The effect of complex decongestive physiotherapy applied with different compression pressures on skin and subcutaneous tissue thickness in individuals with breast cancer-related lymphedema: a double-blinded randomized comparison trial

PURPOSE

The aim of this study was to evaluate the effect of compression bandage applied with different pressures on the skin and subcutaneous thickness in individuals with breast cancer-related lymphedema (BCRL).

METHODS

21 individuals with stage 2 unilateral BCRL participated in the study. Individuals were randomly allocated into two groups as low-pressure bandage (20-30 mmHg) (n: 11) and high-pressure bandage (45-55 mmHg) (n: 10). Skin and subcutaneous tissue thickness, extremity volume, sleep quality, treatment benefit, and comfort were evaluated by ultrasound from 6 reference points (as hand dorsum, wrist volar, forearm volar, arm volar, forearm dorsum, and arm dorsum), volumetric measurement, Pittsburgh Sleep Quality Index, Patient Benefit Index-Lymphedema, and visual analog scale, respectively. Complex decongestive physiotherapy was applied to both groups. Compression bandage was applied according to their group. Individuals were evaluated at the baseline, 1st session, 10th session, 20th session, and at 3-month follow-up.

RESULTS

Skin thickness decreased significantly in the volar reference points of the extremity in the high-pressure bandage group (p = 0.004, p = 0.031, and p = 0.003). Subcutaneous tissue thickness significantly decreased at all reference points in the high-pressure bandage group (p < 0.05). In the low-pressure bandage group, skin thickness only decreased in the forearm dorsum and the arm dorsum (p = 0.002, p = 0.035) and subcutaneous tissue thickness changed for all points (p < 0.05) except for hand and arm dorsum (p = 0.064, p = 0.236). Edema decreased in a shorter time in the high-pressure bandage group (p < 0.001). No significant differences were found in sleep quality, treatment benefit, and comfort for both groups (p = 0.316, p = 0.300, and p = 0.557, respectively).

CONCLUSION

High pressure was more effective in reducing subcutaneous tissue thickness in the dorsum of hand and arm. The usage of high-pressure can be recommended especially in cases which have edema in the dorsum of hand and arm which is difficult to resolve. Also, high-pressure bandage can provide faster edema resolution and can be used in rapid volume reduction as desired. Treatment outcomes may improve with high-pressure bandage without any impairment in comfort, sleep quality, and treatment benefit.

TRIAL REGISTRATION NUMBER AND DATE

NCT05660590, 12/26/2022 retrospectively registered.

Ultrasound: Assessment of breast dermal thickness: Reliability, responsiveness to change, and relationship to patient-reported outcomes

BACKGROUND

The current study assessed the level of reliability of ultrasound to assess dermal thickness, a clinical feature of breast lymphedema. Additionally, the relationship of dermal thickness to patient-reported outcomes was investigated.

METHODS

Women (n = 82) with unilateral breast edema secondary to treatment of breast cancer were randomized to an exercise or control group. Ultrasound measurements of the unaffected and affected breasts were taken at baseline and 12 weeks later at 3-4 cm superior, medial, inferior, and lateral to the nipple. Additionally, women completed breast-related questions from the European Organization Research and Treatment Committee Quality of Life breast cancer module (EORTC-BR23) and Lymphedema Symptom Intensity and Distress Questionnaire (LSIDS). Reliability of ultrasound measurements was determined on the unaffected breast.

RESULTS

Intraclass correlation coefficients (2,1) ranged from 0.66 (95% CI: 0.52-0.77) for the lateral location to 0.84 (0.77-0.90) for the superior location. Percent close agreement (80%) on the unaffected breast ranged from 0.20 to 0.27 mm compared to 0.57 to 0.93 mm on the affected breast. The standard error of measurement (%) on the unaffected breast varied from 9% to 13% with smallest real difference 0.34-0.41 mm. Dermal thickness of the affected breast was not-to-poorly associated with EORTC BR23 and LSIDS scores.

CONCLUSION

Reliability of dermal thickness measurements of the breast was excellent for the superior, medial, and inferior locations, and fair to good for the lateral location. However, these measurements were not related to the symptom's women perceive and measured with the EORTC BR23 or LSIDS.

