1
|
Ahmed S, Imeokparia FO, Hassanein AH. Surgical management of lymphedema: prophylactic and therapeutic operations. CURRENT BREAST CANCER REPORTS 2024; 16:185-192. [PMID: 38988994 PMCID: PMC11233112 DOI: 10.1007/s12609-024-00543-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 07/12/2024]
Abstract
Purpose of Review Lymphedema is chronic limb swelling from lymphatic dysfunction and is currently incurable. Breast-cancer related lymphedema (BCRL) affects up to 5 million Americans and occurs in one-third of breast cancer survivors following axillary lymph node dissection. Compression remains the mainstay of therapy. Surgical management of BCRL includes excisional procedures to remove excess tissue and physiologic procedures to attempt improve fluid retention in the limb. The purpose of this review is to highlight surgical management strategies for preventing and treating breast cancer-related lymphedema. Recent findings Immediate lymphatic reconstruction (ILR) is a microsurgical technique that anastomoses disrupted axillary lymphatic vessels to nearby veins at the time of axillary lymph node dissection (ALND) and has been reported to reduce lymphedema rates from 30% to 4-12%. Summary Postsurgical lymphedema remains incurable. Surgical management of lymphedema includes excisional procedures and physiologic procedures using microsurgical technique. Immediate lymphatic reconstruction has emerged as a prophylactic strategy to prevent lymphedema in breast cancer patients.
Collapse
Affiliation(s)
- Shahnur Ahmed
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Folasade O Imeokparia
- Division of Surgical Oncology, Indiana University School of Medicine, Indianapolis, IN
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
2
|
Watanabe-Asaka T, Hayashi M, Harada T, Uemura S, Takai J, Nakamura Y, Moriguchi T, Kawai Y. Perturbed collagen metabolism underlies lymphatic recanalization failure in Gata2 heterozygous deficient mice. J Biochem 2024; 175:551-560. [PMID: 38168819 DOI: 10.1093/jb/mvad122] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/27/2023] [Indexed: 01/05/2024] Open
Abstract
Lymphedema has become a global health issue following the growing number of cancer surgeries. Curative or supportive therapeutics have long been awaited for this refractory condition. Transcription factor GATA2 is crucial in lymphatic development and maintenance, as GATA2 haploinsufficient disease often manifests as lymphedema. We recently demonstrated that Gata2 heterozygous deficient mice displayed delayed lymphatic recanalization upon lymph node resection. However, whether GATA2 contributes to lymphatic regeneration by functioning in the damaged lymph vessels' microenvironment remains explored. In this study, our integrated analysis demonstrated that dermal collagen fibers were more densely accumulated in the Gata2 heterozygous deficient mice. The collagen metabolism-related transcriptome was perturbed, and collagen matrix contractile activity was aberrantly increased in Gata2 heterozygous embryonic fibroblasts. Notably, soluble collagen placement ameliorated delayed lymphatic recanalization, presumably by modulating the stiffness of the extracellular matrix around the resection site of Gata2 heterozygous deficient mice. Our results provide valuable insights into mechanisms underlying GATA2-haploinsufficiency-mediated lymphedema and shed light on potential therapeutic avenues for this intractable disease.
Collapse
Affiliation(s)
- Tomomi Watanabe-Asaka
- Division of Physiology, Tohoku Medical and Pharmaceutical University, School of Medicine
| | - Moyuru Hayashi
- Division of Physiology, Tohoku Medical and Pharmaceutical University, School of Medicine
| | - Takuya Harada
- Division of Physiology, Tohoku Medical and Pharmaceutical University, School of Medicine
| | - Satoshi Uemura
- Division of Medical Biochemistry, Tohoku Medical and Pharmaceutical University, School of Medicine
| | - Jun Takai
- Division of Medical Biochemistry, Tohoku Medical and Pharmaceutical University, School of Medicine
| | - Yasuhiro Nakamura
- Division of Pathology, Tohoku Medical and Pharmaceutical University, School of Medicine 983-8536 Japan
| | - Takashi Moriguchi
- Division of Medical Biochemistry, Tohoku Medical and Pharmaceutical University, School of Medicine
| | - Yoshiko Kawai
- Division of Physiology, Tohoku Medical and Pharmaceutical University, School of Medicine
| |
Collapse
|
3
|
Ahmed S, Hassanein AH, Lester ME, Manghelli J, Fisher C, Imeokparia F, Ludwig K, Fan B. Trends in Immediate Lymphatic Reconstruction. Cureus 2024; 16:e59194. [PMID: 38807806 PMCID: PMC11131141 DOI: 10.7759/cureus.59194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/20/2024] [Indexed: 05/30/2024] Open
Abstract
Background and objective Immediate lymphatic reconstruction (ILR) is emerging as a useful adjunct after axillary lymph node dissection (ALND), leading to a decrease in lymphedema rates from 30 to 3-13% in breast cancer patients. ILR requires coordination between two surgical specialties for oncologic ALND and microsurgical axillary lymphatic anastomosis. This study aimed to assess the trends in the frequency of ILR performed after ALND at our institution. Methods This study involved a retrospective review of breast cancer patients undergoing ALND with and without ILR at our institution (2017-2022). Data on patient demographics, tumor characteristics, and treatments received were gathered and analyzed. Results A total of 316 patients underwent ALND at our institution and 30.7% (97/316) of them received ILR. There was no significant difference in clinical breast cancer stages between patients who underwent ALND with or without ILR (p>0.05). Neoadjuvant chemotherapy was given to 51.1% (112/219) of patients with ALND only compared to 60.8% (59/97) of patients who underwent ALND with ILR (p=0.09). All patients received adjuvant radiation therapy. ILR was performed after ALND in 4.2% (2/47) in 2017, 25.8% (3/58) in 2018, 17.6% (12/68) in 2019, 35% (21/60) in 2020, 56.9% (41/72) in 2021, and 54.5% (6/11) in 2022. When comparing the first year of the ILR program with the last year of the study period, the odds ratio of receiving ILR after ALND was 1.8 (p=0.04). Conclusions The frequency of performing ILR after ALND in breast cancer patients at our institution witnessed a substantial increase during the study period. The implementation of an established ILR program at an institution can increase procedure uptake accompanied by continued growth in utilization.
Collapse
Affiliation(s)
| | | | - Mary E Lester
- Plastic Surgery, Indiana University, Indianapolis, USA
| | | | - Carla Fisher
- Surgical Oncology, Indiana University School of Medicine, Indianapolis, USA
| | | | | | - Betty Fan
- Breast Surgery, University of Chicago Medicine, Chicago, USA
| |
Collapse
|
4
|
Mohan G, Khan I, Neumann CR, Jorge MD, Ahmed S, Hulsman L, Sinha M, Gordillo GM, Sen CK, Hassanein AH. Topical tissue nanotransfection of Prox1 is effective in the prophylactic management of lymphedema. MOLECULAR THERAPY. NUCLEIC ACIDS 2024; 35:102121. [PMID: 38333673 PMCID: PMC10850858 DOI: 10.1016/j.omtn.2024.102121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
Lymphedema is chronic limb swelling resulting from lymphatic dysfunction. There is no cure for the disease. Clinically, a preventive surgical approach called immediate lymphatic reconstruction (ILR) has gained traction. Experimental gene-based therapeutic approaches (e.g., using viral vectors) have had limited translational applicability. Tissue nanotransfection (TNT) technology uses a direct, transcutaneous nonviral vector, gene delivery using a chip with nanochannel poration in response to a rapid (<100 ms) focused electric field. The purpose of this study was to experimentally prevent lymphedema using focal delivery of a specific gene Prox1 (a master regulator of lymphangiogenesis). TNT was applied to the previously optimized lymphedematous mice tail (day 0) directly at the surgical site with genetic cargo loaded into the TNT reservoir: group I (sham) was given pCMV6 (expression vector backbone alone) and group II was treated with pCMV6-Prox1. Group II mice had decreased tail volume (47.8%) compared to sham and greater lymphatic clearance on lymphangiography. Immunohistochemistry showed greater lymphatic vessel density and RNA sequencing exhibited reduced inflammatory markers in group II compared to group I. Prox1 prophylactically delivered using TNT to the surgical site on the day of injury decreased the manifestations of lymphedema in the murine tail model compared to control.
Collapse
Affiliation(s)
- Ganesh Mohan
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Imran Khan
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Colby R. Neumann
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Miguel D. Jorge
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shahnur Ahmed
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Luci Hulsman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mithun Sinha
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gayle M. Gordillo
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- McGowan Institute for Regenerative Medicine, Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chandan K. Sen
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- McGowan Institute for Regenerative Medicine, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Aladdin H. Hassanein
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|
5
|
陈 君, 邓 呈. [Research advances on stem cell-based treatments in animal studies and clinical trials of lymphedema]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2024; 38:99-106. [PMID: 38225848 PMCID: PMC10796233 DOI: 10.7507/1002-1892.202309045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/16/2023] [Indexed: 01/17/2024]
Abstract
Objective To summarize the progress of the roles and mechanisms of various types of stem cell-based treatments and their combination therapies in both animal studies and clinical trials of lymphedema. Methods The literature on stem cell-based treatments for lymphedema in recent years at home and abroad was extensively reviewed, and the animal studies and clinical trials on different types of stem cells for lymphedema were summarized. Results Various types of stem cells have shown certain effects in animal studies and clinical trials on the treatment of lymphedema, mainly through local differentiation into lymphoid endothelial cells and paracrine cytokines with different functions. Current research focuses on two cell types, adipose derived stem cells and bone marrow mesenchymal stem cells, both of which have their own advantages and disadvantages, mainly reflected in the therapeutic effect of stem cells, the difficulty of obtaining stem cells and the content in vivo. In addition, stem cells can also play a synergistic role in combination with other treatments, such as conservative treatment, surgical intervention, cytokines, biological scaffolds, and so on. However, it is still limited to the basic research stage, and only a small number of studies have completed clinical trials. Conclusion Stem cells have great transformation potential in the treatment of lymphedema, but there is no unified standard in the selection of cell types, the amount of transplanted cells, and the timing of transplantation.
