal changes in morphology and mechanical properties of tissue layers.

METHODS

For the first time, a publicly available ultrasound dataset containing the Radio-Frequency (RF) data of 39 subjects and manual segmentation masks by two experts, are provided. Inter- and intra-observer reproducibility studies performed on the segmentation maps show a high Dice Score Coefficient (DSC) of 0.94±0.08 and 0.92±0.06, respectively. Gated Shape Convolutional Neural Network (GSCNN) is modified for precise automatic segmentation of tissue layers, and its generalization performance is improved by the CutMix augmentation strategy.

RESULTS

We got an average DSC of 0.87±0.11 on the test set, which confirms the high performance of the method.

CONCLUSION

Automatic segmentation can pave the way for convenient and accessible staging of BCRL, and our dataset can facilitate development and validation of those methods.

SIGNIFICANCE

Timely diagnosis and treatment of BCRL have crucial importance in preventing irreversible damage.

Early Detection of Breast Cancer-Related Lymphedema: Accuracy of Indocyanine Green Lymphography Compared with Bioimpedance Spectroscopy and Subclinical Lymphedema Symptoms

Introduction: The reported incidences of breast cancer-related lymphedema (LE) affecting the arms vary greatly. Reason for this variability includes different diagnostic techniques used across studies. In the current study, we compared the accuracy of indocyanine green lymphography (ICG_L) and bioimpedance spectroscopy (BIS) in detecting LE before presentation of clinical signs. Methods and Results: Patients with no initial detectable signs of clinical LE of their arms after axillary lymph node dissection or removal of >5 lymph nodes on sentinel lymph node biopsy were included. Subclinical LE was defined as BIS values outside the normal range [(≥7 units (or >10 units)] or a 7-unit (or 10 unit) change between two measurements. We tracked ICG_L and BIS measurements for 133 potentially affected arms (n = 123). ICG_L detected signs of lymphatic flow disruption in 63 arms (47%). Based on the BIS value of 7 units, 60 arms (45%) had values outside the normal range. When using ICG_L-identified LE cases as true positives, BIS had a 54% accuracy (area under the curve [AUC] = 0.54) in detecting LE. Accuracy was 61% for subclinical LE symptoms when compared with ICG_L (AUC = 0.62). Both BIS and subclinical LE symptoms had <0.70 AUC-receiver characteristic operator curve, suggesting that BIS and development of subclinical LE symptoms are not adequate for identifying patients with subclinical LE. Conclusion: ICG_L is a reliable diagnostic tool for detecting early signs of lymphatic flow disruption in subclinical LE. Utilizing ICG_L to diagnose subclinical LE followed by a personalized treatment plan may provide patients the best chance of preventing disease progression.

Clinical Utility of Bioelectrical Impedance Analysis Parameters for Evaluating Patients with Lower Limb Lymphedema after Lymphovenous Anastomosis

BACKGROUND

 In lymphedema, lymphatic fluid accumulates in the interstitial space, and localized swelling appears. Lymphovenous anastomosis (LVA) is the most widely used surgery to rebuild a damaged lymphatic system; however, assessing outcome of LVA involves performing volume measurements, which provides limited information on body composition changes. Therefore, we analyzed the bioelectrical impedance analysis (BIA) parameters that can reflect the status of lymphedema patients who underwent LVA.

METHODS

 We retrospectively reviewed records of 42 patients with unilateral lower extremity lymphedema who had LVA. We measured the perioperative BIA parameters such as extracellular water (ECW) ratio and volume as defined by the percentage of excess volume (PEV). We evaluated the relationship between the amount of change in PEV and in BIA parameters before and after surgery. We confirmed the correlation between ΔPEV and BIA parameters using Spearman's correlation.

RESULTS

 Most patients included had secondary lymphedema due to cancer. Average age was 51.76 years and average body mass index was 23.27. PEV and all BIA parameters after surgery showed a significant difference (p < 0.01) compared with preoperative measurements. The ECW ratio aff/unaff showed the strongest correlation with PEV with a correlation coefficient of 0.473 (p < 0.01).

CONCLUSION

 Our findings suggest that BIA parameters, especially ECW ratio aff/unaff could reflect the status of patients with lower limb lymphedema after LVA. Appropriate use of BIA parameters may be useful in the postoperative surveillance of patients.

The Use of Ultrasound Imaging for Upper Extremity Lymphedema after Breast Cancer: A Systematic Review

BACKGROUND

 The aim of this study was to analyze the different applications of ultrasound (US) in upper extremity lymphedema (UEL) after breast cancer.

METHODS

 A systematic review of the literature was performed in line with the PRISMA statement using MEDLINE/PubMed databases from January 1970 to December 2021. Articles describing the application of US in patients with UEL after breast cancer were included. The quality of the study, the level of reproducibility, and the different applications and type of US technique were analyzed.

RESULTS

 In total, 30 articles with 1,193 patients were included in the final review. Five different applications were found: (1) diagnosis of UEL (14 studies found a direct correlation between lymphedema and morphological and/or functional parameters); (2) staging/severity of UEL (9 studies found a direct correlation between the clinical stage and the soft-tissue stiffness/texture/thickness); (3) therapeutic assessment (3 studies found an improvement in the circulatory status or in the muscle/subcutaneous thickness after conservative treatments); (4) prognosis assessment of UEL (1 study found a correlation between the venous flow and the risk of UEL); and (5) surgical planning (3 studies determined the location of the lymphatic vessel for lymphovenous anastomosis [LVA] surgery).

