Edema volume, not timing, is the key to success in lymphedema treatment

Evidence for the clinical effectiveness of decongestive lymphoedema treatment for breast cancer-related arm lymphoedema, a systematic review

PURPOSE

Early treatment is advised for breast cancer-related arm lymphoedema (BCRL), a common sequelae of breast cancer treatment. Expert guidance recommends two-phase decongestive lymphoedema treatment (DLT), although evidence is lacking for current treatment protocols and UK women are routinely offered self-treatment with hosiery. This systematic review considered evidence regarding treatment of early BCRL, that is, within 12 months of developing BCRL.

METHODS

A systematic review of evidence for clinical effectiveness of DLT for women with less than 12-month BCRL duration (early BCRL) was undertaken using the Joanna Briggs Institute (JBI) method. Studies included women with < 12-month or mean < 9-month BCRL duration; some studies reported only one eligible group. The original search was conducted in 2016 and updated in 2018 and 2022. Methodological quality of identified studies was assessed using JBI critical appraisal instruments. Outcomes of interest were extracted with eligible results displayed in narrative and tabular format. Strength of evidence was rated using the GRADE system.

RESULTS

Seven trials and three descriptive studies provided weak evidence (grade B) for effectiveness of DLT for early BCRL. Heterogeneous protocols limited comparison of findings. There was no evidence for the most effective treatment or treatment combination or optimal frequency or duration of treatment.

CONCLUSION

There is no evidence to justify change in current lymphoedema treatment, whether self-treatment with hosiery (UK) or two-phase DLT (other countries). Further research for the early BCRL population is required.

IMPLICATIONS FOR CANCER SURVIVORS

Women with early BCRL require early and effective treatment although this updated review shows there is still no evidence for what that treatment should be.

New Strategy for Breast Cancer Related Lymphedema Treatment by Endermology: ELOCS Phase II Randomized Controlled Trial

BACKGROUND

This phase II trial sought to be the first of its kind to estimate the success rate of endermology in reducing breast cancer-related lymphedema.

PATIENTS AND METHODS

ELOCS is a French, monocentric, randomized, open-label phase II trial. Patients were randomized to receive the following over a 5-day treatment period: standard intensive decongestant treatment (IDT) (bandages and manual lymphatic drainage MLD) (group 1); IDT including bandages, MLD, and Cellu M6 (group 2); and IDT including bandages and Cellu M6 (Group 3). The main endpoint was the success rate in each group, (reduction of at least 30% in the excess volume). We estimated that endermology treatment (groups 2 and 3) would be of interest successes occurred in at least 21 out of 31 patients.

RESULTS

A total of 93 patients were included (31 patients in each of the 3 groups). The median age was 64.5 years (IQR: [56.4-71.3]). Patients were treated with mastectomy (n = 35), axillary lymphadenectomy (n = 80), radiotherapy (n = 91), and chemotherapy (n = 68). The mean relative reduction in excess volume was 38% in group 1, 33% in group 2, and 34% in group 3. Success rate was 58.1% in group 1 (18/31, P = ,0237), 51.6% (16/31, P = ,5) in group 2, and 64.5% (20/31, P = ,075) in group 3. In the LPG groups (2 and 3), 10/62 (16%) patients found LPG painful and 9/62 (15%) patients considered it to be unpleasant.

CONCLUSION

Even though the critical threshold of 21 successes was not met, this study was the first to validate a standardized and reproducible endermology protocol.

The agreement between three classification systems used to grade the severity of lymphedema in patients with upper and lower extremity lymphedema: A retrospective study

BACKGROUND

Several classification systems are used to grade the severity of lymphedema. Their agreement with each other has not been reported.

OBJECTIVE

To evaluate the agreement between the American Physical Therapy Association (APTA) criteria, the criteria of Ramos et al., and the International Society of Lymphology (ISL) criteria in patients with upper and lower extremity lymphedema.

METHODS

A total of 156 patients (63 and 93 patients with upper and lower extremity lymphedema, respectively) were included. The circumference measurements and limb volume were measured. The severity of lymphedema of the patients was classified as mild, moderate, and severe lymphedema using the APTA criteria, the criteria of Ramos et al., and the ISL criteria. The agreement between the classification systems was assessed with Krippendorff's alpha.

RESULTS

An acceptable and poor agreement were found between the criteria in upper (Krippendorff's alpha > 0.667) and lower extremity lymphedema (Krippendorff's alpha < 0.667), respectively. In pairwise comparisons, an acceptable agreement was found among each comparison in upper extremity lymphedema (Krippendorff's alpha > 0.667), and a poor agreement was found among each comparison in lower extremity lymphedema (Krippendorff's alpha < 0.667) except between the APTA criteria and the criteria of Ramos et al (Krippendorff's alpha > 0.667).

CONCLUSIONS

Patients with upper extremity lymphedema classified according to these criteria can be assumed to be samples of the same population; however, patients with lower extremity lymphedema graded according to the ISL criteria may be included in a different classification when they grade with the APTA criteria and the criteria of Ramos et al.

Optimal Cut-Off Value for Detecting Breast Cancer-Related Lymphedema Using Ultrasonography

Background: We previously devised an ultrasonographic evaluation to calculate subcutaneous tissue cross-sectional area (△CSA). The reliability and accuracy of this method were demonstrated in healthy individuals and in patients with lymphedema. The purpose of this study was to estimate the optimal cut-off value of the ratio of the △CSA of the involved side (lesion side) to the contralateral side for detecting breast cancer-related lymphedema (BCRL) using ultrasonography. Methods and Results: Ultrasonographic measurements were performed 290 times in 150 patients. BCRLD was defined as a confirmed difference of >2 cm in arm circumference. BCRL confirmed by a clinician (BCRLC) was defined as the patient group that included not only BCRLD but also patients with subcutaneous thickening and abnormal findings on lymphoscintigraphy, even if the difference in arm circumference was <2 cm. The △CSAs of both upper arms and forearms were calculated by measuring the thickness of the subcutaneous tissue at four locations using ultrasonography (superior, medial, inferior, lateral) at 10 cm above the elbow and 10 cm below the elbow. With a 1.35 △CSA ratio as the cut-off value for detecting BCRLD, the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were 0.88, 0.87, and 0.95, respectively. With a 1.20 △CSA ratio as the cut-off value for detecting BCRLC, the sensitivity, specificity, and AUC were 0.92, 0.89, and 0.97, respectively. Conclusions: Our findings suggest that a 1.20 △CSA ratio as determined using ultrasonography, corresponding to a tape measurement of 1.05 cm, can be considered as a diagnostic criterion for lymphedema.

Efficacy of preoperative lymphoscintigraphy in predicting surgical outcomes of lymphaticovenous anastomosis in lower extremity lymphedema: Clinical correlations in gynecological cancer-related lymphedema

BACKGROUND

Lymphaticovenous anastomosis (LVA) is a promising microsurgical treatment for lower extremity lymphedema (LEL). Lymphoscintigraphy effectively assesses lower limb lymphatic systems before LVA, but its role in predicting the therapeutic outcomes of LVA is indeterminate. In this study we investigate the efficacy of preoperative lymphoscintigraphy using clinical findings to predict outcomes in gynecological cancer-related LEL patients who underwent LVA.

METHODS

A retrospective review was conducted on consecutive gynecological cancer patients with LEL who had undergone LVA between June 2018 and June 2021. The therapeutic efficacy was assessed by measuring the change rate of the lower extremity lymphedema index (LELi) six months after surgery. Clinical data and lymphoscintigraphic findings were analyzed to assess therapeutic efficacy of LVA.

RESULTS

Out of the 60 evaluated legs, 83.3% of the legs showed improved results after LVA. Univariable linear regression analysis revealed that higher preoperative LELi, and ovarian cancer were associated with superior LELi change rate (LC rate). Absence of dermal backflow (DBF) on lymphoscintigraphy was associated with inferior LC rate. Multivariable linear regression analysis identified ovarian cancer and higher preoperative LELi were independently correlated with favorable outcomes, while the absence of DBF was independently correlated with inferior outcomes.

CONCLUSION

The results of this study emphasizes the effectiveness of preoperative lymphoscintigraphy, preoperative LELi, and primary malignancy as predictors of LVA outcomes in gynecological cancer-related LEL patients.

