Lymphedema: Pathophysiology and clinical manifestations

Automated CT segmentation for lower extremity tissues in lymphedema evaluation using deep learning

OBJECTIVES

Clinical assessment of lymphedema, particularly for lymphedema severity and fluid-fibrotic lesions, remains challenging with traditional methods. We aimed to develop and validate a deep learning segmentation tool for automated tissue component analysis in lower extremity CT scans.

MATERIALS AND METHODS

For development datasets, lower extremity CT venography scans were collected in 118 patients with gynecologic cancers for algorithm training. Reference standards were created by segmentation of fat, muscle, and fluid-fibrotic tissue components using 3D slicer. A deep learning model based on the Unet++ architecture with an EfficientNet-B7 encoder was developed and trained. Segmentation accuracy of the deep learning model was validated in an internal validation set (n = 10) and an external validation set (n = 10) using Dice similarity coefficient (DSC) and volumetric similarity (VS). A graphical user interface (GUI) tool was developed for the visualization of the segmentation results.

RESULTS

Our deep learning algorithm achieved high segmentation accuracy. Mean DSCs for each component and all components ranged from 0.945 to 0.999 in the internal validation set and 0.946 to 0.999 in the external validation set. Similar performance was observed in the VS, with mean VSs for all components ranging from 0.97 to 0.999. In volumetric analysis, mean volumes of the entire leg and each component did not differ significantly between reference standard and deep learning measurements (p > 0.05). Our GUI displays lymphedema mapping, highlighting segmented fat, muscle, and fluid-fibrotic components in the entire leg.

CONCLUSION

Our deep learning algorithm provides an automated segmentation tool enabling accurate segmentation, volume measurement of tissue component, and lymphedema mapping.

KEY POINTS

Question Clinical assessment of lymphedema remains challenging, particularly for tissue segmentation and quantitative severity evaluation. Findings A deep learning algorithm achieved DSCs > 0.95 and VS > 0.97 for fat, muscle, and fluid-fibrotic components in internal and external validation datasets. Clinical relevance The developed deep learning tool accurately segments and quantifies lower extremity tissue components on CT scans, enabling automated lymphedema evaluation and mapping with high segmentation accuracy.

Benefits of Additional Liposuction in Lymphatic Reconstructive Surgery

BACKGROUND AND OBJECTIVES

The goal of this study was to examine the benefits of immediate adjunctive liposuction in patients undergoing lymphatic reconstructive surgery with a focus on complications, limb volume, and patient-reported outcome measurements (PROMs).

METHODS

We conducted a single-center prospective study on patients receiving reconstructive lymphatic surgery at the Department of Plastic Surgery and Hand Surgery of the University Hospital Zurich. Besides patients characteristics and operation details, volume measurements and PROMs were assessed pre- and postoperatively.

RESULTS

We included 73 patients with upper extremity lymphedema (UEL) or lower extremity lymphedema (LEL). A total of 41 patients received lymphatic reconstruction only, while in 32 patients, an additional liposuction in case of fat accumulation was performed. Mean percentage volume reduction for all limbs was -10.1% (±10.0%) in UEL and -9.3% (±6.9%) in LEL. Volume reduction in the additional liposuction group was not statistically different from reconstruction only. Although patients with liposuction had a significantly lower hemoglobin postoperatively (p = 0.03), there was no difference in length of rehabilitation. Regardless of the surgical technique, PROMs confirmed improvements in a broad range of different domains.

CONCLUSION

Combining reconstructive lymphatic surgery with immediate liposuction is effective for patients with a significant lymphedema-associated fat accumulation without increasing postoperative complications.

Assessment of bilateral lower limb lymphoedema: the use of bioimpedance spectroscopy

PURPOSE

Assessment of bilateral lower limb lymphoedema presents difficulties as there is no unaffected limb for comparison. This study aimed to establish the utility of bioimpedance spectroscopy (BIS) ratios for diagnosing bilateral leg lymphoedema and explored BIS's potential to differentiate between leg lymphoedema and lower limb swelling.

METHODS

A cross-sectional study assessed bilateral leg lymphoedema (n = 98), self-ascribed bilateral leg swelling (n = 52), healthy study (n = 52) and database controls (n = 45) using BIS. Device-derived L-Dex scores were compared, and inter-limb control tolerance ellipses were calculated for lymphoedema and self-ascribed swelling groups. Receiver-operating characteristic (ROC) curves determined sensitivity and specificity.

RESULTS

Extracellular, intracellular, and total fluid resistances were significantly greater in arms than legs. Arm-to-leg ratios were larger in the lymphoedema group irrespective of leg dominance. Between 26.5% and 67.3% of participants in the bilateral lymphoedema group were classified as having lymphoedema using cutoff thresholds of 10 and 6.5 units, respectively. L-Dex ROC analysis showed area under the curves between 0.75 and 0.80.

CONCLUSION

BIS is sensitive in assessing overall extracellular volume but not specific lymph volume compartments. An integrated approach combining clinical history with BIS is crucial for diagnosing bilateral leg lymphoedema.

Intraoperative analysis of lymph nutrient vessels of 104 human lymph vessels using video-capillaroscopy

The vasa vasorum of the superficial collecting lymph vessel (VCL) has been reported to show morphological changes in lymphedematous limbs. This study aimed to develop a pathophysiological severity staging of the superficial collecting lymph vessels (SCLs) based on VCL morphology. A retrospective review was conducted using the medical charts of lower extremity lymphedema patients who underwent video-capillaroscopy (VC) during lymphaticovenular anastomosis (LVA). Intraoperative SCLs were evaluated using VC at 175× and 620× magnifications. The VCL stage was determined based on VCL morphology observed under VC. D2-40 (podoplanin) staining was assessed with a score of 0 for negative, 1 for mildly positive, and 2 for strongly positive. Red blood cell (RBC) movement was scored as 1 for movement and 0 for no movement. A total of 32 patients with 104 SCLs were evaluated. The distribution of VCL stages was as follows: Stage 0 in 4 SCLs (3.8%), Stage 1 in 16 SCLs (15.4%), Stage 2 in 18 SCLs (17.3%), Stage 3 in 36 SCLs (34.6%), Stage 4 in 20 SCLs (19.2%), and Stage 5 in 10 SCLs (9.6%). A significant difference was observed in the prevalence of lymphosclerosis grade according to the VCL stage (p = 0.002). Among the VCL stages (Stage 1 vs. 2 vs. 3 vs. 4 vs. 5), a higher VCL stage was significantly associated with lower positivity to D2-40 staining of the SCL (p < 0.001), as well as with lower positivity to RBC movement in both the main VCL (p < 0.001) and the branch VCL (p < 0.001). These findings indicate that the progression of the VCL stage is associated with pathologic changes in the SCLs and physiological deterioration of the VCLs, highlighting the significance of the VCLs in the progression of lymphedema.

Reliability, concurrent validity and clinical feasibility of measurement methods determining local tissue water in patients with lower limb lymphedema and healthy controls

PURPOSE

To investigate reliability, concurrent validity and clinical feasibility of local tissue water measurements in patients with lower limb lymphedema and healthy controls.

METHODS

In this cross-sectional study the Moisture Meter D Compact device® (MMDC) measurement and "pitting test" were performed three times by two assessors to test intra- and inter-rater reliability in 47 patients and 30 healthy controls. To investigate the between-session reliability, 29 patients and 21 healthy controls were reassessed two weeks later. Time efficiency and practical limitations were evaluated. The concurrent validity was investigated between the two tests. Clinical trial registration number: NCT:05269264.

RESULTS

Of the MMDC values, 58% showed strong to very strong intra-rater reliability, 32% showed strong to very strong inter-rater reliability and 36% had strong to very strong between-session reliability. Absolute values had generally a higher reliability than inter-limb or leg-to-arm ratio values. The pitting test had nil to perfect agreement between assessments (Cohen's kappa = -0.03-1.00) with fewer practical limitations and shorter performance time than the MMDC. Between both tests nil to a moderate relationship was found (Kendall's tau c = 0.00-0.60).

CONCLUSION

The MMDC and pitting test are reliable and feasible measurements to assess local tissue water depending on the location, but should not be used interchangeably.

Postoperative cholesterol changes as early predictors of breast cancer-related lymphedema: a retrospective cohort study

BACKGROUND

Early prediction and management are crucial for treating breast cancer-related lymphedema (BCRL), yet the risk factors remain poorly understood. This study aims to explore the relationship between postoperative changes in serum cholesterol levels and the development of lymphedema.

METHODS

This retrospective study analyzed breast cancer patients who underwent surgery between March 2014 and March 2019. We assessed the development of lymphedema and changes in high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglyceride (TG), and total cholesterol (TC) levels. Preoperative values were compared with those measured within 6 months post-surgery, and logistic regression models were used for statistical analysis.

RESULTS

Among the 906 patients studied, 87 (9.6%) developed lymphedema, with a median onset of 15 months. An increase in serum HDL levels relative to baseline was associated with a reduced risk of lymphedema (odds ratio [OR] 0.94 per unit increase, 95% confidence interval [CI]: 0.92-0.95), even after adjusting for established factors such as body mass index, type of axillary surgery, number of lymph nodes removed, regional radiotherapy, and chemotherapy. In contrast, elevated serum TG levels were linked to a higher risk of lymphedema (OR 1.003 per unit increase, 95% CI: 1.001-1.006). No significant associations were found with changes in LDL or TC levels (p > 0.05).

