Breast Cancer-Related Arm Lymphedema: Incidence Rates, Diagnostic Techniques, Optimal Management and Risk Reduction Strategies

Reimagining Deintensification for Low-Risk Breast Cancer

As outcomes for low-risk breast cancer continue to improve, research and clinical paradigms are increasingly focused on appropriate deintensification with the goal of improving the therapeutic ratio of breast cancer treatment. These deintensification approaches span across disciplines including breast surgery, radiation therapy, and systemic therapy. With regard to breast surgery, studies have continued to push deintensification when it comes to surgical margins with breast conservation, reducing re-excision rates, whereas deintensification of axillary surgery has reduced the rates of axillary lymph node dissection and increasingly the need for any axillary surgery, including sentinel lymph node biopsy for low-risk patients. With regard to radiation therapy, studies have allowed for a drastic reduction in treatment duration, whereas approaches that reduce the target of treatment have led to a change from from treatment daily for 5-7 weeks to many low-risk patients completing treatment in just five treatments. With regard to systemic therapy, use of genomic assays and tumor biology has led to reduced utilization of cytotoxic chemotherapy, with studies also allowing for dose reduction of endocrine therapy for patients with ductal carcinoma in situ. Moving forward, greater focus should be placed on interdisciplinary deintensification approaches such as the consideration of radiation therapy alone as compared with endocrine therapy alone for low-risk breast cancers.

The LYMPH trial: comparing microsurgical with conservative treatment for chronic breast cancer-associated lymphoedema - study protocol of a pragmatic randomised international multicentre superiority trial

INTRODUCTION

Up to one-fifth of breast cancer survivors will develop chronic breast cancer-related lymphoedema (BCRL). To date, complex physical decongestion therapy (CDT) is the gold standard of treatment. However, it is mainly symptomatic and often ineffective in preventing BCRL progression. Lymphovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT) are microsurgical techniques that aim to restore lymphatic drainage. This international randomised trial aims to evaluate advantages of microsurgical interventions plus CDT versus CDT alone for BCRL treatment.

METHODS AND ANALYSIS

The effectiveness of LVA and/or VLNT in combination with CDT, which may be combined with liposuction, versus CDT alone will be evaluated in routine practice across the globe. Patients with BCRL will be randomly allocated to either surgical or conservative therapy. The primary end point of this trial is the patient-reported quality of life (QoL) outcome 'lymphoedema-specific QoL', which will be assessed 15 months after randomisation. Secondary end points are further patient-reported outcomes (PROs), arm volume measurements, economic evaluations and imaging at different time points. A long-term follow-up will be conducted up to 10 years after randomisation. A total of 280 patients will be recruited in over 20 sites worldwide.

ETHICS AND DISSEMINATION

This study will be conducted in compliance with the Declaration of Helsinki and the International Council for Harmonisation-Good Clinical Practice (ICH-GCP) E6 guideline. Ethical approval has been obtained by the lead ethics committee 'Ethikkommission Nordwest- und Zentralschweiz' (2023-00733, 22 May 2023). Ethical approval from local authorities will be sought for all participating sites. Regardless of outcomes, the findings will be published in a peer-reviewed medical journal. Metadata detailing the dataset's type, size and content will be made available, along with the full study protocol and case report forms, in public repositories in compliance with the Findability, Accessibility, Interoperability and Reuse principles.

TRIAL REGISTRATION NUMBER

NCT05890677.

Microsurgical versus complex physical decongestive therapy for chronic breast cancer-related lymphoedema

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of microsurgery versus complex physical decongestive therapy in people with chronic breast cancer-related lymphoedema.

Phase II Study Shows the Effect of Adenoviral Vascular Endothelial Growth Factor C and Lymph Node Transfer in Lymphedema

BACKGROUND

Breast cancer-related lymphedema is a common complication lacking medical treatment. Lymfactin is an adenovirus type 5-based gene therapy and prolymphangiogenic growth factor vector that induces vascular endothelial growth factor C expression. The authors' aim was to evaluate the therapeutic effect of Lymfactin with vascularized lymph node transfer (VLNT).

METHODS

This phase II, double-blind, placebo-controlled, randomized, multicenter study evaluated the efficacy and safety of Lymfactin in combination with VLNT. The primary endpoints were edema volume, quality of life, and lymphoscintigraphy. All adverse events were recorded. A mixed model of repeated measures analysis of covariance was performed. This study was a continuation of a previous phase I Lymfactin study.

RESULTS

Thirty-nine patients with breast cancer-related lymphedema were recruited between June of 2018 and December of 2019 and randomized to receive either Lymfactin ( n = 20) or placebo ( n = 19). The primary endpoints showed a positive effect of VLNT in both groups compared with the baseline, but without statistical differences between groups at 12 months. In addition, greater improvements were observed in the tissue dielectric constant ratios measuring skin interstitial fluid levels in the Lymfactin group compared with the placebo group ( P = 0.020). No differences in adverse events were detected between the groups.

CONCLUSIONS

This study was one of the few studies to objectively show a positive effect of VLNT in a prospective, clinical, multicenter setting. It was also the first-ever randomized prospective clinical study showing a quantitatively positive effect of a medical therapy on the edema of lymphedema but failed to show differences between groups in primary outcome measures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Impact of Physical Exercise on Breast Cancer-Related Lymphedema and Non-Invasive Measurement Tools: A Systematic Review

Background/Objectives: Breast cancer-related lymphedema (BCRL) is a chronic disease with lasting effects, making it one of the most feared sequelae of breast cancer with significant personal and social impacts. Therapeutic exercises play a fundamental role in its treatment. This systematic review aims to provide the most up-to-date findings on the impact of physical exercise on the management of BCRL. Methods: Following the PRISMA statement guidelines, searches were conducted in the Web of Science, Scopus, and Science Direct databases. Results: Sixteen studies published between 2019 and 2024 were analyzed in detail. The combination of strength and aerobic exercises emerged as an effective strategy for both the treatment and prevention of lymphedema, also highlighting the innovative potential of virtual reality. Conclusions: It is essential to emphasize tailoring exercise programs to each patient individually. Additionally, the promising role of thermography as a non-invasive and safe tool for evaluating lymphedema progress is underscored.

Breast cancer-related lymphedema: A critical review on recent progress

Lymphedema is a chronic and debilitating condition characterized by an abnormal buildup of protein-rich fluid in the interstitial tissue, leading to the development of edema and tissue structural alterations. Breast cancer-related lymphedema (BCRL) remains a significant healthcare burden because it can develop within days and up to 11-years after the surgery. Specifically, axillary lymph node dissection leads to 30-50 % upper limb lymphedema, which involves the accumulation of protein-rich fluid. In this article, we provide a comprehensive/critical overview of post-mastectomy lymphedema, focusing on key aspects as diagnosis, prevention, and treatment methods. Beginning with clinical condition, the article explores the pathophysiology and risk factors associated with post-mastectomy lymphedema. It further delves into various diagnostic modalities available, highlighting the importance of early detection for optimal management of BCRL. We also examine preventive strategies, emphasizing the role of patient education, lifestyle modifications, and proactive measures in reducing the risk of lymphedema development. In terms of treatment, the article covers a wide array of interventions ranging from conservative approaches like manual lymphatic drainage and compression therapy to surgical techniques such as lymph node transfer and lymphaticovenular anastomosis. Thus, through a comprehensive synthesis of current evidence and clinical practices updates, the review aims to guide healthcare professionals in delivering preventive and effective care while improving outcomes for individuals affected by post-mastectomy lymphedema.

