Randomized trial of decongestive lymphatic therapy for the treatment of lymphedema in women with breast cancer

Axillary Treatment and Chronic Breast Cancer-Related Lymphedema: Implications for Prospective Surveillance and Intervention From a Randomized Controlled Trial

PURPOSE

The PREVENT randomized trial assessed progression to chronic breast cancer-related lymphedema (cBCRL) after intervention triggered by bioimpedance spectroscopy (BIS) or tape measurement (TM). This secondary analysis identifies cBCRL risk factors on the basis of axillary treatment.

METHODS

Between June 2014 and September 2018, 881 patients received sentinel node biopsy (SNB; n = 651), SNB + regional node irradiation (RNI; n = 58), axillary lymph node dissection (ALND; n = 85), or ALND + RNI (n = 87). The primary outcome was the 3-year cBCRL rate requiring complex decongestive physiotherapy (CDP).

RESULTS

After a median follow-up of 32.8 months (IQR, 21-34.3), 69 of 881 patients (7.8%) developed cBCRL. For TM, 43 of 438 (9.8%) developed cBCRL versus 26 of 443 (5.9%) for BIS (P = .028). The 3-year actuarial risk of cBCRL was 4.4% (95% CI, 2.7 to 6.1), 4.2% (95% CI, 0 to 9.8), 25.8% (95% CI, 15.8 to 35.8), and 26% (95% CI, 15.3 to 36.7). Rural residence increased the risk in all groups. For SNB, neither RNI (SNB, 4.1% v SNB + RNI, 3.4%) nor taxane (4.4%) increased cBCRL, but risk was higher for patients with a BMI of ≥30 (6.3%). For SNB + RNI, taxane use (5.7%) or supraclavicular fossa (SCF) radiation (5.0%) increased cBCRL. For ALND patients, BMI ≥25 or chemotherapy increased cBCRL. For ALND + RNI, most patients received SCF radiation and taxanes, so no additional risk factors emerged.

CONCLUSION

The extent of axillary treatment is a significant risk factor for cBCRL. Increasing BMI, rurality, SCF radiation, and taxane chemotherapy also increase risk. These results have implications for a proposed risk-based lymphedema screening, early intervention, and treatment program.

Effect of Conservative Rehabilitation Interventions on Health-Related Quality of Life in Women with Upper Limb Lymphedema Secondary to Breast Cancer: A Systematic Review

Breast cancer-related lymphedema (BCRL) of the upper limb is a very common condition in women undergoing breast cancer treatment; it can cause considerable alterations in the daily life of patients and a decrease in their health-related quality of life (HRQoL). Currently, there are many conservative therapies that try to palliate the symptoms, but the results are still controversial and there are still no globally accepted treatments. The purpose of this article is to determine the effect, according to the current available evidence, on HRQoL of different conservative interventions in the rehabilitation of BCRL in the upper limb in women. Eighteen articles that compared the effects of standard treatments, such as manual lymphatic drainage-based decongestive therapy or compression measures, and other newer treatments, including new technologies and other types of treatment programs, were reviewed. According to the results of this review, the most recommended modality for the improvement of HRQoL would be a complex decongestive technique without manual lymphatic drainage. Although there are clinical trials that have demonstrated the effectiveness of various treatments, the results of the positive effects on HRQoL remain highly controversial. There is a need to continue to develop studies to help guide therapeutic decisions that can promote HRQoL in women affected by upper limb BCRL.

The Use of Postoperative Compression Garments in Plastic Surgery-Necessary or Not? A Practical Review

This practical review critically evaluates the evidence behind the widespread use of postoperative compression therapy intended to improve surgical outcomes, such as reduced edema, ecchymosis, pain, and seroma formation. A literature search of PubMed was conducted to identify relevant studies concerning the use of compression garments after aesthetic surgery, including rhinoplasty, facelift, neck lift, mammoplasty, abdominoplasty, limb contouring, and others. Additionally, reconstructive and therapeutic procedures closely related in anatomy or technique to these cosmetic operations, such as breast reconstruction, mastectomy, and hernia repair, were also considered to provide further perspective. After study extraction, the volume, quality, and agreement of the evidence found was highly heterogenous depending on the context of specific operations and outcomes evaluated. The most well-supported indications for the use of postoperative compression garments are to mitigate edema and ecchymosis after rhinoplasty and to reduce postoperative pain after breast and abdominal procedures, although no effect on seroma rate was demonstrated. Any potential benefit must be balanced against the associated costs and possible complications of compression, including patient discomfort, increased venous stasis, and skin defects. Thus, we encourage surgeons to critically reassess their use of compression garments. In many settings, such as brachioplasty, there is limited high-quality evidence to inform best practice, and we urge the community to continue researching this important topic so that more definitive and comprehensive guidelines may be established.

Advances in the prevention and treatment of breast cancer-related lymphedema

PURPOSE

Breast cancer-related lymphedema (BCRL) represents a lifelong risk for breast cancer survivors and once acquired becomes a lifelong burden. This review summarizes current BCRL prevention and treatment strategies.