Collapse
Affiliation(s)
- 君哲 陈
- 遵义医科大学附属医院烧伤整形外科(贵州遵义 563003)Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563003, P. R. China
| | - 呈亮 邓
- 遵义医科大学附属医院烧伤整形外科(贵州遵义 563003)Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563003, P. R. China
- 组织损伤修复与再生医学省部共建协同创新中心(贵州遵义 563003)Collaborative Innovation Center of Tissue Repair and Regenerative Medicine, Zunyi Guizhou, 563003, P. R. China
| |
Collapse
|
6
|
Zhang X, Beeraka NM, Sinelnikov MY, Glazachev OS, Ternovoy KS, Lu P, Isaeva A, Cao Y, Zhang J, Nezhad AB, Plotnikova M, Chen K. Breast Cancer-related Lymphedema: Recent Updates on Clinical Efficacy of Therapies and Bioengineering Approaches for a Personalized Therapy. Curr Pharm Des 2024; 30:63-70. [PMID: 38141193 DOI: 10.2174/0113816128269545231218075040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/20/2023] [Accepted: 12/04/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Post-mastectomy lymphedema is a chronic progressive disease characterized by a significant reduction in quality of life and a range of complications. AIM To this date, no single treatment method provides pathological correction of the mechanisms associated with tissue reorganization observed in later-stage breast cancer-related lymphedema (BCRL). METHODS To define a personalized approach to the management of patients with iatrogenic lymphedema, we performed a systematic review of literature without a comprehensive meta-analysis to outline existing molecular- genetic patterns, overview current treatment methods and their efficacy, and highlight the specific tissue-associated changes in BCRL conditions and other bio-engineering approaches to develop personalized therapy. RESULTS Our results show that several tissue-specific and pathological molecular markers may be found, yet current research does not aim to define them. CONCLUSION As such, currently, a strong foundation for further research into molecular-genetic changes in lymphedema tissue exists, and further research should focus on finding specific targets for personalized treatment through bio-engineering approaches.
Collapse
Affiliation(s)
- Xinliang Zhang
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Narasimha M Beeraka
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
- Department of Biotechnology, Raghavendra Institute of Pharmaceutical Education and Research (RIPER), Anantapuramu, Chiyyedu, Andhra Pradesh 515721, India
- Herman B. Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, 1044 W. Walnut Street, R4-168, Indianapolis, IN 46202, Indiana, USA
| | - Mikhail Y Sinelnikov
- Department of Cancer Research, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
- Research Institute of Human Morphology, Moscow, Russian Federation
| | - Oleg S Glazachev
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Konstantin S Ternovoy
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Pengwei Lu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshedong Street, Zhengzhou 450052, China
| | - Aida Isaeva
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Yu Cao
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Jin Zhang
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Arshia Bakhtiari Nezhad
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Maria Plotnikova
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Kuo Chen
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshedong Street, Zhengzhou 450052, China
| |
Collapse
|
7
|
Kurt G, Kiloatar H, Aras B. Knowledge, attitude and practice of physiotherapists about lymphedema: A Turkish perspective. J Bodyw Mov Ther 2024; 37:233-237. [PMID: 38432811 DOI: 10.1016/j.jbmt.2023.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 11/17/2023] [Accepted: 11/26/2023] [Indexed: 03/05/2024]
Abstract
BACKGROUND Physiotherapists are important members of the healthcare team in the management of lymphedema. Therefore, the level of knowledge and awareness of physiotherapists on this disease is substantial. This study was planned to investigate knowledge, attitude, and practice of physiotherapists about lymphedema in Turkey. METHOD This study was a qualitative, prospective, and cross-sectional research. Data were collected with the web-survey which consisted of the demographical characteristics information, evaluation of their own knowledge and practice in lymphedema management, and current knowledge of physiotherapists about lymphedema based on the current literature. RESULTS Two hundred seventy-four physiotherapists (174 Female: 100 Male; mean age: 29.87 ± 6.9 years) completed the web-survey. From 274 physiotherapists, 52.60% of them had no education about lymphedema, 13.90% of them had never seen any patient with lymphedema, and 57.70% of them had not taken part in the management of a patient with lymphedema. 71.90% of the physiotherapists did not think they have enough knowledge about lymphedema. It was identified that physiotherapists' general and risk factors knowledge about lymphedema was sufficient. However, physiotherapists showed a lack of knowledge on the evaluation, treatment, and recommendations for lymphedema. CONCLUSION Physiotherapists' education and experience in lymphedema management are crucial as they are important members of the multidisciplinary team. To raise qualified physiotherapists in this field, from undergraduate education, special training programs about lymphedema should be added to their lifelong learning process.
Collapse
Affiliation(s)
- Gamze Kurt
- Department of Occupational Therapy, Kutahya Health Sciences University, Kutahya, Turkey.
| | - Humeyra Kiloatar
- Department of Physiotherapy and Rehabilitation, Kutahya Health Sciences University, Kutahya, Turkey.
| | - Bahar Aras
- Department of Physiotherapy and Rehabilitation, Kutahya Health Sciences University, Kutahya, Turkey.
| |
Collapse
|
8
|
Rhodes CA, Brandt C, Keller M. Physiotherapy practice in lymphoedema in South Africa: A survey. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2023; 79:1907. [PMID: 37928646 PMCID: PMC10623631 DOI: 10.4102/sajp.v79i1.1907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/31/2023] [Indexed: 11/07/2023] Open
Abstract
Background Lymphoedema is a chronic condition that is increasing in prevalence and requires specialised management to avoid possible life-threatening complications. Objectives To describe the perceived knowledge of physiotherapists about lymphoedema and its management, the lymphoedema patient load seen by physiotherapists, and the current treatment approaches of physiotherapists in South Africa when managing lymphoedema. Method A quantitative study using self-administered, online questionnaires were distributed among physiotherapists. Results Knowledge of lymphoedema management is perceived to be lacking among physiotherapists. Physiotherapists are getting limited referrals and spending little time managing patients with lymphoedema. Only a few physiotherapists have post-graduate education in lymphoedema management, thus international treatment standards still need to be met. Conclusion In order to meet international standards and patient needs, future research investigating the physiotherapy perspective is needed in lymphoedema management. Clinical implications Educational bodies and policymakers may use this data to facilitate improvement in physiotherapy management of the condition and provision of care.
Collapse
Affiliation(s)
- Carys A Rhodes
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Corlia Brandt
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Monique Keller
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
9
|
Kwon JG, Kim Y, Jang MY, Suh HP, Pak CJ, Keeley V, Jeon JY, Hong JP. The Quality of Life after Lymphaticovenous Anastomosis in 118 Lower Limb Lymphedema Patients. Arch Plast Surg 2023; 50:514-522. [PMID: 37808336 PMCID: PMC10556310 DOI: 10.1055/a-2117-4478] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 06/15/2023] [Indexed: 10/10/2023] Open
Abstract
Background This is a prospective study on 118 patients who underwent lymphaticovenous anastomosis (LVA) due to secondary lower limb lymphedema between January 2018 and October 2020 to evaluate patients' quality of life (QOL) using the Quality of Life Measure for Limb Lymphedema (LYMQoL) questionnaire. Methods The outcome measurement included the LYMQoL leg scoring system tool evaluating the function, appearance, symptom, mood, and overall outcome. In addition, correlation analysis was performed for three factors: based on International Society of Lymphology (ISL) stages, disease duration, and amount of volume reduction. Results The LYMQoL tool overall satisfaction score significantly increased at all intervals from 4.4 ± 0.2 preoperative to 6.5 ± 0.3 postoperative at 12 months ( p < 0.001). Significant findings were seen for each domain scores compared preoperatively and at 12 months: function score (18.6 ± 0.5 to 15.4 ± 0.6), appearance score (17.8 ± 0.5 to 16.0 ± 0.6), symptom score (11.8 ± 0.3 to 8.9 ± 0.4), and mood score (14.5 ± 0.4 to 11.4 ± 0.5; p < 0.05). The correlation analysis between improvement of the overall score and the ISL stage ( p = 0.610, correlation coefficient [ r ] = - 0.047), disease duration ( p = 0.659, r = - 0.041), and amount of limb volume reduction ( p = 0.454, r = - 0.070) showed no statistical significance. Conclusion The QOL of secondary lower limb lymphedema patients was significantly improved after LVA regardless of the severity of disease, duration of disease, and amount of volume reduction after LVA. Understanding the patient-reported outcome measurement will help the surgeons to manage and guide the expectations of the patients.
Collapse
Affiliation(s)
- Jin Geun Kwon
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeongsong Kim
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Young Jang
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyunsuk Peter Suh
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Changsik John Pak
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Vaughan Keeley
- Lymphoedema Service, Royal Derby Hospital, Derby, United Kingdom
| | - Jae Yong Jeon
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joon Pio Hong
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
10
|
Finkelstein ER, Crist TE, Shao T, Mella-Catinchi J, Xu KY. The utility of computed tomography venography in the routine evaluation of patients who present to a lymphedema center with lower extremity edema. J Vasc Surg Venous Lymphat Disord 2023; 11:1055-1062. [PMID: 37196921 DOI: 10.1016/j.jvsv.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/13/2023] [Accepted: 05/08/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE Computed tomography venography (CTV) is not routinely used to screen patients presenting with a presumed lower extremity lymphedema diagnosis for left iliac vein obstruction (IVO) or May-Thurner syndrome (MTS). The objective of this study is to determine the utility of routine CTV screening for these patients by evaluating the proportion presenting with clinically significant CTV-identified left IVO. METHODS We retrospectively reviewed 121 patients who had presented to our lymphedema center with lower extremity edema between November 2020 and May 2022. Information regarding demographics, comorbidities, lymphedema characteristics, and imaging reports was collected. Cases of IVO present on CTV were reviewed by a multidisciplinary team to determine the clinical significance of the CTV findings. RESULTS Of the patients with complete imaging studies, 49% (n = 25) had abnormal lymphoscintigraphy findings, 45% (n = 46) had reflux on ultrasound, and 11.4% (n = 9) had IVO on CTV. Seven patients (6%) had CTV findings of IVO and edema of either the isolated left (n = 4) or bilateral (n = 3) lower extremities. Cases of IVO on CTV were determined by the multidisciplinary team to be the predominant cause of lower extremity edema for three of these seven cases (43%; or 2.5% of all 121 patients). CONCLUSIONS Six percent of patients presenting to a lymphedema center with lower extremity edema had left-sided IVO on CTV suggestive of MTS. However, the cases of IVO were determined to be clinically significant <50% of the time or for 2.5% of all patients. CTV should be reserved for patients with isolated left-sided or bilateral lower extremity edema with a greater left-sided component and a history of findings that raise clinical suspicion for MTS.