Evaluation of the Impact of Adaptive Progressive Supervised Resistance Training on Strength and Quality of Life in Patients with Breast Cancer during Chemotherapy: The VALESCO Study

INTRODUCTION

Breast cancer patients (BCP) experience considerable side effects during and after treatment. Several studies have shown positive effects of exercise on therapy-related side-effects such as loss of muscle strength, loss of bone mineral density, lymphedema, and several elements of quality of life (QoL). Resistance exercise has proven effective and beneficial for BCP; however, optimal individual training parameters remain to be determined.

METHODS

The aim of our study was to implement an adaptive, progressive, supervised resistance protocol for BCPs during chemotherapy, improving muscle strength, physical condition, and overall QoL while reducing therapy-induced side-effects. Forty patients receiving adjuvant chemotherapy were included 6-12 weeks post-OP. Twenty patients underwent high intensity resistance-training twice a week for 12 weeks, and the control group received usual care.

RESULTS

Strength parameters improved significantly in the intervention group and in different scales of QoL. We documented a cyclic performance level dependent on the number of days after treatment.

CONCLUSION

Adaptive resistance training with simple training control mechanisms proved to be effective regarding optimal intensity in each training session and needs to be implemented in further studies in order to guarantee adequate loads in accordance to the training protocols.

GLP-1 receptor agonist as an effective treatment for breast cancer-related lymphedema: a case report

Introduction

Lymphedema is a major public health issue for many women undergoing breast cancer treatment. Although weight loss has been reported to be beneficial in the treatment of lymphedema, no studies to date have examined the use of GLP-1RAs for the treatment of secondary lymphedema. This case report describes a patient who experienced significant resolution of her breast cancer-related lymphedema after initiation of a GLP-1RA for weight loss.

Main symptoms and/or important clinical findings

Nine months postoperatively the patient developed arm swelling and disability. While on adjuvant chemo and hormonal therapy, her weight increased dramatically and peaked 4 years later. Corresponding to her weight gain was significant worsening of her symptoms.

The main diagnoses therapeutic interventions and outcomes

Due to adjuvant cancer-related weight gain and inability to lose weight with diet and exercise, she was referred for evaluation and diagnosed with lymphedema. The patient started treatment with a Glucagon-like peptide 1 receptor agonist and lost 24% of her body weight over the next 13 months. The improvement in her lymphedema mirrored her weight loss. Her limb volume difference dropped from 10.3% down to 3.4% and she no longer required a compression garment. Her imaging demonstrated return of lymphatic pumping and she experienced a significant improvement in quality of life, assessed by a validated lymphedema-specific patient reported outcome (PROM). She remains on hormonal therapy, no longer needs compression and is back to regular exercise without impairment.

Conclusions

GLP-1 RAs provide a potential medical option for many patients struggling with weight gain and lymphedema. We have observed by all objective measures a significant reduction in lymphedema and the elimination of compression in the case presented as a direct result of GLP-1 RA. This may also reduce a patient's BMI to the point where they become a good candidate for lymphovenous bypass or vascularized lymph node transplant when indicated.

Does a Resistance Training Program Affect Between-arms Volume Difference and Shoulder-arm Disabilities in Female Breast Cancer Survivors? The Role of Surgery Type and Treatments. Secondary Outcomes of the EFICAN Trial

OBJECTIVE

The aims were (i) to assess the effects of a 12-week resistance training program on between-arms volume difference and shoulder-arm disabilities in breast cancer survivors and (ii) to evaluate whether the main risk factors for developing cancer-related lymphedema and shoulder-arm disabilities were associated with the effects of the training program.

DESIGN

Randomized controlled trial.

SETTING

University facilities.

PARTICIPANTS

60 female breast cancer survivors participated.

ELIGIBILITY CRITERIA

to be a breast cancer survivor, and to have completed surgery, chemotherapy, and/or radiotherapy up to 10 years before recruitment.

EXCLUSION CRITERIA

metastatic breast cancer, a breast reconstruction intervention planned within 6 months, any absolute contraindication for exercise, to perform more than 300 minutes/week of structured exercise.

INTERVENTIONS

Participants were randomized to an exercise group (12-week resistance training program) or a control group.

MAIN OUTCOME MEASURES

Between-arms volume difference, shoulder-arm disabilities, and upper-limb muscular strength were evaluated at baseline and at week 12. Treatment-related information was registered from medical history.

RESULTS

No between-group differences were observed on between-arms volume difference (1.207; 95% CI -0.964, 3.377; P=.270) or shoulder-arm disabilities (2.070; 95% CI -4.362, 8.501; P=.521) after the training program. Likewise, there was no association of surgery type, presence of lymph node resection, chemotherapy, radiotherapy, and hormone therapy with the changes in between-arms volume and perceived shoulder-arm disabilities after the intervention. However, a higher increase in upper limb muscular strength was associated with a reduced shoulder-arm disabilities (-0.429; P=.020) in the exercise group.

CONCLUSIONS

The findings suggest that resistance training does not affect between-arms volume difference and shoulder-arm disabilities in female breast cancer survivors. The main risk factors for developing lymphedema were not associated with the effects of the intervention, although a higher increase in upper-limb muscular strength was associated with reduced shoulder-arm disabilities.

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.

United States insurance coverage of immediate lymphatic reconstruction

INTRODUCTION

Immediate Lymphatic Reconstruction (ILR) is a prophylactic microsurgical lymphovenous bypass technique developed to prevent breast cancer related lymphedema (BCRL). We investigated current coverage policies for ILR among the top insurance providers in the United States and compared it to our institutional experience with obtaining coverage for ILR.

METHODS

The study analyzed the publicly available ILR coverage statements for American insurers with the largest market share and enrollment per state to assess coverage status. Institutional ILR coverage was retrospectively analyzed using deidentified claims data and categorizing denials based on payer reason codes.

RESULTS

Of the 63 insurance companies queried, 42.9% did not have any publicly available policies regarding ILR coverage. Of the companies with a public policy, 75.0% deny coverage for ILR. In our institutional experience, $170,071.80 was charged for ILR and $166 118.99 (97.7%) was denied by insurance.

CONCLUSIONS

Over half of America's major insurance providers currently deny coverage for ILR, which is consistent with our institutional experience. Randomized trials to evaluate the efficacy of ILR are underway and focus should be shifted towards sharing high level evidence to increase insurance coverage for BCRL prevention.

Lymphedema Surveillance and Prevention

ABSTRACT

Lymphedema is a chronic condition, which can impact a person's quality of life and function. Identifying lymphedema at an early stage is key to preventing a person from developing chronic lymphedema. Physiatry can play an important role in education, identification of risk factors, performing prospective lymphedema surveillance programs, and prevention/treatment of lymphedema. Incorporating lymphedema surveillance programs into routine cancer care provides physiatry with the opportunity to assess additional rehabilitation and functional needs of a cancer patient.

Bibliometric analysis of breast cancer-related lymphedema research trends over the last 2 decades

Objective

As breast cancer cases rise globally, post-mastectomy lymphedema garners increasing scholarly attention. This study aims to conduct a comprehensive bibliometric analysis of Breast Cancer-Related Lymphedema (BCRL) research from 2003 to 2022, identifying trends and providing global research insights for future studies.

Method

The literature for this analysis was extracted from the Web of Science (WoS) Core Collection, encompassing 1199 publications, including 702 articles and 101 reviews, totaling 803. Using advanced bibliometric tools such as VOSviewer and CiteSpace, quantitative and visual analyses were performed to map collaboration networks, research clusters, and emerging trends. The search strategy included specific terms related to lymphedema, breast cancer, and BCRL, ensuring a comprehensive representation of the research landscape.