CONCLUSION

 Morphological and functional parameters have been correlated with the diagnosis, stage, therapeutic effect, prognosis of UEL, and surgical planning of LVA.

A critical analysis of American insurance coverage for imaging and surgical treatment of lymphedema

BACKGROUND

Over 35 million Americans have lymphedema. Nonetheless, lymphedema is underdiagnosed and undertreated worldwide. We investigated whether the rates of coverage for imaging and surgical procedures may contribute to the limited care provided for lymphedema.

METHODS

We performed a cross-sectional evaluation of 58 insurers, chosen based on state enrollment and market share. A web-based search or phone call determined whether a publicly available policy on lymphedema-specific imaging, physiological procedures, and excisional procedures was available. Coverage status and corresponding criteria were extracted.

RESULTS

Of the two-thirds of insurers who included a policy on imaging, 4% (n = 2) provided coverage and 4% (n = 2) specified coverage only on a case-by-case basis. Forty-eight percent (n = 28) of insurers had a statement of coverage on lymphovenous bypass or vascularized lymph node transfer, in which reimbursement was almost universally denied (96%, n = 26; 93%, n = 26). Liposuction and debulking procedures were included in 25 (43%) and 13 (22%) policies, in which seven (28%) and four (31%) insurers would provide coverage, with over 75% having criteria. Coverage of liposuction was significantly more than for lymphovenous bypass (P < .04).

CONCLUSIONS

Nearly one-half of American insurers do not have a publicly available policy on most imaging, physiological, or excisional procedures, leaving coverage status ambiguous. Reimbursement was uncommon for imaging and physiological procedures, whereas the majority of insurers who did offer coverage for excisional procedures also had multiple criteria to be met. These elements may together be a limiting factor in receiving appropriate care for lymphedema.

A Prospective Study on the Safety and Efficacy of Vascularized Lymph Node Transplant

PURPOSE

While vascularized lymph node transplant (VLNT) has gained popularity, there are a lack of prospective long-term studies and standardized outcomes. The purpose of this study was to evaluate the safety and efficacy of VLNT using all available outcome measures.

METHODS

This was a prospective study on all consecutive patients who underwent VLNT. Outcomes were assessed with 2 patient-reported outcome metrics, limb volume, bioimpedance, need for compression, and incidence of cellulitis.

RESULTS

There were 89 patients with the following donor sites: omentum (73%), axilla (13%), supraclavicular (7%), groin (3.5%). The mean follow-up was 23.7±12 months. There was a significant improvement at 2 years postoperatively across all outcome measures: 28.4% improvement in the Lymphedema Life Impact Scale, 20% average reduction in limb volume, 27.5% improvement in bioimpedance score, 93% reduction in cellulitis, and 34% of patients no longer required compression. Complications were transient and low without any donor site lymphedema.

CONCLUSIONS

VLNT is a safe and effective treatment for lymphedema with significant benefits fully manifesting at 2 years postoperatively. Omentum does not have any donor site lymphedema risk making it an attractive first choice.

Relationship of Adjuvant Radiation and the Lymphedema Index: A Valuable Trend to Follow Subclinical Lymphedema in Patients After Immediate Lymphatic Reconstruction

BACKGROUND

Immediate lymphaticovenular bypass (immediate lymphatic reconstruction [ILR]) at the time of axillary lymph node dissection has emerged as a preventative paradigm to decrease the incidence of breast cancer-related lymphedema in high-risk patients. These patients are often treated with adjuvant therapies, including radiation. Bioimpedance spectroscopy is a validated tool for trending breast cancer-related lymphedema and identifying subclinical disease. Lymphedema Index (LDEX) values are commonly obtained in ILR patients; however, postoperative trends and relationships with adjuvant treatments are yet to be reported in the literature.

METHODS

After International Review Board approval, 100 consecutive patients underwent axillary lymph node dissection with axillary reverse lymphatic mapping and ILR at a tertiary cancer center. These patients were then followed prospectively in a multidisciplinary lymphedema clinic at 3-month intervals with clinical examination, circumferential limb girth measurements and bioimpedance spectroscopy (LDEX).

RESULTS

Seventy-two patients met inclusion for analysis at 3 months, 60 at 6 months, 51 at 9 months, 45 at 12 months, 41 at 15 months, and 22 at 18 months. A majority of the patients included underwent adjuvant radiation. Average LDEX score for patients who developed lymphedema was 3.02 at 3 months, at 29.1 months, 17.8 at 9 months, 15.05 at 12 months, 18.75 at 15 months, and 7.7 at 18 months. Patients who went on to develop lymphedema had a higher LDEX score at 6 months (29.1 vs 3.20, P = 0.1329), which reached a significant difference beginning at 9 months (17.8 vs 3.19, P = 0.0004). All patients who went on to develop lymphedema received adjuvant radiation.

CONCLUSIONS

These data provide valuable insight guiding follow-up after ILR. Six-month LDEX is much higher in patients who developed lymphedema, all of which underwent adjuvant radiation therapy, which correlates with the time of completion of their treatment. Average LDEX value after this remains significantly higher in this population. Patients who demonstrate this increase in LDEX and received adjuvant radiation are at highest risk to develop lymphedema despite ILR. All patients who developed lymphedema despite ILR had adjuvant radiation, and this is likely a contributing factor. Injury from adjuvant radiation and its impact after ILR is not insignificant and warrants further studies.