FINDINGS

Risk factors for BCRL have been extensively studied and their identification has affected breast cancer treatment practice, with sentinel lymph node removal now standard of care for patients with early stage breast cancer without sentinel lymph node metastases. Early surveillance and timely management aim to reduce BCRL incidence and progression, and are further facilitated by patient education, which many breast cancer survivors report not having adequately received. Surgical approaches to BCRL prevention include axillary reverse mapping, lymphatic microsurgical preventative healing (LYMPHA) and Simplified LYMPHA (SLYMPHA). Complete decongestive therapy (CDT) remains the standard of care for patients with BCRL. Among CDT components, facilitating manual lymphatic drainage (MLD) using indocyanine green fluorescence lymphography has been proposed. Intermittent pneumatic compression, nonpneumatic active compression devices, and low-level laser therapy appear promising in lymphedema management. Reconstructive microsurgical techniques such as lymphovenous anastomosis and vascular lymph node transfer are growing surgical considerations for patients as well as liposuction-based procedures for addressing fatty fibrosis formation from chronic lymphedema. Long-term self-management adherence remains problematic, and lack of diagnosis and measurement consensus precludes a comparison of outcomes. Currently, no pharmacological approaches have proven successful.

CONCLUSION

Progress in prevention and treatment of BCRL continues, requiring advances in early diagnosis, patient education, expert consensus and novel treatments designed for lymphatic rehabilitation following insults.

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

PURPOSE

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

METHODS/RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR CANCER SURVIVORS

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

The prevention and treatment of breast cancer- related lymphedema: A review

Background

Breast cancer- related lymphedema (BCRL) affects about 3 to 5 million patients worldwide, with about 20,000 per year in the United States. As breast cancer mortality is declining due to improved diagnostics and treatments, the long-term effects of treatment for BCRL need to be addressed.

Methods

The American Society of Breast Surgeons Lymphatic Surgery Working Group conducted a large review of the literature in order to develop guidelines on BCRL prevention and treatment. This was a comprehensive but not systematic review of the literature. This was inclusive of recent randomized controlled trials, meta-analyses, and reviews evaluating the prevention and treatment of BCRL. There were 25 randomized clinical trials, 13 systemic reviews and meta-analyses, and 87 observational studies included.

Results

The findings of our review are detailed in the paper, with each guideline being analyzed with the most recent data that the group found evidence of to suggest these recommendations.

Conclusions

Prevention and treatment of BCRL involve a multidisciplinary team. Early detection, before clinically apparent, is crucial to prevent irreversible lymphedema. Awareness of risk factors and appropriate practice adjustments to reduce the risk aids are crucial to decrease the progression of lymphedema. The treatment can be costly, time- consuming, and not always effective, and therefore, the overall goal should be prevention.

A Comparison of Bioimpedance Spectroscopy or Tape Measure Triggered Compression Intervention in Chronic Breast Cancer Lymphedema Prevention

Background: This study compared rates of progression to chronic breast cancer-related lymphedema (defined as ≥ 10% arm volume change from baseline requiring complex decongestive physiotherapy [CDP]) following an intervention for subclinical lymphedema (S-BCRL) triggered by bioimpedance spectroscopy (BIS) or by tape measurement (TM). Methods and Results: This stratified, randomized, international trial enrolled new breast cancer patients undergoing: mastectomy/partial mastectomy, axillary treatment (dissection, sentinel lymph node biopsy [SLNB] >6 nodes or radiation), radiation therapy (chest wall/breast, supraclavicular fossa), or taxane-based chemotherapy. Following postsurgery eligibility reassessment, centralized, 1:1 randomization to prospective surveillance by BIS or TM occurred. S-BCRL detection triggered a 4-week, 12-hour per day, compression sleeve, and gauntlet intervention. The primary outcome (n = 209), rates of postintervention progression to CDP, was assessed over 3 years. Between June 24, 2014 and September 11, 2018, 1200 patients were enrolled, 963 randomized (BIS n = 482; TM n = 481) and 879 analyzed (BIS n = 442; TM n = 437). Median follow-up was 32.9 months (interquartile range = 22, 35). BIS patients triggered an intervention at a lower rate than TM patients (20.1%, n = 89 vs. 27.5%, n = 120, p = 0.011). Median months to trigger were longer with BIS than TM (9.7; 95% confidence interval [CI], 8.2-12.6 vs. 3.9; 95% CI, 2.8-4.5, p = 0.001). Overall, 14.4% (n = 30) progressed post-intervention, with reduced likelihood for BIS patients than TM patients (7.9%, n = 7 vs. 19.2%, n = 23; relative risk = 0.41; 95% CI, 0.13-0.81; absolute reduction 11.3%; 95% CI, 2.3-20.3; p = 0.016). Conclusions: Compared to TM, BIS provides a more precise identification of patients likely to benefit from an early compression intervention. Clinical Trial Registration number: NCT02167659.

Complete decongestive therapy versus compression bandaging alone in advanced secondary lymphedema

Background. Secondary lymphedema results from a known insult to the lymphatic system. Worldwide, secondary lymphedema is more common than primary lymphedema. Compression therapy is the mainstay of management for all stages of lymphedema. Purpose. To compare between the effectiveness of compression bandaging (CB) alone to the international standard treatment of (CDT) in patients with advanced secondary lymphedema. Methods. Sixty patients of both genders with lower limb secondary lymphedema (stage II and III) aged from 40 to 55 years old, with body mass index (BMI) less than 35 and duration of illness ranged from 3-9 years were included in the study. They were randomly assigned into two groups of equal numbers. Group A: Thirty patients received CDT (Manual lymph drainage, CB, exercises, and skin care). Group B: Thirty patients received MCB using short stretch bandages alone. The treatment sessions consisted of twelve sessions, three times per week for a total duration of four weeks. The assessment of limb volume was done using water displacement method and truncated cone volumetric measurements (pre-treatment and after 12 sessions (post-treatment)). Results. Within both groups, there was a significant reduction in water displacement volumetric measurements pre vs. post treatment in groups (A& B) p-value = 0.0001, p-value = 0.0001 respectively. As well, there was a significant reduction in truncated cone lower extremity volumetric measurements between pre and post treatment in groups (A & B) p-value = 0.0001, p-value = 0.028 respectively. However, there were no significant differences in the mean values of water displacement volumetric measurements and truncated cone mean volumetric values between both groups (p = 0.835, p = 0.397) respectively. Conclusion. Compression bandaging alone is as effective as complete decongestive therapy in advanced secondary lymphedema.