Results

The bibliometric analysis revealed a steady increase in BCRL publications over the studied period, reaching a peak in 2018. The United States emerged as the leading contributor to BCRL literature, with China also demonstrating a significant presence. Collaboration networks were visualized, showcasing the interconnectedness of institutions and researchers globally. Key research hotspots identified include preventive strategies, complex decongestive therapy, and reconstructive interventions.

Conclusion

In conclusion, this pioneering bibliometric analysis provides a comprehensive overview of BCRL research trends and collaborations globally. The findings contribute valuable insights into the evolution of the field, highlighting areas of focus and emerging research themes. This study serves as a foundational resource for researchers, clinicians, and policymakers, fostering evidence-based practices and interventions for BCRL in the future.

Relationship between kinesiophobia and quality of life among patients with breast cancer-related lymphedema: Chain-mediating effect of self-care and functional exercise compliance

Objective

Breast cancer-related lymphedema (BCRL) significantly impacts the quality of life (QoL) of breast cancer survivors following treatment. This study explores the association between kinesiophobia (fear of pain caused by movement) and QoL in postsurgical BCRL survivors and examines whether self-care and compliance with functional exercise act as mediators between these variables.

Methods

This cross-sectional study surveyed 274 BCRL patients at three tertiary hospitals in Shenyang City, China, from May 2020 to October 2022. The participants completed self-reported questionnaires on self-care, functional exercise compliance, kinesiophobia, and QoL. Medication analysis was conducted using the PROCESS macro (Model 6).

Results

Kinesiophobia was found to have negative association with self-care (P < 0.001), functional exercise compliance (P < 0.001), and QoL (P < 0.001). Kinesiophobia indirectly affected QoL through three mediating pathways: self-care (effect = -0.132), functional exercise compliance (effect = -0.390), and a combination of self-care and functional exercise compliance (effect = -0.220), collectively accounting for 7.9%, 23.3%, and 13.1% of the total effect, respectively.

Conclusions

This study highlights the substantial chain-mediating role of self-care and functional exercise compliance in the relationship between kinesiophobia and QoL. It provides valuable evidence supporting the protective effects of self-care and functional exercise compliance in mitigating kinesiophobia and enhancing the QoL of BCRL survivors.

Breast Cancer-related Lymphedema: Recent Updates on Clinical Efficacy of Therapies and Bioengineering Approaches for a Personalized Therapy

BACKGROUND

Post-mastectomy lymphedema is a chronic progressive disease characterized by a significant reduction in quality of life and a range of complications.

AIM

To this date, no single treatment method provides pathological correction of the mechanisms associated with tissue reorganization observed in later-stage breast cancer-related lymphedema (BCRL).

METHODS

To define a personalized approach to the management of patients with iatrogenic lymphedema, we performed a systematic review of literature without a comprehensive meta-analysis to outline existing molecular- genetic patterns, overview current treatment methods and their efficacy, and highlight the specific tissue-associated changes in BCRL conditions and other bio-engineering approaches to develop personalized therapy.

RESULTS

Our results show that several tissue-specific and pathological molecular markers may be found, yet current research does not aim to define them.

CONCLUSION

As such, currently, a strong foundation for further research into molecular-genetic changes in lymphedema tissue exists, and further research should focus on finding specific targets for personalized treatment through bio-engineering approaches.

Ultrasonography as an instrument to evaluate lymphedema secondary to breast cancer: systematic review

Lymphedema is a chronic and progressive disease characterized by fluid accumulation, causing tissue edema as a result of a compromised lymphatic system. Diagnostic ultrasound (DUS) is a method capable of assessing soft tissue characteristics that can be used reliably to diagnose lymphedema as well as for measuring tissue compliance in a clinical setting. This is a systematic review, aiming to evaluate articles that made use of DUS in management of lymphedema secondary to breast cancer. A total of 570 articles were selected, exported to the Rayyan QCRI review program, and then screened by two researchers. From this search, 25 articles were selected after the authors reached consensus and were catalogued as to their main results. Diagnostic ultrasound was identified as an advantageous method that is safe, minimally invasive, low cost, and radiation free and is useful for evaluating the efficacy of therapies used in lymphedema treatment.

Prophylactic Lymphovenous Bypass at the Time of Axillary Lymph Node Dissection Decreases Rates of Lymphedema

Background

Breast cancer-related lymphedema impacts 30% to 47% of women who undergo axillary lymph node dissection (ALND). Studies evaluating the effectiveness of prophylactic lymphovenous bypass (LVB) at the time of ALND have had small patient populations and/or short follow-up. The aim of this study is to quantitatively and qualitatively evaluate prophylactic LVB in patients with breast cancer.

Methods

A retrospective review of patients who underwent ALND from 2018 to 2022 was performed. Patients were divided into cohorts based on whether they underwent prophylactic LVB at the time of ALND. Primary outcomes included 30-day complications and lymphedema. Lymphedema was quantitatively evaluated by bioimpedance analysis, with L-dex scores >7.1 indicating lymphedema.

Results

One-hundred five patients were identified. Sixty-four patients (61.0%) underwent ALND and 41 patients (39.0%) underwent ALND+LVB. Postoperative complications were similar between the cohorts. At a median follow-up of 13.3 months, lymphedema occurred significantly higher in the ALND only group compared with ALND+LVB group (50.0% vs 12.2%; P < 0.001). ALND without LVB was an independent risk factor for lymphedema development (odds ratio, 4.82; P = 0.003).

Conclusions

Prophylactic LVB decreases lymphedema and is not associated with increased postoperative complications. A multidisciplinary team approach is imperative to decrease lymphedema development in this patient population.

Risk factors for the development of severe breast cancer-related lymphedema: a retrospective cohort study

BACKGROUND

Severe lymphedema presents a challenge in terms of treatment due to the significant formation of scar tissue that accompanies it. The aim of this study was to identify intraoperative and preoperative risk factors of severe lymphedema and to develop a nomogram for estimating the risk of severe lymphedema within 3 years of surgery.

METHOD

Data was collected from a retrospective cohort of 326 patients with BCRL at the Zhejiang Cancer Hospital from November 2015 to November 2018. Univariate and multivariate logistic regression analysis was conducted to identify predictive indicators of severe lymphedema. A nomogram was developed to further improve the clinical applicability.

RESULTS

In the retrospective cohort, the ratio of severe/non-severe lymphedema within 3 years of surgery was 1:3. Independent risk factors for severe lymphedema were determined to be age, positive lymph nodes, interpectoral (Rotter's) lymph nodes (IPNs) dissection, and educational level. IPNs dissection was found to contribute greatly to the development of severe lymphedema with a higher odds ratio (7.76; 95% CI: 3.87-15.54) than other risk factors. A nomogram was developed by integrating age, positive lymph nodes, IPNs dissection, and educational level, which yielded a C-index of 0.810 and 0.681 in the training and validation cohort, respectively. This suggested a moderate performance of the nomogram in predicting the risk of severe lymphedema within 3 years of surgery. The cut-off values of the low-, medium- and high-risk probabilities were 0.0876 and 0.3498, and the severe lymphedema exhibited a significantly higher risk probability as compared with the non-severe lymphedema.

CONCLUSION

This study identified the risk factors of severe lymphedema and highlighted the substantial contribution of IPNs dissection to the severity of lymphedema.