Early Intervention with a Compression Sleeve in Mild Breast Cancer-Related Arm Lymphedema: A 12-Month Prospective Observational Study

BACKGROUND

In our previous randomized controlled trial (RCT), the progression/no progression of mild breast cancer-related arm lymphedema (BCRL) was examined among women randomized to a compression group (CG) with a compression sleeve (compression class (ccl) 1) or not (NCG) for 6 months. In the present prospective study, BCRL in the CG and NCG was followed for 12 months.

METHODS

At the end of the RCT, 33 women with mild BCRL were eligible in the CG and 37 in the NCG. The proportional differences in no progression/progression of BCRL were defined as a >2% increase from start of RCT or exceeding 10% in the lymphedema relative volume as measured by the water displacement method. In addition, changes in the lymphedema relative volume and tissue dielectric constant ratio, which measures local tissue water, were examined. At the end of the RCT (i.e., after 6 months), a one-month break of the compression treatment was made in the CG. If the lymphedema relative volume progressed by definition, the compression treatment was resumed and continued, with follow-up of all women at 9 and 12 months.

RESULTS

A larger proportion of women in the NCG showed progression (57%, 61%, 67%) compared to the CG (16%, 22%, 31%) at 6, 9, and 12 months (p < 0.001, 0.005, 0.012), respectively. Twelve (33%) women in the NCG did not progress at all. No changes of the lymphedema relative volume and local tissue water were found over time at any follow-ups, but were stable on a low level.

CONCLUSIONS

To avoid the progression of mild BCRL into a chronic issue in the long-term, compression sleeve ccl 1 may be applied immediately after early diagnosis of mild BCRL.

Early intervention with compression garments prevents progression in mild breast cancer-related arm lymphedema: a randomized controlled trial

BACKGROUND

Early diagnosis and compression treatment are important to prevent progression in breast cancer-related arm lymphedema (BCRAL). However, some mild BCRAL can be reversible, and therefore, compression treatment may not be needed. The aim of this study was to investigate the proportion of women with mild BCRAL showing progression/no progression of lymphedema after treatment with or without compression garments, differences in changes of lymphedema relative volume (LRV), local tissue water and subjective symptoms during 6 months. Also, adherence to self-care was examined.

MATERIAL AND METHODS

Seventy-five women diagnosed with mild BCRAL were randomized to a compression group (CG) or noncompression group (NCG). Both groups received self-care instructions, and the CG were treated with a standard compression garment (ccl 1). Women in the NCG who progressed in LRV ≥2%, or exceeded 10% dropped out, and received appropriate treatment. The proportion showing progression/no progression of LRV, and changes in LRV was measured by Water Displacement Method. Changes in local tissue water were measured by Tissue Dielectric Constant (TDC), subjective symptoms by Visual Analogue Scale, and self-care by a questionnaire.

RESULTS

A smaller proportion of LRV progression was found in the CG compared to the NCG at 1, 2 and 6 months follow-up (p ≤ 0.013). At 6 months, 16% had progression of LRV in the CG, compared to 57% in the NCG, (p = 0.001). Thus, 43% in the NCG showed no progression and could manage without compression. Also, CG had a larger reduction in LRV, at all time-points (p ≤ 0.005), and in the highest TDC ratio, when same site followed, at 6 months (p = 0.025). Subjective symptoms did not differ between the groups, except at 1 month, where the CG experienced more reduced tension (p = 0.008). There were no differences in adherence to self-care.

CONCLUSION

Early treatment with compression garment can prevent progression in mild BCRAL. Trial registration: ISRCT nr ISRCTN51918431.

Rehabilitation of Individuals With Cancer

The survival rate of cancer is increasing as treatment improves. As patients with cancer now live longer, impairments may arise that impact quality of life (QOL) and function. Therefore, a focus on QOL is often as important as survival. An interdisciplinary team can achieve goal-oriented and patient-centered rehabilitation, which can optimize function and QOL, and minimize impairments, restrictions, and activity limitations. In most cases, cancer patients must be active participants in therapy and exhibit carryover. Patients with cancer often have impairments that include fatigue, pain, brain fog, impaired cognition, paresis, mood disorders, difficulty with activities of daily living (ADL), bowel/bladder/sexual dysfunction, and bone and soft tissue involvement. Adaptive equipment, exercise, and ADL training can mitigate restrictions on activity. The trajectory and phase of the disease along the continuum of cancer care may influence the goals of rehabilitation in that time window. QOL is often influenced by participation in vocational, recreational, and home-based activities. A holistic perspective should include an analysis of distress, socioeconomic barriers, and transportation limitations when addressing issues.

Effect of Octreotide on Lymphorrhea in Patients After Modified Radical Mastectomy for Carcinoma Breast: A Randomized Controlled Trial

Introduction

Lymphorrhea or seroma formation after modified radical mastectomy (MRM) is a serious and disabling complication of axillary lymphadenectomy. Octreotide is a hormone with general anti-secretory effects. The potential role of octreotide in the treatment of lymphorrhea after axillary lymph node dissection in patients undergoing MRM is being investigated in this study. The purpose of this research is to study the effect of octreotide on the magnitude and duration of lymphorrhea in patients after MRM for carcinoma breast.

Methods

This clinical trial was registered in the Clinical Trials Registry India (CTRI/2017/11/010653). It was conducted in the Department of General Surgery, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi from September 2015 to March 2017. This study is a parallel randomized controlled trial with a 1:1 allocation ratio. Thirty patients were enrolled and allocated equally into two groups. The intervention group received standard medical care plus injection octreotide 100 micrograms eight hourly intravenously post-operatively for five days and the control group received only standard medical care. The primary outcomes were lymphorrhea volume from 24 hours post-surgery till five days post-operatively and the number of days till the suction drain was removed. Secondary outcomes were surgical site infection, the incidence of seroma formation, complications of octreotide, duration of hospital stay, and the number of lymph nodes isolated. All the patients were followed up twice a week for the first six weeks after discharge followed by three monthly visits.

Results

A total of 30 patients were included in the study. The mean age was 46.2 years. The mean operative time in the control group was 137.87 ± 23.28 minutes and in the octreotide group was 128.13 ± 12.29 (p = 0.163). The volume of lymphorrhea in the control group was 354.67 ± 346.28 ml and in the octreotide group was 194.00 ± 240.62 ml (p = 0.081). Seroma occurred in 9% of patients in the control group and 2 % of patients in the octreotide group (p = 0.010). The duration of lymphorrhea was 4.93 ± 2.49 days in the control group and 3.13 ± 1.36 days in the octreotide group (p = 0.029). The duration of stay was 7.07 ± 2.40 days in the control group and 5.13 ± 1.06 days in the octreotide and was found to be statistically significant (p = 0.010). No obvious adverse reactions related to injection octreotide, namely, nausea, vomiting, abdominal discomfort, hypotension, bradycardia, and dysglycemia, were seen in any of our patients.

Conclusion

The duration of lymphorrhea, incidence of seroma formation, and duration of hospital stay were lesser in the octreotide group, and the difference was statistically significant. The wound infection rates were similar in both groups. Thus injection octreotide can be used safely and effectively.

Lymphedema Index Ratio As Predictive Factor of Treatment in Patients with Breast Cancer-Related Lymphedema

Background: This retrospective observational study aimed to evaluate the lymphedema index ratio to predict the effect of complex decongestive therapy (CDT) in patients with breast cancer-related lymphedema (BCRL) and to establish a lymphedema index ratio cutoff value for the extent of CDT effect. Materials and Methods: All 108 enrolled patients with BCRL underwent volume measurements and bioelectrical impedance analysis before and after CDT. The difference in percent excess volume (PEV) before and after CDT was defined as the therapeutic effect, and each patient was assigned to Groups A, B, or C based on therapeutic effects of 0%-5%, 5%-10%, and 10%-20%, respectively. Results: The mean lymphedema index ratios of Groups A, B, and C were 1.27, 1.38, and 1.46, respectively, with significant differences between the groups (p < 0.01). The cutoff lymphedema index ratio values for diagnosis between Groups A and B and between Groups B and C were 1.277 (sensitivity: 71.7%, specificity: 61.8%) and 1.357 (sensitivity: 76.9%, specificity: 62.1%), respectively. The Spearman coefficients for the linear relationship between lymphedema index ratio and initial PEV and between lymphedema index ratio and therapeutic effect were found to be significant at 0.615 and 0.360, respectively (p < 0.01). Conclusion: The results of this study found that the lymphedema index ratio may predict the volume reduction in patients with BCRL. A less reduction (therapeutic effect <5%) was predicted in patients with a lymphedema index ratio of <1.277, while a greater reduction (therapeutic effect >10%) was predicted in patients with a lymphedema index ratio of >1.357.