Collapse
Affiliation(s)
- Emily R Finkelstein
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Taylor E Crist
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Tony Shao
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Juan Mella-Catinchi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Kyle Y Xu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL.
| |
Collapse
|
11
|
Natarajan MK, S J N, Mohanraj J, Vishwanath U. The Effect of Education on Knowledge Regarding Breast Cancer Related Lymphedema Risk Reduction and Prevention Among Nursing Personnel. Cureus 2023; 15:e45331. [PMID: 37849580 PMCID: PMC10577273 DOI: 10.7759/cureus.45331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/19/2023] Open
Abstract
Aim The development of lymphedema post-breast-cancer surgery has been identified as a significant burden worldwide, with nurses at the forefront of prevention and risk reduction practices. Prevention is of crucial importance to avoid lymphedema formation and its complications. This study aims to assess the knowledge gained through an educational session regarding risk reduction and prevention of breast cancer-related lymphedema (BCRL) among nursing professionals and compare the pre-test and post-test knowledge. Methods and material The research approach was quantitative in nature, and the design adopted was a pre-experimental, one-group pre-test post-test design. The study was conducted in a 400-bed multispecialty teaching hospital in Bangalore, Karnataka. After obtaining formal permission from the authorities, the participants were approached and informed about the purpose of the study. Eighty-four staff nurses working with breast cancer-related lymphedema (BCRL) patients participated in the study. The data for the study was collected using a validated questionnaire based on the National Lymphedema Network's (NLN) breast cancer-related lymphedema (BCRL) risk reduction and preventive guidelines. The questionnaire consisted of two sections. Section A consisted of the staff nurses' demographic data, and Section B consisted of questions on risk reduction and prevention of lymphedema. The pre-test was conducted, followed by a structured teaching session on risk reduction and prevention of lymphedema among 84 staff nurses working with BCRL patients. After the teaching session, the post-test was conducted. Results Descriptive and inferential statistics were used for analysis in this study. The t-test determined the statistical significance using the software SPSS (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.). The result showed that the mean knowledge score was 4.286 with SD 0.97 in the pre-test, which increased to 4.452 with SD 1.511 with a significant p-value (<0.001). Conclusion According to the study's findings, nurses must get standardized lymphedema training in order to prevent lymphedema from developing in patients having breast cancer surgery. The study's outcome has implications on the focus areas for nurses in the context of the team's adoption and dissemination of breast cancer-related lymphedema preventive measures. Key messages of this study are - 1) BCRL is an irreversible, progressive complication with no cure if not diagnosed early. 2) Poor knowledge of lymphedema prevention among nurses leads to frustration for BCRL patients. 3) Risk reduction and prevention education enable the patient to reduce BCRL complications, minimize the severity of the condition, and improve the quality of life. 4) Pre-habilitation - patient education on early diagnosis and risk reduction/prevention of BCRL reduces the cost, time, and energy for the patient and health care delivery system.
Collapse
Affiliation(s)
| | - Nalini S J
- Obstetrics and Gynaecology Nursing, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Jaya Mohanraj
- Community Health Nursing, HOSMAT College of Nursing, Bangalore, IND
| | - Usha Vishwanath
- Obstetrics and Gynaecology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| |
Collapse
|
12
|
Kinney JR, Friedman R, Kim E, Tillotson E, Shillue K, Lee BT, Singhal D. Non-Linear Lymphatic Anatomy in Breast Cancer Patients Prior to Axillary Lymph Node Dissection: A Risk Factor For Lymphedema Development. J Mammary Gland Biol Neoplasia 2023; 28:20. [PMID: 37480365 PMCID: PMC10363047 DOI: 10.1007/s10911-023-09545-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/28/2023] [Indexed: 07/24/2023] Open
Abstract
Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has become increasingly utilized for the prevention of breast cancer related lymphedema. Preoperative indocyanine green (ICG) lymphography is routinely performed prior to an ILR procedure to characterize baseline lymphatic anatomy of the upper extremity. While most patients have linear lymphatic channels visualized on ICG, representing a non-diseased state, some patients demonstrate non-linear patterns. This study aims to determine potential inciting factors that help explain why some patients have non-linear patterns, and what these patterns represent regarding the relative risk of developing postoperative breast cancer related lymphedema in this population. A retrospective review was conducted to identify breast cancer patients who underwent successful ILR with preoperative ICG at our institution from November 2017-June 2022. Among the 248 patients who were identified, 13 (5%) had preoperative non-linear lymphatic anatomy. A history of trauma or surgery of the affected limb and an increasing number of sentinel lymph nodes removed prior to ALND appeared to be risk factors for non-linear lymphatic anatomy. Furthermore, non-linear anatomy in the limb of interest was associated with an increased risk of postoperative lymphedema development. Overall, non-linear lymphatic anatomy on pre-operative ICG lymphography appears to be a risk factor for developing ipsilateral breast cancer-related lymphedema. Guided by the study's findings, when breast cancer patients present with baseline non-linear lymphatic anatomy, our institution has implemented a protocol of prophylactically prescribing compression sleeves immediately following ALND.
Collapse
Affiliation(s)
- JacqueLyn R Kinney
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA
| | - Rosie Friedman
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA
| | - Erin Kim
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA
| | - Elizabeth Tillotson
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA
| | - Kathy Shillue
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA
| | - Dhruv Singhal
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, BostonBoston, MA, 02215, USA.
| |
Collapse
|
13
|
Torgbenu E, Luckett T, Buhagiar M, Phillips JL. Practice points for lymphoedema care in low- and middle- income countries developed by nominal group technique. BMC Health Serv Res 2023; 23:740. [PMID: 37422616 DOI: 10.1186/s12913-023-09786-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 07/05/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Lymphoedema is a common, distressing, and debilitating condition affecting more than 200 million people globally. There is a small body of evidence to guide lymphoedema care which underpins several lymphoedema clinical practice guidelines developed for high-income countries (HIC). Some of these recommendations are unlikely to be feasible in low-resource settings. AIM To develop practice points for healthcare workers that optimise lymphoedema care in low- and middle-income countries (LMIC). METHODS A nominal group technique (NGT) was undertaken to gain consensus on which content from HIC guidelines was important and feasible to include in practice points for LMIC, and other important advice or recommendations. Participants included experts, clinicians, and volunteers involved in lymphoedema care in LMIC. The NGT followed five key stages: silent 'ideas' generation, round-robin rationale, clarification, refinement and verification. The first, fourth and fifth stages were completed via email, and the second and third during a video meeting in order to generate a series of consensus based prevention, assessment, diagnosis, and management of lymphoedema in LMIC practice points. RESULTS Of sixteen participants invited, ten members completed stage 1 of the NGT (ideas generation), of whom six contributed to stages 2 (round-robin) and 3 (clarification). All those who completed stage 1 also completed stages 4 (refinement) and 5 (verification). Practice points unanimously agreed on included Complex Decongestive Therapy (CDT) and good skin care, with management to be determined by lymphoedema stage. For podoconiosis-endemic areas, the use of socks and shoes was identified as very important in the prevention of non-filarial lymphoedema and other lymphoedema-causing conditions. Participants indicated that diagnosing lymphoedema using the lymphoscintigraphy and Indocyanine green (ICG) fluorescent lymphography was not possible due to unavailability and cost in LMIC. Surgical procedures for lymphoedema management were unanimously eliminated due to the unavailability of technology, limited workforce, and expensive cost in LMIC. CONCLUSION The consensus-based practice points generated by this project provide healthcare workers with guidance on caring for people with lymphoedema in LMIC. Further development of workforce capacity is needed.
Collapse
Affiliation(s)
- Eric Torgbenu
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.
| | - Tim Luckett
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Mark Buhagiar
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
- Catholic Diocese of Parramatta, Parramatta, NSW, Australia
| | - Jane L Phillips
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
- School of Nursing, Queensland University of Technology, Brisbane, Australia
| |
Collapse
|
14
|
Kruger N, Plinsinga ML, Noble-Jones R, Piller N, Keeley V, Hayes SC. The Lymphatic System, Lymphoedema, and Medical Curricula-Survey of Australian Medical Graduates. Cancers (Basel) 2022; 14:6219. [PMID: 36551705 PMCID: PMC9777454 DOI: 10.3390/cancers14246219] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022] Open
Abstract
The aim of this study was to survey the perceptions of recent (i.e., within the past 12 months) Australian medical graduates regarding (i) their understanding of the lymphatic system and lymphoedema, and (ii) the extent to which the lymphatic system and lymphoedema were covered as part of their medical degree. Medical graduates were invited to participate in a 17-item online survey that asked respondents to rate their level of agreement (using a 5-point Likert scale; higher scores = higher agreement) to statements that explored their understanding and comprehensiveness of their medical degree. Responses to each item were described using n (%). Subscale scores for understanding and medical degree were computed by summing scores of individual items, described using means (SD) and compared by participant characteristics. Medical graduates (n = 230) perceived their understanding of the lymphatic system and lymphoedema to be low, and comprehensiveness of medical curricula specific to the lymphatic system and lymphoedema to be lacking. Subscale scores did not differ by participant characteristics. Improvement of medical graduates understanding of lymphoedema may facilitate greater awareness of lymphoedema, thus optimizing the timeliness of diagnosis and access to treatment.
Collapse
Affiliation(s)
- Natalie Kruger
- Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, QLD 4111, Australia
- School of Health Sciences and Social Work, Griffith University, Brisbane, QLD 4111, Australia
- Physiotherapy Department, Royal Brisbane and Women’s Hospital, Nathan, Brisbane, QLD 4006, Australia
| | - Melanie L. Plinsinga
- Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, QLD 4111, Australia
- School of Health Sciences and Social Work, Griffith University, Brisbane, QLD 4111, Australia
| | - Rhian Noble-Jones
- Lymphoedema Clinical Network Wales, Swansea University, Swansea SA2 8PP, UK
| | - Neil Piller
- School of Medicine, Flinders University, Adelaide, SA 5042, Australia
| | - Vaughan Keeley
- Lymphoedema Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby DE22 3NE, UK
| | - Sandra C. Hayes
- Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, QLD 4111, Australia
- School of Health Sciences and Social Work, Griffith University, Brisbane, QLD 4111, Australia
| |
Collapse
|
15
|
Grünherz L, Gousopoulos E, Barbon C, Uyulmaz S, Lafci B, Razansky D, Boss A, Giovanoli P, Lindenblatt N. Preoperative Mapping of Lymphatic Vessels by Multispectral Optoacoustic Tomography. Lymphat Res Biol 2022; 20:659-664. [PMID: 35230197 DOI: 10.1089/lrb.2021.0067] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: In lymphatic reconstructive surgery, visualization of lymph vessels is of paramount importance. Indocyanine green (ICG) lymphography is the current gold standard in preoperative lymphatic imaging. However, visualization of lymph vessels is often limited by an overlying dermal backflow of ICG, becoming particularly prominent in advanced lymphedema stages. Multispectral optoacoustic tomography (MSOT) has recently been introduced as a promising noninvasive tool for lymphatic imaging. Methods and Results: A single-center proof-of-concept study with a prospective observational design was conducted at the Department of Plastic Surgery and Hand Surgery of the University Hospital Zurich. Between February 2021 and August 2021, seven patients with different grades of lymphedema were analyzed by the MSOT Acuity system before undergoing lymphovenous anastomosis (LVA). Conventional ICG lymphography served as comparison. MSOT succeeded to accurately depict blood and lymphatic vessels at different locations in six patients, including areas of dermal backflow. The MSOT signal of lymph vessels further correlated well with their macroscopic appearance. Conclusion: We could successfully visualize lymphatic vessels in patients with lymphedema by MSOT and establish the new method for preoperative mapping and selection of incision sites for LVA. Regardless of dermal backflow patterns, MSOT proved to be a valuable approach for identifying and clearly discerning between lymphatic and blood vessels.