Rehabilitation interventions for the management of breast cancer-related lymphedema: developing a patient-centered, evidence-based plan of care throughout survivorship

PURPOSE

A work group from the American Physical Therapy Association Academy of Oncologic Physical Therapy developed and published a clinical practice guideline (CPG) to aid clinicians in identifying interventions for individuals with breast cancer-related lymphedema (BCRL). This guideline reviewed the evidence for risk mitigation and volume reduction beginning at cancer diagnosis and continuing through survivorship. Application of CPGs can be challenging due to the variability of clinical settings, heterogeneous patient populations, and range of rehabilitation clinician expertise. The purpose of this paper is to assist these clinicians in implementing the recommendations from the CPG to develop a patient-centered, evidence-based plan of care.

METHODS/RESULTS

This publication presents important considerations for the implementation of recommended rehabilitation interventions across the trajectory of BCRL.

CONCLUSION

Current evidence supports specific interventions to treat or mitigate the risk for the various stages of BCRL. As clinicians implement these recommendations into practice, they also need to address other impairments that may exist in every individual. Continued collaboration between clinicians and researchers is necessary to further develop optimal treatment modalities and parameters.

IMPLICATIONS FOR CANCER SURVIVORS

By implementing evidence-based interventions as outlined in the CPG, clinicians can improve the quality of care for survivors of breast cancer.

Association between Immediate Breast Reconstruction and the Development of Breast Cancer-Related Lymphedema

BACKGROUND

With the increasing number of patients undergoing immediate breast reconstruction after mastectomy, the impact of immediate breast reconstruction on the risk of breast cancer-related lymphedema has become an emerging area of interest. This study aimed to identify the association between immediate breast reconstruction and postoperative lymphedema.

METHODS

A retrospective cohort study was conducted from 2006 to 2016 with 5900 consecutive patients who underwent mastectomy for primary breast cancer with or without immediate breast reconstruction. After excluding patients with synchronous contralateral breast cancer, lymphedema before mastectomy, history of procedures performed in the axillary region, and follow-up data of less than 1 year, the cumulative incidence of lymphedema after immediate breast reconstruction and after no reconstruction was calculated and compared using multivariate Cox regression analysis.

RESULTS

Overall, 5497 patients (mean age, 51.7 years) were included, and 630 developed lymphedema. The 5-year cumulative incidence rate of lymphedema was significantly reduced in patients who underwent immediate breast reconstruction versus control patients (9.6% versus 12.2%; P = 0.02). In the multivariate analysis, immediate breast reconstruction status (hazard ratio, 0.75; 95% confidence interval, 0.56 to 0.99; P = 0.042) was an independent predictor for lymphedema. Similar significant associations were observed in the subgroup analyses of patients with a body mass index less than 30 kg/m2 (P = 0.024), in those with fewer than 10 dissected lymph nodes (P = 0.042), or in those with adjuvant radiotherapy (P = 0.048).

CONCLUSIONS

Immediate breast reconstruction was associated with a reduced risk of lymphedema. These results may be used for predicting the development of lymphedema following breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

What do we know about treating breast-cancer-related lymphedema? Review of the current knowledge about therapeutic options

Breast-cancer-related lymphedema (BCRL) is a common consequence of oncological treatment. Its management is a complicated, chronic, and arduous process. Therapeutic options can be divided on non-surgical and surgical methods, although there is still no clear consensus about their effectiveness in preventing or stopping the disease. That brings problems in everyday practice, as there are no guidelines about proper time for starting therapy and no agreement about which management will be beneficial for each patient. The aim of this review is to summarize current knowledge about possible treatment choices, non-surgical so as surgical, indicate knowledge gaps, and try to direct pathways for future studies.

Bioimpedance spectroscopy for breast cancer-related lymphedema assessment: clinical practice guidelines

PURPOSE

Breast cancer-related lymphedema (BCRL) represents a significant concern for patients following breast cancer treatment, and assessment for BCRL represents a key component of survivorship efforts. Growing data has demonstrated the benefits of early detection and treatment of BCRL. Traditional diagnostic modalities are less able to detect reversible subclinical BCRL while newer techniques such as bioimpedance spectroscopy (BIS) have shown the ability to detect subclinical BCRL, allowing for early intervention and low rates of chronic BCRL with level I evidence. We present updated clinical practice guidelines for BIS utilization to assess for BCRL.

METHODS AND RESULTS

Review of the literature identified a randomized controlled trial and other published data which form the basis for the recommendations made. The final results of the PREVENT trial, with 3-year follow-up, demonstrated an absolute reduction of 11.3% and relative reduction of 59% in chronic BCRL (through utilization of compression garment therapy) with BIS as compared to tape measurement. This is in keeping with real-world data demonstrating the effectiveness of BIS in a prospective surveillance model. For optimal outcomes patients should receive an initial pre-treatment measurement and subsequently be followed at a minimum quarterly for first 3 years then biannually for years 4-5, then annually as appropriate, consistent with previous guidelines; the target for intervention has been changed from a change in L-Dex of 10 to 6.5. The lack of pre-operative measure does not preclude inclusion in the prospective surveillance model of care.

CONCLUSION

The updated clinical practice guidelines present a standardized approach for a prospective model of care using BIS for BCRL assessment and supported by evidence from a randomized controlled trial as well as real-world data.

Thyroid Hormone Ameliorates Lymphedema by Suppressing Adipogenesis in a Murine Lymphedema Model

Background: Exogenous supplementation of thyroid hormone could inhibit excessive fat deposition in lymphedema tissue by suppressing adipogenesis. Methods and Results: Cell viability, adipogenic differentiation, and mRNA expression were measured in 3T3-L1 preadipocytes treated with L-thyroxine. Twelve mice were divided into control and L-thyroxine groups. Two weeks after lymphedema was surgically induced, the experimental mice were fed L-thyroxine for 4 weeks. Tail volume and body weight were measured, and 6 weeks after the surgery, tail skin and subcutaneous tissue were harvested for histopathologic examination and protein isolation. In 3T3-L1 cells, treatment with 10-500 μM L-thyroxine did not affect cell viability. Eight days after induction of adipogenic differentiation, lipid accumulation decreased significantly in the 50 and 100 μM L-thyroxine groups (p < 0.001). mRNA levels of peroxisome proliferator-activated receptor γ (PPARγ), CCAAT/enhancer binding protein α (C/EBPα), and fatty acid-binding protein 4 (FABP4) decreased significantly in the 100 μM L-thyroxine group compared with the control group (p = 0.017). Lymphedema tails treated with L-thyroxine exhibited decreased volume (p = 0.028) and thickness of dermal and subcutaneous tissue (p = 0.01) and increased vascular endothelial growth factor-C protein expression (p = 0.017) compared with the control. Conclusion: Thyroid hormone therapy inhibits the adipogenesis of 3T3-L1 cells in vitro and decreases the volume of murine lymphedema tail in vivo. These findings suggest that thyroid hormone therapy could be used to treat lymphedema.

Prospective Surveillance with Compression for Subclinical Lymphedema: Symptoms, Skin, and Quality-of-Life Outcomes

Background: Patients underwent a compression (sleeve and gauntlet) intervention for subclinical breast cancer-related lymphedema (S-BCRL). Physical, emotional, and quality-of-life (QoL) outcomes were examined. Associations of change in extracellular fluid alone through bioimpedance spectroscopy (BIS) or change in whole-arm volume through tape measure with the outcomes at time of S-BCRL were explored. Methods and Results: We enrolled newly diagnosed nonmetastatic breast cancer patients for surveillance up to 36 months postoperatively. Upon detection of S-BCRL, a 28-day compression intervention was initiated. Data were obtained through physical examination/measurement and self-report instruments: skin examination, Lymphedema Symptom Intensity and Distress Survey-Arm, and Functional Assessment of Cancer Therapy General (FACT-G), Breast (FACT-B), and FACT-B+4. Improvements with intervention were observed in the proportion of patients reporting symptom scores ≥3 in function (Cohen's d = -0.46, p < 0.01), in biobehavioral (Cohen's d = -0.30, p < 0.05), maximum number of skin conditions (Cohen's d = -0.34, p < 0.05. 3), FACT-B (Cohen's d = 0.52, p < 0.01), and FACT-B + four (Cohen's d = -0.42, p < 0.01). At the study endpoint, compared with those who did not progress, chronic breast cancer-related lymphedema (C-BCRL) progressing patients had higher overall symptom scores (p = 0.037), more skin conditions (p = 0.009), and lower total FACT-G and FACT-B scores (p < 0.05). At the time of S-BCRL, detection of greater BIS unit change correlated with higher symptom, skin condition, and QoL values. Greater whole-arm volume change correlated with higher FACT-B+4 scores (all p < 0.05). Conclusions: Prospective surveillance, symptom assessment, and compression intervention promote low progression rates from S-BCRL to C-BCRL and as such reduce symptom burden. This closed study is registered with ClinicalTrials.gov NCT02167659.