Tissue Dielectric Constant and Water Displacement Method Can Detect Changes of Mild Breast Cancer-Related Arm Lymphedema

Background: Most commonly, volume measurements are used to evaluate the effect of lymphedema treatment, but as the accumulation of lymph fluid can be local, this method may not always be the best. Tissue dielectric constant (TDC) can be applied to identify local lymphedema changes, but has not been used before when evaluating treatment in mild arm lymphedema. Thus, the overall aim of this study was to examine if TDC and water displacement method (WDM) can measure changes in mild breast cancer-related lymphedema during the 6-month standard treatment. More specifically, we examined changes within and between three defined groups based on lymphedema thresholds of TDC and WDM at start of treatment, as well as changes of the highest TDC ratio and site. Methods and Results: Forty-six women with mild arm lymphedema, received treatment with compression sleeves, mostly ccl 1, and instructions about self-care. Local tissue water was measured by TDC at six defined sites and lymphedema relative volume (LRV) by WDM before treatment and at first, second, third, and sixth month. There was a significant decrease in the site with the highest TDC ratio, as well as LRV at all follow-up visits. At 6 months, TDC ratio had decreased mean 0.26 (p < 0.001) and LRV mean - 3.3% (p < 0.001). There was a significant difference between the groups in change of TDC ratio, but not in LRV. Sixty percent changed the overall highest TDC ratio to another site during 6 months. Conclusion: Both TDC and WDM could detect changes in mild arm lymphedema but should be interpreted separately.

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.

Lymphoedema, a significant health problem in Israel: A descriptive community-based study

Lymphoedema (LE) is recognised as a chronic disabling disease. Knowledge on patient characteristics, treatments, and outcomes in Israel is lacking. The aim of the study was to (a) describe demographic and health characteristics, treatments, utilisation, and functional outcomes of patients receiving physical therapy due to LE in a large nationwide healthcare provider in Israel; and (b) assess the feasibility of conducting a future practice-based evidence (PBE) study. This is a retrospective observational cohort study. Descriptive analyses of an electronic medical record database were performed. Data from 6013 patient episodes were analysed. A high proportion of patients had two or more comorbidities (80%) and chronic medication use (85%) with increasing rates over the 8-year period. The most frequent LE classification was stage 2 (45%). A majority of LE was in the lower limbs (51%) with increasing rates over the years. The most frequent treatment-related activity was measuring limb circumference and the most frequent intervention was educating for self-management. This study provides a first comprehensive description of patient characteristics receiving physical therapy for LE in Israel. The available database offers an opportunity for PBE studies. Recommendations for improvements in specific data collection processes were identified.

The role of ultrasonography in follow-up of effectiveness of Complex Decongestive Therapy (CDT) in different subgroups of patients with breast cancer-related lymphoedema

OBJECTIVE

To determine the role of ultrasonography in the follow-up of effectiveness of complex decongestive therapy (CDT) in different subgroups of patients with breast cancer-related lymphoedema (BCRL).

METHODS

Forty-seven patients with unilateral upper BCRL were enrolled in the study. The patient group was divided into two subgroups according to body mass index (BMI) as obese and non-obese and three subgroups according to International Society of Lymphology staging. All patients underwent CDT, the circumference measurements and ultrasonographic soft tissue thicknesses evaluations were performed at two anatomic sites, and upper extremity limb volumes were calculated using the truncated cone formula before and after CDT.

RESULTS

There were significant decreases in both circumferential measurements and ultrasonographic soft tissue thicknesses in non-obese patients and stage 2 lymphoedema patients after 15 sessions of CDT. The ultrasonographic soft tissue thickness values were correlated with the upper arm and forearm circumference values before (r = 0.491, p < .001, r = 0.841, p < .001, respectively) and after (r = 0.535, p < .001, r = 0.714, p < .001, respectively) CDT.

CONCLUSIONS

Ultrasonography presents as a reliable method to measure the soft tissue thickness and treatment efficacy after CDT in only non-obese and stage 2 patients with BCRL.

The results of the intensive phase of complete decongestive therapy and the determination of predictive factors for response to treatment in patients with breast cancer related-lymphedema

BACKGROUND

Lymphedema is a common complication of breast cancer or its treatment. The gold standard treatment for lymphedema is complete decongestive therapy. There are few studies about the predictive factors for the effectiveness of complete decongestive therapy.

AIM

To evaluate the results of the intensive phase of complete decongestive therapy, and to determine the predictive factors for the response to treatment in patients with breast cancer-related lymphedema.

METHODS AND RESULTS

Fifty-seven patients with breast cancer-related lymphedema (mean age: 56.2 ± 11.2 years) who underwent complete decongestive therapy between 2014 and 2016 were evaluated retrospectively. Extremity volume was calculated using circumferential measurements and the truncated cone formula technique. Response to treatment was evaluated using the percentage reduction of excess volume formula, which was obtained by calculating the extremity volume before and after treatment. The median percentage reduction of excess volume was 27.7% (IQR,13.6-50.3). The history of skin infection was related to lower percentage reduction of excess volume (P = 0.001). Although percentage reduction of excess volume was positively correlated with education level (r = 0.286, P = 0.031), percentage reduction of excess volume was negatively correlated with lymphedema duration (r = -0.361, P = 0.006), postoperative duration (r = -0.314, P = 0.018), percentage of excess volume (r = -0.398, P = 0.002), and number of complete decongestive therapy sessions (r = -0.436, P = 0.001). Univariate and multivariate analyses showed that the independent variables for percentage reduction of excess volume were percentage of excess volume (P = 0.009) and education level (P = 0.021).

CONCLUSION

Complete decongestive therapy is an effective method in patients with breast cancer related-lymphedema. The most important predictive factors for the efficacy of treatment were found as percentage of excess volume and education level. Patients with breast cancer should be followed up regularly and receive complete decongestive therapy in the early stage of lymphedema.

Effectiveness of four types of bandages and kinesio-tape for treating breast-cancer-related lymphoedema: a randomized, single-blind, clinical trial

OBJECTIVE

To compare the effects of four types of bandages and kinesio-tape and determine which one is the most effective in women with unilateral breast cancer-related lymphoedema.

DESIGN

Randomized, single-blind, clinical trial.

SETTING

Physiotherapy department in the Women's Health Research Group at the University of Alcalá, Madrid, Spain.

SUBJECTS

A total of 150 women presenting breast-cancer-related lymphoedema.

INTERVENTIONS

Participants were randomized into five groups (n = 30). All women received an intensive phase of complex decongestive physiotherapy including manual lymphatic drainage, pneumatic compression therapy, therapeutic education, active therapeutic exercise and bandaging. The only difference between the groups was the bandage or tape applied (multilayer; simplified multilayer; cohesive; adhesive; kinesio-tape).

MAIN MEASUREMENTS

The main outcome was percentage excess volume change. Other outcomes measured were heaviness and tightness symptoms, and bandage or tape perceived comfort. Data were collected at baseline and finishing interventions.

RESULTS

This study showed significant differences between the bandage groups in absolute value of excess volume (P < 0.001). The most effective were the simplified multilayer (59.5%, IQR = 28.7) and the cohesive bandages (46.3%, IQR = 39). The bandages/tape with the least difference were kinesio-tape (4.9%, IQR = 17.7) and adhesive bandage (21.7%, IQR = 17.9). The five groups exhibited a significant decrease in symptoms after interventions, with no differences between groups. In addition, kinesio-tape was perceived as the most comfortable by women and multilayer as the most uncomfortable (P < 0.001).

CONCLUSION

Simplified multilayer seems more effective and more comfortable than multilayer bandage. Cohesive bandage seems as effective as simplified multilayer and multilayer bandage. Kinesio taping seems the least effective.

Advanced pneumatic compression for treatment of lymphedema of the head and neck: a randomized wait-list controlled trial

PURPOSE

Lymphedema associated with head and neck cancer (HNC) therapy causes adverse clinical outcomes. Standard treatment includes professionally administered complete decongestive therapy (CDT). Cost and availability of trained therapists are known barriers to therapy. Advanced pneumatic compression devices (APCD) may address these issues. A randomized, wait-list controlled trial was undertaken to evaluate an APCD in post-treatment HNC patients with lymphedema.