CONCLUSION

Postoperative changes in HDL and TG levels are significantly associated with the risk of developing lymphedema, suggesting their potential role as early indicators. These results have important clinical implications for guiding follow-up care and early intervention strategies, although further validation is needed.

Deep learning-based classification of lymphedema and other lower limb edema diseases using clinical images

Lymphedema is a chronic condition characterized by lymphatic fluid accumulation, primarily affecting the limbs. Its diagnosis is challenging due to symptom overlap with conditions like chronic venous insufficiency (CVI), deep vein thrombosis (DVT), and systemic diseases, often leading to diagnostic delays that can extend up to ten years. These delays negatively impact patient outcomes and burden healthcare systems. Conventional diagnostic methods rely heavily on clinical expertise, which may fail to distinguish subtle variations between these conditions. This study investigates the application of artificial intelligence (AI), specifically deep learning, to improve diagnostic accuracy for lower limb edema. A dataset of 1622 clinical images was used to train sixteen convolutional neural networks (CNNs) and transformer-based models, including EfficientNetV2, which achieved the highest accuracy of 78.6%. Grad-CAM analyses enhanced model interpretability, highlighting clinically relevant features such as swelling and hyperpigmentation. The AI system consistently outperformed human evaluators, whose diagnostic accuracy plateaued at 62.7%. The findings underscore the transformative potential of AI as a diagnostic tool, particularly in distinguishing conditions with overlapping clinical presentations. By integrating AI with clinical workflows, healthcare systems can reduce diagnostic delays, enhance accuracy, and alleviate the burden on medical professionals. While promising, the study acknowledges limitations, such as dataset diversity and the controlled evaluation environment, which necessitate further validation in real-world settings. This research highlights the potential of AI-driven diagnostics to revolutionize lymphedema care, bridging gaps in conventional methods and supporting healthcare professionals in delivering more precise and timely interventions. Future work should focus on external validation and hybrid systems integrating AI and clinical expertise for comprehensive diagnostic solutions.

Vascularized lymph node transfer (VLNT) versus lymphaticovenous anastomosis (LVA) for chronic breast cancer-related lymphedema (BCRL): a retrospective cohort study of effectiveness over time

PURPOSE

Microsurgical reconstruction, including vascularized lymph node transfer (VLNT) and lymphaticovenous anastomosis (LVA), have emerged as promising treatment options for chronic breast cancer-related lymphedema (BCRL). Despite their clinical relevance, the precise timelines for patient improvement following these interventions remain rather unexplored. Therefore, the goal of this study was to compare the long-term outcomes and improvement patterns over time of VLNT versus LVA to lay open potential differences and aid in personalized counseling of future patients.

METHODS

A prospectively maintained, encrypted database was analyzed for patients with chronic BCRL treated with either VLNT or LVA with a minimum follow-up of one year. Patient-specific variables, such as body weight and circumferential arm measurements at distinct locations on both arms were documented preoperatively and on regular postoperative outpatient follow-ups.

RESULTS

This study comprised 112 patients, of which 107 patients fully completed the one-year follow-up period. Both VLNT and LVA achieved significant arm size reductions. LVA showed an early peak in effectiveness within the first three months, followed by a subsequent decrease and eventual stabilization. Contrarily, VLNT exhibited a distinct pattern with two significant peaks at three and eighteen months.

CONCLUSIONS

VLNT and LVA are both effective in long-term lymphedema management, yet they demonstrate marked differences in the timing of improvement. VLNT shows a delayed but more durable response, in contrast to the greater but shorter-lasting surge in effectiveness achieved by LVA. Interestingly, VLNT demonstrates an earlier onset of therapeutic impact than previously understood.

Notoginsenoside R1 reduces acquired lymphedema and increases lymphangiogenesis by promoting VEGF-C expression via cAMP/PKA/CREB signaling

BACKGROUND

Acquired lymphedema is a global health concern with limited treatment options. While vascular endothelial growth factor C (VEGF-C) administration has shown promise for the treatment of this patient population, no small-molecule compounds have hitherto been identified to improve lymphedema by stimulating VEGF-C expression and lymphangiogenesis.

OBJECTIVE

This study investigated the therapeutic effect of notoginsenoside R1 (R1) on a mouse model of tail acquired lymphedema and explored the underlying mechanisms.

METHODS

C57BL/6J mice and lymphatic endothelial cells (LECs) specific VEGFR-3 knockout transgenic mice underwent surgical induction of tail acquired lymphedema. Tail circumference, lymphatic drainage function, VEGF-C expression, and lymphangiogenesis were measured. LECs' function was assessed using wound healing and tube formation assays. Quantitative PCR (q-PCR) and western blot were conducted to measure VEGF-C expression levels. In addition, RNA sequencing analysis and western blot were performed to elucidate the signal pathways involved. Luciferase reporter assays assessed VEGF-C promoter activity.

RESULTS

R1 treatment improved lymphedema, lymphatic function, and lymphangiogenesis in the mouse model. R1 enhanced migration, tube formation, and VEGF-C expression of LECs. These effects were abolished by VEGF-C siRNA and VEGFR-3 inhibitors. VEGFR3 knockout in LECs completely blocked R1's ability to promote lymphangiogenesis and lymphatic drainage while partially but significantly reducing its improvement on lymphedema. R1 activated the cAMP/PKA signaling pathway, leading to PKA and CREB phosphorylation. The PKA inhibitor and CREB siRNA inhibited R1-induced VEGF-C expression. Additionally, R1 activated VEGF-C promoter activity in a CREB-dependent manner.

CONCLUSION

R1 emerges as the first reported small natural compound to promote VEGF-C expression. It reduces acquired lymphedema and enhances lymphangiogenesis via the cAMP/PKA/CREB signaling pathway. These findings suggest R1 as a potential novel oral medication for treating acquired lymphedema patients.

The association between allostatic load and lymphedema in breast cancer survivors

PURPOSE

Allostatic load, a measure of physiological dysregulation secondary to chronic exposure to socioenvironmental stressors, is associated with 30-day postoperative complications and mortality in patients with breast cancer. This study aimed to examine the association between allostatic load (AL) at diagnosis and development of breast cancer-related lymphedema (BCRL).

METHODS

Patients aged 18 years or older who received surgical treatment for stage I-III breast cancer between 2012 and 2020 were identified from The Ohio State University Cancer Registry. AL was calculated using biomarkers from the cardiovascular, metabolic, renal, and immunologic systems. A high AL was defined as AL > median. Logistic regression analyses examined the association between AL and BRCL, adjusting for sociodemographic, clinical, and treatment factors.

RESULTS

Among 3,609 patients, 18.86% (n = 681) developed lymphedema. A higher proportion of patients with lymphedema were Black (11.89% vs. 7.38%, p < 0.0001), Medicaid insured (12.19% vs. 6.97%, p < 0.0001), had stage 3 disease (7.05% vs. 1.57%, p < 0.0001), and had a high AL (53.63% vs. 46.90%, p = 0.0018). In adjusted analysis, high AL was associated with higher odds of developing lymphedema than low AL (OR 1.281 95% CI 1.06-1.55). Moreover, a 1-unit increase in AL was associated with 10% higher odds of lymphedema (OR 1.10, 95% CI 1.04-1.16). There was no statistically significant association between AL and severity of lymphedema (OR 1.02, 95% CI 0.82-1.23).

CONCLUSION

In this retrospective cohort of breast cancer survivors, high AL at diagnosis was associated with higher odds of developing lymphedema. Future research should elucidate the pathways by which AL influences lymphedema.

The Role of Bioelectrical Impedance Analysis in Predicting Secondary Surgical Interventions for Lymphedema

Background: Bioelectrical impedance analysis (BIA), known for its utility in monitoring fluid balance and lymphedema progression, is non-invasive and practical. However, circumferential tape measurements remain the gold standard for assessing limb volume changes, despite operator variability. This study investigated whether BIA could reliably assess the need for secondary surgical interventions in lymphedema patients. Methods: We retrospectively analyzed lower extremity lymphedema patients who underwent multiple lymphaticovenous anastomoses on both legs from April 2017 to June 2023. This study involved 14 patients with a single surgery and 34 requiring additional surgeries. Logistic regression evaluated associations between the number of surgeries and valuables, including extracellular water-to-total body water (ECW/TBW) ratios measured via BIA, the sum of five-part circumferential values via tape measuring, age, and body mass index. Receiver operating characteristic (ROC) curve analysis calculated the area under the curve (AUC) for ECW/TBW and circumference values, analyzed separately for left and right legs. Results: ECW/TBW values were significantly associated with the need for a second surgery for both the right leg (p = 0.02, ROC-AUC = 0.86) and the left leg (p = 0.04, ROC-AUC = 0.86). In contrast, circumference measurements were not significant predictors for either the right leg (p = 0.46, ROC-AUC = 0.77) or the left leg (p = 0.60, ROC-AUC = 0.78). ECW/TBW demonstrated a higher AUC compared to circumference measurements, indicating its potential as a more sensitive tool for predicting the need for additional surgical interventions. Conclusions: BIA may serve as a valuable tool for monitoring treatment outcomes and guiding secondary surgical planning. Larger studies are needed to validate its clinical utility.

Efficacy study of lymphaticovenular anastomosis via the lymphosome-based four-incision approach for lower limb lymphedema

OBJECTIVE

Lower limb lymphedema (LLL) is a chronic condition with impaired lymphatic drainage. Lymphaticovenular anastomosis (LVA) is a promising microsurgical treatment for LLL. Refined surgical techniques, such as optimal incision placement and precise lymphatic vessel identification, are essential for better clinical outcomes. For patients with LLL, we performed an LVA via the lymphosome-based four-incision approach. We standardized incision positioning and identified lymphatic vessels for LVA to improve surgical outcomes.