Collapse
Affiliation(s)
- Lisanne Grünherz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Carlotta Barbon
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Semra Uyulmaz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Berkan Lafci
- Institute for Biomedical Engineering and Institute of Pharmacology and Toxicology, Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Department of Information Technology and Electrical Engineering, Institute for Biomedical Engineering, ETH Zurich, Zurich, Switzerland
| | - Daniel Razansky
- Institute for Biomedical Engineering and Institute of Pharmacology and Toxicology, Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Department of Information Technology and Electrical Engineering, Institute for Biomedical Engineering, ETH Zurich, Zurich, Switzerland
| | - Andreas Boss
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Nicole Lindenblatt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
16
|
Murray S. Adapting standard care to support self-management for a patient with lymphoedema and neurological co-morbidities: a case report. Br J Community Nurs 2022; 27:S14-S20. [PMID: 36205410 DOI: 10.12968/bjcn.2022.27.sup10.s14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
This case report discusses the role of a practitioner managing a patient with secondary lymphoedema as part of a self-management regime. The patient was diagnosed with multiple sclerosis and lumbar spinal stenosis. The focus is on compression therapy, which is used as part of complete decongestive therapy to reduce and control lymphoedema. The case report illustrates how a patient-centred plan can help people with lymphoedema and co-morbidities to achieve their personal goals. The evidence behind treatment decisions is considered, and modifications made to the care plan to accommodate the needs of the individual are described. The teaching and rehabilitation role of the practitioner is explored, including strategies used to support patients with long-term conditions. This report also identifies a lack of research-based evidence supporting the management of oedema as a symptom of multiple sclerosis. Further research is needed to inform clinical guidelines which would promote the management of secondary lymphoedema.
Collapse
Affiliation(s)
- Sarah Murray
- Lymphoedema Nurse, East Lancashire Hospitals NHS Trust; Student at University of Glasgow
| |
Collapse
|
17
|
Chima C, George S, Murray B, Moore Z, Costello M. Health-related quality of life and assessment in patients with lower limb lymphoedema: a systematic review. J Wound Care 2022; 31:690-699. [PMID: 36001703 DOI: 10.12968/jowc.2022.31.8.690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the impact of lower limb lymphoedema (LLL) on health-related quality of life (HRQoL), and to identify the methodologies used to assess HRQoL and their adherence to the World Health Organization (WHO)-recommended HRQoL dimensions. METHOD A systematic review was used following the PRISMA guidance. Studies were eligible if they assessed HRQoL in adult patients with LLL. The search was conducted between September 2019 and February 2020 using CINAHL, PubMed, Scopus, EMBASE and the Cochrane Library database. Data were placed onto a pre-developed data extraction table and analysed using a narrative synthesis. Evidence-based Librarianship (EBL) was used for quality appraisal. RESULTS A total of 18 studies were identified, among which 10 were cross-sectional and eight were longitudinal studies. Twelve HRQoL questionnaires were identified and the Lymphoedema Quality of Life tool (LYMQoL) was the most commonly used. All of the studies except one had an EBL validity score of ≥75%. Although LLL causes a considerable impairment in HRQoL, the findings varied across the studies. All the studies considered at least four of the six WHO recommended dimensions, with none considering the spirituality dimension. Furthermore, physical functioning and wellbeing were discovered to be the worst affected HRQoL dimensions. CONCLUSION LLL adversely affects physical function, wellbeing and thus the HRQoL. The LYMQoL is the most commonly used questionnaire; despite this, all elements of the WHO recommendations were not captured in the included studies. However, accurate information on HRQoL indicating the impact of the disease on survivors' lives and complete wellbeing is needed to inform evidence-based decision-making. Furthermore, having a universally accepted, disease-specific methodology will facilitate comparison and contrasting of HRQoL in patients with LLL. DECLARATION OF INTEREST The authors have no conflicts of interest.
Collapse
Affiliation(s)
- Comfort Chima
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland University of Medicine and Health Science.,School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland University of Medicine and Health Science
| | - Sherly George
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland University of Medicine and Health Science.,School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland University of Medicine and Health Science
| | - Bridget Murray
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland University of Medicine and Health Science.,School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland University of Medicine and Health Science
| | - Zena Moore
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland University of Medicine and Health Science.,School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland University of Medicine and Health Science.,Faculty of Science, Medicine and Health, University of Wollongong, Australia.,Fakeeh College of Health Sciences, Jeddah, Saudi Arabia.,Lida Institute, Shanghai.,Monash University, Melbourne, Australia.,Faculty of Medicine and Health Sciences, Ghent University.,Cardiff University, Wales
| | | |
Collapse
|
18
|
Sung C, Wang S, Hsu J, Yu R, Wong AK. Current Understanding of Pathological Mechanisms of Lymphedema. Adv Wound Care (New Rochelle) 2022; 11:361-373. [PMID: 34521256 PMCID: PMC9051876 DOI: 10.1089/wound.2021.0041] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Significance: Lymphedema is a common disease that affects hundreds of millions of people worldwide with significant financial and social burdens. Despite increasing prevalence and associated morbidities, the mainstay treatment of lymphedema is largely palliative without an effective cure due to incomplete understanding of the disease. Recent Advances: Recent studies have described key histological and pathological processes that contribute to the progression of lymphedema, including lymphatic stasis, inflammation, adipose tissue deposition, and fibrosis. This review aims to highlight cellular and molecular mechanisms involved in each of these pathological processes. Critical Issues: Despite recent advances in the understanding of the pathophysiology of lymphedema, cellular and molecular mechanisms underlying the disease remains elusive due to its complex nature. Future Directions: Additional research is needed to gain a better insight into the cellular and molecular mechanisms underlying the pathophysiology of lymphedema, which will guide the development of therapeutic strategies that target specific pathology of the disease.
Collapse
Affiliation(s)
- Cynthia Sung
- Keck School of Medicine of USC, Los Angeles, California, USA.,Division of Plastic Surgery, City of Hope National Medical Center, Duarte, California, USA
| | - Sarah Wang
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Jerry Hsu
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, California, USA.,Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Roy Yu
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Alex K. Wong
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, California, USA.,Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, USA.,Correspondence: Division of Plastic Surgery, City of Hope National Medical Center, 1500 Duarte Road, Familian Science Building 1018, Duarte, CA 91010, USA.
| |
Collapse
|
19
|
Cook JA, Sinha M, Lester M, Fisher CS, Sen CK, Hassanein AH. Immediate Lymphatic Reconstruction to Prevent Breast Cancer-Related Lymphedema: A Systematic Review. Adv Wound Care (New Rochelle) 2022; 11:382-391. [PMID: 34714158 DOI: 10.1089/wound.2021.0056] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Significance: Lymphedema is chronic limb swelling from lymphatic dysfunction. The condition affects up to 250 million people worldwide. In breast cancer patients, lymphedema occurs in 30% who undergo axillary lymph node dissection (ALND). Recent Advances: Immediate lymphatic reconstruction (ILR), also termed Lymphatic Microsurgical Preventing Healing Approach (LyMPHA), is a method to decrease the risk of lymphedema by performing prophylactic lymphovenous anastomoses at the time of ALND. The objective of this study is to assess the risk reduction of ILR in preventing lymphedema. Critical Issues: Lymphedema has significant effects on the quality of life and morbidity of patients. Several techniques have been described to manage lymphedema after development, but prophylactic treatment of lymphedema with ILR may decrease risk of development to 6.6%. Future Directions: Long-term studies that demonstrate efficacy of ILR may allow for prophylactic management of lymphedema in the patient undergoing lymph node dissection.
Collapse
Affiliation(s)
- Julia A. Cook
- Division of Plastic Surgery; Indianapolis, Indiana, USA
| | - Mithun Sinha
- Division of Plastic Surgery; Indianapolis, Indiana, USA
- Indiana Center for Regenerative Medicine, Department of Surgery; Indianapolis, Indiana, USA
| | - Mary Lester
- Division of Plastic Surgery; Indianapolis, Indiana, USA
| | - Carla S. Fisher
- Division of Surgical Oncology; Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Chandan K. Sen
- Division of Plastic Surgery; Indianapolis, Indiana, USA
- Indiana Center for Regenerative Medicine, Department of Surgery; Indianapolis, Indiana, USA
| | - Aladdin H. Hassanein
- Division of Plastic Surgery; Indianapolis, Indiana, USA
- Indiana Center for Regenerative Medicine, Department of Surgery; Indianapolis, Indiana, USA
| |
Collapse
|
20
|
Herrada AA, Olate-Briones A, Lazo-Amador R, Liu C, Hernández-Rojas B, Riadi G, Escobedo N. Lymph Leakage Promotes Immunosuppression by Enhancing Anti-Inflammatory Macrophage Polarization. Front Immunol 2022; 13:841641. [PMID: 35663931 PMCID: PMC9160822 DOI: 10.3389/fimmu.2022.841641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/25/2022] [Indexed: 11/16/2022] Open
Abstract
Lymphatic vasculature is a network of capillaries and vessels capable of draining extracellular fluid back to blood circulation and to facilitate immune cell migration. Although the role of the lymphatic vasculature as coordinator of fluid homeostasis has been extensively studied, the consequences of abnormal lymphatic vasculature function and impaired lymph drainage have been mostly unexplored. Here, by using the Prox1+/- mice with defective lymphatic vasculature and lymphatic leakage, we provide evidence showing that lymph leakage induces an immunosuppressive environment by promoting anti-inflammatory M2 macrophage polarization in different inflammatory conditions. In fact, by using a mouse model of tail lymphedema where lymphatic vessels are thermal ablated leading to lymph accumulation, an increasing number of anti-inflammatory M2 macrophages are found in the lymphedematous tissue. Moreover, RNA-seq analysis from different human tumors shows that reduced lymphatic signature, a hallmark of lymphatic dysfunction, is associated with increased M2 and reduced M1 macrophage signatures, impacting the survival of the patients. In summary, we show that lymphatic vascular leakage promotes an immunosuppressive environment by enhancing anti-inflammatory macrophage differentiation, with relevance in clinical conditions such as inflammatory bowel diseases or cancer.