MATERIAL AND METHODS

Eligible patients had completed treatment for HNC, were disease free, and had lymphedema at enrollment. Participants were randomized to wait-list lymphedema self-management (standard of care) or lymphedema self-management plus the use of the APCD bid. Safety (CTCAE V4.0) and feasibility were primary endpoints; secondary endpoints included efficacy measure by objective examination and patient reported outcomes (symptoms, quality of life, function), adherence barriers, and satisfaction. Assessments were conducted at baseline and weeks 4 and 8.

RESULTS

Forty-nine patients were enrolled (wait-list n = 25; intervention n = 24). In total, forty-three patients completed the study. No device-related Serious Adverse Events were reported. Most patients used the APCD once per day, instead of the prescribed twice per day, citing time related factors as barriers to use. APCD use was associated with significant improvement in perceived ability to control lymphedema (p = 0.003) and visible external swelling (front view p < 0.001, right view p = 0.004, left p = 0.005), as well as less reported pain.

CONCLUSION

This trial supports the safety and feasibility of the APCD for the treatment of secondary lymphedema in head and neck cancer patients. In addition, preliminary data supports efficacy.

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

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

Effectiveness of Kinesio Taping on Anastomotic Regions in Patients with Breast Cancer-Related Lymphedema: A Randomized Controlled Pilot Study

Background: The purpose of the study was to investigate the effect of using Kinesio Taping^® (KT) on anastomotic regions along with complex decongestive physiotherapy (CDP) in patients with breast cancer-related lymphedema (BCRL). Methods and Results: Patients with unilateral BCRL were divided into two groups in this randomized controlled study: Group 1 (CDP, n = 14) and Group 2 (CDP+ KT, n = 18). Assessment of limb size was quantified by using circumferential limb measurements and then calculated for each segment by using the frustum formula. CDP included manual lymphatic drainage, compression bandages, exercises, and skin care. KT was applied to lymphatic anastomosis. All patients received treatment for 1 hour per day, 5 days per week for 4 weeks. The outcome measure was difference in the reduction of limb volumes between the groups. There was a significant difference in both groups before and after treatment (p < 0.05), but there was no significant difference between the two groups regarding changes in limb volume (p > 0.05). Conclusion: The results suggest that applying KT to lymphatic anastomotic regions is not effective in reducing limb volume in the management of BCRL.

Easy Volumeter in Detection of Breast Cancer-Related Lymphedema: A Validity Study

Aim and Hypothesis: The standard volumeter is heavy and fragile, and using the same volumeter for different patients can result in hygiene problems. These disadvantages point to the need for the development of a new model of volumeter. The new volumeter put forward in this study is lighter, smaller, sturdier, and easier to clean, while also having its own scale. In this study, the validity of this newly designed volumeter is investigated. Materials and Methods: In the first step, the volume of standard cylinders was measured thrice using a standard volumeter and an easy-measurement volumeter, after which a total of 30 arm volumes of 15 volunteers were measured. In the final stage, the arms of 28 patients with breast cancer-related lymphedema were measured once with both volumeters and the mean results were compared. Results: There was a high degree of consistency between the measured volumes of cylinders of known volume when measured with a standard volumeter and the "Easy volumeter." The measured mean volumes with the two volumeters were assessed with paired sample t-test, resulting in a significance (p value) of 0.927, indicating no difference between the measurements of the two volumeters. The variance of measurement of the devices was assessed with a Levene's test, and the significance (p value) was obtained as 0.981. Based on this result, the null hypothesis cannot be rejected, meaning that there is no difference in the variances of measurements of the two volumeters. Likewise, a paired sample t-test was used to evaluate the differences between the mean measurements of the healthy volunteers group, and no difference was detected between the mean arm volumes measured with each volumeter (significance=0.105). The measurements between the two volumeters were also consistent in the lymphedema patient group (involved arm significance = 0.842 and normal arm significance = 0.075). Conclusion: Our study revealed the validity of the newly designed "Easy Volumeter" for the measurement of arm volumes, indicating its appropriateness for use in daily practice.

Early surveillance is associated with less incidence and severity of breast cancer-related lymphedema compared with a traditional referral model of care

Background

Bioimpedance spectroscopy (BIS) has enabled the early identification of breast cancer‐related lymphedema. In this study, differences in health service metrics and in the incidence of breast cancer‐related lymphedema are evaluated in an early surveillance model of care compared with a traditional referral model of care.

Methods

In a retrospective analysis of data from 753 women who underwent BIS measures between January 1, 2007 and December 31, 2016, 188 women were assigned to the “early surveillance” group if they began lymphedema monitoring presurgery (n = 121) or within 90 days postsurgery (n = 67), and 285 women were assigned to the “traditional referral” group if they began monitoring after 90 days postsurgery. Health service metrics were calculated as the time to the first BIS measure after 90 days postsurgery, the median follow‐up, and the number of health care visits. Lymphedema was diagnosed based on BIS measures.

Results

Women in the early surveillance group received lymphedema care significantly earlier than those in the traditional referral group. However, there was no difference in the number of visits per year to the clinic between groups. Significantly more women in the traditional referral group were diagnosed with clinical lymphedema (stage I‐III, 39 % vs 14%; P < .001) and with greater severity (stage II‐III, 24%) compared with those in the early surveillance group (4%).

Conclusions

The current findings support the adoption of an early prospective surveillance model of care using BIS for the early detection and management of breast cancer–related lymphedema.

The differences in health service metrics and in the incidence of breast cancer–related lymphedema are evaluated in an early surveillance model of care compared with a traditional referral model of care. The findings support the adoption of an early prospective surveillance model of care using bioimpedance spectroscopy for the early detection and management of breast cancer–related lymphedema.

Communicating vessels volumeter to measure upper extremity lymphedema after breast cancer: reliability and criterion validity compared to the gold standard

BACKGROUND

The traditional overflow method for measuring limb volume remains the gold standard, but many disadvantages still inhibit its routine use in clinical practice.

OBJECTIVE

To assess the intra-rater and inter-rater reliability and criterion validity of the 'communicating vessels volumeter' (CVV) for volume measurement of lymphedematous upper extremities (LUE) by using the overflow volumeter (OV) as the reference standard.

METHODS

Twelve LUE of 12 women undergoing mastectomy for breast cancer were measured three times each by three raters using both methods, totaling 216 volume measurements. Criterion validity was estimated by 33 volume measurements of one cylinder of known volume by three raters using both methods, totaling 198 measurements.

RESULTS

Measurement time was short with both CVV and OV. The intraclass correlation coefficient_3,1 was high for both CVV and OV in intra-rater (0.99 vs 0.99) and inter-rater (0.99 vs 0.99) analyses. The bias between methods was low (7.50mL; 0.40%) and the limits of agreement were narrow (-5.80 to 6.50%). The volumes were statistically equal with a strong correlation (R²=0.98) between methods. CVV was more accurate than OV (0.00 vs 0.02%) in cylinder measurements.

CONCLUSION

The high intra-rater and inter-rater reliability rates of CVV were comparable to those of OV, and the volumes resulting from LUE measurements were statistically equal in the two methods. Criterion validity rates indicated that CVV measurements were closer to the actual value of the cylinder than those obtained with the OV.

Effect of Bandage Compliance on Upper Extremity Volume in Patients with Breast Cancer-Related Lymphedema

BACKGROUND

Complex decongestive physiotherapy (CDP) is an effective treatment for patients with breast cancer-related lymphedema (BCRL). Bandaging is an important component of CDP. Although the literature suggests that bandages must be kept on for about 24 hours, some patients cannot tolerate keeping them on for this length of time. Also, it has been observed that limb volume decreased in patients who did not keep bandages on for 24 hours in clinical trials. But there is no evidence that this reduction in time is statistically significant. Our purpose was to compare the effectiveness of bandage compliance for a longer or a shorter period on limb volume in patients with BCRL.

METHODS AND RESULTS

We retroprospectively reviewed the medical records of 39 patients who received CDP. Twenty-eight eligible patients were divided into two groups, group 1 (n = 18) and group 2 (n = 10), according to the average number of hours of bandage compliance, which was 13-24 and 7-12 hours, respectively. The primary outcome was the change in limb volume between groups. The values for the limb volumes showed a statistically significant decrease in both groups. There was no significant difference in volume reduction between the groups.

CONCLUSION

This study shows that keeping bandages on for between about 12 and 24 hours has the same effect on patients with BCRL as receiving CDP.