METHODS

A retrospective study was conducted on 59 patients with LLL who underwent LVA. Among them, 32 patients in the study group received LVA using the four-incision approach, and 27 patients in the control group underwent LVA with empirically determined incision placement. All patients were followed up for 12 months after the operation. The outcome measures included the number of lymphatic-to-venous anastomoses, surgical duration, Lymphedema Functioning, Disability, and Health Questionnaire for Lower Limb Lymphedema and Lower Extremity Lymphedema Index, Patient Health Questionnaire-9 items, and subcutaneous thickness.

RESULTS

At the 6-month and 12-month follow-ups, there was a significant interaction between the two groups of patients in terms of Lower Extremity Lymphedema Index and Lymphedema Functioning, Disability, and Health Questionnaire for Lower Limb Lymphedema (P < .05). The Patient Health Questionnaire-9 items showed no interaction between the two groups (P > .05). After treatment, the subcutaneous thickness in the study group was lower than that in the control group (P < .05). There were no significant differences between the two groups regarding surgical duration and the number of lymphatic-to-venous anastomoses (P > .05).

CONCLUSIONS

LVA via the lymphosome-based four-incision approach can significantly enhance the quality of life, limb volume, and subcutaneous thickness in patients with LLL. This study presents new incision selection criteria for LVA and underlines the necessity of comprehensively addressing patients' mental health.

Noncontrast MRI-based machine learning and radiomics signature can predict the severity of primary lower limb lymphedema

OBJECTIVE

According to International Lymphology Society guidelines, the severity of lymphedema is determined by the difference in volume between the affected limb and the healthy side divided by the volume of the healthy side. However, this method of measuring volume is time consuming, laborious, and has certain errors in clinical applications. Therefore, this study aims to explore whether machine learning radiomics features based on noncontrast magnetic resonance imaging (MRI) can predict the severity of primary lower limb lymphedema.

METHODS

A retrospective analysis of 119 patients with primary lower limb lymphedema. The enrolled patients were divided into a nonsevere group (mild and moderate) and a severe group. Using the semiautomatic threshold method in ITK-snap software on the patient's noncontrast MRI, we filled the area between the subcutaneous tissue and muscle of the edematous site. The PyRadiomics software package was used to extract radiomic features. The radiomic features were analyzed using the t test or Mann-Whitney test. Subsequently, Pearson correlation testing and least absolute shrinkage and selection operator screening were performed. Using Scikit-learn, the remaining features were used to construct five models: logistic regression, support vector machine, random Forest, ExtraTrees, and light gradient boosting machine. The predictive performance were evaluated by the receiver operating characteristic curve, and the sensitivity and specificity of these measures were calculated. The predictive curve was used to evaluate the performance of the predictive model in guiding decisions for nonsevere and severe lymphedema patients.

RESULTS

The enrolled patients including 28 patients with mild lymphedema (grade I), 38 patients with moderate lymphedema (grade II), and 53 patients with severe lymphedema (grade III) was conducted. A total of 1196 features were extracted, and after Pearson correlation testing and least absolute shrinkage and selection operator screening, 21 nonzero features were selected. The ExtraTree model performed the best, with an area under the curve of 0.974 (95% confidence interval, 0.9437-1.0000) in the training set, a sensitivity of 89.2%, and a specificity of 95.7%. In the test set, these values were 0.938 (95% confidence interval, 0.8539-1.0000), 75%, and 100%, respectively. The decision curve showed that when the predicted probability was between 16% and 78%, the net benefit of the ExtraTree model was greater than that of the two extreme curves, indicating strong clinical value in guiding decisions for nonsevere and severe lymphedema patients.

CONCLUSIONS

All five models performed well in distinguishing between the nonsevere group and the severe group. Noncontrast MRI-based machine learning radiomics signature can predict the severity of primary lower limb lymphedema.

Incidence of lymphedema among adults with cerebral palsy

BACKGROUND

Lymphedema is a chronic and progressive condition but is understudied among adults with cerebral palsy (CP).

OBJECTIVE

To compare the 2-year incidence of lymphedema between adults with versus without CP before and after accounting for multimorbidity, cancer diagnosis/treatment, and lymph node/channel surgery.

DESIGN

Retrospective cohort study.

SETTING

Nationwide commercial claims data from January 1, 2011 to December 31, 2017.

PARTICIPANTS

Adults ≥18 years old with and without CP with at least 12 months of continuous health plan enrollment, defined as the baseline period, were included for analysis. The 12-month baseline period was used to establish information on preexisting lymphedema (for exclusion), presence of cancer, including radiation treatment and lymph node surgery, and the Whitney Comorbidity Index (WCI).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The 2-year incidence rate (IR) and IR ratio (IRR) of lymphedema were evaluated. Cox regression estimated the hazard ratio (HR) of 2-year lymphedema after adjusting for age, gender, WCI, cancer diagnosis/treatment, and lymph node/channel surgery.

RESULTS

The 2-year IR of lymphedema was 5.73 (95% confidence interval [CI] = 4.59-6.88) for adults with CP (n = 9922) and 1.81 (95% CI = 1.79-1.83) for adults without CP (n = 12,932,288); the IRR was 3.17 (95% CI = 2.59-3.87) and the adjusted HR was 2.43 (95% CI = 1.98-2.98). There was evidence of effect modification by gender, age, and WCI score. All HRs were elevated, but men with versus without CP had higher HRs than women with versus without CP; HRs for adults with versus without CP were higher for younger participants and those with lower WCI scores.

CONCLUSIONS

Adults with CP had a higher 2-year rate of lymphedema compared with those without CP. Men with CP had a disproportionately higher rate than women with CP when compared with their gender-based reference cohorts without CP.

Magnetic resonance imaging features of primary lower extremity lymphedema: A retrospective analysis of 228 patients

BACKGROUND

The value of magnetic resonance imaging (MRI) presentation of primary lower extremity lymphedema in assessing the severity of lower extremity lymphedema is uncertain. The purpose of this study was to assess the role of MRI presentation in staging primary lower extremity lymphedema.

METHODS

We enrolled 228 patients with clinically diagnosed primary lower limb lymphoedema from January 2018 to December 2019 in our hospital retrospectively. Patients were divided into stages I, II, and III based on the 2020 International Society of Lymphology clinical staging standards. Two radiologists assessed the following characteristics of the short-term inversion recovery sequence: the extent of edema (longitudinally and transversely); the frequency of MRI manifestations, including the presence of dermal thickening; and the morphology of edema (grid, honeycomb, parallel lines, banded, crescent, and lymphatic lake). The kappa test was used to assess interobserver agreement. The χ2 test was used to compare the frequency differences of MRI manifestations between different clinical stages. The Spearman test evaluated the correlation between edema extent and clinical stage.

RESULTS

The extent of edema was correlated positively with clinical stage, both longitudinally and transversely. When comparing stages, the incidence of dermal thickening in stages II and III was significantly higher than in stage I. The incidence of parallel lines in stage I was significantly higher than that in stages II and III. The grid and banded sign incidence in stages I and II were significantly higher than in stage III. The incidence of honeycomb in stages II and III was significantly higher than in stage I. The incidence of lymphatic lake and crescent in stage III was significantly higher than in stages I and II (P < .001).

CONCLUSIONS

Short-term inversion recovery can sensitively diagnose lymphedema and assist in clinical staging. MRI manifestations of primary lower extremity lymphedema in different stages have specific MRI features.

Prevalence of lower extremity edema following inguinal lymphadenectomy: A systematic review and meta-analysis

Background

Lower extremity lymphedema (LEL) can develop because of inguinal lymph node dissection in the treatment of gynecologic, genitourinary, and dermatological malignancies. To optimize patient counseling and patient selection for microsurgical interventions aimed at preventing or treating LEL, its prevalence and associated patient characteristics must be accurately documented. This systematic review and meta-analysis provides a comprehensive overview of literature on the reported prevalence of LEL in patients undergoing inguinal lymphadenectomy.

Methods

From Embase, PubMed, and Web of Science databases, 23 studies were identified that met the inclusion criteria. This review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. Risk of bias was assessed using the Risk of Bias in Non-randomized Studies-of Exposure tool.

Results

Random-effects meta-analyses of proportions estimated a 24% (95% confidence interval [CI]: 17-31) pooled prevalence of LEL with a high degree of heterogeneity between the studies (I2 =96%, p < 0.01). Subgroup analysis revealed significant differences in LEL prevalence based on the indications for inguinal lymphadenectomy. The pooled LEL prevalence was 25.75% (95% CI: 0.00-96.16) for patients who underwent lymphadenectomy for melanoma, 12.22% (95% CI: 1.03-23.40) for penile cancer, 30.96% (95% CI: 21.08-40.84) for vulvar cancer, and 13.62% (95% CI: 0.00-51.02) for miscellaneous indications.

Conclusion

The findings from this study emphasize the importance of considering malignancy etiology when assessing the risk of LEL following inguinal lymphadenectomy. This knowledge could aid physicians in informing patients about the risk of LEL, while also facilitating proper patient selection for microsurgical interventions.

Long-term results of lymphedema treatment with Combined lymph node transfer and collagen scaffolds: An Observational Study

Aim

Vascularized lymph node transfer (VLNT) accelerates growth factor secretion, lymphatic endothelial cell migration toward the interstitial flow and lymphagiogenesis in a multidirectional pattern. Our observational study aimed to examine the hypothesis that nanofibrillar collagen scaffolds (NCS) combined with VLNT can provide guided lymphagiogenesis creating long-lasting lymphatic pathways.