Emerging Anti-Inflammatory Pharmacotherapy and Cell-Based Therapy for Lymphedema

Secondary lymphedema is a common complication of lymph node dissection or radiation therapy for cancer treatment. Conventional therapies such as compression sleeve therapy, complete decongestive physiotherapy, and surgical therapies decrease edema; however, they are not curative because they cannot modulate the pathophysiology of lymphedema. Recent advances reveal that the activation and accumulation of CD4+ T cells are key in the development of lymphedema. Based on this pathophysiology, the efficacy of pharmacotherapy (tacrolimus, anti-IL-4/IL-13 antibody, or fingolimod) and cell-based therapy for lymphedema has been demonstrated in animal models and pilot studies. In addition, mesenchymal stem/stromal cells (MSCs) have attracted attention as candidates for cell-based lymphedema therapy because they improve symptoms and decrease edema volume in the long term with no serious adverse effects in pilot studies. Furthermore, MSC transplantation promotes functional lymphatic regeneration and improves the microenvironment in animal models. In this review, we focus on inflammatory cells involved in the pathogenesis of lymphedema and discuss the efficacy and challenges of pharmacotherapy and cell-based therapies for lymphedema.

Prevention, Diagnosis, and Management of Upper Extremity Lymphedema Complications: Altmetric Analysis of Online Media

Background:

Traditional citation-based metrics do not capture the dissemination of upper extremity lymphedema (UEL) research that occurs online and in mainstream media. There is limited literature reporting the most impactful UEL articles based on citation rate and/or online mentions. We sought to use the Altmetric Attention Score (AAS) to determine the most impactful UEL articles in online media and to report trends in the diagnosis, treatment, and prevention of complications.

Methods:

The Altmetric database was queried to identify all published articles regarding the management, diagnosis, and prevention of complications seen in the setting of UEL. Extracted data points included article topic and type, journal, and number of online mentions on several platforms.

Results:

Our index search yielded 638 studies published between 2000 and 2021. Fifty articles with the highest AAS scores were included for analysis. The median AAS was 27.5, but the top four articles had AAS scores that were substantially higher (AAS ≥ 334) than all other studies. Of the top 50 articles, 68% (34/50) were original research. Of those, 23.5% (8/34) were randomized control trials. The most common article topic was the treatment of UEL (36%; 18/50) followed by diagnostic methods of UEL (30%; 15/50). There were a total of 1156 Twitter mentions (median:14) for the top 50 articles. Of all media platforms, news mentions correlated most strongly with AAS (R² = 0.99, P < 0.001).

Conclusions:

Our findings suggest that alternative metrics measure distinct components of article impact and add an important dimension to understanding the overall impact of published research on UEL.

Outcomes analysis of microsurgical physiologic lymphatic procedures for the upper extremity from the United States National Surgical Quality Improvement Program

INTRODUCTION

Physiologic microsurgical procedures to treat lymphedema include vascularized lymph node transfer (VLNT) and lymphovenous bypass (LVB). The purpose of this study was to assess 30-day outcomes of VLNT and LVB using the National Surgical Quality Improvement Program (NSQIP) database.

METHODS

NSQIP was queried (2012-2018) for lymphatic procedures for upper extremity lymphedema after mastectomy. Prophylactic lymphatic procedures and those for lower extremity lymphedema were excluded. Outcomes were assessed for three groups: LVB, VLNT, and patients who had procedures simultaneously (VLNA+LVB). Primary outcomes measured were operative time, 30-day morbidities, and hospital length of stay.

RESULTS

The study included 199 patients who had LVB (n = 43), VLNT (n = 145), or VLNT+LVB (n = 11). There was no difference in co-morbidities between the groups (p = 0.26). 30-day complication rates including unplanned reoperation (6.9% VLNT vs. 2.3% LVB) and readmission (0.69% VLNT vs. none in LVB) were not statistically significant (p = 0.54). Surgical site infection, wound complications, deep vein thromboembolism, and cardiac arrest was also similar among the three groups. Postoperative length of stay for VLNT (2.5 days± 2.3), LVB (1.9 days± 1.9), and VLNT+LVB (2.8 days± 0.3) did not differ significantly (p = 0.20). Operative time for LVB (305.4 min ± 186.7), VLNT (254 min ± 164.4), and VLNT+LVB (295.3 min ± 43.2) was not significantly different (p = 0.21).

CONCLUSIONS

Our analysis of the NSQIP data revealed that VLNT and LVB are procedures with no significant difference in perioperative morbidity. Our results support that choice of VLNT versus LVB can be justifiably made per the surgeon's preference and experience as the operations have similar complication rates.

Retrograde Manual Lymphatic Drainage following Vascularized Lymph Node Transfer to Distal Recipient Sites for Extremity Lymphedema: A Retrospective Study and Literature Review

BACKGROUND

Vascularized lymph node transfer is an efficacious treatment for extremity lymphedema. This study investigated the outcome of retrograde manual lymphatic drainage for vascularized lymph node transfer to distal recipient sites.

METHODS

Lymphedema patients who underwent either complete decongestive therapy or vascularized lymph node transfer between 2013 and 2018 were retrospectively included. Retrograde manual lymphatic drainage was started with intermittent manual compression and the assistance of a sphygmomanometer and proximal-to-distal massage of the limb 1 month postoperatively. Outcomes evaluations used the circumferential reduction rate and the Lymphedema-Specific Quality-of-Life Questionnaire. Outcomes of vascularized lymph node transfer to proximal versus distal recipient sites in the literature between 2006 and 2018 were also compared.