Segmental Bioimpedance Informs Diagnosis of Breast Cancer-Related Lymphedema

BACKGROUND

Detection of lymphedema, particularly its mild stage, is clinically challenging. The aim of this study was to determine whether segmental bioimpedance spectroscopy (BIS) provided additional information to whole arm BIS in assessing women with or at risk of lymphedema following breast cancer.

METHODS AND RESULTS

Participants (n = 66), aged 61.6 ± 10.5 years (mean ± standard deviation [SD]), were grouped according to lymphedema status: (1) at-risk (n = 24) had no indicators of lymphedema and (2) lymphedema (n = 42) were suspected to be developing lymphedema or had previously met lymphedema diagnostic criteria and undergone treatment. For each upper limb, impedance was measured for the whole arm, hand and four 10 cm segments of the arm, commencing at the ulnar styloid. Interlimb impedance ratios for corresponding locations were calculated and compared to previously determined, normatively based thresholds based on 2SD and 3SD above the mean. Segmental BIS classified 19% more women with lymphedema than 3SD whole arm thresholds and the same number as 2SD whole arm thresholds. Segmental BIS identified localized lymphedema and patterns in lymphedema distribution that were undetectable by whole arm BIS. Neither 3SD whole arm nor segmental BIS thresholds found lymphedema where it was not present; however, 2SD whole arm thresholds alone classified one woman in the at-risk group as having lymphedema.

CONCLUSION

Segmental BIS classified as many or more cases of lymphedema than whole arm BIS thresholds without finding lymphedema where it was likely not present while also providing additional information regarding the distribution of lymphedema within the limb.

Effects of Aqua-Lymphatic Therapy on Lower Extremity Lymphedema: A Randomized Controlled Study

BACKGROUND

The purpose of this study is to investigate the effects of the aqua-lymphatic therapy (ALT) on unilateral lower extremity lymphedema in the maintenance phase.

MATERIALS AND METHODS

This is a randomized controlled trial with a blinded assessor. The study was completed with 30 ALT and 27 control group participants. Foot volume was assessed by a water displacement device, limb volume by circumference measurements, functional capacity by a 6-minute walk test, quality of life by Short Form-36, and social appearance by Social Appearance Anxiety Scale and hopeless by Beck Hopeless Scale. The ALT and the control group had group sessions twice in a week for 6 weeks directed by a physiotherapist.

RESULTS

The mean age of ALT patients was 44.50 ± 13.69 years, whereas that of the control patients was 47.66 ± 16.82 years. After the intervention, both groups' measurement of edema, functional level, quality of life, as well as social and future concerns improved significantly but this improvement was higher in the ALT group (p < 0.05, p ≤ 0.001).

CONCLUSIONS

ALT was found to be a safe effective method for unilateral lower extremity lymphedema patients during the maintenance phase of Complex Decongestive Physiotherapy.

The effects of bandaging with an additional pad and taping on secondary arm lymphedema in a patient after mastectomy

[Purpose] The purpose of this case study was to determine the effectiveness of bandaging the arm of a patient with secondary lymphedema on the patient's quality of life, arm volume and arm function using an additional pad and taping along with some other standard therapy modalities for lymphedema. [Subjects and Methods] I used a bandage with an additional pad and taping, along with MLD, exercise, and skin care to treat a patient with unilateral breast-cancer-related arm lymphedema who had fibrotic tissue on her lower arm and hand. I made a pad called a "muff" and applied it under tape while using Vodder's technique. Treatment was performed during 5 therapy sessions a week for 2 weeks. [Results] After the physiotherapy sessions, the excess edema volume decreased to 608 ml, and the percentage of excess volume (PEV) was 9.6%. The therapeutic efficacy, measured as percentage reduction of excess volume (PREV), was -79.5%, meaning that the edema volume was reduced 79.5%. The use of an additional pad and taping on a large edematous site with fibrotic changes can produce more efficacious lymphedema care. [Conclusion] The use of an additional pad and taping on a large edematous site with fibrotic changes has demonstrated a positive result in lymphedema management for a post mastectomy patient and, therefore, further studies on this method are suggested with a larger sample size.

A Galvanic Intrabody Method for Assessing Fluid Flow in Unilateral Lymphoedema

Lymphoedema is a disease associated with abnormal functioning of the lymph that leads to swelling of the body due to accumulation of tissue fluid on the affected area. Tissue fluid contains ions and electrolytes that affect electrical conductivity. The flow of tissue fluid helps to distribute vital nutrients and other important elements necessary for healthy living. When tissue fluid is stagnated, a high concentration of electrolytes accumulate on the affected area, which in turn affects an electrical signal passing through that area to be minimally attenuated in relation to a free-flowing fluid. We demonstrate that a galvanic coupled signal propagating along a lymphoedema affected limb could capture these changes by the amount of attenuation the propagating signal experiences in time. Our results show that average rate of signal attenuation on a lymphoedema affected part of the body could be as slow as 0.16 dB/min, while the rate of signal attenuation on a healthy part is as high as 1.83 dB/min. This means that fluid accumulation could slow down the exchange of body electrolytes up to twice less the rate on an unaffected contralateral part of the body. Monitoring these changes by observing the average rate of change of a galvanic coupled signal attenuation on the affected body part can be used for diagnosing early developments of oedema in the body and for evaluating recovery in response to treatment procedures.

Tc-99m-Human Serum Albumin Transit Time as a Measure of Arm Breast Cancer-Related Lymphedema

BACKGROUND

Lymphoscintigraphy has often been used for evaluating arm lymphatic dysfunction, but no optimal approach for quantification has so far emerged. We propose a quantifiable measure of lymphatic function that we applied in patients treated for breast cancer.

METHODS

Eleven patients, aged 34-68 years, with unilateral arm lymphedema following breast cancer treatment underwent bilateral lymphoscintigraphy using intradermal injection in both hands of technetium-99m-labeled human serum albumin and sequential 5 min imaging for 5 hours. The mean transit time (MTT) in the arms was calculated based on time activity curves generated from injection site and arm regions. Visual lymphedema scoring was performed based on dermal backflow and lymph node presence. Excess arm volume was calculated from circumference measurements.

RESULTS

The MTT (mean ± SD) was significantly longer in the lymphedema arm than in the normal arm: 60.1 ± 27.7 versus 5.4 ± 2.5 minutes (mean difference, 54.7 minutes; 95% confidence interval, 36.5-72.9 minutes; P < 0.0001). Patients with previous erysipelas infection had significantly longer MTT than other patients (mean difference, 43.7 minutes; 95% confidence interval, 18.6-68.7 minutes; P < 0.001). There was a positive correlation between MTT and excess arm volume (r = 0.64; P = 0.04) and number of lymph nodes removed (r = 0.65; P = 0.03) but no correlation between visual score and MTT.

CONCLUSION

Measurements of MTT were able to discriminate lymphedema from healthy arm and MTT correlated with relevant markers for lymphedema severity. We encourage further research using the MTT approach for monitoring lymphedema and evaluation of treatment response.

The Impact of L-Dex(®) Measurements in Assessing Breast Cancer-Related Lymphedema as Part of Routine Clinical Practice

PURPOSE

With improved survivorship, the prevalence of breast cancer-related lymphedema (BCRL) continues to increase, leading to impairment of a patients' quality of life. While traditional diagnostic methods are limited by an inability to detect BCRL until clinically apparent, bioimpedance spectroscopy (BIS) has been shown to detect subclinical BCRL. The purpose of this study is to evaluate the role of BIS in the early detection of BCRL, as well as assessment of response to BCRL treatment.

METHODS

A retrospective review of 1,133 patients treated between November 2008 and July 2013 at two surgical practices was performed. Eligible patients (n = 326) underwent preoperative and postoperative L-Dex measurements. Patients were identified as having subclinical lymphedema if they were asymptomatic and the L-Dex score increased >10 U above baseline and were monitored following treatment. Patients were stratified by lymph node dissection technique [sentinel lymph node biopsy (SLNB) vs. axillary lymph node dissection (ALND)] and receipt of BCRL treatment.

RESULTS

The average age of the cohort was 56.2 years old, and mean follow-up was 21.7 months. Of the 326 patients, 210 underwent SLNB and 116 underwent ALND. BCRL was identified by L-Dex in 40 patients (12.3%). The cumulative incidence rate of subclinical lymphedema was 4.3% for SLNB (n = 9) and 26.7% for ALND (n = 31). Of those diagnosed with BCRL, 50% resolved following treatment, 27.5% underwent treatment without resolution, and 22.5% had resolution without treatment. The prevalence of persistent, clinical BCRL was 0.5% for SLNB and 8.6% for ALND.