Collapse
Affiliation(s)
- Andrés A. Herrada
- Lymphatic Vasculature and Inflammation Research Laboratory, Instituto de Ciencias Biomédicas, Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca, Chile
| | - Alexandra Olate-Briones
- Lymphatic Vasculature and Inflammation Research Laboratory, Instituto de Ciencias Biomédicas, Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca, Chile
| | - Rodrigo Lazo-Amador
- Lymphatic Vasculature and Inflammation Research Laboratory, Instituto de Ciencias Biomédicas, Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca, Chile
| | - Chaohong Liu
- Department of Pathogen Biology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bairon Hernández-Rojas
- Ph.D Program in Sciences Mention in Modeling of Chemical and Biological Systems, Faculty of Engineering, University of Talca, Talca, Chile
| | - Gonzalo Riadi
- Agencia Nacional de Investigación y Desarrollo (ANID) – Millennium Science Initiative Program Millennium Nucleus of Ion Channels-Associated Diseases (MiNICAD), Center for Bioinformatics, Simulation and Modeling, CBSM, Department of Bioinformatics, Faculty of Engineering, University of Talca, Talca, Chile
| | - Noelia Escobedo
- Lymphatic Vasculature and Inflammation Research Laboratory, Instituto de Ciencias Biomédicas, Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca, Chile
| |
Collapse
|
21
|
Torgbenu E, Luckett T, Buhagiar M, Requena CM, Phillips JL. Improving care for cancer-related and other forms of lymphoedema in low- and middle-income countries: a qualitative study. BMC Health Serv Res 2022; 22:461. [PMID: 35395942 PMCID: PMC8990607 DOI: 10.1186/s12913-022-07840-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lymphoedema is a common, distressing and debilitating condition that can be related to cancer and its treatment or other conditions. Little is known about current practices in the diagnosis, assessment and management of lymphoedema in low- and middle-income countries (LMIC). AIM To describe current practices in diagnosing, assessing and managing cancer-related and other forms of lymphoedema in LMIC, and related barriers and facilitators. METHODS An exploratory-descriptive qualitative study. Participants were lymphoedema experts or health care professionals identified via published lymphoedema papers and professional organizations respectively. Sampling was purposive to ensure a diversity of perspectives and experience. Data collection was via semi-structured telephone/video interviews, and questions canvassed participants' experiences and perceptions of lymphoedema care in LMIC. Interviews were audio-recorded and transcribed verbatim. Analysis proceeded via inductive coding before mapping codes to the World Health Organization's (WHO) Innovative Care for Chronic Conditions Framework. RESULTS Nineteen participants were interviewed, most of whom were physiotherapists (n = 11). Ten participants worked permanently in a LMIC, while the remainder were based in a high-income country (HIC) and had been involved in initiatives to improve lymphoedema care across multiple LMIC. Participants indicated that management of cancer versus non-cancer related lymphoedema was similar, but that pathways to care were more straight-forward for those receiving cancer care, leading to earlier diagnosis. Key facilitators to optimizing lymphoedema care in LMIC included: 1) joining forces to overcome lymphoedema-related stigma; 2) building workforce capabilities; and 3) partnering with patients and families to support self-management. Ideas for building workforce included developing health professional knowledge, supporting a commitment to multidisciplinary team care, and adapting HIC guidelines for lymphoedema care to LMIC. Partnering with patients and families to support self-management involved following the person-centred approach, establishing clear communication, promoting adherence to management, adapting management to available resources, and involving patient family and friends in lymphoedema care. CONCLUSION Raising community and health professional awareness regarding lymphoedema and its management is a key first step to improving care outcomes. Resources for clinicians and patients/families developed for lymphoedema care in HIC need to be adapted for low resource settings.
Collapse
Affiliation(s)
- Eric Torgbenu
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney NSW, Sydney, Australia. .,School of Allied Sciences, Department of Physiotherapy and Rehabilitation Sciences, University of Health and Allied Sciences, Ho, Ghana.
| | - Tim Luckett
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney NSW, Sydney, Australia
| | - Mark Buhagiar
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney NSW, Sydney, Australia.,Catholic Diocese of Parramatta, Parramatta, NSW, Australia
| | | | - Jane L Phillips
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney NSW, Sydney, Australia.,School of Nursing, Queensland University of Technology, Brisbane, Australia
| |
Collapse
|
22
|
Healthcare Practitioners' Knowledge of Lymphedema. Int J Vasc Med 2022; 2021:3806150. [PMID: 35003807 PMCID: PMC8741388 DOI: 10.1155/2021/3806150] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/03/2021] [Accepted: 12/08/2021] [Indexed: 01/26/2023] Open
Abstract
Objectives Lymphedema is neglected in medical education, and a review on healthcare practitioners' (HCPs) knowledge is necessary to shed light on gaps and to provide evidence for establishing educational programs on lymphedema. Methods This systematic review was performed based on the PRISMA guideline in PubMed, Scopus, Web of Science, and Google Scholar databases. There was no limitation on the type of lymphedema or HCPs. The quality assessment was performed based on QATSDD. Data regarding study characteristics, questionnaire context, and findings of the study were summarized from each article. Results After the screening, 16 articles were included that 12 were cross-sectional, two were qualitative, and two were interventional pilot studies. Breast cancer and other cancer-related lymphedema, lymphatic filariasis, and podoconiosis were included, and the majority of articles were focused on primary HCPs. The overall knowledge was low and average in five and 11 articles, respectively, and prior education was a significant factor related to higher knowledge of lymphedema in two studies. Conclusion Structured education of lymphedema is needed to increase the knowledge of HCPs and to enhance their collaboration in multidisciplinary care teams. Improvement of HCPs' knowledge may lead to better outcomes of lymphedema patients' management which are neglected.
Collapse
|
23
|
Um SI, Sohn UD, Jung SY, You SH, Kim C, Lee S, Lee H. Longitudinal study of the impact of three major regulations on the Korean pharmaceutical industry in the last 30 years. Health Res Policy Syst 2022; 20:4. [PMID: 34991612 PMCID: PMC8734354 DOI: 10.1186/s12961-021-00797-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 11/25/2021] [Indexed: 11/23/2022] Open
Abstract
Background The pharmaceutical industry is heavily regulated. Partly for this reason, new drugs generally take over 10 years from the product development stage to market entry. Although regulations affect the pharmaceutical industry over a long period, previous studies investigating the impact of new regulatory policies have usually focused on the short period before and after implementing that policy. Therefore, the purpose of this study is to examine whether and how significantly regulatory policies affect long-term innovation in the pharmaceutical industry in Korea. Methods This study focused on three significant regulatory policies: the introduction of the product patent system, changes in the Good Manufacturing Practice (GMP) system, and the Drug Expenditure Rationalization Plan (DERP). The study used interrupted time series (ITS) analysis to investigate the long-term impacts of the policies before and after implementation. Results Our results show that introducing the product patent system in 1987 significantly increased the number of Korean patent applications. The effect of the revised GMP policies was also statistically significant, both before and after implementation and between pre-emptive companies and non-pre-emptive ones. However, due to the companies' negotiations with the regulatory authorities or the regulatory system that links drug approval and price evaluation, the DERP did not significantly delay new drug registration in Korea. Conclusion This study showed that the policies of the product patent system, GMP policies, and DERP regulations have significantly encouraged pharmaceutical companies to strive to meet regulatory requirements and promote innovation in Korea. The study suggests that it is necessary for companies to pre-emptively respond to systemic changes in development and production strategies to deal with regulatory changes and achieve sustainable growth. Also, our study results indicate that since government policies motivate the innovative system of the pharmaceutical industry, governmental authorities, when formulating pharmaceutical policies, need to consider the impact on the long-term innovation of the industry.
Collapse
Affiliation(s)
- Seung In Um
- Korea Pharmaceutical and Bio-Pharma Manufacturers Association, Seoul, South Korea
| | - Uy Dong Sohn
- Department of Pharmacology, Chung-Ang University, Seoul, South Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, South Korea
| | - Seung-Hun You
- Department of Global Innovative Drugs, Chung-Ang University, Seoul, South Korea
| | - Changone Kim
- Graduate School of Global Entrepreneurship, Keimyung University, Daegu, South Korea
| | - Sora Lee
- Graduate School of Management of Technology, Sungkyunkwan University, Suwon, South Korea
| | - Heesang Lee
- Graduate School of Management of Technology, Sungkyunkwan University, Suwon, South Korea.
| |
Collapse
|
24
|
Rosalia L, Lamberti KK, Landry MK, Leclerc CM, Shuler FD, Hanumara NC, Roche ET. A Soft Robotic Sleeve for Compression Therapy of the Lower Limb. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:1280-1283. [PMID: 34891519 DOI: 10.1109/embc46164.2021.9630924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
'We present the development of a soft robotic-inspired device for lower limb compression therapy with application in the treatment of lymphedema. This device integrates the control capabilities of pneumatic devices with the wearability and low cost of compression garments. The design consists of a three-layered soft robotic sleeve that ensures safe skin contact, controls compression, and secures the device to the patient limb. The expandable component is made of interconnected pockets of various heights, which passively create a graduated compression profile along the lower limb. The system is inflated by a pump and a microcontroller-actuated valve, with force sensors embedded in the sleeve that monitor the pressure applied to the limb. Testing on healthy individualsq demonstrated the ability to reach clinically relevant target pressures (30, 40, 50 mmHg) and establish a distal-to-proximal descending pressure gradient of approximately 40 mmHg. Device function was shown to be robust against variations in subject anatomy.Clinical Relevance- This system provides controllable, graduated, compression therapy to lymphedema patients in an economical, portable, and customizable package.
Collapse
|
25
|
Mailey BA, Alrahawan G, Brown A, Yamamoto M, Hassanein AH. Sentinel Lymph Node Biopsy, Lymph Node Dissection, and Lymphedema Management Options in Melanoma. Clin Plast Surg 2021; 48:607-616. [PMID: 34503721 DOI: 10.1016/j.cps.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Melanoma tumor thickness and ulceration are the strongest predictors of nodal spread. The recommendations for sentinel lymph node biopsy (SLNB) have been updated in recent American Joint Committee on Cancer and National Comprehensive Cancer Network guidelines to include tumor thickness ≥0.8 mm or any ulcerated melanoma. Mitotic rate is no longer considered an indicator for determining T category. Improvements in disease-specific survival conferred from SLNB were demonstrated through level I data in the Multicenter Selective Lymphadenectomy Trial (MSLT) I. The role for completion lymph node dissection has evolved to less surgery in lieu of recent domestic (MSLT II) and international (Dermatologic Cooperative Oncology Group Selective Lymphadenectomy Trial [DeCOG-SLT]) level I data having similar melanoma-specific survival. Treatment options for the prevention of treatment of lymphedema have progressed to include immediate lymphatic reconstruction, lymphovenous anastomosis, and vascularized lymph node transfer.