Methods

Twenty-four patients (21 female, 3 male) underwent a lymphatic microsurgery for upper (n = 11) or lower (n = 13) limb secondary lymphedema and completed at least 18 months follow-up were selected and equally divided in 2 groups; Group-A underwent VLNT, Group-B underwent combined VLNT and NCS procedure. Lymph node flap sizes, harvesting procedure, and implantation location were similar in both groups. Demographics, lymphedema etiology and staging, limb volumetry, and somatometric data were recorded. Pre- and post-operative data for limb-volume difference, infection episodes/year, and indocyanine-green (ICG) lymphography changes were documented in all patients.

Results

Mean follow-up was period was 42 months (24-60 months) in Group-A, and 27 months (18-48 months) in Group-B patients. Demographic data, lymphedema etiology, and staging were comparable in both groups. Pre- and post-operative edema volume difference for Group-A was 36 % and 25 % (p < 0.001), and 33 % and 14 % in Group-B (p = 0.001), respectively. The mean number of infection episodes decreased in Group-A and B from 1.75 to 0.33 and from 2.17 to 0.42 per patient/year, respectively. ICG mean stage in Group-A was 3.58 pre- and 3 post-operatively (p = 0.045), and 3.67 pre- and 2.08 post-operatively in Group-B (p = 0.506). A statistically significant difference was found in post-operative volume difference between the 2 groups (p = 0.008) and post-operative ICG changes (p < 0.001). ICG-lymphography demonstrated new lymphatic vessel formation at the NCS implantation location.

Conclusions

Long-term follow-up of the patients treated using combined VLNT-NCS approach revealed a statistically significant improvement regarding volume reduction, infection episodes per year, ICG downstaging, and new lymphatic vessel formation, compared to VLNT alone.

Objectifying Clinical Outcomes After Lymphaticovenous Anastomosis and Vascularized Lymph Node Transfer in the Treatment of Extremity Lymphedema: A Systematic Review and Meta-Analysis

BACKGROUND

Upper extremity lymphedema (UEL) and lower extremity lymphedema (LEL) can develop as a result of lymph node dissection in the treatment of various malignancies. While emerging microsurgical interventions using lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) show promising outcomes for patients with lymphedema, the best approach to implementing the two procedures remains to be defined. This systematic review and meta-analysis provide a comprehensive overview of published literature on the clinical improvement of extremity lymphedema in patients who undergo either LVA, VLNT, or a combined microsurgical procedure.

METHODS

From Embase, PubMed, and Web of Science databases, 52 studies were identified that met inclusion criteria. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The risk of bias was assessed using the Risk Of Bias In Nonrandomized Studies-of Interventions (ROBINS-I) tool and the Cochrane tool for randomized trials (RoB 2).

RESULTS

Random-effects meta-analyses of means estimated a pooled clinical improvement of 36.46% (95% CI: 29.44-43.48) for UEL and 34.16% (95% CI: 23.93-44.40) for LEL. Subgroup analyses revealed differences in clinical improvement according to the microsurgical approach. Clinical improvement of UEL was 29.44% (95% CI: 15.58-43.29) for LVA, 41.66% (95% CI: 34.13-49.20) for VLNT, and 32.80% (95% CI: 21.96-43.64) for combined VLNT + LVA, while the improvement of LEL was 31.87% (95% CI: 18.60-45.14) for LVA and 39.53% (95% CI: 19.37-59.69) for VLNT.

CONCLUSION

The findings from this study elucidate the clinical improvement in extremity lymphedema from various microsurgical approaches. This knowledge could aid physicians in the shared decision-making process with UEL and LEL patients and better facilitate proper patient selection for microsurgical interventions.

Single-nuclear transcriptomics of lymphedema-associated adipose reveals a pro-lymphangiogenic stromal cell population

Chronic lymphedema is a progressive, disfiguring disease that results from dysfunction of the lymphatic vasculature, causing distal accumulation of interstitial fluid, localized development of tissue edema, and expansion of subcutaneous adipose tissue (SAT). As the molecular mechanisms governing SAT remodeling in this disease are unclear, we performed single-nucleus RNA sequencing on paired control and affected SAT biopsies from patients with unilateral lymphedema. Lymphedema samples were characterized by expansion of SAA + adipocytes, pro-adipogenic stem cells, and proliferation of lymphatic capillaries. A GRIA1 + lymphedema-enriched stromal cell population expressing VEGFC , ADAMTS3 , and CCBE1 was identified, suggesting an enhanced axis of communication between adipose stem and progenitor cells (ASPCs) and lymphatic endothelial cells. Furthermore, lymphedema ASPC-conditioned media promoted lymphatic endothelial tube elongation in vitro . These findings indicate a critical role for ASPCs in regulating adipocyte differentiation and lymphatic vascular remodeling in lymphedema, and provide a valuable resource for better understanding this disease.

A New Secondary Chronic Lymphedema Rat Model Improved by High-Fat Diet

Purpose: Secondary chronic lymphedema is a complication that seriously affects the quality of life of cancers survivors which is urgent to be studied. However, the current animal models generally have some defects such as short duration that affect the research process. To acquire an animal model which is easier to accomplish as well as higher success rate is the main goal of our experiment. Methods: The hind limb model of rats with secondary chronic lymphedema was established by near infrared fluorescence-guided lymphatic system destruction combined with high-fat diet innovation. The model was evaluated by limb circumference, volume, near-infrared fluorescence imaging of lymphatic vessels, and a series of histopathological staining. Results: The model was successfully established by operation combined with a high-fat diet and kept persistent effective lasting up to 16 weeks. Compared with the normal diet group, the high-fat group received a higher success rate (77.77% vs. 55.55%), a more obvious degree of limb swelling, and a more significant level of subcutaneous inflammatory factor infiltration at the edema site. Based on it, we kept research and found out that there was no significant difference in the process of subcutaneous fibrosis between the two groups. Conclusions: High-fat diet may improve secondary chronic lymphedema rat model success rate as well as effectiveness by changing the level of inflammatory infiltration in the site of lymphedema.

The prognostic effect and mechanism of erysipelas in cancer-associated lymphedema

Lymphedema is a chronic condition that can follow cancer treatment, and liposuction has been shown to be an effective approach for reducing limb volume in advanced cases. However, recurrence rates vary widely, with prior erysipelas identified as a potentially significant factor influencing prognosis. This study aimed to identify key risk factors for recurrence following liposuction in patients with cancer-associated secondary lymphedema, develop a predictive nomogram model, and investigate the molecular mechanisms by which previous erysipelas may affect recurrence. In a retrospective analysis of 1,016 patients, multivariate logistic regression and propensity score matching identified four independent risk factors, namely, prior erysipelas, hyperlipidemia, severe distal limb edema, and older age, with erysipelas showing the strongest association with poor outcomes (OR 3.98; 95% CI: 2.81-5.69). A validated nomogram demonstrated high predictive accuracy (C-index 0.757, Brier score 0.176) and net clinical benefit in estimating recurrence risk. The nomogram supports personalized treatment strategies, potentially improving patient outcomes. Transcriptome sequencing further revealed that previous erysipelas exacerbates lymphedema through inflammation, tissue remodeling, and metabolic dysregulation, suggesting potential therapeutic targets.

Similarities and differences in the clinical features and management of primary lymphedema and kaposiform hemangioendothelioma associated with lymphedema in children

Background

Primary lymphedema (PLE) and kaposiform hemangioendothelioma-related lymphedema (KLE) are rare vascular anomalies (VAs). This study aimed to examine the clinical features, management, and prognosis of PLE and KLE.

Method

The clinical features, imaging, treatments, and outcomes of 12 patients with PLE and 12 patients with KLE were retrospectively reviewed.

Results

The mean age at which signs/symptoms were diagnosed was 68.2 months for PLE patients and 25 months for KLE patients. In PLE, the involvement of multiple sites is common, whereas in KLE, it typically affects a single site. Morbid obesity, which is common in adult patients, is rare in pediatric PLE and KLE patients. Imaging agent accumulation was observed in KLE but not in PLE via lymphoscintigraphy. In contrast, complications of PLE primarily involve skin and soft tissue, whereas musculoskeletal system complications are more common in KLE. Regarding prognosis, most patients stabilize or even experience lesion regression after standard treatment.

Conclusion

PLE and KLE share clinical symptoms. PLE often involves multiple sites, whereas KLE typically presents unilaterally with local lymphatic stasis. Standardized treatment enables the majority of children with lymphedema to control the disease without progression, with KLE showing potential reversibility. Given their rarity, a multidisciplinary approach is crucial for diagnosis and management.

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.

Research trends on lymphedema after mastectomy for breast cancer patients from 2000 to 2023: a scientometric analysis

Background

Breast cancer-related lymphedema (BCRL) is a common and debilitating complication following breast cancer treatment. Despite its significant impact on patients' quality of life, bibliometric analyses focusing on BCRL are scarce. This study aims to explore global research trends on BCRL from 2000 to 2023, identify existing knowledge gaps, and highlight emerging focus areas through a bibliometric approach.

Methods

A comprehensive search was conducted using the Web of Science (WOS) database to retrieve literature published between January 2000 and November 2023. Bibliometric analyses and visualizations were performed using R Studio, CiteSpace, and VOSviewer. Key data extracted included publication trends, contributing countries and institutions, leading authors, journals, research categories, and keywords. Outcome measures for analysis included the number of publications, citation counts, author productivity, and keyword co-occurrence.