CONCLUSION

This study demonstrates both the feasibility and clinical utility of implementing L-Dex measurements in routine breast cancer care. L-Dex identified patients with possible subclinical BCRL and allowed for assessment of response to therapy.

The Effect of Education on Upper Extremity Function in Patients with Lymphedema after Breast Cancer Treatments

BACKGROUND

The aim of this study was to evaluate the effects of education on the upper extremity functions of patients with lymphedema (LE) after breast cancer treatments.

METHODS

Thirty-eight patients with LE after breast cancer treatments participated in the study. The patients were separated into two groups. Group 1 (n = 19) was educated about the causes and symptoms of LE and the methods for minimizing complications from LE, such as skin care, changes that must be made in daily life activities, exercises, and protective clothing. Group 2 (n = 19) was treated through standard means (surgical, chemotherapy, radiotherapy). A universal goniometer was used to assess the range of motion of the upper extremity of the patients. The Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the Shoulder Pain and Disability Index (SPADI) were used to assess shoulder function. The measures were carried out once by the same physiotherapist. The chi-square and Mann-Whitney U tests were used to analyze the data.

RESULTS

Group 1, educated about LE, performed better than the other group in shoulder flexion range. When shoulder abduction, internal-external rotation, and elbow flexion motions were compared by using the DASH and SPADI, no significant difference was observed between the groups (p > 0.05). However, when shoulder function was compared, Group 1 was better. There was no significant difference between the groups when the severity of LE was compared.

CONCLUSION

This study underscores the need to develop and implement strategies for LE prevention and education for all breast cancer patients.

The impact of early detection and intervention of breast cancer-related lymphedema: a systematic review

Breast cancer-related lymphedema (BCRL) has become an increasingly important clinical issue as noted by the recent update of the 2015 NCCN breast cancer guidelines which recommends to "educate, monitor, and refer for lymphedema management." The purpose of this review was to examine the literature regarding early detection and management of BCRL in order to (1) better characterize the benefit of proactive surveillance and intervention, (2) clarify the optimal monitoring techniques, and (3) help better define patient groups most likely to benefit from surveillance programs. A Medline search was conducted for the years 1992-2015 to identify articles addressing early detection and management of BCRL. After an initial search, 127 articles were identified, with 13 of these studies focused on early intervention (three randomized (level of evidence 1), four prospective (level of evidence 2-3), six retrospective trials (level of evidence 4)). Data from two, small (n = 185 cases), randomized trials with limited follow-up demonstrated a benefit to early intervention (physiotherapy, manual lymphatic drainage) with regard to reducing the rate of chronic BCRL (>50% reduction) with two additional studies underway (n = 1280). These findings were confirmed by larger prospective and retrospective series. Several studies were identified that demonstrate that newer diagnostic modalities (bioimpedance spectroscopy, perometry) have increased sensitivity allowing for the earlier detection of BCRL. Current data support the development of surveillance programs geared toward the early detection and management of BCRL in part due to newer, more sensitive diagnostic modalities.

Validity of Quantitative Lymphoscintigraphy as a Lymphedema Assessment Tool for Patients With Breast Cancer

Objective

To evaluate the validity of quantitative lymphoscintigraphy as a useful lymphedema assessment tool for patients with breast cancer surgery including axillary lymph node dissection (ALND).

Methods

We recruited 72 patients with lymphedema after breast cancer surgery that included ALND. Circumferences in their upper limbs were measured in five areas: 15 cm proximal to the lateral epicondyle (LE), the elbow, 10 cm distal to the LE, the wrist, and the metacarpophalangeal joint. Then, maximal circumference difference (MCD) was calculated by subtracting the unaffected side from the affected side. Quantitative asymmetry indices (QAI) were defined as the radiopharmaceutical uptake ratios of the affected side to the unaffected side. Patients were divided into 3 groups by qualitative lymphoscintigraphic patterns: normal, decreased function, and obstruction.

Results

The MCD was highest in the qualitative obstruction (2.76±2.48) pattern with significant differences from the normal (0.69±0.78) and decreased function (1.65±1.17) patterns. The QAIs of the axillary LNs showed significant differences among the normal (0.82±0.29), decreased function (0.42±0.41), and obstruction (0.18±0.16) patterns. As the QAI of the axillary LN increased, the MCD decreased. The QAIs of the upper limbs were significantly higher in the obstruction (3.12±3.07) pattern compared with the normal (1.15±0.10) and decreased function (0.79±0.30) patterns.

Conclusion

Quantitative lymphoscintigraphic analysis is well correlated with both commonly used qualitative lymphoscintigraphic analysis and circumference differences in the upper limbs of patients with breast cancer surgery with ALND. Quantitative lymphoscintigraphy may be a good alternative assessment tool for diagnosing lymphedema after breast cancer surgery with ALND.

A pilot randomized trial evaluating lymphedema self-measurement with bioelectrical impedance, self-care adherence, and health outcomes

BACKGROUND

Less than half of breast cancer survivors with lymphedema perform self-care as directed. Effective lymphedema self-care is required to obtain acceptable health outcomes. Self-Regulation Theory suggests that objective self-measurement of physiological conditions is necessary to promote self-regulation/self-care. Bioelectric Impedance Spectroscopy (BIS) represents a potential self-measurement method for arm lymphedema. The purpose of this pilot study was to examine the impact of arm self-measurement on daily self-care activities and health outcomes in breast cancer survivors with lymphedema.

METHODS AND RESULTS

A pilot randomized clinical trial compared outcomes between breast cancer survivors with lymphedema who self-monitored for 3 months and breast cancer survivors with lymphedema who did not self-monitor. Data were collected at baseline, months 1, 2, 3, and 4. Eighty-six women with lymphedema were screened: 62 were eligible, 50 were enrolled, 10 withdrew, and 1 had incomplete data, thus N=39. No between group differences were noted in participant characteristics. The self-monitored group had higher days of garment use (p=0.005) that remained stable after self-monitoring stopped. The median number of days of simple manual lymphatic drainage increased in the intervention group (p=0.004) with a downward trend after self-monitoring ceased.

CONCLUSIONS

Objective self-monitoring of arms using BIS is possible. Self-monitoring may positively impact self-care behaviors. Highly symptomatic patients may require coaching or other psychological support to improve their self-care. Studies that combine a cognitive behavioral therapy component along with self-measurement should be considered as potential interventions to impact lymphedema self-care. Other applications of self-monitoring warrant investigation.

Twisting Tourniquet(©) Technique: introducing Schnogh, a novel device and its effectiveness in treating primary and secondary lymphedema of extremities

Twisting Tourniquet^© or in Thai “Schnogh” is a new invention for compression therapy of lymphedema. Twisting Tourniquet^© Technique (TTT) is totally noninvasive for lymphedema management. After the amazing successful evidence in the first series of 28 patients, we have conducted preliminary studies in lymphedema clinics. It was found that the combination of gradually increasing constriction force by Schnogh until desired pressure was reached and maintained for 15 min, followed by a 5-min release, doing repeatedly this compression-decompression for at least 10 sessions a day, can generate acceptable results. The aim of the study was to evaluate the scientific effectiveness and establish a treatment protocol of TTT proposed as a therapeutic approach for clinical management of lymphedema. During 2006–2013, from over 3500 patients, 647 with primary/secondary lymphedema passed inclusion criteria, 307 for upper, and 340 for lower extremity. In the 5-day course of TTT, each day patients underwent 10 sessions of a 15-min compression followed by a 5-min decompression. Vegan diet was encouraged as an adjuvant therapy. Among lymphedema patients whose spectrum of edema severity ranged from mild to gigantic, TTT yielded an average volume reduction rate (VR) at 50.2% and 55.6%, making the average edema reduction volume attained at 463 and 1856 mL for upper and lower limb, respectively. The uniformed practice by Schnogh which supports a continual compression–decompression maneuver over 3.5 h daily for five consecutive days could induce an average VR at above half of the swelling in extremities of 647 patients. Schnogh is therefore effective in clinical management of lymphedema under TTT treatment of fibroblastic interstitium.