RESULTS

One hundred thirty-eight unilateral extremity lymphedema patients, including 68 patients in the complete decongestive therapy group and 70 patients in the vascularized lymph node transfer group, were included. The mean circumferential reduction rate of 38.9 ± 2.5 percent in the vascularized lymph node transfer group was statistically greater than the 13.2 ± 10.1 percent rate in the complete decongestive therapy group (p = 0.01). At a mean follow-up of 36 months, the improvement of overall Lymphedema-Specific Quality-of-Life Questionnaire score from 3.8 ± 0.3 to 7.5 ± 1.8 in the vascularized lymph node transfer group was statistically greater than that in the complete decongestive therapy group (from 4.7 ± 0.9 to 5.0 ± 1.9; p < 0.01). In total, 536 lymphedema patients who underwent 548 vascularized lymph node transfers in 23 published articles were reviewed; the distal recipient-site group was found to have more efficacious results than the proximal recipient-site group.

CONCLUSION

Vascularized lymph node transfer to a distal recipient site with standard retrograde manual lymphatic drainage significantly improved circumferential reduction rates and Lymphedema-Specific Quality-of-Life Questionnaire scores.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Combined Complete Decongestive Therapy Reduces Volume and Improves Quality of Life and Functional Status in Patients With Breast Cancer-Related Lymphedema

BACKGROUND

The aim of this study was to evaluate the effects of complete decongestive therapy (CDT) in patients with breast cancer-related lymphedema (BCRL), in regard to volume reduction, functional status and quality of life (QoL).

METHODS

Fifty patients with unilateral BCRL were included. The demographic variables focusing on lymphedema were recorded. All patients received combined phase 1 CDT including skin-care, manual lymphatic drainage, multilayer bandaging and supervised exercises, 5 times a week for 3 weeks, as a total of 15 sessions. Patients were assessed by limb volumes and excess volumes according to geometric approximation derived from serial circumference-measurements of the limb, prior and at the end of third week. The functional disability was evaluated by quick disability of arm, shoulder and hand questionnaire (Q-DASH). QoL was assessed by the European Organization for Research and Treatment of Cancer Core Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its breast-cancer-module (EORTC QLQ-BR23).

RESULTS

Fifty females with mean age of 53.22 ± 11.2 years were included. The median duration of lymphedema was 12 months. There were 22 patients in stage1, 26 in stage2 and 2 patients in stage3. The mean baseline limb and excess volumes were significantly decreased at the end of therapies (3262 ± 753 cm³ vs. 2943 ± 646.6 cm³ and 31.36% ± 16.5% vs. 19.12% ± 10.4%, pP= 0.000 respectively). The Q-DASH and EORTC QLQ-C30 and BR23 scores were also decreased significantly (pP< 0.05). The improvements in volumes were related negatively with the duration of lymphedema, and the stage of lymphedema.

CONCLUSION

In conclusion phase 1 CDT in a combined manner performed daily for 3 weeks, greatly reduces the volumes as well as improves the disability and QoL, especially when performed earlier.

Effects of Complex Physical Therapy and Multimodal Approaches on Lymphedema Secondary to Breast Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

What are the immediate, short-term, and long-term effects of complex physical therapy and multimodal approaches on lymphedema secondary to breast cancer?

DATA SOURCES

Four electronic databases (MEDLINE, Embase, Cochrane Library, Physiotherapy Evidence Database) were searched from inception up to August 2020.

STUDY SELECTION

Randomized controlled trials comparing complex physical therapy and multimodal approaches to the conservative treatment of lymphedema secondary to breast cancer.

DATA EXTRACTION

Two independent researchers performed data extraction and assessed the risk of bias, respectively, using the predefined form and Cochrane Collaboration of Risk of Bias. The determination of evidence quality was carried out using the Grading of Recommendations Assessment, Development, and Evaluation tools.

DATA SYNTHESIS

Fourteen studies were identified for the systematic review and 11 studies for the meta-analysis with standardized mean difference (SMD), 95% CI, and random-effect model. The common outcomes involved total volume, pain, and physical function of the upper limb. Complex physical therapy has shown a favorable tendency to control outcomes in the short- and long-term. The meta-analysis indicated a small effect for volume reduction (SMD, -0.18; 95% confidence interval [CI], -0.35 to 0.00) and a moderate effect for short-term pain reduction (SMD, -0.61; 95% CI, -1.19 to -0.02).

CONCLUSIONS

High-quality evidence suggests a more significant effect of complex physical therapy on multimodal approaches to the control of the upper limb total volume, substantiating the absence of changes in the current clinical practice in the management of lymphedema secondary to breast cancer. Future research should aim to identify concrete effect of therapeutic modalities in the immediate-, short-, and long-term.

Quality of Life evaluation and lack of correlation with volumetric results after lymphovenous anastomoses in lymphedema therapy of the lower extremity

OBJECTIVE

Chronic primary or secondary lymphedema has a huge impact on quality of life (QOL) because of associated swelling, pain, decreased range of motion, depression and anxiety, and generally requires numerous adaptations. Many studies have shown a positive objective effect of lymphovenous anastomoses (LVAs) on chronic lymphedema. In this study, we assessed the effect of LVAs on QOL in patients with primary or secondary lymphedema of the lower extremity 6 months after surgery, and examine the correlation between changes in QOL and volumetric measurements.