Results

A total of 919 eligible publications from 52 countries and regions, 1,163 institutions, and 3,550 authors were identified. These publications appeared in 255 journals, with "Lymphology" emerging as the journal with the highest citation count. The USA was the most prolific contributor to the field. The annual number of publications demonstrated a consistent upward trend. Keyword co-occurrence analysis revealed prominent research hotspots, including "lymphedema," "women," "breast cancer," "arm lymphedema," and "quality of life." Emerging keyword trends from 2021 to 2023 highlighted "prevention" and "validity" as pivotal research frontiers.

Conclusions

This bibliometric study highlights the growing interest in breast cancer-related lymphedema research and identifies key areas for future investigation, including prevention, diagnosis, and treatment strategies. The results underscore the need for further exploration of these emerging research areas to improve patient outcomes.

Biflex Self Adjust: a compression wrap system for lymphoedema and venous leg ulcers

Compression is the foundation of treatment for chronic oedema, including lymphoedema and chronic venous insufficiency (CVI). However, adherence with conventional compression wraps is often poor. This article introduces Biflex Self Adjust, a new compression wrap system for lymphoedema and venous leg ulcers, a common consequence of CVI. A Velcro system and an integrated loop ensures patients can easily and quickly take Biflex Self Adjust on and off. Biflex Self Adjust uses a patented integrated device that allows healthcare professionals and patients to easily adjust the pressure. In addition, Biflex Self Adjust completely covers the limb using an optimised number of overlapping bandages, which helps prevent oedema migration. The open-cell foam used in Biflex Self Adjust allows moisture transfer, which enhances comfort. Case studies illustrate the effectiveness of the Biflex Self Adjust in clinical practice.

Measurement Properties and Determinants of the 6-Minute Walk Test in Patients with Lower Limb Lymphedema

Background: The aim of this study was to investigate the validity and reliability and identify determinants of the 6-minute walk test (6MWT) in patients with lower limb lymphedema (LLL). Methods and Results: The study included 28 patients with LLL and 28 healthy subjects. To investigate the convergent validity and determinants of the 6MWT, patients were assessed using the following measurements: circumference measurement for lymphedema severity, hand-held dynamometry for muscle strength, time up and go for functional mobility, five-time sit-to-stand test for functional lower extremity strength, Lower Extremity Functional Scale for lower extremity functionality, Lymphedema Life Impact Scale for quality of life, and International Physical Activity Questionnaire-Short Form for physical activity level. The test-retest reliability of the 6MWT was assessed using intraclass correlation coefficients (ICCs). 6MWT, a test-retest reliability analysis was carried out with 28 patients within 3-7 days. The receiver operating characteristic (ROC) curve was employed to determine the cut-off point of 6MWT. The test-retest reliability of 6MWT was detected as excellent (ICC [95%] 0.93 [0.87-0.97]). Significant correlations were found between the 6MWT health-related and disease-specific parameters, indicating sufficient convergent validity (r ≥ 0.3). The ROC curve indicated a cut-off point of 504 meters (area under the curve [AUC] 0.712 [95%CI: 0.575-0.849]). Multiple linear regression analysis demonstrated that lymphedema severity, hip abduction muscle strength, and lower limb functionality were the predictors of 6MWT. Conclusions: The 6MWT has been shown to be a reliable and valid tool for assessing the functional capacity of patients with LLL.

3D scanner's potential as a novel tool for lymphedema measurement in mouse hindlimb models

Lymphedema is characterized by persistent swelling due to impaired lymphatic function and presents significant challenges in both research and clinical settings. Traditional contact-based measurement techniques such as paw thickness and circumferential measurements using calipers or silk thread are useful but limited by observer variability and measurement accuracy. Non-contact methods, including various imaging techniques, offer improvements but often at higher cost and complexity. In this study, we address the need for a more reliable, cost-effective, and non-invasive method for assessing lymphedema in mouse models. Here we show that 3D scanning technology can enhance the measurement of lymphedema in a mouse hindlimb model. Our results indicate that 3D scanners provide more consistent measurements with lower variability compared with conventional methods and without the need for direct contact, which could potentially alter the measurement outcomes. The findings of this study suggest that 3D scanning could replace traditional methods, offering a more standardized and less subjective tool for lymphedema research in the near future. This technology would not only improve upon conventional methods but also extend the capabilities for detailed anatomical analyses in small animal models, which could have implications for other areas of biomedical research.

Clinical Variables Associated with Lymphedema Surgery: Physiologic versus Excisional

BACKGROUND

 As surgical interventions for lymphedema become increasingly available, it is important to understand characteristics of patients that undergo lymphedema surgery. The goal of this study was to define clinical variables of patients evaluated at a medical center who underwent lymphedema surgery to better inform which referred patients are surgical candidates.

METHODS

 A cross-sectional observational study was performed on patients referred to plastic surgery for lymphedema between January 2016 and June 2023. The operative group included patients who underwent lymphedema surgery, including physiologic surgery (PS) and excisional surgery (ES). The nonoperative group consisted of patients referred for lymphedema who did not undergo lymphatic surgery. Patient records were collected, and between-group comparisons were performed.

RESULTS

 A total of 285 total patients were identified (n = 66 operative, n = 219 nonoperative). The operative cohort had higher body mass index (BMI) than the nonoperative (33.5 vs. 31.2 kg/m2, p < 0.035) and was more likely to have undergone physical therapy/occupational therapy (68.2 vs. 53.4%, p = 0.005). Within the operative cohort (PS = 37, ES = 29), PS patients were more likely to be White (91.9 vs. 69.0%, p = 0.043) and have lower BMI (32 vs. 42.7 kg/m2, p = 0.007). PS patients were diagnosed for a longer period (8 vs. 3 years, p = 0.03) before seeing a plastic surgeon, more commonly had upper extremity lymphedema (43.2 vs. 13.8%, p = 0.016) and presented at an earlier lymphedema stage (stage 1 64.9 vs. 27.6%, p = 0.002). PS patients were more likely to have prior radiation (56.8 vs. 20.7%, p = 0.005), previous surgery (75.5 vs. 48.3%, p = 0.038), and prior lymphatic intervention (67.6 vs. 17.2%, p < 0.001) near the affected area.

CONCLUSION

 Defining patient characteristics associated with surgical intervention for lymphedema can aid surgeons to increase the proportion of patients seen in clinic who are surgical candidates. Factors relating to oncological and surgical history in the affected area may suggest a patient is more likely to undergo PS.

Ultrasound-Mediated Piezoelectric Microneedles Regulating Macrophage Polarization and Remodeling Pathological Microenvironment for Lymphedema Improvement

Lymphedema, a severe and complex inflammatory disease caused by lymphatic system insufficiency and impeded lymphatic drainage that causes an enormous physical and psychological burden on patients and may even lead to death, has long been a challenging issue in the medical field. Clinically, conventional approaches including surgical treatment and conservative treatment have been employed for lymphedema therapy, but their curative effect is still unsatisfactory because of high operational difficulty, high cost, and long-term reliance. In this study, a novel kind of piezoelectric microneedle driven by ultrasound (US) is proposed to regulate macrophage polarization and remodel the pathological inflammatory microenvironment in a noninvasive manner, thereby promoting lymphatic regeneration and improving lymphedema. US-mediated piezoelectric microneedles can significantly enhance the anti-inflammatory M2-type polarization of macrophages while suppressing pro-inflammatory M1-type polarization in vitro. Enhancements in macrophage M2 polarization can trigger increased secretion of anti-inflammatory factors (e.g., IL-4, IL-10, and Arg-1) that promote inflammatory microenvironment remodeling and immune rebalancing. In a mouse-tail lymphedema model, a higher proportion of M2 macrophage polarization marker CD206 is observed accompanied by normal lymphangiogenesis and lymphedema subsiding following piezoelectric microneedles with US stimulation treatment. Additionally, based on RNA sequencing and mechanistic investigation, it was revealed that US-mediated piezoelectric microneedles can activate signaling pathways related to M2 macrophage polarization that regulate inflammatory responses and improve lymphatic function, consequently alleviating lymphedema. Collectively, this study provides a new strategy for lymphedema therapy in a noninvasive and drug-free manner as well as a potent tool to manipulate macrophages for other immunological diseases.

Cross-Sectional Analysis of Patients Referred to a Tertiary Lymphatic Surgery Center

BACKGROUND

Secondary lymphedema has become an increasingly common reason for referral to plastic surgery. Understanding referral patterns for lymphedema patients is crucial to optimizing care.

PATIENTS AND METHODS

Patients referred to plastic surgery for lymphedema at a lymphatic surgery center between January 2016 and 2023 were identified. Primary outcomes of interest included clinical lymphedema staging and characteristics, patient demographics, and referral sources. Secondary outcomes were prior lymphedema treatment, agreement between referring provider and plastic surgeon's diagnosis, and patient disposition after surgical evaluation. Descriptive statistics and multivariate logistic regression analysis were performed.

RESULTS

A total of 285 patients with extremity edema were referred to plastic surgery; 60.0% of patients had prior malignancy, 45.6% of patients had undergone a prior lymph node procedure, and 40% had received radiation, while 56.8% of patients had previously seen occupational therapy. Body mass index (BMI, OR 1.09, p = 0.013), age (OR 1.25, p = 0.005), and prior physical or occupational therapy (OR 1.23, p = 0.011) were associated with later stages of lymphedema upon presentation, while prior radiation (OR 0.79, p = 0.006) and malignancy (OR 0.85, p = 0.034) were associated with earlier stages of lymphedema. Self-referral (27.4%), primary care (17.9%), and medical oncology (14.7%) were the most common referral sources. Lymphedema was confirmed in 68.1% of referrals, and 28.5% of these patients proceeded to surgery. Patients were more likely to be operative candidates if referred by primary care (RR 2.1, p = 0.006) or occupational therapy (RR 4.6, p = 0.010).