The role of bioimpedance spectroscopy method in severity and stages of breast cancer-related lymphedema

Objective: The correlation between lymphedema severity and stages determined by standard diagnostic methods and Bioimpedance Spectroscopy (BIS) technique was examined in breast cancer-related lymphedema (BCRL) patients.

Material and Methods: The bioimpedance analyzer device was connected to the 1.0 cm disc electrodes which were connected to the affected and unaffected (healthy) arm of the patients. We evaluated the performance of the impedance (Z) at multiple frequencies (5-50-100-200 kHz) and phase angle (PA), resistance (R), and reactance (XC) at 50 kHz on the lymphedema severity and stages. Bioimpedance measurements were applied to all volunteers in cooperation with the Physical Therapy and Rehabilitation Department. In this study, the correlation between BCRL severity and stages and bioimpedance values was examined.

Results: A total of 31 female patients were recruited to compare the BIS technique with standard diagnostic techniques. The severity of lymphedema was found among the patients as follows; mild 14 (45.2%), moderate 10 (32.3%), and severe 7 (22.6%). The stage distribution of volunteers was; 15 (48.4%) patients in Stage 0, 10 (32.3%) patients in Stage 1, 5 (16.1%) patients in Stage 2, and 1 (3.2%) patient in Stage 3. The ratio of affected and unaffected arm bioimpedance mean values were calculated. Although, this ratio at 50-100-200 kHz Z and 50kHz R were significantly correlated with the lymphedema stages (p< 0.05), there was no correlation and significant difference between the ratio of the bioimpedance values and lymphedema severity (p> 0.05).

Conclusion: The BIS technique is timesaving and can determine lymphedema stages. We found a significant correlation between BCRL stages and BIS, and it appears that BIS is an appropriate, inexpensive, simple, and noninvasive technique for detecting the stages of BCRL.

Invention and Clinical Application of an Oversleeve for Measuring Limb Volume in Postoperative Breast Cancer Patients

Background

Lymphedema is a common complication of breast cancer treatment, affecting 1/5 of breast cancer survivors, but there is no reliable way to detect subclinical lymphedema.

Objective

The purpose of this study was to determine the feasibility and reliability of using an oversleeve as a postoperative limb volume measurement tool in breast cancer patients.

Methods

Fifty patients were analyzed based on inclusion criteria. A body volume measurement kit was designed based on the drainage volume method and the circumference measurement method. Twenty-two normal healthy people were measured by the drainage volume (LV) and oversleeve measuring limb volume (OMLV) methods, so as to verify the accuracy of OMLV. Twenty-eight patients with lymphedema diagnosed by the circumdiameter measurement (CDM) method were measured with OMLV for comparison. The difference in measurements between OMLV and CDM was compared in 50 patients with early lymphedema diagnosed by the LV method.

Results

There was no significant difference between the sleeve method and the drainage volume method in the normal population (P = 0.74). All patients with lymphedema diagnosed by CDM met the diagnostic criteria by the OMLV method. In patients with early lymphedema diagnosed by LV, the diagnostic rate with OMLV was significantly higher than that with CDM (P = 0.008).

Conclusion

Similar to LV in the diagnosis of lymphedema, OMLV can effectively improve the diagnostic rate of early lymphedema, providing a new option for the diagnosis and treatment of lymphedema.

Novel Wireless Bioimpedance Device for Segmental Lymphedema Analysis Post Dual-Site Free Vascularized Lymph Node Transfer: A Prospective Cohort Study

An innovative wireless device for bioimpedance analysis was developed for post-dual-site free vascularized lymph node transfer (VLNT) evaluation. Seven patients received dual-site free VLNT for unilateral upper or lower limb lymphedema. A total of 10 healthy college students were enrolled in the healthy control group. The device was applied to the affected and unaffected limbs to assess segmental alterations in bioimpedance. The affected proximal limb showed a significant increase in bioimpedance at postoperative sixth month (3.3 [2.8, 3.6], p = 0.001) with 10 kHz currents for better penetration, although the difference was not significant (3.3 [3.3, 3.8]) at 1 kHz. The bioimpedance of the affected distal limb significantly increased after dual-site free VLNT surgery, whether passing with the 1 kHz (1.6 [0.7, 3.4], p = 0.030, postoperative first month; 2.8 [1.0, 4.2], p = 0.027, postoperative third month; and 1.3 [1.3, 3.4], p = 0.009, postoperative sixth month) or 10 kHz current ((1.4 [0.5, 2.7], p = 0.049, postoperative first month; 3.2 [0.9, 6.3], p = 0.003, postoperative third month; and 3.6 [2.5, 4.1], p < 0.001, postoperative sixth month). Bioimpedance alterations on the affected distal limb were significantly correlated with follow-up time (rho = 0.456, p = 0.029 detected at 10 kHz). This bioimpedance wireless device could quantitatively monitor the interstitial fluid alterations, which is suitable for postoperative real-time surveillance.