Evaluation of the Effect of Axillary Radiotherapy Dose and the Development of Lymphedema in Breast Cancer Patients

Purpose

The present study is aiming to correlate different radiotherapy techniques, fractionations, and doses received by each axillary LN level and axillary vessels with the development of breast cancer-related lymphedema (BCRL).

Methods and Materials

We retrospectively studied 181 female breast cancer patients who were diagnosed and treated by radiation therapy during the period from January 2012 to December 2017. The radiotherapy treatment plans were recalled from the archives. The axillary LN levels I, II, III, supraclavicular LN were contoured as well as axillary vessels. New dose volume histograms were generated to correlate between the radiotherapy dose t and the development of BCRL.

Results

The study included 162 patients treated with a 3D radiotherapy technique and 19 treated with a 2D radiotherapy technique; 124 patients underwent MRM, while 57 patients underwent BCS; 117 patients were treated with a hypofractionated technique, while 64 patients were treated with a conventional radiotherapy technique. The cumulative incidence of BCRL after radiotherapy was 20.4%. There was a statistically significant relationship between the 2D radiotherapy technique compared with 3DCRT and development of lymphedema (55 vs. 16.6, respectively; p < 0.001). Patients who were treated with conventional radiotherapy had significantly higher rates of lymphedema (42.2%) compared with hypofractionated radiotherapy (8.5%) (p < 0.001). There was a non-significant relationship between mean radiotherapy dose to axillary levels or axillary vessels and development of lymphedema.

Conclusion

Breast cancer radiotherapy with the 2D technique and conventional fractionation protocol might increase the risk of BCRL. No correlation was observed between radiotherapy dose to each axillary LN level, axillary vessels and BCRL.

Breast cancer-related lymphoedema and resistance exercise: An evidence-based review of guidelines, consensus statements and systematic reviews

AIMS AND OBJECTIVES

Breast cancer-related lymphoedema (BCRL) is a side effect of cancer treatment and can be alleviated by resistance exercise. This systematic, evidence-based review examined the existing best evidence on resistance exercise for BCRL to accurately describe the current status of the field and offer recommendations for clinicians.

METHODS

This review adheres to the PRISMA guidelines. Clinical practice guidelines, consensus documents, systematic reviews and other related evidence-based resources about resistance exercise for BCRL were retrieved through the English databases and guideline websites. The publication data limit was set to December 2020. The following search terms were used: 'breast cancer/breast neoplasm/breast carcinoma/breast tumor/breast malignancy, lymphedema/swelling/edema/lymphoedema, resistance/weight/strength training, best practice/clinical practice/guideline/consensus documents'. The quality of the included studies was evaluated by two authors independently using AGREE II and AMSTAR II tools. Evidence-based recommendations on resistance exercise relevant for BCRL were synthesised and categorised.

RESULTS

Twenty two articles (seven guidelines, four consensus documents and eleven systematic reviews) were included. The overall quality of the eleven eligible guidelines and consensus documents was moderate to high according to the AGREE II criteria. The quality of the eleven systematic reviews was critically low to high according to the AMSTAR criteria. Six clinical topics involving 43 recommendations were identified. Recommendations were categorised by safety of resistance training, effectiveness of resistance training, evaluation prior to resistance exercise, resistance exercise prescription, resistance training outcome index and points for attention.

CONCLUSIONS

This study summarises 43 recommendations for resistance training for BCRL and provides guidance for clinicians. Based on randomised trials and systematic reviews published in recent years, there is an urgent need to update the guidelines and consensus documents in terms of topics, for example effectiveness of resistance training and resistance training outcome index.

Physiotherapy in the prevention and treatment of upper limb complications in women with breast cancer

Breast cancer is the one that most affects the female population in Brazil and the world. Upper limb complications are common after cancer treatment, including conservative procedures. Old studies have already shown the effectiveness of physiotherapy in the rehabilitation of these complications. However, currently, physiotherapeutic care must be initiated from the diagnosis of the disease. Pre-rehabilitation prepares the patient to receive cancer treatment and promotes a reduction in rehabilitation time. Rehabilitation decreased the axillary cord by 57%, increased the range of motion (ROM) by 45º for flexion and 70º for shoulder abduction, the incidence of lymphedema was 11%, and there was a decrease of 3.4 points concerning pain on the Visual Scale Analog (EVA). The physical therapist should work with breast cancer to diagnose, prevent, and rehabilitate after cancer treatment, promoting functionality and quality of life for patients with breast cancer.

Decongestive progressive resistance exercise with an adjustable compression wrap for breast cancer-related lymphoedema (DREAM): protocol for a randomised controlled trial

INTRODUCTION

Breast cancer-related lymphoedema (BCRL) is a chronic swelling in the arm on the side of the breast cancer surgery, affecting one in five women. Recent studies in BCRL have demonstrated that resistance exercise can improve symptoms and quality of life without worsening lymphoedema. No studies have explored whether combining the principles of progressive resistance exercise training with therapeutic strategies of compression therapy and the decongestive lymphatic exercise sequence are beneficial in reducing arm lymphoedema volume. The aim of this three-arm, provincial randomised controlled trial is to determine the efficacy of a 12-week decongestive progressive resistance exercise (DRE) programme in combination with the one of two types of compression garments compared with standard care.

METHODS AND ANALYSIS

Sixty women with BCRL will be recruited and randomly assigned to one of the following three groups: (1) Standard care, (2) DRE with use of a daytime compression garment during exercise and (3) DRE with use of an adjustable compression wrap during exercise. The primary outcome is the percentage reduction in arm lymphoedema volume. Secondary outcomes include bioimpedance analysis, muscular strength, shoulder range of motion, physical activity level and health-related quality of life. Exploratory outcomes include evaluating changes in arm tissue composition using MRI and examining outcomes between the two DRE experimental groups. The primary analysis will compare changes between the groups from baseline to week 12 reflecting the end of the randomised control trial period.

ETHICS AND DISSEMINATION

The trial has received ethics approval from the Health Research Ethics Board of Alberta: Cancer Committee. The study results will be disseminated through scientific peer-reviewed publications, and presented at national and international conferences, and other media portals. The programme protocol will be shared with healthcare professionals and patient groups through clinical workshops and webinars.

TRIAL REGISTRATION NUMBER

NCT05022823.

PROTOCOL VERSION

12 November 2021.

ISSUE DATE

26 April 2021.

Methods for Forming Human Lymphatic Microvessels In Vitro and Assessing their Drainage Function

This chapter describes methods to engineer human lymphatic microvessels in vitro and to assess their fluid and solute drainage capacities. The lymphatics are formed within micropatterned type I collagen gels that contain a blind-ended channel for the growth of lymphatic endothelial cells. Because the vessels have one blind end and one open end each, they mimic the terminal structure of the native lymphatic microvascular tree. The solute drainage rates that are measured from the engineered lymphatics in vitro can be directly compared with published results from intact vessels in vivo. Practical considerations to increase the accuracy of the drainage assays are discussed.