Manual lymphatic drainage for lymphedema following breast cancer treatment

BACKGROUND

More than one in five patients who undergo treatment for breast cancer will develop breast cancer-related lymphedema (BCRL). BCRL can occur as a result of breast cancer surgery and/or radiation therapy. BCRL can negatively impact comfort, function, and quality of life (QoL). Manual lymphatic drainage (MLD), a type of hands-on therapy, is frequently used for BCRL and often as part of complex decongestive therapy (CDT). CDT is a fourfold conservative treatment which includes MLD, compression therapy (consisting of compression bandages, compression sleeves, or other types of compression garments), skin care, and lymph-reducing exercises (LREs). Phase 1 of CDT is to reduce swelling; Phase 2 is to maintain the reduced swelling.

OBJECTIVES

To assess the efficacy and safety of MLD in treating BCRL.

SEARCH METHODS

We searched Medline, EMBASE, CENTRAL, WHO ICTRP (World Health Organization's International Clinical Trial Registry Platform), and Cochrane Breast Cancer Group's Specialised Register from root to 24 May 2013. No language restrictions were applied.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) or quasi-RCTs of women with BCRL. The intervention was MLD. The primary outcomes were (1) volumetric changes, (2) adverse events. Secondary outcomes were (1) function, (2) subjective sensations, (3) QoL, (4) cost of care.

DATA COLLECTION AND ANALYSIS

We collected data on three volumetric outcomes. (1) LE (lymphedema) volume was defined as the amount of excess fluid left in the arm after treatment, calculated as volume in mL of affected arm post-treatment minus unaffected arm post-treatment. (2) Volume reduction was defined as the amount of fluid reduction in mL from before to after treatment calculated as the pretreatment LE volume of the affected arm minus the post-treatment LE volume of the affected arm. (3) Per cent reduction was defined as the proportion of fluid reduced relative to the baseline excess volume, calculated as volume reduction divided by baseline LE volume multiplied by 100. We entered trial data into Review Manger 5.2 (RevMan), pooled data using a fixed-effect model, and analyzed continuous data as mean differences (MDs) with 95% confidence intervals (CIs). We also explored subgroups to determine whether mild BCRL compared to moderate or severe BCRL, and BCRL less than a year compared to more than a year was associated with a better response to MLD.

MAIN RESULTS

Six trials were included. Based on similar designs, trials clustered in three categories.(1) MLD + standard physiotherapy versus standard physiotherapy (one trial) showed significant improvements in both groups from baseline but no significant between-groups differences for per cent reduction.(2) MLD + compression bandaging versus compression bandaging (two trials) showed significant per cent reductions of 30% to 38.6% for compression bandaging alone, and an additional 7.11% reduction for MLD (MD 7.11%, 95% CI 1.75% to 12.47%; two RCTs; 83 participants). Volume reduction was borderline significant (P = 0.06). LE volume was not significant. Subgroup analyses was significant showing that participants with mild-to-moderate BCRL were better responders to MLD than were moderate-to-severe participants.(3) MLD + compression therapy versus nonMLD treatment + compression therapy (three trials) were too varied to pool. One of the trials compared compression sleeve plus MLD to compression sleeve plus pneumatic pump. Volume reduction was statistically significant favoring MLD (MD 47.00 mL, 95% CI 15.25 mL to 78.75 mL; 1 RCT; 24 participants), per cent reduction was borderline significant (P=0.07), and LE volume was not significant. A second trial compared compression sleeve plus MLD to compression sleeve plus self-administered simple lymphatic drainage (SLD), and was significant for MLD for LE volume (MD -230.00 mL, 95% CI -450.84 mL to -9.16 mL; 1 RCT; 31 participants) but not for volume reduction or per cent reduction. A third trial of MLD + compression bandaging versus SLD + compression bandaging was not significant (P = 0.10) for per cent reduction, the only outcome measured (MD 11.80%, 95% CI -2.47% to 26.07%, 28 participants).MLD was well tolerated and safe in all trials.Two trials measured function as range of motion with conflicting results. One trial reported significant within-groups gains for both groups, but no between-groups differences. The other trial reported there were no significant within-groups gains and did not report between-groups results. One trial measured strength and reported no significant changes in either group.Two trials measured QoL, but results were not usable because one trial did not report any results, and the other trial did not report between-groups results.Four trials measured sensations such as pain and heaviness. Overall, the sensations were significantly reduced in both groups over baseline, but with no between-groups differences. No trials reported cost of care.Trials were small ranging from 24 to 45 participants. Most trials appeared to randomize participants adequately. However, in four trials the person measuring the swelling knew what treatment the participants were receiving, and this could have biased results.

AUTHORS' CONCLUSIONS

MLD is safe and may offer additional benefit to compression bandaging for swelling reduction. Compared to individuals with moderate-to-severe BCRL, those with mild-to-moderate BCRL may be the ones who benefit from adding MLD to an intensive course of treatment with compression bandaging. This finding, however, needs to be confirmed by randomized data.In trials where MLD and sleeve were compared with a nonMLD treatment and sleeve, volumetric outcomes were inconsistent within the same trial. Research is needed to identify the most clinically meaningful volumetric measurement, to incorporate newer technologies in LE assessment, and to assess other clinically relevant outcomes such as fibrotic tissue formation.Findings were contradictory for function (range of motion), and inconclusive for quality of life.For symptoms such as pain and heaviness, 60% to 80% of participants reported feeling better regardless of which treatment they received.One-year follow-up suggests that once swelling had been reduced, participants were likely to keep their swelling down if they continued to use a custom-made sleeve.

Lymphedema Characteristics and the Efficacy of Complex Decongestive Physiotherapy in Malignant Lymphedema

The aim of this study is to identify the lymphedema characteristics and the efficacy of complex decongestive physiotherapy (CDP) in 29 patients with malignant lymphedema. After CDP, total decreased volume of lymphedema was 306 mL, percentage of excess volume (PEV) changed from 43.4% to 22.7%, and lymphedema severity improved from severe to moderate status. The CDP efficacy-percentage reduction in excess volume (PREV) was 46.6%. The stage of lymphedema ( P = .004), range of motion ( P < .001), pain, heaviness, and tension scores ( P < .001) were significantly improved after CDP. This shows that CDP is efficacious and useful in malignant lymphedema.

Long-term effects of complex decongestive therapy in breast cancer patients with arm lymphedema after axillary dissection

Objective

To investigate the long-term effects of complex decongestive therapy (CDT) on edema reduction in breast cancer-related lymphedema patients after axillary dissection, according to the initial volume of edema.

Methods

A retrospective review of 57 patients with unilateral arm after an axillary dissection for breast cancer was performed. The patients, treated with two weeks of CDT and self-administered home therapy, were followed for 24 months. Arm volume was serially measured by using an optoelectronic volumeter prior to and immediately after CDT; and there were follow-up visits at 3, 6, 12, and 24 months. Patients were divided into two groups according to the percent excess volume (PEV) prior to CDT: group 1, PEV<20% and group 2, PEV≥20%.

Results

In group 1, mean PEV before CDT was 11.4±5.0% and 14.1±10.6% at 24 months after CDT with no significant difference. At the end of CDT, PEV was 28.8±15.7% in group 2, which was significantly lower than the baseline (41.9±19.6%). The reduction of PEV was maintained for 24 months in group 2.

Conclusion

The long-term effects of CDT were well-maintained for 24 months, but there was a difference in progression of PEV between the two groups. The patients with more initial PEV showed significant volume-reducing effects of CDT. In patients with less initial PEV, the severity of lymphedema did not progress to higher grades.

Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship

Adult cancer survivors suffer an extremely diverse and complex set of impairments, affecting virtually every organ system. Both physical and psychological impairments may contribute to a decreased health-related quality of life and should be identified throughout the care continuum. Recent evidence suggests that more cancer survivors have a reduced health-related quality of life as a result of physical impairments than due to psychological ones. Research has also demonstrated that the majority of cancer survivors will have significant impairments and that these often go undetected and/or untreated, and consequently may result in disability. Furthermore, physical disability is a leading cause of distress in this population. The scientific literature has shown that rehabilitation improves pain, function, and quality of life in cancer survivors. In fact, rehabilitation efforts can ameliorate physical (including cognitive) impairments at every stage along the course of treatment. This includes prehabilitation before cancer treatment commences and multimodal interdisciplinary rehabilitation during and after acute cancer treatment. Rehabilitation appears to be cost-effective and may reduce both direct and indirect health care costs, thereby reducing the enormous financial burden of cancer. Therefore, it is critical that survivors are screened for both psychological and physical impairments and then referred appropriately to trained rehabilitation health care professionals. This review suggests an impairment-driven cancer rehabilitation model that includes screening and treating impairments all along the care continuum in order to minimize disability and maximize quality of life.