Diagnostic Criteria for Breast Cancer-Related Lymphedema of the Upper Extremity: The Need for Universal Agreement

With advances in breast cancer treatments and resultant increased survival rates, emphasis has been placed on post-treatment complications such as breast cancer-related lymphedema (BCRL), a chronic, negative sequela of breast cancer treatment. Accurate BCRL diagnosis necessitates longitudinal screening beginning at preoperative baseline. Prospective screening programs incorporating symptoms, objective measurements and clinical examination allow for early detection, early intervention, and improved BCRL prognosis. Currently, varied diagnostic criteria for BCRL exist, and this lack of consensus leads to variation in diagnostic and screening practices across institutions. This review outlines current diagnostic tools, including subjective and objective measurement methods and clinical examination. The merits of different criteria are evaluated and recommendations are made regarding measurement tools and diagnostic criteria for BCRL. Ultimately, the BCRL diagnostic process should be universalized and combine objective measurements, clinical evaluation, and symptoms assessment, and adhere to the best practices of the measurement tools used.

Cellulitis Is Associated with Severe Breast Cancer-Related Lymphedema: An Observational Study of Tissue Composition

Simple Summary

Cellulitis is a common complication in Breast Cancer-Related Lymphedema (BCRL); however, it is not known whether cellulitis is associated with the severity and biocompositon of BCRL. This study showed that cellulitis was associated with more excess volume, fat, and lean arm mass. Treatments should aim to prevent cellulitis in BCRL to possibly avoid the condition exacerbating.

Abstract

Cellulitis is a common complication in Breast Cancer-Related Lymphedema (BCRL). The excess amount of fat and lean mass in BCRL is a vital factor in patient stratification, prognosis, and treatments. However, it is not known whether cellulitis is associated with the excess fat and lean mass in BCRL. Therefore, this prospective observational study was designed to fundamentally understand the heterogonous biocomposition of BCRL. For this study, we consecutively enrolled 206 patients with unilateral BCRL between January 2019 and February 2020. All patients underwent Dual-Energy X-Ray Absorptiometry scans, bioimpedance spectroscopy, indocyanine green lymphangiography comprehensive history of potential risk factors, and a clinical exam. Multivariate linear and beta regression models were used to determine the strength of association and margins effect. Sixty-nine patients (33%) had at least one previous episode of cellulitis. Notably, a previous episode of cellulitis was associated with 20 percentage points more excess fat and 10 percentage points more excess lean mass compared to patients without cellulitis (p < 0.05). Moreover, each 1 increase in the patients BMI was associated with a 0.03 unit increase in the fat mass proportion of the lymphedema arm. Cellulitis was associated with more excess fat and lean arm mass in BCRL. In addition, patients BMI affect the proportion of fat mass in the arm.

Use of bioimpedance spectroscopy for prospective surveillance and early diagnosis of breast cancer-related lymphedema

BACKGROUND

Bioimpedance spectroscopy has been suggested as a useful tool for early diagnosis of breast cancer-related lymphedema (BCRL). We aimed to describe the outcomes of published studies that evaluated bioimpedance analysis as a method for prospective surveillance and early diagnosis of BCRL.

METHODS

We queried the PubMed, Ovid Medline, and EMBASE databases to identify studies that evaluated use of bioimpedance spectroscopy as a diagnostic tool. We used the keywords "bioimpedance" AND ("lymphedema" OR "lymphoedema") in the search. Only English-language studies that reported quantitative outcomes for patients with BCRL were included.

RESULTS

Of 152, 235 and 116 identified articles in PubMed, Ovid Medline and EMBASE databases, only 22 were included. Use of bioimpedance analysis for prospective surveillance has been shown to prevent chronic BCRL. All the cross-sectional and retrospective studies that evaluated bioimpedance for diagnosis of BCRL reported significantly different L-Dex scores between lymphedema patients and healthy participants; in addition, bioimpedance scores were positively correlated with volume of lymphedema.

CONCLUSION

Bioimpedance analysis is a potential tool with demonstrated benefits for prevention of chronic BCRL and may be an economic and great alternative for early diagnosis of BCRL.

Use of technology to facilitate a prospective surveillance program for breast cancer-related lymphedema at the Massachusetts General Hospital

Breast cancer-related lymphedema (BCRL) is a negative sequela of breast cancer (BC) caused by trauma to the lymphatic system during surgery or radiation to the axillary lymph nodes. BCRL affects approximately one in five patients treated for BC, and patients are at a lifelong risk for BCRL after treatment. Early diagnosis of BCRL may prevent its progression and reduce negative effects on quality of life, necessitating comprehensive prospective screening. This paper provides an overview of technology that may be used as part of a BCRL screening program, including objective measures such as perometry, bioimpedance spectroscopy, tissue tonometry, and three-dimensional optical imaging. Furthermore, this paper comprehensively reviews the technology incorporated into the established prospective screening program at Massachusetts General Hospital. Our prospective screening program consists of longitudinal measurements via perometry, symptoms assessment, and clinical examination by a certified lymphedema therapist (CLT) as needed. Discussion about use of perometry within the screening program and incorporation of arm volume measurements into equations to determine change over time and accurate diagnosis is included [relative volume change (RVC) and weight-adjusted change (WAC) equations]. Use of technology throughout the program is discussed, including a HIPPA-compliant online research database, the patient's electronic medical record, and incorporation of BCRL-related symptoms [BC and lymphedema symptom experience index (BCLE-SEI) survey]. Ultimately, both subjective and objective data are used to inform BCRL diagnosis and treatment by the CLT. In conclusion, the role of technology in facilitating BCRL screening is indispensable, and the continued development of objective assessment methods that are not only reliable and valid, but also cost-effective and portable will help establish BCRL screening as the standard of care for patients treated for BC.