Spermidine-induced recovery of human dermal structure and barrier function by skin microbiome

An unbalanced microbial ecosystem on the human skin is closely related to skin diseases and has been associated with inflammation and immune responses. However, little is known about the role of the skin microbiome on skin aging. Here, we report that the Streptococcus species improved the skin structure and barrier function, thereby contributing to anti-aging. Metagenomic analyses showed the abundance of Streptococcus in younger individuals or those having more elastic skin. Particularly, we isolated Streptococcus pneumoniae, Streptococcus infantis, and Streptococcus thermophilus from face of young individuals. Treatment with secretions of S. pneumoniae and S. infantis induced the expression of genes associated with the formation of skin structure and the skin barrier function in human skin cells. The application of culture supernatant including Streptococcal secretions on human skin showed marked improvements on skin phenotypes such as elasticity, hydration, and desquamation. Gene Ontology analysis revealed overlaps in spermidine biosynthetic and glycogen biosynthetic processes. Streptococcus-secreted spermidine contributed to the recovery of skin structure and barrier function through the upregulation of collagen and lipid synthesis in aged cells. Overall, our data suggest the role of skin microbiome into anti-aging and clinical applications.

Dermal thickness and echogenicity using DermaScan C high frequency ultrasound: Methodology and reliability testing in people with and without primary lymphoedema

BACKGROUND

DermaScan C high frequency ultrasound was investigated for image capture and analysis of dermal measures in people with and without primary lymphoedema.

METHOD

Three repeated images were taken at six sites in people without lymphoedema (NLO). Intra-rater reliability was assessed by taking three sets of measures on images from 10 people and inter-session reliability by capturing three images, lifting the probe from the skin in between. Methods were adjusted, and repeated images from four sites were taken in people with primary lymphoedema (PLO) and reliability re-assessed.

RESULTS

Intra-rater reliability in NLO and PLO for echogenicity measures were excellent (NLO ICC_(3,1) : .989; PLO .997) across all sites and specific to each site (calf: ICC_(3,1) : .989; and foot: ICC_(3,1) : .999, respectively). Inter-session reliability was moderate for NLO (ICC_(3,1) : .727), improving after method modifications for PLO (ICC_(3,1) : .916). When investigated by site, inter-session reliability was good in the foot (ICC_(3,1) : .811) and moderate in the calf (ICC_(3,1) : .616). Mean thickness analysed by site resulted in good inter-session reliability only in the foot (ICC_(3,1) .838).

CONCLUSION

Intra-rater reliability was excellent using the DermaScan C for dermal measures in people with primary lymphoedema. Inter-session reliability required particular attention to method and gain settings.

Assessment of Mechanical Properties of Tissue in Breast Cancer-Related Lymphedema Using Ultrasound Elastography

Breast cancer-related lymphedema is a consequence of a malfunctioning lymphatic drainage system resulting from surgery or some other form of treatment. In the initial stages, minor and reversible increases in the fluid volume of the arm are evident. As the stages progress over time, the underlying pathophysiology dramatically changes with an irreversible increase in arm volume most likely due to a chronic local inflammation leading to adipose tissue hypertrophy and fibrosis. Clinicians have subjective ways to stage the degree and severity such as the pitting test which entails manually comparing the elasticity of the affected and unaffected arms. Several imaging modalities can be used but ultrasound appears to be the most preferred because it is affordable, safe, and portable. Unfortunately, ultrasonography is not typically used for staging lymphedema, because the appearance of the affected and unaffected arms is similar in B-mode ultrasound images. However, novel ultrasound techniques have emerged, such as elastography, which may be able to identify changes in mechanical properties of the tissue related to detection and staging of lymphedema. This paper presents a novel technique to compare the mechanical properties of the affected and unaffected arms using quasi-static ultrasound elastography to provide an objective alternative to the current subjective assessment. Elastography is based on time delay estimation (TDE) from ultrasound images to infer displacement and mechanical properties of the tissue. We further introduce a novel method for TDE by incorporating higher order derivatives of the ultrasound data into a cost function and propose a novel optimization approach to efficiently minimize the cost function. This method works reliably with our challenging patient data. We collected radio frequency ultrasound data from both arms of seven patients with stage 2 lymphedema, at six different locations in each arm. The ratio of strain in skin, subcutaneous fat, and skeletal muscle divided by strain in the standoff gel pad was calculated in the unaffected and affected arms. The p -values using a Wilcoxon sign-rank test for the skin, subcutaneous fat, and skeletal muscle were 1.24×10^-5 , 1.77×10^-8 , and 8.11×10^-7 respectively, showing differences between the unaffected and affected arms with a very high level of significance.