Collapse
Affiliation(s)
- Brian A Mailey
- Brachial Plexus and Tetraplegia Clinic, Institute for Plastic Surgery, Southern Illinois University School of Medicine, 747 N. Rutledge Street, PO Box 19653, Springfield, IL 62794, USA.
| | - Ghaith Alrahawan
- University of Missouri Columbia, School of Medicine, 1 Hospital Dr, Columbia, MO 65212, USA
| | - Amanda Brown
- Southern Illinois University, School of Medicine, 747 N. Rutledge Street, PO Box 19653, Springfield, IL 62794, USA
| | - Maki Yamamoto
- Division of Surgical Oncology, Department of Surgery, University of California, Irvine, 333 City Blvd West, Suite 1600, Orange, CA 92868, USA
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Suite 232, Indianapolis, IN 46202, USA
| |
Collapse
|
26
|
Jiga LP, Campisi CC, Jandali Z, Ryan M, Maruccia M, Santecchia L, Cherubino M, Georgiadis J. Role of the Cadaver Lab in Lymphatic Microsurgery Education: Validation of a New Training Model. J INVEST SURG 2021; 35:758-767. [PMID: 34157922 DOI: 10.1080/08941939.2021.1937756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Microsurgical transplantation of vascularized lymph nodes (VLNT) or lymphatic vessels (VLVT) alongside derivative lymphaticovenous procedures are promising approaches for treatment of lymphedema. However, clinically relevant training models for mastering these techniques are still lacking. Here we describe a new training model in human cadaver and validate its use as training tool for microsurgical lymphatic reconstruction. METHODS 10 surgeons with previous exposure to microsurgery were trained in a controlled environment. Lymphatic vessel mapping and dissection in 4 relevant body regions, harvesting of five different VLNTs and one VLVT were performed in 5 fresh-frozen cadavers. The number of lymphatic vessels and lymph nodes for each VLNT were recorded. Finally, the efficacy of this model as training tool was validated using the Dundee Ready Education Environment Measure (DREEM). RESULTS The average cumulative DREEM score over each category was 30,75 (max = 40) while individual scoring for each relevant category revealed highly positive ratings from the perspective of teaching (39,3), training 40,5 (max = 48) and self perception of the training 30,5 (max = 32) from all participants. The groin revealed the highest number of lymphatic vessels (3.2 ± 0.29) as all other regions on the upper extremity, while the gastroepiploic VLNT had the highest number of lymph nodes (4.2 ± 0.37). CONCLUSIONS This human cadaver model represents a new, reproducible "all-in-one" tool for effective training in lymphatic microsurgery. Its unique diligence in accurately reproducing human lymphatic anatomy, should make this model worth considering for each microsurgeon willing to approach lymphatic reconstruction.
Collapse
Affiliation(s)
- Lucian P Jiga
- Department for Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelic Hospital, Oldenburg, Germany
| | - Corrado C Campisi
- Department of Surgery, Plastic, Reconstructive and Aesthetic Surgery, ICLAS, GVM Care & Research, Genoa, Italy
| | - Zaher Jandali
- Department for Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelic Hospital, Oldenburg, Germany
| | - Melissa Ryan
- Faculty of Medicine and Surgery, University of Pavia, Pavia, Italy
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Luigino Santecchia
- Orthopaedic Unit of Palidoro, Bambino Gesù Children's Hospital Research Institute, Rome, Italy
| | - Mario Cherubino
- Microsurgery and Hand Surgery Unit" ASST Sette Laghi, University of Insumbria, Varese, Italy
| | - Janniko Georgiadis
- Department Biomedical Cell & Systems, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
27
|
Mills M, van Zanten M, Borri M, Mortimer PS, Gordon K, Ostergaard P, Howe FA. Systematic Review of Magnetic Resonance Lymphangiography From a Technical Perspective. J Magn Reson Imaging 2021; 53:1766-1790. [PMID: 33625795 PMCID: PMC7611641 DOI: 10.1002/jmri.27542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Clinical examination and lymphoscintigraphy are the current standard for investigating lymphatic function. Magnetic resonance imaging (MRI) facilitates three-dimensional (3D), nonionizing imaging of the lymphatic vasculature, including functional assessments of lymphatic flow, and may improve diagnosis and treatment planning in disease states such as lymphedema. PURPOSE To summarize the role of MRI as a noninvasive technique to assess lymphatic drainage and highlight areas in need of further study. STUDY TYPE Systematic review. POPULATION In October 2019, a systematic literature search (PubMed) was performed to identify articles on magnetic resonance lymphangiography (MRL). FIELD STRENGTH/SEQUENCE No field strength or sequence restrictions. ASSESSMENT Article quality assessment was conducted using a bespoke protocol, designed with heavy reliance on the National Institutes of Health quality assessment tool for case series studies and Downs and Blacks quality checklist for health care intervention studies. STATISTICAL TESTS The results of the original research articles are summarized. RESULTS From 612 identified articles, 43 articles were included and their protocols and results summarized. Field strength was 1.5 or 3.0 T in all studies, with 25/43 (58%) employing 3.0 T imaging. Most commonly, imaging of the peripheries, upper and lower limbs including the pelvis (32/43, 74%), and the trunk (10/43, 23%) is performed, including two studies covering both regions. Imaging protocols were heterogenous; however, T2 -weighted and contrast-enhanced T1 -weighted images are routinely acquired and demonstrate the lymphatic vasculature. Edema, vessel, quantity and morphology, and contrast uptake characteristics are commonly reported indicators of lymphatic dysfunction. DATA CONCLUSION MRL is uniquely placed to yield large field of view, qualitative and quantitative, 3D imaging of the lymphatic vasculature. Despite study heterogeneity, consensus is emerging regarding MRL protocol design. MRL has the potential to dramatically improve understanding of the lymphatics and detect disease, but further optimization, and research into the influence of study protocol differences, is required before this is fully realized. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY: Stage 2.
Collapse
Affiliation(s)
- Michael Mills
- Molecular and Clinical Sciences Research Institute, St George’s University, London, UK
| | - Malou van Zanten
- Molecular and Clinical Sciences Research Institute, St George’s University, London, UK
| | - Marco Borri
- Molecular and Clinical Sciences Research Institute, St George’s University, London, UK
- Department of Neuroradiology, King’s College Hospital, London, UK
| | - Peter S. Mortimer
- Molecular and Clinical Sciences Research Institute, St George’s University, London, UK
| | - Kristiana Gordon
- Lymphovascular Medicine, Dermatology Department, St George’s Hospital, London, UK
| | - Pia Ostergaard
- Molecular and Clinical Sciences Research Institute, St George’s University, London, UK
| | - Franklyn A. Howe
- Molecular and Clinical Sciences Research Institute, St George’s University, London, UK
| |
Collapse
|
28
|
Gogia SB, Rekha A, Sood S. Chronic Lymphedema Management: Case Series Analysis of 9 Years from a Specialized Clinic in Delhi. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02931-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
29
|
Gastroepiploic Lymph Node Flap Harvest for Patients With Lymphedema: Minimally Invasive Versus Open Approach. Ann Plast Surg 2021; 85:S87-S91. [PMID: 32530851 DOI: 10.1097/sap.0000000000002460] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Vascularized gastroepiploic lymph node flaps have become a popular option to treat patients with extremity lymphedema. Overall, 2 surgical approaches to harvest this flap have been described: laparoscopic and open. In this study, we analyzed complications, harvesting time, and patient satisfaction scores, comparing these 2 techniques. METHODS Between 2012- and 2018, all patients with extremity lymphedema and candidates for the gastroepiploic flap harvest were included. Two groups were compared: open and laparoscopic approaches. Flap harvest time, postoperative pain, complications, return of gastrointestinal motility, time to discharge, and patient satisfaction scores were assessed. RESULTS A total of 177 patients were included, of which 126 underwent laparoscopic harvest and 51 patients underwent open approach. Only 2 patients in the laparoscopic group had prior abdominal surgery not related to cancer treatment compared with 7 patients in the open approach (P < 0.01). Average surgical completion time for the laparoscopic versus open approach was 136 and 102 minutes, respectively (P < 0.02). Postoperative complications for the laparoscopic versus open were as follows: 1 patient developed pancreatitis and 2 developed ileus in the laparoscopic approach, whereas 3 patients developed ileus, 1 developed small bowel obstruction, 2 developed superficial site infection, and 1 developed minor wound dehiscence in the open approach. No patient required further surgical intervention. Average return of gastrointestinal function was 1 day (laparoscopic) and 2 days (open), respectively. On a pain scale, pain scores at postoperative day 1 and upon discharge were on average 3 versus 7 and 2 versus 5, respectively (P < 0.05). Lengths of hospital stay were on average 2 days in the laparoscopic group and 5 days in the open group (P < 0.001). Patient satisfaction scores based on pain and scars were significantly better in the laparoscopic group versus open group (P < 0.03). CONCLUSIONS These data support that a minimal invasive approach is ideal and efficient when resources are available. In addition, the lower complication rate and high patient satisfaction scores give promising feedback to continue offering this technique.
Collapse
|
30
|
Sundrasekaran A, Abdalla E, Sobani S, Shafi M, Al-Mudahka NR. Physiotherapy Management Response for Patients With Lymphedema Amid the COVID-19 Pandemic in the State of Qatar: A Perspective Study. REHABILITATION ONCOLOGY 2021. [DOI: 10.1097/01.reo.0000000000000255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
31
|
Stout NL, Brunelle C, Scheiman N, Thawer H. Surveillance Protocols for Survivors at Risk for Lymphedema. CURRENT BREAST CANCER REPORTS 2021. [DOI: 10.1007/s12609-020-00402-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
32
|
Patient-reported outcomes following lymph reconstructive surgery in lower limb lymphedema: A systematic review of literature. J Vasc Surg Venous Lymphat Disord 2020; 9:811-819.e2. [PMID: 33309902 DOI: 10.1016/j.jvsv.2020.11.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/26/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Lymphedema is a chronic, progressive and burdensome disease that is known to have a substantial impact on quality of life (QOL). Hence, the assessment of QOL is an important aspect of any study which seeks to evaluate outcomes after lymph reconstructive surgery. We therefore aimed to analyze currently available patient-reported outcome measurements (PROMS) for patients with lower limb lymphedema (LLL) with regard to their psychometric properties. Furthermore, we intended to evaluate the change in QOL in patient undergoing lymphovenous anastomosis (LVA) or vascularized lymph node transfer (VLNT). METHODS A literature research of four databases on studies that included PROMS for LLL was conducted. All selected studies were assessed for validity according Consensus-based Standards for the selection of Health Measurement Instruments. Studies that used the Lymph Quality of Life Measure for Limb Lymphedema (LYMQOL) after LVA and/or VLNT were included for quantitative analysis. RESULTS In total, 988 studies were screened, of which 30 studies were included in this review. We identified six validated PROMS to assess LLL. Of those, the LYMQOL was the most commonly used questionnaire. Based on the LYMQOL, a significant improvement of QOL in LLL was noted in all studies after reconstructive lymph surgery (LVA/VLNT) regardless of lymphedema etiology, stage, or time since diagnosis. On the basis of the Consensus-based Standards for the selection of Health Measurement Instruments criteria, the Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema seems to be superior in terms of its psychometric properties. CONCLUSIONS A significant improvement in the QOL in patients with LLL after reconstructive lymph surgery can be observed. Future studies on reconstructive lymph surgery need to include both objective and congruent volume measurements, as well as data on QOL based a well-validated PROM such as the Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema.