Comparison of Vectra three-dimensional stereophotogrammetry measurement and tape measurement in the evaluation of perioperative volume change of the lower abdomen in association with lymphatic microsurgery

BACKGROUND

Although microsurgical treatment for lower extremity lymphedema (LEL) can improve lower abdominal morphology, methods to evaluate the volume change of the lower abdomen have yet to be established. This study aimed to determine the accuracy and reproducibility of three-dimensional stereophotogrammetry (3DSM) in measuring the volume change in the lower abdomen.

METHODS

The perioperative volume changes in the lower abdomen were estimated using tape measurement (TM) and 3DSM in 26 patients with LEL. Thirteen patients with suprapubic lymphedema underwent abdominoplasty simultaneously. Each of them underwent multiple lymphaticovenular anastomoses (LVAs), and five of them underwent vascularized lymph node transfer, simultaneously. Thirteen patients with pelvic lymphatic fluid underwent multiple LVAs. Two patients underwent this surgery twice. When assessed on the Internal Society of Lymphology scale, eight patients were Stage I, 10 patients were Stage II, four patients were late Stage II, and four patients were Stage III. The difference between the two measurement methods and reproducibility of each method were analyzed.

RESULTS

During a mean follow-up period of 6 months, all patients had no postoperative complications and their chief complaint improved. The calculated reduction volume between TM and 3DSM showed a high correlation (p < .0001, r = .84). The reduction volume based on TM was significantly larger than 3DSM (991.1 ± 460.3 ml vs. 862.3 ± 333.5 ml, p = .02). The interrater ICC was 0.94 and 0.98 based on TM and 3DSM, respectively.

CONCLUSION

3DSM may be a useful method for assessment of the lower abdominal morphology due to its high accuracy and reproducibility.

Lymphovenous Anastomosis for Treating Lymphedema in IgG4-Related Disease

Immunoglobin G4-related disease (IgG4RD) is a multi-organ immune-mediated condition, and lymphoplasmacytic infiltration is one of the main pathologic features.^1,2 Lower extremity lymphedema is likely to occur if the infiltration involves multiple inguinal lymph nodes and thus disrupting lymphatic transport. Lymphovenous anastomosis (LVA) is a surgical procedure used to treat obstructive lymphedema in extremities^3,4 or in the head and neck area.⁵ It basically reroutes the obstructed lymph flow into patent venous system by making microsurgical anastomosis between lymphatic duct and vein over the swollen area. Herein, we reported a patient with recalcitrant lower extremity lymphedema caused by IgG4RD, whose lymphedema subsided after being treated with LVA.

Lymphedema Incidence After Axillary Lymph Node Dissection: Quantifying the Impact of Radiation and the Lymphatic Microsurgical Preventive Healing Approach

BACKGROUND

Axillary surgery and radiotherapy are important aspects of breast cancer treatment associated with development of lymphedema. Studies demonstrate that Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) may greatly reduce the incidence of lymphedema in high-risk groups. The objective of this study is to summarize the evidence relating lymphedema incidence to axillary lymph node dissection (ALND), regional lymph node radiation (RLNR) therapy, and LYMPHA.

METHODS

We performed a literature search to identify studies involving breast cancer patients undergoing ALND with or without RLNR. Our primary outcome was the development of lymphedema. We analyzed the effect of LYMPHA on lymphedema incidence. We chose the DerSimonian and Laird random-effects meta-analytic model owing to the clinical, methodological, and statistical heterogeneity of studies.

RESULTS

Our search strategy yielded 1476 articles. After screening, 19 studies were included. Data were extracted from 3035 patients, 711 of whom had lymphedema. The lymphedema rate was significantly higher when RLNR was administered with ALND compared with ALND alone (P < 0.001). The pooled cumulative incidence of lymphedema was 14.1% in patients undergoing ALND versus 2.1% in those undergoing LYMPHA and ALND (P = 0.029). The pooled cumulative incidence of lymphedema was 33.4% in those undergoing ALND and RLNR versus 10.3% in those undergoing ALND, RLNR, and LYMPHA (P = 0.004).

CONCLUSION

Axillary lymph node dissection and RLNR are important interventions to obtain regional control for many patients but were found to constitute an increased risk of development of lymphedema. Our findings support that LYMPHA, a preventive surgical technique, may reduce the risk of breast cancer-related lymphedema in high-risk patients.

Treatment of Post-mastectomy Lymphedema with Herbal Medicine: An Innovative Pilot Study

Background

Lymphedema of the arms or legs is a difficult clinical problem yet devoid of effective treatment. Lymphedema is the result of obstructed lymphatic flow secondary to chronic infection, parasitic infestation, or postsurgical obstruction (eg, after axillary dissections). We arranged this clinical trial to investigate whether patients with limb lymphedema can benefit from a standard dose of Astragalus plus Paeoniae rubra to improve the symptomatology, functional capacity, and quality of life (QOL).

Method

The pilot study was designed as a self-control clinical trial. Patients with post-mastectomy lymphedema were recruited. A double-herb formulation (Astragalus, Paeoniae rubra) with standard dosage was administered orally in a powdered form, 6 times per week for 6 months. Outcome measurements included standard limb volume changes measured by water displacement method; handgrip strength; and QOL for limb lymphedema questionnaire (LYMQOL).

Results

There were no reported adverse effects or complications; there were no episodes of infection during the period of study. There was a tendency of limb volume reduction by 6 months, which, however, did not reach statistical significance. There was a significant improvement in appearance and symptom scores as was assessed with the LYMQOL questionnaire.