Clinical effects of an oral supplement rich in antioxidants on skin radiance in women

Background

Environmental factors impact the skin aging resulting in decrease of skin radiance. Nutrition and particularly antioxidants could help to fight against skin degradation.

Objective

The aim of this study was to evaluate the effects of an oral supplement rich in specific antioxidants, SkinAx^2TM, on the improvement of the skin radiance in women.

Methods

The open-label clinical study enrolled 35 women, aged 40–70, with facial dull complexion. Subjects were supplemented orally with a daily dosage of 150 mg of an antioxidant-rich formulation containing superoxide dismutase-rich melon concentrate, grape seed extract rich in monomers of flavanols, vitamin C, and zinc for 8 weeks. Each subject served as her own control. The C.L.B.T.^™ test has been used to evaluate facial skin coloring (C), luminosity (L), brightness (B), and transparency (T) involved in skin radiance. Facial skin imperfections have been assessed by clinical assessment. Firmness has been evaluated by clinical assessment and cutometer measurement. Finally, an auto-questionnaire has been carried out in order to evaluate the satisfaction of the subjects concerning different parameters involved in skin radiance and the global efficacy of the supplement.

Results

Skin “red pink” and “olive” colors were significantly improved after supplementation (P<0.0001). Luminosity was increased by 25.9% (P<0.0001) whereas brightness and transparency were not affected by the supplementation. Facial skin imperfections were significantly reduced after the antioxidant-rich formulation intake (global reduction: −18.0%; P<0.0001). Indeed, dark circles, redness, and spots significantly diminished after oral treatment. Firmness and elasticity have been shown to be improved. Subjects were globally satisfied by the product (82.4%) and have found improvements on their facial skin. Furthermore, 64.7% reported to look better at the end of the supplementation.

Conclusion

The oral supplement containing the antioxidant-rich formulation was found to improve skin radiance by reducing skin coloring, increasing face luminosity, reducing imperfections, and improving skin firmness in women with dull complexion.

[Complex decongestive therapy]

The amount of physical pressure plays an important role in complex decongestive therapy (CDT). As a function of pressure, microcirculation takes place between blood vessels and tissue. As part of the total lymphatic system, lymphatic vessels transport the lymphatic load from the interstitial space to the blood stream. The lymphatic vessel system, characterized by specific anatomical conditions like initial lymphatic vessels, precollectors, collectors, and lymphatic strains, is the therapeutic target of complex decongestive therapy. Components of CDT include manual lymphatic drainage, compression therapy, decongestive kinesitherapy, and good skin care, which increase the transport capacity of the lymphatic vessel system. Currently, CDT is acknowledged as the main conservative treatment of lymphedema of primary and secondary genesis, lipolymphedema, and phlebolymphedema. In clinical practice, we are increasingly confronted with edema of multifactorial genesis requiring a critical discussion and stocktaking of comprehensive clinical findings in terms of the indication for CDT. Therapeutic success depends on a joint application of all CDT components and patient compliance. To an increasing extent, medical research tries to combine successfully CDT with adjunct treatment options.

A new soft tissue volume measurement strategy using ultrasonography

Abstract Various techniques are available for measuring the status of lymphedema. A modified imaging technique using ultrasonography was developed to measure the structure of soft tissue area in a cost-effective manner. The purpose of this study was to measure the reliability and the accuracy of this new method. Ultrasonography was performed on both arms of twenty healthy female participants. At 10 cm above (AE) and below (BE) the elbow crease, soft tissue thickness at medial, lateral, inferior, and superior locations were measured by two examiners with minimal unnecessary pressure. After measuring twice on 16 sites for each participant, the amount of soft tissue in the cross-sectional area (ΔCSA) was acquired by a designed formulation. The ΔCSA was also compared with volumetry data (Perometer(®)). Cronbach's alpha coefficient test was used for statistics. The intra-class and inter-class reliability measurements for all soft tissue areas were very strong (α=0.980 and 0.960, respectively; p<0.01). All AE and BE reliabilities showed very strong correlation and strong correlation of inter-BE measurement. All reliabilities of ΔCSA were very strong (≥0.950). All CCs (correlation coefficients) between ΔCSA, circumference, and volumetry were strong for AE and BE measurements, except for ΔCSA and circumference at BE. The strongest CC was between volumetry and circumference measurements. This study suggests that measuring the ΔCSA by ultrasonography could be an alternative way to measure the status of soft tissue indirectly with structural consideration.