Collapse
|
33
|
Jiang X, Tian W, Granucci EJ, Tu AB, Kim D, Dahms P, Pasupneti S, Peng G, Kim Y, Lim AH, Espinoza FH, Cribb M, Dixon JB, Rockson SG, Semenza GL, Nicolls MR. Decreased lymphatic HIF-2α accentuates lymphatic remodeling in lymphedema. J Clin Invest 2020; 130:5562-5575. [PMID: 32673288 PMCID: PMC7524470 DOI: 10.1172/jci136164] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 07/09/2020] [Indexed: 12/22/2022] Open
Abstract
Pathologic lymphatic remodeling in lymphedema evolves during periods of tissue inflammation and hypoxia through poorly defined processes. In human and mouse lymphedema, there is a significant increase of hypoxia inducible factor 1 α (HIF-1α), but a reduction of HIF-2α protein expression in lymphatic endothelial cells (LECs). We questioned whether dysregulated expression of these transcription factors contributes to disease pathogenesis and found that LEC-specific deletion of Hif2α exacerbated lymphedema pathology. Even without lymphatic vascular injury, the loss of LEC-specific Hif2α caused anatomic pathology and a functional decline in fetal and adult mice. These findings suggest that HIF-2α is an important mediator of lymphatic health. HIF-2α promoted protective phosphorylated TIE2 (p-TIE2) signaling in LECs, a process also replicated by upregulating TIE2 signaling through adenovirus-mediated angiopoietin-1 (Angpt1) gene therapy. Our study suggests that HIF-2α normally promotes healthy lymphatic homeostasis and raises the exciting possibility that restoring HIF-2α pathways in lymphedema could mitigate long-term pathology and disability.
Collapse
Affiliation(s)
- Xinguo Jiang
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Wen Tian
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Eric J. Granucci
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Allen B. Tu
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Dongeon Kim
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Petra Dahms
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Shravani Pasupneti
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Gongyong Peng
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Yesl Kim
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Amber H. Lim
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Matthew Cribb
- Georgia Institute of Technology, Atlanta, Georgia, USA
| | | | | | - Gregg L. Semenza
- Vascular Biology, Institute for Cell Engineering
- Department of Pediatrics
- Department of Medicine
- Department of Oncology
- Department of Radiation Oncology, and
- Department of Biological Chemistry, and
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark R. Nicolls
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
34
|
Drobot A, Bez M, Abu Shakra I, Merei F, Khatib K, Bickel A, Ganam S, Bogouslavski G, Karra N, Mahran B, Kassis W, Kogan L, Drobot D, Weiss M, Koshima I, Kakiashvili E. Microsurgery for management of primary and secondary lymphedema. J Vasc Surg Venous Lymphat Disord 2020; 9:226-233.e1. [PMID: 32446874 DOI: 10.1016/j.jvsv.2020.04.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/14/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the efficacy and safety of lymphaticovenular anastomosis (LVA) in patients with lymphedema. METHODS A retrospective analysis was conducted of 70 patients suffering from primary or secondary lymphedema who underwent LVA surgery with indocyanine green fluorescence lymphangiography. Postoperative evaluation included qualitative and quantitative volumetric assessment and analysis. Limb volume was measured by circumferential tape measurement volumetric method, in which the limb is subdivided into five segments and each segment's circumference is measured. RESULTS LVA was performed in 70 patients, 22 with primary lymphedema and 48 with secondary lymphedema. The difference in preoperative upper limb volume was 35% with mean postoperative follow-up of 9 months. The mean number of lymphovenous bypasses was 3.9. The reduction in limb volume at 3, 6, and 12 months was 40.4%, 41%, and 45%, respectively. Patients with early-stage lymphedema had significantly higher volume reductions than patients with late-stage lymphedema at 3, 6, and 12 months (48% vs 18%, 49% vs 22%, and 65% vs 31%; P < .001). For lower extremity lymphedema, the preoperative volume differential was 25.5%. The mean postoperative follow-up was 9 months. The reduction in limb volume at 3, 6, and 12 months was 28%, 37%, and 39%, respectively. CONCLUSIONS LVA surgery is a safe and effective method of reducing lymphedema severity, especially in upper extremity lymphedema at an earlier disease stage.
Collapse
Affiliation(s)
- Assi Drobot
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Maxim Bez
- Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | - Ibrahim Abu Shakra
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Fahed Merei
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Kamal Khatib
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Amitai Bickel
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel; Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | - Samer Ganam
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Grigori Bogouslavski
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Nour Karra
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Badran Mahran
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Walid Kassis
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Leonid Kogan
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Denis Drobot
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Michael Weiss
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Isao Koshima
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima
| | - Eli Kakiashvili
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel; Medical Corps, Israel Defense Forces, Ramat Gan, Israel.
| |
Collapse
|
35
|
Hassani C, Tran K, Palmer SL, Patel KM. Vascularized Lymph Node Transfer: A Primer for the Radiologist. Radiographics 2020; 40:1073-1089. [PMID: 32412827 DOI: 10.1148/rg.2020190118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Lymphedema, the accumulation of lymphatic fluid in the tissues, is a chronic disease and a major cause of long-term morbidity and disability. Lymphedema is usually a secondary condition, often caused by prior oncologic therapy, such as surgery for cancers, radiation therapy, and chemotherapy. Treatment for lymphedema has traditionally been conservative and limited, but new surgical and microsurgical procedures have arisen in recent years. Vascularized lymph node transfer (VLNT) is one of the most promising new microsurgeries. VLNT involves the transfer of functional lymph nodes (LNs) from a healthy donor site to an area of the body with damaged or diseased lymphatic drainage. The goal of the transplant is to restore physiologic LN drainage and improve lymphedema. Donor LNs are commonly found in the groin, axilla, neck, omentum, or submental region. Imaging can be used for preoperative planning to identify donor sites with the richest number of LNs. This can help identify those patients who may be candidates for VLNT and can help identify the best anatomic site for surgical harvest in those candidates. Imaging can be performed with US, CT, or MRI. VLNT preoperative imaging often requires acquisition techniques and reconstruction parameters that differ from those used in routine diagnostic imaging. Furthermore, to properly identify target LNs, the radiologist must be aware of surgical anatomic landmarks. Online supplemental material is available for this article. ©RSNA, 2020.
Collapse
Affiliation(s)
- Cameron Hassani
- From the Departments of Radiology (C.H., K.T., S.L.P.) and Plastic and Reconstructive Surgery (K.M.P.), Keck Hospital of the University of Southern California, 1500 San Pablo St, Los Angeles, CA 90033
| | - Khoa Tran
- From the Departments of Radiology (C.H., K.T., S.L.P.) and Plastic and Reconstructive Surgery (K.M.P.), Keck Hospital of the University of Southern California, 1500 San Pablo St, Los Angeles, CA 90033
| | - Suzanne L Palmer
- From the Departments of Radiology (C.H., K.T., S.L.P.) and Plastic and Reconstructive Surgery (K.M.P.), Keck Hospital of the University of Southern California, 1500 San Pablo St, Los Angeles, CA 90033
| | - Ketan M Patel
- From the Departments of Radiology (C.H., K.T., S.L.P.) and Plastic and Reconstructive Surgery (K.M.P.), Keck Hospital of the University of Southern California, 1500 San Pablo St, Los Angeles, CA 90033
| |
Collapse
|
36
|
Manrique OJ, Bustos SS, Kapoor T, Lin J, Ciudad P, Forte AJ, Del Corral G, Mani M, Maruccia M, Terzic A. Gastroepiploic vascularized lymph node transfer for the treatment of extremity lymphedema: comparison between middle and distal inset. Gland Surg 2020; 9:528-538. [PMID: 32420288 PMCID: PMC7225493 DOI: 10.21037/gs.2020.02.10] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 12/12/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Middle and distal insets of gastroepiploic vascularized lymph node transfer (GE-VLNT) for extremity lymphedema have been described. However, there has been no prior comparison of surgical or patient-reported outcomes between these techniques. We analyzed the outcomes between both insets in patients with extremity lymphedema. METHODS Retrospective review of patients with extremity-lymphedema who underwent GE-VLNT. Two groups were analyzed: middle and distal recipient inset. We analyzed 6-month surgical and patient-reported outcomes using the Lymphedema Life Impact Scale-v2 (LLISv2) and scar satisfaction utilizing the Patient Scar Assessment Questionnaire (PSAQ). RESULTS Between 2017 and 2019, 26 patients with stage II unilateral extremity lymphedema underwent laparoscopically-harvested GE-VLNT (13 distal and 13 middle inset). There were no differences in patient demographics between groups. Mean hospital stay for patients with upper extremity lymphedema was 1.3 vs. 4.0 days (P<0.05), and for lower extremity lymphedema was 1.0 vs. 4.5 days (P<0.05), middle vs. distal inset, respectively. Mean return to daily activities for patients with upper extremity lymphedema was 13.4 vs. 33.4 days (P<0.05), and for lower extremity lymphedema was 16.0 vs. 29.5 days (P<0.05), middle vs. distal inset, respectively. Both middle and distal inset showed significant mean excess volume reduction at 6 months postoperatively for both upper and lower extremity lymphedema (upper extremity: middle inset 23.3%, distal inset: 22.0%; lower extremity: middle inset 23.3% and distal inset 13.3%). LLISv2 scores showed improved functional outcomes postoperatively in both upper and lower extremity lymphedema with both insets. Scar satisfaction with appearance and symptoms was higher with middle inset (P<0.05). CONCLUSIONS GE-VLNT is an effective surgical treatment for extremity lymphedema. The middle placement showed shorter hospital stay, early return to work and higher patient satisfaction.
Collapse
Affiliation(s)
- Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samyd Said Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Jason Lin
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Antonio J. Forte
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Gabriel Del Corral
- MedStar Plastic and Reconstructive Surgery, Georgetown University Hospital, Washington D.C., USA
| | - Maria Mani
- Department of Plastic Surgery, Uppsala Universitet, Uppsala, Sweden
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Andre Terzic
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
37
|
Daneshgaran G, Lo AY, Paik CB, Cooper MN, Sung C, Jiao W, Park SY, Ni P, Yu RP, Vorobyova I, Jashashvili T, Hong YK, Kim GH, Conti PS, Chai Y, Wong AK. A Pre-clinical Animal Model of Secondary Head and Neck Lymphedema. Sci Rep 2019; 9:18264. [PMID: 31797883 PMCID: PMC6892928 DOI: 10.1038/s41598-019-54201-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/04/2019] [Indexed: 12/30/2022] Open
Abstract
Head and neck lymphedema (HNL) is a disfiguring disease affecting over 90% of patients treated for head and neck cancer. Animal models of lymphedema are used to test pharmacologic and microsurgical therapies; however, no animal model for HNL is described in the literature to date. In this study we describe the first reproducible rat model for HNL. Animals were subjected to two surgical protocols: (1) lymphadenectomy plus irradiation; and (2) sham surgery and no irradiation. Head and neck expansion was measured on post-operative days 15, 30 and 60. Magnetic resonance imaging (MRI) was acquired at the same time points. Lymphatic drainage was measured at day 60 via indocyanine green (ICG) lymphography, after which animals were sacrificed for histological analysis. Postsurgical lymphedema was observed 100% of the time. Compared to sham-operated animals, lymphadenectomy animals experienced significantly more head and neck swelling at all timepoints (P < 0.01). Lymphadenectomy animals had significantly slower lymphatic drainage for 6 days post-ICG injection (P < 0.05). Histological analysis of lymphadenectomy animals revealed 83% greater subcutis thickness (P = 0.008), 22% greater collagen deposition (P = 0.001), 110% greater TGFβ1+ cell density (P = 0.04), 1.7-fold increase in TGFβ1 mRNA expression (P = 0.03), and 114% greater T-cell infiltration (P = 0.005) compared to sham-operated animals. In conclusion, animals subjected to complete lymph node dissection and irradiation developed changes consistent with human clinical postsurgical HNL. This was evidenced by significant increase in all head and neck measurements, slower lymphatic drainage, subcutaneous tissue expansion, increased fibrosis, and increased inflammation compared to sham-operated animals.