Conclusions

The oral herbal formula improved the symptomatology and QOL among the pilot group of patients with post-mastectomy lymphedema. Side effects were absent, and there was a trend of lymphedema reduction.

Effects of 12 weeks of water aerobics on body composition in those affected by breast cancer

Exercise may prevent changes in body composition and provide an effective means of improving the side effects of treatment without causing lymphedema.

PURPOSE

Test the effectiveness of a 12-week water aerobics program on body composition and lymphedema risk in breast cancer survivors.

METHODS

Body composition analysis was completed at weeks 0, 6, and 12 weeks.

RESULTS

Ten females completed all testing. Baseline subject characteristics were as follows: age (59.40 ± 8.22 years), weight (169.91 ± 41.70 lbs), body fat percent (%BF) (40.15 ± 9.84%), body fat mass (BFM) (71.27 ± 31.50 lbs), lean body mass (LBM) (98.66 ± 13.24 lbs), skeletal muscle mass (SMM) (53.17 ± 8.09 lbs), intracellular water (ICW) (44.24 ± 6.18 lbs), and extracellular water (ECW) (28.91 ± 3.62 lbs). One-way ANOVA showed no statistically significant differences over time as determined for weight (F(2.27) = 0.002, P = 0.96), %BF (F(2.27) = 0.004, P = 0.97), BFM (F(2.27) = 0.001, P = 0.97), LBM (F(2.27) = 0.013, P = 0.95), SMM (F(2.27) = 0.027, P = 0.91), ICW (F(2.27) = 0.021, P = 0.93), and ECW (F(2.27) = 0.01, P = 0.94) across the 12 weeks.

CONCLUSIONS

A water aerobics program for 12 weeks was not enough to observe changes in body composition nor did it increase the risk for lymphedema and may be a safe exercise method for breast cancer survivors.

Bioimpedance Spectroscopy for Assessment of Breast Cancer-Related Lymphedema: A Systematic Review

Bioimpedance spectroscopy is currently used to evaluate patients with breast cancer-related lymphedema (BCRL). We aimed to describe published studies on the use of bioimpedance spectroscopy for assessment for BCRL. We queried the PubMed, Ovid Medline, and Embase databases to identify studies that evaluated the use of bioimpedance spectroscopy as an assessment tool. We searched for the keywords "bioimpedance" AND ("lymphedema" OR "lymphoedema"). We included English-language studies that reported the use of bioimpedance spectroscopy for assessment of BCRL. Out of 152, 116, and 235 articles identified in each database, respectively, only a total of 11 articles were included. Bioimpedance spectroscopy was studied as a method to assess and predict response to BCRL treatment, assess volume changes, and calibrate L-Dex scores for conversion to units of volume. All studies reported that bioimpedance spectroscopy is a promising tool for predicting response to BCRL treatment and measuring volume changes. Bioimpedance spectroscopy can be used for assessment of BCRL. However, the accuracy of bioimpedance spectroscopy for BCRL assessment has not been determined, and consequently further studies are needed.

Resistance exercise and breast cancer-related lymphedema-a systematic review update and meta-analysis

BACKGROUND

The purpose of this systematic review update and meta-analysis was to analyze resistance exercise (RE) intervention trials in breast cancer survivors (BCS) regarding their effect on breast cancer-related lymphedema (BCRL) status and upper and lower extremity strength.

METHODS

Systematic literature search was conducted utilizing PubMed, MEDLINE, and Embase databases. Any exercise intervention studies-both randomized controlled and uncontrolled-which assessed the effects of RE on BCRL in BCS in at least one intervention group published between 1966 and 31st January 2020 were included. Included articles were analyzed regarding their level of evidence and their methodological quality using respective tools for randomized and nonrandomized trials of the Cochrane collaboration. Meta-analysis for bioimpedance spectroscopy (BIS) values as well as upper and lower extremity strength was conducted.

RESULTS

Altogether, 29 studies were included in the systematic review. Results of six studies with altogether twelve RE intervention groups could be pooled for meta-analysis of the BCRL. A significant reduction of BCRL after RE was seen in BIS values (95% CI - 1.10 [- 2.19, - 0.01] L-Dex score). Furthermore, strength results of six studies could be pooled and meta-analysis showed significant improvements of muscular strength in the upper and lower extremities (95% CI 8.96 [3.42, 14.51] kg and 95% CI 23.42 [11.95, 34.88] kg, respectively).

CONCLUSION

RE does not have a systematic negative effect on BCRL and, on the contrary, potentially decreases it.

Lymphoedema screening: setting the standard

Existing literature which is changing practice should be scrutinised, in the interest of all women at risk for lymphoedema after breast cancer (BC). Bundred et al.'s prospective, multicentre trial of 1100 women made several solid findings, and novel screening recommendations presented may assist in incorporating lymphoedema screening into standard of care.

Comparison of the short-term effects of hyperbaric oxygen therapy and complex decongestive therapy on breast cancer-related lymphedema: A pilot study

Although there have been some reports that hyperbaric oxygen therapy (HBOT) is effective in treating breast cancer-related lymphedema (BCRL), controversy regarding its therapeutic effects remains.We sought to evaluate the efficacy of HBOT in addition to conventional complex decongestive therapy (CDT) for BCRL.A prospective observational study was conducted on 10 patients with BCRL. After screening, the subjects were stratified into a CDT-only group and a CDT and HBOT combination (CDT-HBOT) group. All patients received a total of 10 treatments over 2 weeks. Changes in the circumference of the upper limbs, quality-of-life questionnaire results, and bioelectrical impedance values were compared between the 2 groups.Between both groups, there were no significant differences in demographic or clinical characteristics and in the quality-of-life outcomes for lymphedema of the limbs. The parameters measured by bioimpedance spectroscopy showed more significant improvements in the CDT-HBOT group than in the CDT-only group.In patients with BCRL, HBOT may be recommended as an adjunct treatment to the existing therapies.