METHOD

Only patients with either primary or secondary lymphedema of the lower extremity who had LVAs were included in the study. To assess QOL, a specially designed questionnaire based on the "Lymphedema Quality of Life Inventory" (LyQLI) was used to evaluate the subjective therapeutic results from the patients' perspectives. Objective therapy success was assessed by 3D volumetric measurements of the lower leg. Measuring points, for both subjective and objective measurements, were the day before and 6 months after therapy.

RESULTS

The mean volume change 6 months after LVAs was -6.5% (sd 5.6, p < 0.001). A significantly better quality of life in terms of physical (37.6%, sd 25.2) and psychosocial (27.0%, sd 43.0) suffering as well as practical restrictions (22.3%, sd 24.8) was found (p values < 0.001). No correlation was found between QOL improvement and volume decrease (p values > 0.05).

CONCLUSION

In patients suffering from lymphedema of the lower extremity, lymphovenous anastomoses lead to a significant volumetric decrease and quality of life improvement six months after treatment with no demonstrable relationship between QOL improvement and volume reduction.

Far Infrared Radiation Therapy for Gynecological Cancer-Related Lymphedema Is an Effective and Oncologically Safe Treatment: A Randomized-Controlled Trial

Background: Gynecological cancer-related lymphedema (GCRL) is a devastating condition that adversely influences function, health, and quality of life. We conducted a randomized-controlled clinical study as well as in vitro experiments to investigate the efficacy and safety of far infrared radiation (FIR) to treat lymphedema in patients having previously undergone surgery for gynecological tumors. Materials and Methods: Seventy-four women with GCRL, cancer free for 5 years or more, were randomly allocated into two treatment groups: standard of care with bandage treatment and treatment with FIR plus bandage. Variations of fluid, circumference of lymphedematous limbs, serum tumor markers (cancer antigen 125 [CA125]), inguinal-pelvic lymph nodes, vagina, lungs, and adverse reactions were assessed after 1 year. In vitro experiments examined the effects on cell viability, proliferation, apoptosis, and the cell cycle of fibroblast, A2780, SKOV-3, HELA, and Ishikawa cells. Results: The FIR+bandage group showed significantly decreased tissue fluid and reduced limb circumference (p < 0.05) in comparison with the control group at 1 year. There was no increase of serum CA125 in both groups, and no recurrence of neoplasia or lymphadenopathy was detected. No adverse reactions were recorded. In addition, no changes were detected after FIR treatment for fibroblast, A2780, SKOV-3, HELA, and Ishikawa cells in cell viability, proliferation, apoptosis, and cell cycle. Conclusion: FIR can be used to treat patients with GCRL following gynecological cancer treatment. Following clinical and experimental studies, we confirm that FIR is an oncologically safe treatment for lymphedema in gynecological tumor patients.

Tissue Engineering Strategies for Cancer-Related Lymphedema

Tissue engineering has witnessed remarkable advancement in various fields of medicine and has the potential of revolutionizing the management of lymphedema. Combining approaches of biotechnology with the evolving understanding of lymphangiogenesis may offer promising treatment modalities for patients suffering from lymphedema. The strategies to lymphatic vessels tissue engineer can be grouped into four main categories: Delivery of chemokines, cytokines, and other growth factors to induce lymphangiogenesis; cell-based approach using lymphatic endothelial cells or stem-cells; scaffold-based tissue engineering; or a combination of these. This review will summarize the current approach to cancer-related lymphedema and advances in lymphatic tissue engineering strategies and the challenges facing the regeneration of lymphatic vasculature, particularly in an oncologic setting.

Reduction Scrotoplasty in 100 kg Scrotums

Scrotal elephantiasis is a rare form of lymphedema of the scrotum. Its pathophysiology is diverse and often not clear, as there are only a few diagnostic tools available. Primary therapy consists, as usual for lymphedema, of conservative measures. However, due to anatomical and physiological findings, conservative therapy options are not always applicable. Although the only possible therapy in severe cases is the surgical resection, there is a lack in the literature regarding a standardized surgical approach. Surgical treatment of massive scrotal elephantiasis was performed in two patients according to a standardized strategy. After computed tomography and planning the operation, the penis and testicles were first exposed. Then, the reduction of the scrotum was performed, by holding the lateral flaps to the contralateral side and setting the cutoff line to the center. The cranial flap was decreased as in a modified abdominoplasty. After surgical treatment following the standardized approach, both patients showed functionally and esthetically positive results. Scrotal elephantiasis has a huge impact on life quality of the affected patients. With the described combination of intense conservative therapy and a standardized surgical procedure, these challenging patients can be helped.

The impact of monitoring techniques on progression to chronic breast cancer-related lymphedema: a meta-analysis comparing bioimpedance spectroscopy versus circumferential measurements

BACKGROUND

Chronic breast cancer-related lymphedema (BCRL) is a potentially serious complication following treatment. Monitoring for progression to BCRL may allow for earlier detection and intervention, reducing the rate of progression to chronic BCRL. Therefore, the purpose of this meta-analysis is to evaluate the impact of monitoring techniques on the incidence of chronic BCRL among patients monitored by bioimpedance spectroscopy (BIS) and circumference as compared to background rates.

METHODS

Eligible peer-reviewed studies from PubMed, CINHAL, or Google Scholar that were published in English from 2013 onward and conducted in North America, Europe, or Oceania. Incidence rates abstracted from studies were classified by BCRL monitoring method: background (no standardized BIS or circumference assessments), BIS or circumference. A random-effects model was used to calculate a pooled annualized estimate of BCRL incidence while accounting for clinical and methodological heterogeneity. Subgroup analyses examined differences in duration of follow-up as well as breast and axillary surgery.