CONCLUSIONS

Referred patients ultimately undergo lymphedema surgery at relatively low rates, indicating that most referred patients are not ideal surgical candidates. Optimizing referral patterns through multidisciplinary education may enhance the referral process and improve access to lymphedema surgery.

Effective Management Strategies for Primary Lymphedema of the Lower Extremities: Integrating Conservative and Surgical Therapies in Early and Late Stages

INTRODUCTION

Lymphedema, a debilitating characterized by localized fluid retention and tissue swelling, results from abnormalities in the lymphatic system. In the case of primary lymphedema, this condition is attributed to malformations in lymphatic vessels or nodes, and it is marked by a relentless progression leading to irreversible tissue fibrosis after repetitive inflammation. Many questions regarding its treatment, such as the choice of the type of intervention and the timing, still remain unanswered. This study aims to present our comprehensive approach to treat this challenging condition.

METHODS

To elucidate our approach, we conducted a retrospective chart review of 42 patients treated for primary lymphedema at 3 hospitals between July 2010 and December 2022. The study included two patient groups, those with early-stage disease (20) and those in the advanced stages (22). We outline our algorithm, based on our clinical experience in Taiwan. Patients were followed for at least 12 months post-treatment, and assessments were made, including photographic evidence.

RESULTS

A total of 42 patients participated in our study: 20 in the early stage and 22 in the late stage. Our approach yielded significant functional improvements and symptom regression in both groups. In the early-stage cohort, all 20 patients underwent VLNT procedures and SAL, with 15 (75%) undergoing unilateral procedures and 5 (25%) bilateral. Among the advanced-stage patients, 12 (54.5%) were treated with the modified Charles' procedure, and 10 (45.5%) with RRPP. The outcomes showed an average circumference reduction of 4.1 cm (2.9-5.3) after VLNT and liposuction. Reductions were noted at various levels: 5.7 cm (4.6-6.8) at mid-thigh, 4.3 cm (2.5-6.1) at mid-calf, 3.5 cm (2.7-4.3) at the ankle, and 1.4 cm (0.7-2.1) at mid-foot. Tonicity decreased by 5.9% (5.2-6.6), indicating significant tissue softening. Tissue removal averaged 3.7 kg (2.9-4.5) after the modified Charles' procedure and 2.6 kg (2.3-2.9) after RRPP. Patients experienced a mean of 3 (2-4) episodes of cellulitis per year, with no cellulitis in early-stage treated limbs during the follow-up period. Complications were minimal, including 4 partial skin graft losses that healed with conservative treatment and 3 postoperative infections after the modified Charles' procedure, treated successfully with antibiotics. No major complications were reported at the lymph node flap donor site.

CONCLUSION

Primary lymphedema poses a considerable challenge, primarily due to its relentless progression if left untreated. The existing literature offers limited guidance on its management. Our algorithm, developed over years of experience, aims to fill this gap. By integrating surgical and conservative interventions, as well as individualized patient follow-up, we provide a comprehensive framework for managing both early and late- stage cases.

[Cost comparison of conservative vs. surgical treatment of chronic lymphedema]

BACKGROUND

Lymphedema is primarily treated conservatively using complex physical decongestion treatment (CDT). Lymphovenous anastomosis (LVA), vascularized lymph node transplantation (VLNT) and liposuction are available as surgical treatment methods; however, reimbursement in the diagnosis-related groups (DRG) system is sometimes inadequate or only possible following an individual application. The costs of these relatively new surgical procedures have not yet been set in relation to those of CDT.

METHOD

The costs of conservative treatment were determined in accordance with the guidelines. The costs for LVA, VLNT and liposuction of the upper and lower extremities were estimated on the basis of the DRG reimbursement per case and the expected reduction in conservative measures according to current knowledge. The annual treatment costs were then compared.

RESULTS

The annual treatment costs of LVA and VLNT are already lower than conservative treatment alone in the second postoperative year. Liposuction reaches this point in the 6th (upper extremity) or 47th postoperative year (lower extremity).

CONCLUSION

The evidence for the positive effects of lymphatic surgery is still limited; however, it is recognizable that the curative surgical approach can significantly reduce the treatment costs and improve the quality of life of lymphedema patients; however, there is a lack of adequate reflection of the surgical effort in the reimbursement.

Anti-CTLA4 treatment reduces lymphedema risk potentially through a systemic expansion of the FOXP3+ Treg population

Secondary lymphedema is a common sequel of oncologic surgery and presents a global health burden still lacking pharmacological treatment. The infiltration of the lymphedematous extremities with CD4+T cells influences lymphedema onset and emerges as a promising therapy target. Here, we show that the modulation of CD4+FOXP3+CD25+regulatory T (Treg) cells upon anti-CTLA4 treatment protects against lymphedema development in patients with melanoma and in a mouse lymphedema model. A retrospective evaluation of a melanoma patient registry reveals that anti-CTLA4 reduces lymphedema risk; in parallel, anti-CTLA4 reduces edema and improves lymphatic function in a mouse-tail lymphedema model. This protective effect of anti-CTLA4 correlates with a systemic expansion of Tregs, both in the animal model and in patients with melanoma. Our data thus show that anti-CTLA4 with its lymphedema-protective and anti-tumor properties is a promising candidate for more diverse application in the clinics.

Effect of Strength Training on Body Composition, Volumetrics and Strength in Female Breast Cancer Survivors

BACKGROUND/AIMS

This cross-sectional study investigates body composition and strength in female breast cancer survivors, focusing on the effects of radical mastectomy and the presence of upper extremity lymphoedema. The main objective was to understand body composition, volumetry, and strength, as well as response to strength training in female breast cancer survivors.

METHODS

Twenty-three women (aged 42-74 years old) with radical mastectomy in the last five years were assessed by measuring body composition (weight, water percentage, fat, muscle, and lean mass), maximal strength, perimeters, and brachial volumes. Participants completed a 10-week strength training program of moderate intensity with 20 training sessions. No significant differences were found between the affected/healthy hemispheres in terms of composition, perimeters, and volumetrics. However, 11 women were found to have lymphoedema (47.8%). No statistically significant differences were found between hemibodies after the intervention, although improvements were obtained in pectoral strength and manual grip, as well as in muscle mass and lean mass [p = 0.002 each]. Cases with lymphoedema were reduced to 5 (21.73%).

CONCLUSIONS

While strength training is shown to benefit body composition, strength, and the incidence of lymphoedema in mastectomized women, further scientific evidence is needed with larger controlled trials and follow-up studies to validate these findings, as well as the impact on the quality of life of these survivors.

Illness Perception and Risk Management Behaviors Among Patients With Gynecologic Cancer at Risk of Lower Extremity Lymphedema

BACKGROUND

Patients with gynecologic cancer who undergo lymphadenectomy are at increased risk of lower extremity lymphedema (LEL). They are encouraged to be alert to the possibility of LEL and take risk-management measures throughout life. However, we know little about the perception for LEL and adherence to risk-management measures of Chinese patients with gynecologic cancer.

OBJECTIVE

To assess the illness perception and risk management behaviors of Chinese gynecologic cancer patients and further examine the effect of illness perception on risk management behaviors.

METHODS

This was a cross-sectional study. From June to December 2023, gynecologic cancer patients at risk of LEL were surveyed (n = 223). Questionnaires on illness perception and risk management behaviors specifically for LEL were utilized. Descriptive statistics, Pearson correlation analysis, univariate analysis, and multiple linear regression analysis were used for data analysis.

RESULTS

The participants exhibited suboptimal LEL risk management behaviors, with the physical activity dimension receiving the lowest score (3.24 ± 1.02). Patients' self-perceived understanding of LEL was relatively low (2.88 ± 0.83). Multiple linear regression analysis revealed that the identity, cause, and control dimensions of illness perception, as well as several demographic and disease variables, were significant predictors of patients' LEL risk management behaviors.

CONCLUSIONS

The LEL risk management behaviors of patients with gynecologic cancer need to be improved. Consideration of perceptions of identity, cause, and control is crucial for enhancing LEL risk management behaviors.

IMPLICATIONS FOR PRACTICE

Health professionals can implement targeted health education based on an assessment of patients' perceptions of LEL, thereby promoting lymphedema risk management.

Lymphedema: Current Strategies for Diagnostics and Management

ABSTRACT

Lymphedema (LE) is characterized by the accumulation of lymph in the extremities, impairing functionality and quality of life. Despite its prevalence, accurate diagnoses and management remains complex because of inconsistencies in diagnostic criteria and limited epidemiological studies. This review aims to address this gap by providing a comprehensive overview of LE classifications, diagnostic approaches, and current management strategies. By synthesizing existing knowledge, this study seeks to contribute to a deeper understanding of LE for improvement of clinical consistency and education.