The untold story of late effects: a qualitative analysis of breast cancer survivors' emotional responses to late effects

PURPOSE

Breast cancer survivors are at increased risk of adverse outcomes, called late effects, years after the completion of active treatment. Late effects can significantly impair physical functioning. The current study aimed to explore breast cancer survivors' experiences of late effects, their emotional responses to existing or potential late effects and their perceived impact.

METHODS

A total of 36 women treated for breast cancer in the last 10 years participated in semi-structured telephone interviews. Participant views were sought with respect to knowledge, experience, and perceived longer-term risk. A thematic analysis was conducted.

RESULTS

Four themes emerged from the data: (1) late effects awareness, (2) framing and coping, (3) uncertainty and (4) management. There was a range of emotional responses to late effects; however, many participants reported being unaware of their risk of late effects. Participants conceptualised late effects as any long-term effect of treatment regardless of the time of onset. Women reported living with constant uncertainty and feared cancer recurrence. Many were focused on managing long-term treatment side effects, rather than late effects.

CONCLUSION

Many women undergo treatment and remain unaware of associated late effect risks. National guidelines recommend patients be informed about late effects; however, the results of this study suggest a gap between policy and practice. Evidence-based interventions are needed to equip women with strategies to physically and emotionally manage late effects.

Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for Lymphedema Prevention after Axillary Lymph Node Dissection—A Single Institution Experience and Feasibility of Technique

While surgical options exist to treat lymphedema after axillary lymph node dissection (ALND), the lymphatic microsurgical preventive healing approach (LYMPHA) has been introduced as a preventive measure performed during the primary surgery, thus avoiding the morbidity associated with lymphedema. Here, we highlight details of our operative technique and review postoperative outcomes. For our patients, limb measurements and body composition analyses were performed pre- and postoperatively. Intraoperatively, axillary reverse lymphatic mapping was performed with indocyanine green (ICG) and lymphazurin. SPY-PHI imaging was used to visualize the ICG uptake into axillary lymphatics. Cut lymphatics from excised nodes were preserved for lymphaticovenous anastomosis (LVA). At the completion of the microanastomosis, ICG was visualized draining from the lymphatic through the recipient vein. A retrospective review identified nineteen patients who underwent complete or partial mastectomy with ALND and subsequent LYMPHA over 19 months. The number of LVAs performed per patient ranged between 1–4 per axilla. The operating time ranged from 32–95 min. There were no surgical complications, and thus far one patient developed mild lymphedema with an average follow up of 10 months. At the clinic follow up, ICG and SPY angiography were used to confirm intact lymphatic conduits with an uptake of ICG across the axilla. This study supports LYMPHA as a feasible and effective method for lymphedema prevention.

Extracorporeal Shock Wave Therapy Combined with Complex Decongestive Therapy in Patients with Breast Cancer-Related Lymphedema: A Systemic Review and Meta-Analysis

Breast cancer-related lymphedema (BCRL) is one of the most significant complications seen after surgery. Several studies demonstrated that extracorporeal shock wave therapy (ESWT), in addition to conventional complex decongestive therapy (CDT), had a positive effect on BCRL in various aspects. The systematic review and meta-analysis aim to explore the effectiveness of ESWT with or without CDT on BRCL patients. We searched PubMed, Embase, PEDro, Cochrane Library Databases, and Google Scholar for eligible articles and used PRISMA2020 for paper selection. Included studies were assessed by the PEDro score, Modified Jadad scale, STROBE assessment, and GRADE framework for the risk of bias evaluation. The primary outcomes were the volume of lymphedema and arm circumference. Secondary outcome measures were skin thickness, shoulder joint range of motion (ROM), and an impact on quality-of-life questionnaire. Studies were meta-analyzed with the mean difference (MD). Eight studies were included in the systemic review and four in the meta-analysis. In summary, we found that adjunctive ESWT may significantly improve the volume of lymphedema (MD = -76.44; 95% CI: -93.21, -59.68; p < 0.00001), skin thickness (MD = -1.65; 95% CI: -3.27, -0.02; p = 0.05), and shoulder ROM (MD = 7.03; 95% CI: 4.42, 9.64; p < 0.00001). The evidence level was very low upon GRADE appraisal. ESWT combined with CDT could significantly improve the volume of lymphedema, skin thickness, and shoulder ROM in patients with BCRL. There is not enough evidence to support the use of ESWT as a replacement for CDT. This study was registered with PROSPERO: CRD42021277110.

Magnetic resonance lymphangiography: with or without contrast?

Lymphedema is an important medical issue around the world, caused by an anomalous collection of fluid in soft tissue due to congenital malformations or stenosis or obstruction of lymphatic vessels. Magnetic resonance lymphangiography (MRL) is an emerging technique focused on noninvasive or minimally invasive imaging of lymphatics with the goal to diagnose and treat lymphedema. This review will briefly discuss lymphatic imaging starting with lymphography and radionuclide lymphoscintigraphy up to the newest methods, focusing on MRL, a rising technique, and highlighting the technical aspects fundamental for achieving high-resolution MRL.

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.

Manual Lymphedema Drainage for Reducing Risk for and Managing Breast Cancer-Related Lymphedema After Breast Surgery: A Systematic Review

OBJECTIVE

To examine the effects of manual lymphatic drainage (MLD) on reducing the risk of and managing breast cancer-related lymphedema (BCRL).

DATA SOURCES

The electronic databases ScienceDirect, Scopus, PubMed, and CINAHL were searched for articles published in the English language from January 2000 to June 2020.

STUDY SELECTION

A total of 518 articles were retrieved. After the removal of duplicates, 472 articles remained, 433 of which were excluded based on title and abstract consideration. Thereafter, 39 studies were further inspected, and 27 articles were excluded because they were not randomized controlled trials, did not measure BCRL, and/or were an incomplete study. Ten studies were included for the final review.

DATA EXTRACTION

Data from the 10 studies were extracted and compiled into a summary table.

DATA SYNTHESIS

Based on the results of this systematic review, it cannot be concluded that MLD helps reduce the risk of BCRL for women after breast surgery. Regarding the effect of MLD on managing BCRL, the findings indicate that MLD alone or MLD combined with other treatments was likely to give similar benefits in terms of reducing arm volume for women diagnosed with BCRL.

CONCLUSION

Scientific evidence to support the benefits of MLD on preventing or reducing BCRL remains unclear. More rigorous studies to confirm findings on the effectiveness of MLD are needed.

Development and Evaluation of a Satisfaction Questionnaire About Therapeutic Textile Devices Used for Breast Cancer-Related Lymphedema

Background: There is a need for an appropriate instrument to measure the satisfaction of patients about therapeutic textile devices used for breast cancer-related lymphedema (BCRL). Methods and Results: A new satisfaction questionnaire about therapeutic textile devices used for BCRL was developed and psychometrically tested. An approach to criterion validity by contrast of hypothesis was made. Different average scores were expected depending on the type of therapeutic textile device: Kinesio taping, compression garment, and multilayer low-stretch bandage. Items were analyzed in nine phases: apparent validity, missing responses, internal consistency, factor analysis, reproducibility, confirmation of factor analysis, contrast of hypothesis, variability, and time for completion. One hundred fifty women were sampled in a consecutive order. A final questionnaire was drafted that fulfilled the validation hypothesis, including 20 items that explored 4 dimensions: mood, patient comfort, patient compliance, and perceived benefits. The total Cronbach's α was 0.87. The intraclass correlation coefficient was 0.93 for test-retest and 0.91 for inter-rater. Neither ceiling nor floor effects were observed. The average burden for the respondent and interviewer was 5.6 (standard deviation [SD] = 3.8) and 2.2 (SD = 1.3) minutes, respectively. Conclusion: This preliminary analysis supports the content validity, reliability, and validity of construct of the questionnaire.