RESULTS

50 studies were included, representing over 67,000 women. The annualized incidence of BCRL was 4.9% (95% CI: 4.3-5.5) for background studies (n = 35), 1.5% (95% CI: 0.6-2.4) for BIS-monitored studies (n = 7), and 7.7% (95% CI: 5.6-9.8) for circumference-monitored studies (n = 11). The cumulative BCRL incidence rate in BIS-monitored patients was 3.1% as compared to 12.9% with background monitoring (69% reduction) and 17.0% with circumference-monitored patients (81% reduction).

CONCLUSIONS

Evidence suggests that monitoring with BIS allowing for early intervention significantly reduces the relative risk of chronic BCRL with a 69% and 81% reduction compared to background and circumference, respectively. Circumference monitoring did not appear to provide a benefit with respect to chronic BCRL incidence. Based on these results, BIS should be considered for BCRL screening in order to detect subclinical BCRL and reduce rates of chronic BCRL, particularly in high-risk patients.

Development and Validation of a Risk Model for Breast Cancer-Related Lymphedema

IMPORTANCE

Approximately 1 in 5 patients with breast cancer who undergo axillary lymph node dissection will develop lymphedema. To appropriately triage and monitor these patients for timely diagnosis and treatment, robust risk models are required.

OBJECTIVE

To evaluate the prognostic value of mammographic breast density in estimating lymphedema severity.

DESIGN, SETTING, AND PARTICIPANTS

This prognostic study collected data from July 16, 2018, to March 3, 2020, from the electronic health records of patients of the Cancer Rehabilitation and Survivorship Program at the Princess Margaret Cancer Centre in Toronto, Ontario, Canada. Participants included women who had completed curative treatment for a first diagnosis of breast cancer and who were referred to the program. Also included were a sample of patients in the general breast oncology population who were receiving follow-up care at the center during the same period but who were not referred to the program. All patients attended follow-up appointments at the Princess Margaret Cancer Centre from January 1, 2016, to May 1, 2018. The cohort was randomly split 2:1 to group patients into a training cohort and a validation cohort.

EXPOSURES

Participant demographic and clinical characteristics included age, sex, body mass index (BMI), medical history, cancer characteristics, and cancer treatment.

MAIN OUTCOMES AND MEASURES

Spearman correlation coefficient between measured and predicted volume of lymphedema was calculated. Area under the curve (AUC) values were generated for predicting the occurrence of at least mild lymphedema (volume, >200 mL) and severe lymphedema (volume, >500 mL) at the time of initial lymphedema diagnosis.

RESULTS

A total of 373 female patients (median [interquartile range] age, 52.3 [45.9-60.1] years) were eligible for this analysis. Multivariate linear regression identified 3 patient factors (age, BMI, and mammographic breast density), 1 cancer factor (number of pathological lymph nodes), and 1 treatment factor (axillary lymph node dissection) as independent prognostic variables. In validation testing, Spearman correlation revealed a statistically significant moderate correlation (coefficient, 0.42; 95% CI, 0.26-0.56; P < .001) between measured volume and predicted volume of lymphedema. The AUC values were 0.72 (95% CI, 0.60-0.83) for predicting the occurrence of mild lymphedema and 0.83 (95% CI, 0.74-0.93) for severe lymphedema.

CONCLUSIONS AND RELEVANCE

This prognostic study found that patients with low breast density appeared to be at a higher risk of developing severe lymphedema. The finding suggests that by combining breast density with established risk factors a multivariate linear regression model could be used to predict the development of lymphedema and provide volumetric estimates of lymphedema severity in patients with breast cancer.

Manual Lymphatic Drainage May Not Have an Additional Effect on the Intensive Phase of Breast Cancer-Related Lymphedema: A Randomized Controlled Trial

Background: Breast cancer-related lymphedema (BCRL) is a potentially debilitating complication of breast cancer and its treatment. The aim of this study was to determine the efficacy of manual lymphatic drainage (MLD) added to multilayer compressive bandage treatment in addition to an exercise program, on arm volume, subjective symptoms, upper limb functions, and health-related quality of life (HRQoL) in patients with BCRL. Methods: This prospective, randomized, single-blind interventional trial involved 54 patients with BCRL. Eligible patients were randomly allocated to a complex decongestive therapy (CDT) group (n = 27) and a standard therapy (ST) group (n = 27). Both groups participated in a 15-session program (every weekday for 3 weeks) that included compressive multilayer bandaging and exercise training. The patients who were allocated to the CDT group received MLD before bandaging in addition to the ST. Bilateral arm circumferences were measured using a measuring tape at six reference points. Subjective symptoms, such as discomfort, heaviness, and swelling severity were measured using a visual analog scale (VAS). Upper limb functions and HRQoL were assessed using the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) and Lymphedema Functioning, Disability, and Health Questionnaire (Lymph-ICF), respectively. Results: The excess arm volume, percent change of excess arm volume, Quick-DASH scores, and Lymph-ICF subscale scores significantly decreased (p < 0.001) in both treatment groups. However, there was no significant difference between the two groups (p > 0.05) in terms of changes in these outcomes. The VAS discomfort (p = 0.015) and VAS heaviness (p = 0.014) scores decreased significantly in the CDT group compared to the ST group. Conclusion: The study findings indicated that both treatment approaches were effective in patients with BRCL. However, no additional effect of MLD was found with regard to percent reduction in arm volume in the intensive treatment period of BRCL.

Current advances in lymphoedema management

Lymphoedema is the accumulation of protein-rich interstitial fluid within subcutaneous tissue and skin as a result of dysfunction of the lymphatic system. It is an underestimated, widely neglected and debilitating chronic condition. This article presents an overview of lymphoedema and recent advances in its management.