Phospholipase A2 (PLA2) injured lymphatic endothelial cells leading to progression of secondary lymphoedema

Secondary lymphoedema is one of the common complications after lymph node dissection for gynecologic malignancies and breast cancer. In this study, the relationship between PLA2 and postoperative lymphoedema in cancer at the molecular level has been explored through transcriptomics and metabolomic assays. Transcriptome sequencing technology, as well as metabolomic assays, were utilized to explore the expression of PLA2 in lymphoedema patients, and search for potential pathways in the pathogenesis and exacerbation mechanism of lymphoedema. The effect of sPLA2 on human lymphatic endothelial cells was investigated by culturing human lymphatic endothelial cells. Secretory phospholipases A2 (sPLA2) showed high expression levels in lymphoedema tissues, however, cytoplasmic phospholipases A2 (cPLA2), showed low expression in lymphoedema, as demonstrated by RT-qPCR. By culturing human lymphatic vascular endothelial cells, the study found that sPLA2 causes HLEC vacuolization and has an inhibitory effect on HLEC proliferation and migration. By detecting sPLA2 in the serum of lymphoedema patients and analyzing clinical data, it was found that sPLA2 was positively correlated with the severity of lymphoedema. Secretory Phospholipase A2 (sPLA2) is highly expressed in lymphoedema tissue, damages lymphatic vessel endothelial cells, is strongly associated with disease severity, and can be used as a potential predictor of disease severity.Abbreviations: PLA2: Phospholipase A2; DEGs: differentially expressed genes; DMP: differential metabolic production.

Evolving Role of Lymphedema Surgery on Breast Reconstruction: A Systematic Review and Multi-Institutional Algorithmic Approach

Background/Objectives: Recent advancements in breast cancer treatment have led to increased survival rates, prompting a shift towards addressing breast cancer-related lymphedema (BCRL). Despite the evolving role of lymphatic surgery in breast reconstruction, there is limited literature evaluating the current role of lymphatic surgery in breast reconstruction. This review aims to evaluate the state of lymphatic surgery in breast reconstruction, analyzing surgical techniques and proposing a multi-institutional algorithmic approach. Methods: Through a search and screening of literature, data regarding the study type, type of operation (bypass, pLVB/ILR/LYMPHA, VLNT, or a combination of treatments), and clinical outcomes were collected. Results: The systematic review included 184 studies. Overall, the number of publications on lymphatic surgery increased from 4.4 per year (2010-2016) to 21.1 per year since 2017. The most published procedure was vascularized lymph node transfer (34.6%), followed by preventive lymphatic surgery (31.4%), therapeutic lymphovenous bypass (23.3%), and combined breast and lymphatic reconstruction (10.7%). While VLNT was the most published procedure, preventive surgery has been the most published topic since 2020, with 11.7 articles per year since. Similarly, there has been an increase in studies on combined lymphatic surgery and breast reconstruction in the last five years, with 16 articles published. Conclusions: The role of lymphatic surgery in breast cancer patients is evolving, with an increasing emphasis on preventive procedures and combined reconstructive approaches. However, our study shows that the current literature is predominantly based on lower-level evidence, highlighting the need for more randomized controlled trials to establish stronger clinical recommendations.

Perforator-to-Perforator SCIP-Based Vascularized Lymphnode Transfer to Reduce Morbidity and Increase Efficacy in Lymphedema Surgery: Preliminary Results With 12 Cases

BACKGROUND

Vascularized lymphnode transfer (VLNT) is one of the most common surgical treatments for moderate and severe lymphedema. Various techniques have been described for harvesting lymph nodes from different donor sites. However, a standardized harvest procedure is still lacking. The transplantation of inguinal lymph nodes using the perforator-to-perforator technique may represent a significant advancement in this context. This approach relies always on the same vascular pedicle, offers a lower morbidity, and allows for a more superficial inset at the recipient site.

PATIENTS AND METHODS

Between 2019 and 2022, 12 patients received a perforator-to-perforator VLNT for the treatment of late stage (Late II) lymphedema, both primary and secondary. In all cases, the lymphnodes were harvested from the groin supplied by the superficial circumflex iliac artery perforator (SCIP) vessels. The average age was 62.2 years old (range 47-73 years old); nine patients were females and three were males. In 11 cases, the lower limb was affected, and in one case, the upper limb was affected. Eight patients received additional lymphovenous anastomosis.

RESULTS

All the patients reported an improvement of the symptoms after surgery in terms of tissue quality (tenderness, lymphangiectasia, and pain), and no cases of recurrent cellulitis were reported. Postoperative lymphoscintigraphy was performed at 6 months, and in all cases, the function of transplanted lymphnodes was confirmed. No complications were encountered, neither at donor nor at recipient site. The follow-up was at least 12 months in all patients.

CONCLUSIONS

Despite being more technically demanding, the systematic implementation of the perforator-to-perforator technique for the transfer of SCIP-based inguinal lymphnodes can be a valuable evolution of VLNT. The aim of this study is to present how this technical approach may become a standardized procedure for inguinal-based VLNT, offering a reduced donor and recipient site morbidity and potentially enhancing the lymph draining effects due to a more superficial inset.

Factors Predicting the Effect of a Complex Decongestive Therapy in Patients with Mild Lymphedema Following Mastectomy for Early Stage Breast Cancer

Background: Complex decongestive therapy (CDT) is being used in breast cancer-related lymphedema (BCRL). The degree of initial edema and bioimpedance analysis (BIA) are known to be related with the therapeutic effect of CDT. D-dimer can indirectly reflect lymphangiogenesis because IL-6 regulates D-dimer and vascular endothelial growth factor, which is the most important lymphangiogenic factor. We assessed whether D-dimer could be used for the prediction of therapeutic effect of CDT, as well as BIA and initial edema. Methods: The participants were patients who took inpatient treatment for BCRL from July 2016 to May 2020. Percent excess volume (PEV) was calculated by dividing the difference in volume of both arms by the edema arm, and the difference in PEV before and after 2 weeks of CDT was defined as the CDT effect. BIA and D-dimer tests were performed before treatment. Results: The single frequency bioimpedance analysis (SFBIA) ratio and D-dimer showed significant correlations with β coefficients of 0.581 and 0.402 (p < 0.01), respectively, and the explanatory power of these models was confirmed to be 0.704.The areas under the curve of initial PEV, SFBIA ratio, D-dimer for determining the CDT effect were identified as 0.849, 0.795, and 0.725, respectively. Conclusions: Initial PEV, SFBIA ratio, and blood D-dimer levels could be used as predictors for CDT treatment effect. Their usefulness order was in the order of initial PEV, SFBIA ratio, and D-dimer. These factors could be used as predictors to establish therapeutic plan in patients with mild lymphedema.

Translation, Cross-Cultural Adaptation and Validation of the Lymphedema Quality of Life Questionnaire (LYMQOL) in German-Speaking Patients with Upper Limb Lymphedema

Objectives: The LYMQOL is the most frequently translated, validated, objective tool for assessing Health-Related Quality of Life (HRQoL) in individuals with upper limb lymphedema (ULL). There have been adaptations and validations in a number of different countries. While a German version of LYMQOL Leg for lower limb lymphedema is available, a validated translation of LYMQOL Arm to German is lacking. We aimed to perform a cross-cultural adaption and translation according to ISPOR principles. Methods: Patients suffering from ULL from Germany, Austria, and Switzerland (n = 52) were questioned twice using the translated LYMQOL Arm, SF-36, and an evaluation questionnaire. The assessment of the content validity and face validity proved this version of LYMQOL Arm to be acceptable for interviewing German-speaking patients with ULL in Germany. Results: Comparison of LYMQOL Arm and SF-36 demonstrated good construct validity. Test-retest reliability was moderate to good (intraclass correlation coefficients 0.66-0.73). Cronbach's alpha values varied between 0.79 and 0.89 in both interviews, indicating good internal consistency. Factor analysis revealed a cumulative variance of 59.5% for the four domains of the questionnaire. Conclusion: There was no significant association between lymphedema stage and LYMQOL Arm score. This trial tested the appropriateness of the German version of the LYMQOL Arm for measuring HRQoL in German-speaking individuals with ULL.

Andrographolide promotes lymphangiogenesis and lymphatic vessel remodeling to alleviate secondary lymphedema

Lymphedema, a prevalent, multifaceted, and chronic ailment, is mainly managed through physical manipulation and suffers from a lack of specific pharmacological treatments. Secondary lymphedema is mainly caused by impaired lymphatic drainage. Therapeutic lymphangiogenesis is a promising strategy in the treatment of lymphedema. Andrographolide, a natural product from Andrographis paniculata, is unknown whether andrographolide promotes lymphangiogenesis to improve secondary lymphedema. By using the murine tail lymphedema model, we demonstrated that andrographolide can reduce the thickness of subcutaneous tissue in the mice's tail and enhance lymphatic drainage. Moreover, immunofluorescence staining showed that the number of capillary lymphatic vessels in the ANDRO25 group was significantly more than that in the ANDRO50 and Model groups. Near-infrared lymphography images showed that highlighted sciatic lymph nodes could be seen in the ANDRO25 and ANDRO50 groups. In vitro, andrographolide could promote the proliferation and migration of LEC. In conclusion, andrographolide enhanced the recovery of lymphatic vessels, and promoted lymphatic drainage in the murine tail lymphedema model by promoting the proliferation of lymphatic endothelial cells, thereby reducing the symptoms of lymphedema. This suggested andrographolide may be used as a potential therapeutic drug or medical food ingredient to help patients with secondary lymphedema.

Synchronous supraclavicular vascularized lymph node transfer and liposuction for gynecological cancer-related lower extremity lymphedema: A clinical comparative analysis of three different procedures

OBJECTIVE

Gynecological cancer-related lower extremity lymphedema (GC-LEL), a chronic, progressive condition, lacks a standardized treatment. Currently, supraclavicular vascularized lymph node transfer (SC-VLNT) is a favored approach in the treatment of lymphedema, and there is a trend toward combination technology. This study conducts a comparative analysis of three techniques for treating GC-LEL with simultaneous SC-VLNT and liposuction.