Effect of Aqua Therapy Exercises on Postmastectomy Lymphedema: A Prospective Randomized Controlled Trial

Objective

To investigate the effect of aqua therapy resistance exercise on arm volume, pain, and shoulder range of movements in post-mastectomy lymphedema.

Methods

This was a single-blind randomized controlled trial. Fifty eligible breast cancer survivors (median, 10 years after surgery) with lymphedema (median, 21% inter-limb difference) were assigned randomly to group A (n=25) or control group B (n=25). The study group underwent 60 minutes of aqua therapy exercise comprising of warm-up for 10 minutes, 40 minutes of strengthening exercises, and 10 minutes of cooling down, three times a week for 8 weeks. The control group underwent 60 minutes of land-based exercise three times a week for 8 weeks. Arm volume calculated by measuring the arm circumference, shoulder flexion, and abduction range of motion (ROM), and pain using a visual analog scale (VAS) were assessed at baseline and after 8 weeks of treatment.

Results

There was a statistically significant difference in limb volume, shoulder flexion and abduction ROM, and VAS scores in favor of the study group (p<0.001) after 8 weeks of intervention. The mean±standard deviation for limb volume, shoulder flexion, abduction, and pain score were 2,108.71±200.97 mL, 169.68°±4.54°, 150.44°±3.92°, and 3.16±1.1 in the study group and 2,256.41±186.94 mL, 147.36°±5.32°, 131.32°±4.38°, and 5.68±0.94 in the control group, respectively.

Conclusion

Adding aqua therapy resistance exercise to routine physical therapy might be more effective in decreasing the limb volume and pain intensity and improving ROM of the shoulder in postmastectomy lymphedema.

Tissue Dielectric Constant Combined With Arm Volume Measurement as Complementary Methods in Detection and Assessment of Breast Cancer-Related Lymphedema

Aim: To investigate the role of tissue dielectric constant (TDC) in the detection and assessment of breast cancer-related lymphedema (BCRL) and to determine whether the TDC could potentially be used as a complementary method for arm volume measurement. Methods: Sixty-nine patients with BCRL were enrolled in this study. Local tissue water was assessed bilaterally by using the TDC method in four sites: upper arm, forearm, hand, and lateral thorax. Arm circumferences were measured at the 4-cm interval, starting from the shoulder to the wrist by using a tape measure. The arm volume was calculated by a standard formula. Patients' demographic information and clinical characteristics were also recorded. Results: Fifty-one of the 69 patients were diagnosed with clinical lymphedema. Using a TDC ratio of 1.2 or a diagnostic reference standard of ≥2 cm arm circumference, the sensitivity of these two methods was found to be identical at 73.9%. The TDC values in four sites on the affected side were significantly higher (p < 0.05) relative to the unaffected side. The inter-side TDC ratio of upper arm and forearm was substantially higher than that of lateral thorax and hand (p < 0.05). The TDC ratio of upper arm, forearm, and hand, especially of the upper arm and forearm, was positively correlated with inter-limb volume difference and stage of lymphedema. Conclusion: The TDC method elucidated a meaningful clinical correlation to the arm volume measurement. Applying those two methods together showed promise in the detection and assessment of BCRL. The forearm and upper arm were reliable examination sites for TDC measurements in the clinic.

Development and validation of a nomogram to predict the risk of breast cancer-related lymphedema among Chinese breast cancer survivors

PURPOSE

Breast cancer-related lymphedema (BCRL) is a major long-term complication for post-surgery breast cancer survivors. Although several risk factors have been identified, lifestyle characteristics have been neglected in previous studies. The aim of this study was to develop and validate a nomogram for estimating this population's risk of developing lymphedema, taking into consideration their demographic, clinical, and personal lifestyle behaviors.

METHODS

In a cross-sectional study, we collected data from 775 post-operative breast cancer survivors who had attended a follow-up session in the recent 10 years (primary cohort). Lymphedema was assessed using the Norman telephone questionnaire, self-reported by patients. Multiple logistic regression was used to identify risk factors for lymphedema, including demographic, clinical, and lifestyle-related factors. A nomogram was constructed based on those factors and was validated using a separate group of 314 breast cancer patients (validation cohort).

RESULTS

The factors independently associated with lymphedema were higher body mass index (BMI), modified radical mastectomy (MRM), postsurgical infection, chemotherapy, radiotherapy, exercise of the affected arm, and the active participation in physical activity (P<0.05). The area under the curve (AUC) values of the primary and the validation cohorts were 0.721 (95% confidence interval: 0.685-0.756) and 0.702 (95% confidence interval: 0.646-0.759), respectively.

CONCLUSIONS

BCRL risk factors include MRM, radiotherapy, chemotherapy, and higher BMI, while the active physical activity behavior of patients appears to be a factor against lymphedema. The nomogram incorporating the patients' clinical and lifestyle factors might be useful for predicting lymphedema in breast cancer survivors.

Longitudinal impact of postmastectomy radiotherapy on arm lymphedema in patients with breast cancer: An analysis of serial changes in arm volume measured by infrared optoelectronic volumetry

BACKGROUND AND PURPOSE

This study was conducted to evaluate the longitudinal impact of postmastectomy radiation therapy (PMRT) on persistent severe lymphedema (PSL) using arm volume measurements by an infrared optoelectronic volumetry.

MATERIALS AND METHODS

Of the patients who underwent mastectomy between 2008 and 2016, we included 330 patients with secondary arm lymphedema. Percentage of excessive volume (PEV) of the arm were serially assessed using an optoelectronic volumetry 1, 3, 6, 12, 18, 24, 36, and 48 months after the lymphedema diagnosis (T_{lymh_Dx}). We defined PSL as 2 or more episodes of PEV ≥ 20%. Risk factors for PSL were evaluated using stepwise regression analyses.

RESULTS

Patients who received PMRT (n = 202, 61.2%) were more likely to have larger extent of axillary node dissection (AND), and frequent stage II/III lymphedema at T_{lymh_Dx} than those who did not receive PMRT (p < 0.001). With a median follow-up of 72.5 months, PSL occurred in 71 (21.5%) patients. Patients with PSL were more frequently treated with AND of ≥ 20 nodes without reconstruction, had advanced lymphedema stage and higher PEV at T_{lymh_Dx}, and more frequent events of cellulitis compared to those without PSL. The risk of developing PSL was significantly associated with PMRT with regional node irradiation (RNI), AND of ≥20 nodes, lymphedema stage, and PEV at T_{lymh_Dx}, cellulitis, and compliance with physical therapy.

CONCLUSION

PMRT, especially RNI, was associated with a consistent increase in PEV in patients with arm lymphedema. Therefore, timely physical therapy is necessary for this patient population.