Interventions for Breast Cancer-Related Lymphedema: Clinical Practice Guideline From the Academy of Oncologic Physical Therapy of APTA

A work group from the American Physical Therapy Association (APTA) Academy of Oncologic Physical Therapy developed a clinical practice guideline to aid clinicians in identifying interventions for people with breast cancer-related lymphedema, targeting volume reduction, beginning at breast cancer diagnosis and continuing through cancer treatments and survivorship. Following a systematic review of published studies and a structured appraisal process, recommendations were developed to guide physical therapists and other health care clinicians in their intervention selection. Overall, clinical practice recommendations were formulated based on the evidence for each intervention and were assigned a grade based on the strength of the evidence. The evidence for each specific intervention was synthesized and appraised by lymphedema stage, when the information was available. In an effort to make recommendations clinically applicable, they were presented by modality throughout the care trajectory. Methodology and research populations varied significantly across studies, and it will be important for future research to use standardized definitions for participant characteristics, diagnostic criteria, and interventions.

A quasi-randomized clinical trial: virtual reality versus proprioceptive neuromuscular facilitation for postmastectomy lymphedema

BACKGROUND

Postmastectomy lymphedema can be considered the main cause of upper extremity functional impairment in patients with breast cancer. Fatigue, pain, and limited range of motion are common symptoms. If left untreated, lymphedema causes cellulitis, which can lead to gangrene in rare cases. This study was carried out to identify and compare the therapeutic advantages of virtual reality-based exercises and proprioceptive neuromuscular facilitation for postmastectomy lymphedema. Thus, a quasi-randomized comparative study of thirty female patients with unilateral postmastectomy lymphedema was conducted. Fifteen patients performed virtual reality-based exercises as well as manual lymphatic drainage, pneumatic compression, and home programs, while the other fifteen patients performed proprioceptive neuromuscular facilitation as well as manual lymphatic drainage, pneumatic compression, and home programs. The excess arm volume between the healthy and affected limbs was estimated before and after eight sessions of treatment for both groups. In addition, the affected limb functional score was calculated. Arm volume was calculated by the truncated cone formula and girth measurements obtained by the circumferential method. The Arabic version of the QuickDASH-9 scale was used to assess extremity function.

RESULTS

The excess arm volume significantly decreased in both the virtual reality group (p = 0.001) and proprioceptive neuromuscular facilitation group (p = 0.005), and there was no significant difference between the two groups (p = 0.902). Age was inversely related to the improvement percentage of the QuickDASH-9 score in the virtual reality group. The functional improvement percentage was statistically significantly different between the two groups (p = 0.045).

CONCLUSION

It can be concluded that both virtual reality and proprioceptive neuromuscular facilitation have a beneficial therapeutic effect on edema in patients with unilateral postmastectomy lymphedema; neither method was found to be superior, except virtual reality was found to be superior to proprioceptive neuromuscular facilitation in motivating patients and providing visual feedback.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04185181 Registered 4 December 2019 - Retrospectively registered.

Improving the quality of life of patients with breast cancer-related lymphoedema by lymphaticovenous anastomosis (LVA): study protocol of a multicentre randomised controlled trial

INTRODUCTION

Early breast cancer detection and advancements in treatment options have resulted in an increase of breast cancer survivors. An increasing number of women are living with the long-term effects of breast cancer treatment, making the quality of survivorship an increasingly important goal. Breast cancer-related lymphoedema (BCRL) is one of the most underestimated complications of breast cancer treatment with a reported incidence of 20%. A microsurgical technique called lymphaticovenous anastomosis (LVA) might be a promising treatment modality for patients with BCRL. The main objective is to assess whether LVA is more effective than the current standard therapy (conservative treatment) in terms of improvement in quality of life and weather it is cost-effective.

METHODS AND ANALYSIS

A multicentre, randomised controlled trial, carried out in two academic and two community hospitals in the Netherlands. The study population includes 120 women over the age of 18 who have undergone treatment for breast cancer including axillary treatment (sentinel lymph node biopsy or axillary lymph node dissection) and/or axillary radiotherapy, presenting with an early stage lymphoedema of the arm, viable lymphatic vessels and received at least 3 months conservative treatment. Sixty participants will undergo the LVA operation and the other sixty will continue their regular conservative treatment, both with a follow-up of 24 months. The primary outcome is the health-related quality of life. Secondary outcomes are societal costs, quality adjusted life years, cost-effectiveness ratio, discontinuation rate of conservative treatment and excess limb volume.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of Maastricht University Medical Center (METC) on 19 December 2018 (NL67059.068.18). The results of this study will be disseminated in presentations at academic conferences, publications in peer-reviewed journals and other news media.

TRIAL REGISTRATION NUMBER

NCT02790021; Pre-results.

Identification and Management of Lymphedema in Patients With Breast Cancer

Breast cancer–related lymphedema (BCRL) is a potentially debilitating and often irreversible complication of breast cancer treatment. Risk of BCRL is proportional to the extent of axillary surgery and radiation. Other risk factors include obesity and infections. Given the 5-year survival rate of 90% and its potential impact on the quality of life of survivors of breast cancer, BCRL has become a significant financial burden on the health care system. Minimizing axillary surgery and radiation has been proven to reduce the risk of BCRL. Comprehensive multidisciplinary assessment at the time of initial diagnosis; early referral to physical therapy after surgery; and patient education regarding weight loss, skin, and nail care are cornerstones of the management of early-stage lymphedema. End-stage lymphedema may benefit from referral to a plastic surgeon specializing in lymphedema surgery. In this review, we attempt to review the incidence, risk factors, staging, prevention, and management of this complication of breast cancer treatment. We also describe our multidisciplinary approach for the prevention of this complication at the time of initial diagnosis.