METHODS

A cohort of 35 patients with GC-LEL was examined, comprising 13 patients who underwent single lymph nodes flap with a skin paddle (SLNF+P), 12 who received single lymph nodes flap without a skin paddle (SLNF), and 10 who accepted dual lymph nodes flap without a skin paddle (DLNF). Patient demographics and outcomes were meticulously documented, covering intra- and postoperative variables.

RESULTS

The median limb volume reduction were 56.4% (SLNF+P), 60.8% (SLNF), and 50.5% (DLNF) in stage II, and 54.0% (SLNF+P), 59.8% (SLNF), and 54.4% (DLNF) in stage III. DLNF group procedures entailed longer flap harvesting and transplantation times. The SLNF+P group, on average, had an 8-day postoperative hospitalization, longer than others. All patients noted subjective improvements in Lymphedema Quality of Life scores, with lymphoscintigraphy revealing enhanced lymphatic flow in 29 of the 35 cases. A notable decrease in cellulitis incidence was observed. Additionally, the occurrence of cellulitis decreased significantly, except for DLNF (Stage Ⅱ). The median follow-up time was 16 months (range, 12-36 months), with no reported severe postoperative complications.

CONCLUSIONS

For advanced GC-LEL, SLNF combined with liposuction is a preferred treatment, offering fewer complications, shorter operative time, and hospitalization.

The value of the dermal rim sign on nonenhanced magnetic resonance imaging for predicting dermal backflow in patients with primary lower extremity lymphedema

PURPOSE

The dermal rim sign (DRS) on nonenhanced magnetic resonance imaging has been shown to predict dermal backflow (DBF) in patients with secondary upper limb lymphedema. However, whether the DRS has the same effects on primary lower extremity lymphedema (PLEL) has not been clearly reported. Therefore, this study aimed to explore whether the DRS can be used to diagnose DBF on lymphoscintigraphy in patients with PLEL.

METHODS

A total of 94 patients who were diagnosed with PLEL were recruited for this retrospective study from January 2022 to December 2023. All the patients were divided into two groups according to the lymphoscintigraphy findings: no DBF and DBF. The magnetic resonance imaging data of the two groups were recorded and statistically compared for the following indicators: range of lymphedema involvement (left, right, whole lower limbs, only thigh, only calf and ankle), signs of lymphedema (notable thickening of skin, parallel line sign, grid sign, honeycomb sign, band sign, lymph lake sign, crescent sign, DRS), and lymphedema measurement (skin thickness, band width). The DRS is characterized by notable thickening of the skin plus the grid sign and/or honeycomb sign, plus the band sign.

RESULTS

The following statistically significant differences in the following indicators were found between the two groups (P < .05): notable skin thickening, parallel line sign, grid sign, honeycomb sign, band sign, DRS, skin thickness, and band width. The sensitivity, specificity, and accuracy for predicting for DBF with the DRS was 82%, 64%, and 77%, respectively.

CONCLUSIONS

This study confirmed good consistency between the DRS and DBF from the perspective of imaging. This tool is suitable for children, adolescents, and patients with contraindications to lymphoscintigraphy. The DRS has important value in assessing the severity of PLEL. The DRS is suggested for the clinical use of combined surgical treatment of PLEL.

A surgical site abscess caused by an ant bite on foot 7 years after mastectomy: A case report

Key Clinical Message

Abscess at a previous surgical site induced by an insect bite has rarely been reported. Here we report a case of abscess at the breast surgical site, which occurred 7 years after mastectomy following an ant bite.

Abstract

Surgical site abscess generally occurs following operation within 30 days. However, surgical site abscess induced by an insect bite, which occurs several years after surgery, has rarely been reported. Here, we report a 65-year-old female patient with a history of breast cancer presenting with an abscess at the site of her mastectomy and ipsilateral arm lymphedema. Her left foot was bitten by an ant 25 days earlier and itchy red bumps with whiteheads were raised. After antibiotic treatment and abscess incision and drainage, the abscess healed, but the ipsilateral arm lymphedema persisted. This unique case demonstrates that surgical procedures can alter the susceptibility of tissues to allergic or infectious cues long after the operation.

Rictor, an mTORC2 Protein, Regulates Murine Lymphatic Valve Formation Through the AKT-FOXO1 Signaling

BACKGROUND

Lymphatic valves are specialized structures in collecting lymphatic vessels and are crucial for preventing retrograde lymph flow. Mutations in valve-forming genes have been clinically implicated in the pathology of congenital lymphedema. Lymphatic valves form when oscillatory shear stress from lymph flow signals through the PI3K/AKT pathway to promote the transcription of valve-forming genes that trigger the growth and maintenance of lymphatic valves. Conventionally, in many cell types, AKT is phosphorylated at Ser473 by the mTORC2 (mammalian target of rapamycin complex 2). However, mTORC2 has not yet been implicated in lymphatic valve formation.

METHODS

In vivo and in vitro techniques were used to investigate the role of Rictor, a critical component of mTORC2, in lymphatic endothelium.

RESULTS

Here, we showed that embryonic and postnatal lymphatic deletion of Rictor, a critical component of mTORC2, led to a significant decrease in lymphatic valves and prevented the maturation of collecting lymphatic vessels. RICTOR knockdown in human dermal lymphatic endothelial cells not only reduced the level of activated AKT and the expression of valve-forming genes under no-flow conditions but also abolished the upregulation of AKT activity and valve-forming genes in response to oscillatory shear stress. We further showed that the AKT target, FOXO1 (forkhead box protein O1), a repressor of lymphatic valve formation, had increased nuclear activity in Rictor knockout mesenteric lymphatic endothelial cells in vivo. Deletion of Foxo1 in Rictor knockout mice restored the number of valves to control levels in lymphatic vessels of the ear and mesentery.

CONCLUSIONS

Our work identifies a novel role for RICTOR in the mechanotransduction signaling pathway, wherein it activates AKT and prevents the nuclear accumulation of the valve repressor, FOXO1, which ultimately enables the formation and maintenance of lymphatic valves.

Resources on lymphedema surgery: How effective are they for patients?

Online patient education materials (PEMs) on lymphedema surgery were assessed for quality, readability, and content. A total of 37 PEMs were identified, primarily authored by academic/medical organizations. Readability scores indicated materials were difficult to read, with an average Flesch-Kincaid Grade Level of 10.4. PEM Assessment Tools showed acceptable understandability (72.3%) but poor actionability (28.5%). PEMs often lacked information on surgical risks, postoperative care, and long-term follow-up. Simplifying language and adding visual aids could improve PEM effectiveness.

Impact of sentinel node use in lymphedema formation among gynecologic cancer patients

PURPOSE OF REVIEW

The most common surgical procedure associated with lymphedema formation is the regional lymphadenectomy. One of the advantages of sentinel node biopsy is the reduction of the risk of lymphedema formation. The purpose of this review is to collect and analyze the most relevant and recent evidence of the use of sentinel node biopsy and its implication on the development of postoperative lymphedema in gynecological cancer.

RECENT FINDINGS

The current evidence of the use of sentinel node biopsy in cervical cancer to reduce lymphedema is heterogeneous and more data is needed to establish its role.Sentinel lymph node biopsy in endometrial cancer is a staging procedure with lower surgical complications, as well as lymphedema formation; while the results of prospective trials evaluating its impact on quality of life are still lacking.Sentinel lymph node biopsy in vulvar cancer minimizes the need for extensive dissection and reduces the incidence of complications associated with overharvesting of lymph nodes such as lymphedema without compromising oncological outcomes.

SUMMARY

The prevalence of lymphedema in gynecological cancer varies based on the surgical treatment or additional therapies applied. Over the past years, one of the most important surgical modifications to decrease lymphedema formation has been implementation of sentinel lymph node technique mainly in vulvar cancer patients.

The Predictive Role of Illness Perception on Lymphedema Risk-Management Behaviors in Women After Breast Cancer Surgery: A Longitudinal Study

BACKGROUND

Illness perception affects lymphedema risk-management behaviors. However, little is known about these behavioral changes within 6 months after surgery and how illness perception predicts behavioral trajectories.

OBJECTIVE

The aim of this study was to explore the trajectories of lymphedema risk-management behaviors in breast cancer survivors within 6 months after surgery and the predictive role of illness perception.

METHODS

Participants were recruited from a cancer hospital in China and completed a baseline survey (Revised Illness Perception Questionnaire) and follow-up assessments (Lymphedema Risk-Management Behavior Questionnaire and the physical exercise compliance dimension of the Functional Exercise Adherence Scale) at the first, third, and sixth months postoperatively.

RESULTS

A total of 251 women were analyzed. Regarding the Lymphedema Risk-Management Behavior Questionnaire, the total scores were stable. The scores of the "lifestyle" and "skin care" dimensions showed upward trends; the scores of the "avoiding compression and injury" and "other matters needing attention" dimensions showed downward trends. For "physical exercise compliance," scores remained stable. Furthermore, key illness perceptions (especially "personal control" and "causes") at baseline could predict the starting levels of and changes in behavioral trajectories.

CONCLUSION

Different lymphedema risk-management behaviors exhibited different trajectories and could be predicted by illness perception.

IMPLICATIONS FOR PRACTICE

Oncology nurses should focus on the early development of behaviors related to "lifestyle" and "skin care" and the later maintenance of "avoiding compression and injury" and "other matters needing attention" during follow-up, as well as help women strengthen their personal control beliefs and correctly understand the causes of lymphedema during hospitalization.