Collapse
Affiliation(s)
- Giulia Daneshgaran
- Albert Einstein College of Medicine, 1300 Morris Park, Bronx, NY, 10461, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Andrea Y Lo
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Connie B Paik
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Michael N Cooper
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
- Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA, 70112, USA
| | - Cynthia Sung
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Wan Jiao
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Sun Y Park
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Pauline Ni
- Department of Molecular and Cell Biology, University of California Berkeley, 2121 Berkeley Way, Berkeley, CA, 94720, USA
| | - Roy P Yu
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Ivetta Vorobyova
- Molecular Imaging Center, Keck School of Medicine of USC, 2250 Alcazar St, Los Angeles, CA, 90089, USA
| | - Tea Jashashvili
- Molecular Imaging Center, Keck School of Medicine of USC, 2250 Alcazar St, Los Angeles, CA, 90089, USA
| | - Young-Kwon Hong
- Department of Surgery, Keck School of Medicine of USC, 1975 Zonal Ave., Los Angeles, CA, 90033, USA
| | - Gene H Kim
- Department of Dermatology, Keck School of Medicine of USC, 1975 Zonal Ave., Los Angeles, CA, 90033, USA
| | - Peter S Conti
- Molecular Imaging Center, Keck School of Medicine of USC, 2250 Alcazar St, Los Angeles, CA, 90089, USA
| | - Yang Chai
- Center for Craniofacial and Molecular Biology, Herman Ostrow School of Dentistry of USC, 2250 Alcazar St, Los Angeles, CA, 90089, USA
| | - Alex K Wong
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA.
- Department of Surgery, Keck School of Medicine of USC, 1975 Zonal Ave., Los Angeles, CA, 90033, USA.
| |
Collapse
|
38
|
Boyages J, Koelmeyer LA, Suami H, Lam T, Ngo QD, Heydon-White A, Czerniec S, Munot S, Ho-Shon K, Mackie H. The ALERT model of care for the assessment and personalized management of patients with lymphoedema. Br J Surg 2019; 107:238-247. [PMID: 31696506 DOI: 10.1002/bjs.11368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/09/2019] [Accepted: 08/22/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND This study documents the development and evaluation of a comprehensive multidisciplinary model for the assessment and personalized care of patients with lymphoedema. METHODS The Australian Lymphoedema Education Research and Treatment (ALERT) programme originated as an advanced clinic for patients considering surgery for lymphoedema. The programme commenced liposuction surgery in May 2012 and then introduced lymph node transfer in 2013 and lymphovenous anastomosis (LVA) in 2016. An outpatient conservative treatment clinic was established in 2016. ALERT commenced investigations with indocyanine green (ICG) lymphography in late 2015, leading to the creation of a diagnostic assessment clinic offering ICG in 2017. RESULTS Since 2012, 1200 new patients have been referred to ALERT for assessment of lymphoedema for a total of 5043 episodes of care. The introduction of ICG lymphography in 2015 initially allowed better screening for LVA, but is now used not only to guide surgical options, but also as a diagnostic tool and to guide manual lymphatic drainage massage. The total number of new patients who attended the surgical assessment clinic to December 2018 was 477, with 162 patients (34·0 per cent) undergoing surgery. CONCLUSION The ALERT programme has developed a multidisciplinary model of care for personalized lymphoedema treatment options based on clinical, imaging and ICG lymphography. Patients are selected for surgery based on several individual factors.
Collapse
Affiliation(s)
- J Boyages
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - L A Koelmeyer
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - H Suami
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - T Lam
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Q D Ngo
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - A Heydon-White
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - S Czerniec
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - S Munot
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - K Ho-Shon
- Macquarie Medical Imaging, Macquarie University Hospital, Macquarie University, Sydney, Australia
| | - H Mackie
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Mount Wilga Private Hospital, Hornsby, New South Wales, Australia
| |
Collapse
|
39
|
Douglass J, Kelly-Hope L. Comparison of Staging Systems to Assess Lymphedema Caused by Cancer Therapies, Lymphatic Filariasis, and Podoconiosis. Lymphat Res Biol 2019; 17:550-556. [PMID: 30789319 PMCID: PMC6797069 DOI: 10.1089/lrb.2018.0063] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Lymphedema is a disease of the skin and subcutaneous tissue resulting from a disturbance in lymph flow. Anyone can be affected, and causes include cancer therapy when lymph nodes are removed or irradiated, the parasitic disease lymphatic filariasis, and damage caused by exposure to irritant soils known as podoconiosis. Manifest lymphedema is progressive and a major contributor to disability, stigma, and social isolation for affected people. Although the pathogenesis of connective tissue changes in lymphedema will follow a similar course regardless of the disease of causation, several systems are used to stage progression. Disparity in these staging systems leads to inconsistency in reporting of the severity of lymphedema and prevents meta-analysis of research results. In the global health environment, integrated morbidity management for chronic illness is essential to meet the needs of affected people and to be sustainable for health care systems. Clinical descriptors for staging criteria within each system may assist clinicians in assessment and provide a format for consistency in reporting by lymphedema researchers. Methods and Results: Lymphedema staging systems used in oncology, filariasis, and podoconiosis settings were reviewed and the assessment techniques, diagnostic procedures, and clinical observations used by each system are described. The most commonly used staging systems are compared to identify similarities, and a matrix approach to lymphedema staging is proposed. Conclusion: A universal staging system would contribute to more consistent reporting of research on and clinical management of lymphedema arising from multiple causes.
Collapse
Affiliation(s)
- Janet Douglass
- Department of Tropical Disease Biology, Centre for Neglected Tropical Diseases, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Louise Kelly-Hope
- Department of Tropical Disease Biology, Centre for Neglected Tropical Diseases, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| |
Collapse
|
40
|
Yoo HJ, Kim W, Lee SY, Choi J, Kim YJ, Koo DS, Nam Y, Cho KJ. Wearable Lymphedema Massaging Modules: Proof of Concept using Origami-inspired Soft Fabric Pneumatic Actuators. IEEE Int Conf Rehabil Robot 2019; 2019:950-956. [PMID: 31374752 DOI: 10.1109/icorr.2019.8779525] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Lymphedema is a non-curative chronic swelling caused by impairment of the lymphatic system, affecting up to 250 million patients worldwide. The patients suffer from low quality of life because of discomfort and reduced range of motion due to the swelling. Severe swellings can be immediately mediated with special massaging technique known as the Manual Lymphatic Drainage (MLD). Limitations of MLD involves long travel distances, the cost of regular treatment sessions, and the lack of lymphedema specialists. Since MLD is performed very gently, described as caressing a baby's head, soft wearable robotics with its inherent compliance and safety is the perfect solution to creating a light and safe wearable lymphedema massaging device. In this paper, origami-inspired soft fabric pneumatic actuator is developed that creates not only normal force, but also shear force which is essential in the performance of MLD. The shear is created by the unfolding of the Z-shaped fold-lines as the actuator is inflated. One Z-folded actuator module of 30 x 60 mm dimension with a single fold of 15 mm fold height creates maximum shear force of about 1.5 N and stroke displacement of about 30 mm when subjected to compression loading of 5 N. The range of forces exerted can be tuned by varying the tension of the compressive clothing covering the actuators, and the stroke displacement can be varied by changing the parameter of the actuator module itself, such as the fold height and the number of the folds. The modules can also be repeatedly actuated under compressive clothing, and therefore, the developed actuator modules have high potential as a wearable massaging device.
Collapse
|
41
|
Daneshgaran G, Paik CB, Cooper MN, Sung C, Lo A, Jiao W, Park SY, Kim GH, Hong YK, Wong AK. Prevention of postsurgical lymphedema via immediate delivery of sustained-release 9-cis retinoic acid to the lymphedenectomy site. J Surg Oncol 2019; 121:100-108. [PMID: 31240729 DOI: 10.1002/jso.25587] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 05/29/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Previously, we have shown that 9-cis retinoic acid (9-cis RA) stimulates lymphangiogenesis and limits postsurgical lymphedema in animal models when administered via daily intraperitoneal injections. In this study, we investigate whether a single-use depot 9-cis RA drug delivery system (DDS) implanted at the site of lymphatic injury can mitigate the development of lymphedema in a clinically relevant mouse limb model. METHODS Hind limb lymphedema was induced via surgical lymphadenectomy and irradiation. Animals were divided into two treatment groups: (1) 9-cis RA DDS, (2) placebo DDS. Outcomes measured included paw thickness, lymphatic clearance and density, epidermal thickness, and collagen deposition. RESULTS Compared with control animals, 9-cis RA-treated animals had significantly less paw swelling from postoperative week 3 (P = .04) until the final timepoint at week 6 (P = .0007). Moreover, 9-cis RA-treated animals had significantly faster lymphatic clearance (P < .05), increased lymphatic density (P = .04), reduced lymphatic vessel size (P = .02), reduced epidermal hyperplasia (P = .04), and reduced collagen staining (P = .10). CONCLUSIONS Animals receiving 9-cis RA sustained-release implants at the time of surgery had improved lymphatic function and structure, indicating reduced lymphedema progression. Thus, we demonstrate that 9-cis RA contained within a single-use depot DDS has favorable properties in limiting pathologic responses to lymphatic injury and may be an effective strategy against secondary lymphedema.
Collapse
Affiliation(s)
- Giulia Daneshgaran
- Albert Einstein College of Medicine, Jack and Pearl Resnick Campus, New York, New York.,Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of Southern California, University of Southern California, Los Angeles, California
| | - Connie B Paik
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of Southern California, University of Southern California, Los Angeles, California
| | - Michael N Cooper
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of Southern California, University of Southern California, Los Angeles, California.,Tulane University School of Medicine, New Orleans, Louisiana
| | - Cynthia Sung
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of Southern California, University of Southern California, Los Angeles, California
| | - Andrea Lo
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of Southern California, University of Southern California, Los Angeles, California
| | - Wan Jiao
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of Southern California, University of Southern California, Los Angeles, California
| | - Sun Young Park
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of Southern California, University of Southern California, Los Angeles, California
| | - Gene H Kim
- Department of Dermatology, Keck School of Medicine of University of Southern California, University of Southern California, Los Angeles, California
| | - Young-Kwon Hong
- Department of Surgery, Keck School of Medicine of University of Southern California, University of Southern California, Los Angeles, California
| | - Alex K Wong
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of Southern California, University of Southern California, Los Angeles, California.,Department of Surgery, Keck School of Medicine of University of Southern California, University of Southern California, Los Angeles, California
| |
Collapse
|