Regional Patterns of Fluid and Fat Accumulation in Patients with Lower Extremity Lymphedema Using Magnetic Resonance Angiography

BACKGROUND

Fat accumulation is frequently observed in patients with lymphedema but is not accounted for in existing staging systems. In addition, the specific regional patterns of fat and fluid accumulation remain unknown and might affect outcomes following medical or surgical intervention. The purpose of this study was to evaluate fluid and fat distribution in patients with lower extremity lymphedema using magnetic resonance angiography.

METHODS

Magnetic resonance angiographic examinations of patients with lower extremity lymphedema were reviewed. Fluid-fat grade and location were assessed by three observers. Three-point scales were developed to grade fluid (0 = no fluid, 1 = reticular pattern of fluid, and 2 = continuous stripe of subcutaneous fluid) and fat (0 = normal, 1 = subcutaneous thickness less than twice that of the unaffected side, and 2 = subcutaneous thickness greater than twice that of the unaffected side) accumulation.

RESULTS

In total, 76 magnetic resonance angiographic examinations were evaluated. Using the proposed grading system, there was good interobserver agreement for fat and fluid accumulation location (91.5 percent; κ = 0.9), fluid accumulation grade (95.7 percent; κ = 0.95), and fat accumulation grade (87.2 percent; κ = 0.86). Patients with International Society of Lymphology stage 2 lymphedema had a wide range of fluid and fat grades (normal to severe). The most common location of fluid accumulation was the lateral lower leg, whereas the most common location of fat accumulation was the medial and lateral lower leg.

CONCLUSION

The proposed magnetic resonance angiographic grading system may help stratify patients with International Society of Lymphology stage 2 lymphedema on the basis of tissue composition.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, IV.

Preoperative Assessment of Upper Extremity Secondary Lymphedema

Introduction: The purpose of this study was to evaluate the most commonly used preoperative assessment tools for patients undergoing surgical treatment for secondary upper extremity lymphedema. Methods: This was a prospective cohort study performed at a tertiary cancer center specializing in the treatment of secondary lymphedema. Lymphedema evaluation included limb volume measurements, bio-impedance, indocyanine green lymphography, lymphoscintigraphy, magnetic resonance angiography, lymphedema life impact scale (LLIS) and upper limb lymphedema 27 (ULL-27) questionnaires. Results: 118 patients were evaluated. Limb circumference underestimated lymphedema compared to limb volume. Bioimpedance (L-Dex) scores highly correlated with limb volume excess (r2 = 0.714, p < 0.001). L-Dex scores were highly sensitive and had a high positive predictive value for diagnosing lymphedema in patients with a volume excess of 10% or more. ICG was highly sensitive in identifying lymphedema. Lymphoscintigraphy had an overall low sensitivity and specificity for the diagnosis of lymphedema. MRA was highly sensitive in diagnosing lymphedema and adipose hypertrophy as well as useful in identifying axillary vein obstruction and occult metastasis. Patients with minimal limb volume difference still demonstrated significantly impaired quality of life. Conclusion: Preoperative assessment of lymphedema is complex and requires multimodal assessment. MRA, L-Dex, ICG, and PROMs are all valuable components of preoperative assessment.

Palpation of Increased Skin and Subcutaneous Thickness, Tissue Dielectric Constant, and Water Displacement Method for Diagnosis of Early Mild Arm Lymphedema

Background: Early diagnosis of mild lymphedema and treatment are important to prevent its progress. The tissue dielectric constant (TDC), measuring local tissue water in the skin and upper subcutis, has neither been related to the water displacement method (WDM) nor been used to diagnose mild arm lymphedema in patients at risk. Our aims were to evaluate TDC and WDM in combination with palpation, examine the association between TDC and WDM measurements, and compare lymphedema-related factors. Methods and Results: Seventy-two women treated for breast cancer were diagnosed with mild arm lymphedema using skin palpation in combination with TDC from fixed measurement sites (threshold ratio for upper arm ≥1.45 and forearm ≥1.3) and/or WDM (lymphedema relative volume [LRV]: ≥5% to ≤8%). Results revealed that 32 (45%) women were diagnosed by TDC only, 19 (26%) by WDM only, and 21 (29%) by both TDC and WDM. TDC ratios exceeding the threshold were most frequently identified on the medial site of the arm, proximal and distal to the antecubital fossa. TDC and WDM were negatively associated; LRV (r = -0.545, p < 0.001). The women diagnosed by TDC only were diagnosed earlier after surgery (p = 0.003) and had a lower LRV (1.3%) than those diagnosed by WDM only (6.3%) or both TDC and WDM (6.2%; p < 0.001). Conclusions: TDC and WDM can be used together for early diagnosis of arm lymphedema, but TDC is the most valid method, determining the diagnosis earlier after surgery and at a lower arm volume than WDM.