Predictors of Quality of Life in Patients with Breast Cancer-Related Lymphedema: Effect of Age, Lymphedema Severity, and Anxiety

Background: Patients with breast cancer-related lymphedema (BCRL) have lower quality of life (QOL). However, some important predictors, such as the effect of age, lymphedema severity, depression, and anxiety, have not yet been discovered. The overall objective of this study is to explore the QOL predictors associated with BCRL in China. Methods and Results: A cross-sectional design was conducted. Data were collected before treatment, including sociodemographic characteristics (height, heaviness, age, education level, work status, marital status, and economic status), clinical characteristics (surgical method, clinical cancer stage, lymphedema severity, and lymphedema duration), the hospital anxiety (HA) and depression scale, and the functional assessment of cancer therapy-breast quality of life instrument. Univariate analysis or bivariate correlation was first made to explore the correlation of QOL with sociodemographic/clinical characteristics, anxiety, and depression. The multiple linear regression model was used to identify the independent QOL predictors. Seventy-one patients with BCRL were recruited. Age, education level, work status, family income, lymphedema duration, lymphedema severity, and HA and hospital depression scale scores are significantly correlated with QOL (p < 0.05). Age, lymphedema severity, and HA accounted for 85.9% in QOL (F = 62.76, p < 0.001). Conclusions: Age, lymphedema, and anxiety are the most important QOL predictors. Therefore, it is very important to establish a BCRL prevention system and pay attention to psychological distress in the patients with BCRL.

The Clinical Usefulness of Lymphedema Measurement Technique Using Ultrasound

Background: We previously invented a new technique to measure the cross-sectional area of soft tissue of a limb (ΔCSA) with lymphedema using ultrasonography. The measurement correlated strongly with both circumference and volumetry in normal subjects. The purpose of this study was to measure the reliability and accuracy of the method in patients with lymphedema. Methods and Results: Ultrasonography was performed on both arms of 69 female patients diagnosed with stage ≥1 lymphedema related to advanced breast cancer. At 10 cm above elbow (AE) and below elbow (BE), soft-tissue thicknesses at various locations were measured by two examiners. Subcutaneous tissue stiffness was also obtained by measuring thickness differences of soft tissue when applying minimal and maximal pressure to the skin (compliance) and its ratio to the initial thickness (compliance ratio). ΔCSA showed a strong positive correlation with circumference (r = 0.758 to 0.951), and a moderate negative correlation with Z at 5 Hz (r = -0.326 to -0.486). Intra- and interclass coefficients of all ultrasonography measurements were moderate to excellent (0.623-0.990). Compliance measured at 10 cm BE on the lesion side was significantly higher than on the normal side (p < 0.001), and compliance measured at 10 cm AE showed no difference between the two sides (p = 0.653). Conversely, compliance ratios measured at 10 cm AE and BE on the lesion side were significantly lower than on the normal side (p < 0.001). Conclusion: Thus, ΔCSA using ultrasonography could be a particularly viable option for determining status in lymphedema patients.

An infrared 3D scanning device as a novel limb volume measurement tool in breast cancer patients

Abstract

Background

Lymphedema is a common complication of breast cancer treatment that affects one in five breast cancer survivors, yet there is no reliable method to detect lymphedema in the subclinical range. The objective of this study was to determine the feasibility and reliability of using an infrared 3D scanning device (ISD) as a peri-operative limb volume measurement tool.

Methods

Fifteen patients were analyzed based on inclusion criteria. Peri-operative measurements were obtained using tape measure and an ISD. Volumes were calculated using a standard algorithm for tape measure and a custom algorithm for ISD measurements. Linear regression models were used to assess ISD and tape measurement volume and circumference correlation. One-way ANOVA was used to compare change in percent difference at set time points post-operatively (2–3 weeks, 4–6 weeks, and 7–12 weeks) for both ISD and tape measure. t tests for unequal variances with the Bonferroni correction were performed among these groups.

Results

There is a positive linear correlation (R² = 0.8518) between absolute volume measurements by the ISD and tape measure. Analyses over 2–10 weeks post-operatively showed that the ISD was able to detect volume changes in both the unaffected and the affected arm. Furthermore, the affected arm tended to have a greater increase in volume in the majority of patients, indicating these patients could be at risk for lymphedema.

Conclusions

Technology utilizing infrared 3D scanners can reliably measure limb volume pre- and post-treatment similarly to tape measure in a small sample of patients. Further research using 3D scanning technology with a longer follow up is warranted.

Feasibility of Bioimpedance Analysis to Assess the Outcome of Complex Decongestive Therapy in Cancer Treatment-Related Lymphedema

Background: Cancer treatment-related lymphedema (CTRL) affects patients physically, psychologically and emotionally, and remains a significant quality of life issue among patients with cancer. Reliable methods to measure changes in lymphedema are required for early detection, acute intensive treatment, and long-term management. Here, we evaluated the use of bioimpedance analysis (BIA) as a tool to measure lymphedema before and after treatment.

Patients and Methods: Patients with CTRL who were admitted to a secondary university hospital between October 2017 and July 2018 for complex decongestive therapy (CDT) were eligible for this prospective cohort study. Circumferential measure (CM) and BIA were used to evaluate lymphedema at admission (initial) and before discharge (follow-up, FU). Volume was calculated from the CM using the truncated cone formula. The inter-limb ratios (ILRs) of the circumference, volume, and impedance were also calculated as the unaffected limb to affected limb. Each parameter before and after treatment and correlations between parameters also were analyzed.

Results: A total of 29 patients (12 upper- and 17 lower-extremity CTRL) completed were included in this analysis. Absolute value and the ILRs of circumference, volume or impedance, and extracellular water/total body water (ECW/TBW) were significantly improved at FU (p < 0.01, p < 0.05). The initial and FU absolute values, ILRs, ECW/TBW correlated significantly with each other (p < 0.01, p < 0.05). The cutoff values of ECW/TBW for moderate and severe degree of CTRL were 0.3855 and 0.3955, respectively. The changes of ILRs between initial and FU assessments were significantly different among three groups according to lymphedema severity (p < 0.01, p < 0.05).

Conclusions: BIA data correlates significantly with clinical measurement, and therefore can be a practical tool in monitoring outcome measure after lymphedema treatment. In addition, BIA is more sensitive to subtle changes in lymphedema, and therefore can be useful for the long-term maintenance of lymphedema.

Vascularized Lymph Node Transfer for Patients with Breast Cancer-Related Lymphedema Can Potentially Reduce the Burden of Ongoing Conservative Management

Background: Vascularized lymph node transfer (VLNT) microsurgery is conducted in selected specialist lymphatic programs as a surgical treatment option for breast cancer-related lymphedema (BCRL) with variation in treatment outcomes. Methods and Results: Ten patients with BCRL underwent VLNT from 2012 to 2015. Donor sites were the inguinal (n = 6) or supraclavicular fossa/neck (n = 4) regions and recipient sites were the axilla (n = 6) or elbow regions (n = 4). Outcomes included changes in limb volume and extracellular fluid ratios, postoperative garment use, number of cellulitis episodes, and self-reported symptom improvement. At a mean follow-up of 46 months from surgery (range: 28-66 months), the excess volume in the affected arm had reduced (n = 4) or remained stable (n = 1) for 5 of 10 patients (50%) (mean change: -106.4 mL, range: -515.5 to +69.6 mL). Four of these five patients had also reduced (n = 3) or discontinued (n = 1) wearing compression garments and three reported a reduction in episodes of cellulitis. The remaining five patients had an increase of over 100 mL in postoperative excess volume (mean change: 295.8 mL, range: 142.1-382.8 mL). Three of these five patients reported noncompliance with compression garments. Despite the increase in limb volume, some patients reported softness in swelling (n = 3) and better response to conservative treatment (n = 1). Conclusion: Our results warrant continuation of VLNT as a surgical treatment option for patients with BCRL and show that the burden of conservative management such as wearing garments can be reduced over time for some patients. Longer term follow-up with standardized measures across all centers is required to further investigate VLNT.