A pilot randomized trial evaluating low-level laser therapy as an alternative treatment to manual lymphatic drainage for breast cancer-related lymphedema

PURPOSE/OBJECTIVES

To examine the impact of advanced practice nurse (APN)-administered low-level laser therapy (LLLT) as both a stand-alone and complementary treatment for arm volume, symptoms, and quality of life (QOL) in women with breast cancer-related lymphedema.

DESIGN

A three-group, pilot, randomized clinical trial.

SETTING

A private rehabilitation practice in the southeastern United States.

SAMPLE

46 breast cancer survivors with treatment-related lymphedema.

METHODS

Patients were screened for eligibility and then randomized to either manual lymphatic drainage (MLD) for 40 minutes, LLLT for 20 minutes, or 20 minutes of MLD followed by 20 minutes of LLLT. Compression bandaging was applied after each treatment. Data were collected pretreatment, daily, weekly, and at the end of treatment.

MAIN RESEARCH VARIABLES

Independent variables consisted of three types of APN-administered lymphedema treatment. Outcome variables included limb volume, extracellular fluid, psychological and physical symptoms, and QOL.

FINDINGS

No statistically significant between-group differences were found in volume reduction; however, all groups had clinically and statistically significant reduction in volume. No group differences were noted in psychological and physical symptoms or QOL; however, treatment-related improvements were noted in symptom burden within all groups. Skin improvement was noted in each group that received LLLT.

CONCLUSIONS

LLLT with bandaging may offer a time-saving therapeutic option to conventional MLD. Alternatively, compression bandaging alone could account for the demonstrated volume reduction.

IMPLICATIONS FOR NURSING

APNs can effectively treat lymphedema. APNs in private healthcare practices can serve as valuable research collaborators.

KNOWLEDGE TRANSLATION

Lasers may provide effective, less burdensome treatment for lymphedema. APNs with lymphedema certification can effectively treat this patient population with the use of LLLT. In addition, bioelectrical impedance and tape measurements can be used to assess lymphedema.

Diagnosis and treatment of lymphedema after breast cancer: a population-based study

OBJECTIVE

To examine factors associated with variations in diagnosis and rehabilitation treatments received by women with self-reported lymphedema resulting from breast cancer care.

DESIGN

A large, population-based, prospective longitudinal telephone survey.

SETTING

California, Florida, Illinois, and New York.

PARTICIPANTS

Elderly (65+ years) women identified from Medicare claims as having had an incident breast cancer surgery in 2003.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Self-reported incidence of lymphedema symptoms, formal diagnosis of lymphedema, treatments for lymphedema.

RESULTS

Of the 450 breast cancer survivors with lymphedema who participated in the study, 290 (64.4%) were formally diagnosed with the condition by a physician. An additional 160 (35.6%) reported symptoms consistent with lymphedema (ie, arm swelling on the side of surgery that is absent on the contralateral arm) but were not formally diagnosed. Of those who reported being diagnosed by a physician, 39 (13.4%) received complete decongestive therapy that included multiple components of treatment (ie, manual lymphatic drainage, bandaging with short stretch bandages, the use of compression sleeves, skin care, and remedial exercises); 24 (8.3%) were treated with manual lymphatic drainage only; 162 (55.9%) used bandages, compression garments, or a pneumatic pump only; 8 (2.8%) relied solely on skin care or exercise to relieve symptoms; and 65 (22.4%) received no treatment at all. Multivariate regressions revealed that race (African American), lower income, and lower levels of social support increased a woman's probability of having undiagnosed lymphedema. Even when they were formally diagnosed, African American women were more likely to receive no treatment or to be treated with bandages/compression only rather than to receive the multimodality, complete decongestive therapy.

CONCLUSIONS

Lymphedema is a disabling chronic condition related to breast cancer treatment. Our results suggest that a substantial proportion of persons reporting symptoms were not formally diagnosed with the condition, thereby reducing their opportunity for treatment. The variation in rehabilitation treatments received by women who were formally diagnosed with the condition by a physician suggests that lymphedema might not have been optimally addressed in many cases despite the availability of effective interventions.

A systematic review of the evidence for complete decongestive therapy in the treatment of lymphedema from 2004 to 2011

OBJECTIVE

To critically analyze the contemporary published research that pertains to the individual components of complete decongestive therapy (CDT), as well as CDT as a bundled intervention in the treatment of lymphedema.

DATA SOURCES

Publications were retrieved from 11 major medical indices for articles published from 2004-2010 by using search terms for lymphedema and management approaches. Literature archives of the authors and reference lists were examined through 2011.

STUDY SELECTION

A research librarian assisted with initial literature searches by using search terms used in the Best Practice for the Management of Lymphoedema, plus expanded terms, for literature related to lymphedema. Authors sorted relevant literature for inclusion and exclusion; included articles were sorted into topical areas for data extraction and assessment of level of evidence by using a published grading system and consensus process. The authors reviewed 99 articles, of which 26 met inclusion criteria for individual studies and 1 case study did not meet strict inclusion criteria. In addition, 14 review articles and 2 consensus articles were reviewed.

DATA EXTRACTION

Information on study design and/or objectives, participants, outcomes, intervention, results, and study strengths and weaknesses was extracted from each article. Study evidence was categorized according to the Oncology Nursing Society Putting Evidence into Practice level of evidence guidelines after achieving consensus among authors.

DATA SYNTHESIS

Levels of evidence were only moderately strong, because there were few randomized controlled trials with control groups, well-controlled interventions, and precise measurements of volume, mobility and/or function, and quality of life. Treatment interventions were often bundled, which makes it difficult to determine the contribution of each individual component of treatment to the outcomes achieved.

CONCLUSIONS

CDT is seen to be effective in reducing lymphedema. This review focuses on original research about CDT as a bundled intervention and 2 individual components, manual lymph drainage and compression bandages. Additional studies are needed to determine the value and efficacy of the other individual components of CDT.

Assessment of the intraobserver and interobserver reliability of a communicating vessels volumeter to measure wrist-hand volume

BACKGROUND

Traditional volumetry based on Archimedes' principle is the gold standard for the measurement of limb volume, but the routine use of this technique is discouraged because of several disadvantages.

OBJECTIVE

The purpose of this study was to evaluate intraobserver and interobserver reliability of direct measurements of wrist-hand volume using a new communicating vessels volumeter based on Pascal's law.

DESIGN

A reliability study was conducted.

METHODS

To evaluate the reliability of the communicating vessels volumeter in generating measurements, 30 hands of 15 participants (9 women, 6 men) were measured 3 times each by 3 observers, totaling 270 volumetric results.

RESULTS

Measurement time was short (X =3 minutes 42 seconds). The intraclass correlation coefficient (ICC) was .9977 for observer 1 and .9976 for observers 2 and 3. The interobserver ICC was .9998. The standard error of measurement was about 3 mL for all observers; the interobserver result was 1 mL. The interrater coefficient of variance (CV) was 1.15% for the series of 9 measurements collected for each segment; the intrarater CV was 1.20%. Limitations No swollen hands were measured, and measurements were not compared with the gold standard technique. Thus, accuracy of the new volumeter was not determined in this study.

CONCLUSION

A new device has been developed for plethysmography of the extremities, and the results of its use to measure the volume of the wrist-hand segment were reliable in both intraobserver and interobserver analyses.

Case Report: Manual Lymphatic Drainage and Kinesio Taping in the Secondary Malignant Breast Cancer-Related Lymphedema in an Arm With Arteriovenous (A-V) Fistula for Hemodialysis

Lymphedema is a dreaded complication of breast cancer treatment. The standard care for lymphedema is complex decongestive physiotherapy, which includes manual lymphatic drainage (MLD), short stretch bandaging, exercise, and skin care. The Kinesio Taping could help to improve lymphatic uptake. We reported a patient with unilateral secondary malignant breast cancer-related lymphedema and arteriovenous (A-V) fistula for hemodialysis happened in the same arm, and used kinesio taping, MLD, and exercise to treat this patient because no pressure could be applied to the A-V fistula. The 12-session therapy created an excellent effect. We do not think the kinesio taping could replace short stretch bandaging, but it could be another choice for contraindicating pressure therapy patients, and we should pay attention to wounds induced by kinesio tape.