Reducing Breast Cancer-Related Lymphedema (BCRL) Through Prospective Surveillance Monitoring Using Bioimpedance Spectroscopy (BIS) and Patient Directed Self-Interventions

BACKGROUND

Breast cancer-related lymphedema (BCRL) is a chronic progressive disease that results from breast cancer treatment and nodal surgery. NCCN guidelines support baseline measurements with prospective assessment for early diagnosis and treatment. We sought to determine if baseline measurement with bioimpedance spectroscopy (BIS) and serial postoperative evaluations provide early detection amenable to conservative interventions that reduce BCRL.

METHODS

Breast cancer patients with unilateral disease high-risk for BCRL from a single institution were evaluated from November 2014 to December 2017. High risk was defined as axillary lymph node dissection with radiation and/or taxane chemotherapy. Patients received preoperative baseline BIS measurements followed by postoperative measurements with at least two follow-ups. Patients with BIS results that were 2 standard deviations above baseline (10 + points) started home conservative interventions for 4-6 weeks. Postintervention measurements were taken to assess improvement.

RESULT

A total of 146 patients high-risk for BCRL were included. Forty-nine patients (34%) developed early BCRL and started self-directed treatment. Forty patients (82%) had elevated BIS measurements return to normal baseline range. Nine (6%) patients had persistent BCRL requiring referral for advanced therapy. Patients with persistent BCRL had significant nodal burden on surgical pathology; eight (89%) had N2/N3 disease. Six (76%) with BCRL refractory to conservative measures died of their breast cancer.

CONCLUSION

Our results demonstrated that early conservative intervention for breast cancer patients high risk for BCRL who were prospectively monitored by utilizing BIS significantly lowers rates of BCRL. These findings support early prospective screening and intervention for BCRL. Early detection with patient-directed interventions improves patient outcomes and decreases the risk of persistent BCRL.

Diagnostic accuracy of bioimpedance spectroscopy in patients with lymphedema: A retrospective cohort analysis

BACKGROUND

Bioimpedance spectroscopy (BIS) is used by healthcare specialists to diagnose lymphedema. BIS measures limb fluid content by assessing tissue resistance to the flow of electric current. However, there is debate regarding the validity of BIS in diagnosing early lymphedema. Indocyanine green (ICG) lymphography has been established as the most accurate diagnostic modality to date for lymphedema diagnosis. In this retrospective study, we test the sensitivity, specificity, and diagnostic accuracy of BIS in diagnosing lymphedema by referencing its results with ICG lymphography.

METHODS

Patients presented to the University of Iowa Lymphedema Center from 2015 to 2017 were evaluated with a standardized protocol that included history and physical examination, a validated lymphedema-specific quality-of-life assessment (LYMQOL), circumference -measurement-based index, BIS, and ICG lymphography. Diagnostic accuracy of BIS was assessed using ICG lymphography as a reference test.

RESULTS

Fifty-eight patients had positive ICG lymphography results, which confirmed the diagnosis of lymphedema. ICG lymphographic findings consistently correlated with clinical examination, LYMQOL evaluation, and lymphedema indices. By contrast, BIS demonstrated a false-negative rate of 36% - 21 out of 58 patients had normal BIS readings, but a positive ICG lymphography result. The 21 false-negative results occurred in patients with early-stage disease. Sensitivity and specificity for BIS were 0.64 and 1, respectively.

CONCLUSION

BIS carries an excessively high rate of false-negative results to be dependably used as a diagnostic modality for lymphedema. ICG lymphography highly correlates with other tracking modalities, and it remains the most reliable tool for diagnosing lymphedema.

Lymphedema: Diagnostic workup and management

Lymphedema is a localized form of tissue swelling resulting from excessive retention of lymphatic fluid in the interstitial compartment. It is caused by impaired lymphatic drainage. Lymphedema is a chronic progressive disease with serious physical and psychosocial implications. It can be challenging to diagnose, especially in obese patients and in those with coexisting venous disease. We performed PubMed and Google Scholar searches of the English-language literature (1966-2017) using the terms lymphedema, lymphedema management, and lymphatic complications. Relevant publications were manually reviewed for additional resources. There are currently no standard guidelines for the diagnosis of lymphedema. There is no cure yet for lymphedema, and the objective for management is to limit disease progression and prevent complications.

Intra-abdominal fat: Comparison of computed tomography fat segmentation and bioimpedance spectroscopy

Background

Intra-abdominal fat is an important factor in determining the metabolic syndrome/insulin resistance, and thus the risk of diabetes and ischaemic heart disease. Computed Tomography (CT) fat segmentation represents a defined method of quantifying intra-abdominal fat, with attendant radiation risks. Bioimpedance spectroscopy may offer a method of assessment without any risks to the patients. A comparison is made of these two methods.

Methods

This was a preliminary study of the utility of multifrequency bioimpedance spectroscopy of the mid abdomen as a measure of intra-abdominal fat, by comparison with fat segmentation of an abdominal CT scan in the −30 to −190 HU range.

Results

There was a significant (P < 0.01) correlation between intra-abdominal fat and mid-upper arm circumference, as well as the bioimpedance parameter, the R/S ratio. Multivariate analysis showed that these were the only independant variables and allowed the derivation of a formula to estimate intra-abdominal fat: IAF = 0.02 × MAC − 0.757 × R/S + 0.036.

Conclusions

Circumabdominal bioimpedance spectroscopy may prove a useful method of assessing intra-abdominal fat, and may be suitable for use in studies to enhance other measures of body composition, such as mid-upper arm circumference.