Profile of women with lymphedema after breast cancer treatment

ABSTRACT Objective: To identify the profile of women with lymphedema after breast cancer treatment. Methods: This is a descriptive, retrospective and quantitative study with data from medical records of women with lymphedema who began treatment between 2010 and 2015 in a rehabilitation center. An instrument was used for data collection to characterize the participants and analysis was performed by means of descriptive statistics, the Chi-Square test and Fisher’s exact test. Results: 235 women with a mean age of 56.8 years were included, with an association between lymphedema and age (p = 0.016). It was observed that 76.6% of the sample had some comorbidity associated with breast cancer, especially hypertension (48.1%). They underwent radical surgery (60%), axillary lymphadenectomy (77.9%), sentinel lymph node biopsy (16.6%) and radiotherapy (74%). Treatments carried out for lymphedema were decongestant therapy and complementary treatments with 95.7% of adherence of women to therapies. Conclusion and implications for practice: Women with lymphedema presented risk factors such as radical surgery, axillary lymphadenectomy and radiotherapy, and good adherence to the required treatments of lymphedema. Knowing the profile of this population is crucial to the treatment choice.

Optimizing Patient Positioning to Reduce Variation in the Measurement of Breast Cancer-Related Lymphedema

Background: Prospective lymphedema screening is recommended for breast cancer patients. We observed interoperator variation in perometer-acquired arm volume measurements (P-AVMs) due to patient instability during measurements. We hypothesized that improved positioning during perometry would reduce P-AVM variability. Methods and Results: Each arm was measured three times by each operator using a perometer. With the original configuration, P-AVM was performed by 2 operators in 30 patients and four cohorts of 5 to 6 operators in 5 volunteers. Repeatability, reproducibility, and gage precision/tolerance (P/T) ratio were calculated. A customized handlebar was installed to optimize patient positioning. P-AVMs were performed in 20 patients with both configurations. Student's t-test was used to compare variation. With the new configuration, P-AVMs were performed by three operators in five volunteers and five operators in three volunteers. Repeatability, reproducibility, and gage P/T ratio were calculated. For the original configuration, gage P/T ratio was 19.9% for two operators and 35.9% for four cohorts of five to six operators. One operator using the new handlebar decreased P-AVM variability by 28% (p = 0.02). For the new configuration, gage P/T ratio was 6.5% for three operators and 18.7% for five operators. Conclusions: Optimizing patient setup improved P-AVM accuracy. P-AVM accuracy is critical as lack of accuracy results in either overdiagnosis or underdiagnosis of lymphedema, which in turn results in either over- or undertreatment of this dreaded condition. A higher number of operators were associated with greater P-AVM variability.

Manual lymphatic drainage adds no further volume reduction to Complete Decongestive Therapy on breast cancer-related lymphoedema: a multicentre, randomised, single-blind trial

BACKGROUND

We investigated the comparability of Complete Decongestive Therapy (CDT) including manual lymphatic drainage (MLD) vs. without MLD in the management of arm lymphoedema in patients with breast cancer.

METHODS

Patients randomised into either treatment including MLD (T+MLD) or treatment without MLD (T-MLD) received treatment 2×weekly for 4 weeks. The primary outcome was the volume reduction (%) of arm lymphoedema at 7-month follow-up. The secondary outcomes were volume reduction after the end of treatment, circumference of the arm, patient experience of heaviness and tension, and health status.

RESULTS

Despite difficulties enrolling the planned number of patients (160), 77 were randomised and 73 (38 in T+MLD, 35 in T-MLD) completed the trial. In both groups, the volume of lymphoedema decreased significantly, with no difference between groups (1.0% [95% CI, -4.3;2.3%]): the precision in the 95% confidence interval indicates that the efficacy was comparable; the mean (SE) changes at month 7 were -6.8%(1.2) and -5.7% (1.2) in the T+MLD and T-MLD, respectively. There were no statistically significant differences with respect to any of the secondary outcomes. The results were robust and the conclusion was not sensitive even to various alternative assumptions or analytic approaches to data analysis.

CONCLUSION

Manual lymphatic drainage adds no further volume reduction in breast cancer patients.

A Systematic Review of the Outcomes Used to Assess Upper Body Lymphedema

PURPOSE

To ascertain how change in upper body lymphedema is assessed and understand how clinically significant change is determined.

METHOD

A systematic search of the literature resulted in 55 eligible studies for analysis.

RESULTS

A range of assessment methods, measurement protocols, and outcomes were used in the literature. Of the 21 studies in which thresholds for change were set a priori, 20 different thresholds were reported.

CONCLUSION

How data was measured, analysed and reported was inconsistent across studies. Consensus on a core outcome set with standardised assessment protocols and reporting; and investigation into empirically based minimum important differences (MID) is needed.

Lymphovascular invasion and extranodal tumour extension are risk indicators of breast cancer related lymphoedema: an observational retrospective study with long-term follow-up

Background

Breast cancer related lymphoedema (BCRL) occurs in a substantial proportion of breast cancer survivors and is a major contributor to patients’ disability. Regrettably, there are no validated predictive biomarkers, diagnostic tools, and strong evidence-supported therapeutic strategies for BCRL. Here, we provide an integrative characterization of a large series of women with node-positive breast cancers and identify new bona fide predictors of BCRL occurrence.

Methods

Three hundred thirty-two cases of surgically-treated node-positive breast cancers were retrospectively collected (2–10.2 years of follow-up). Among them, 62 patients developed BCRL. To identify demographic and clinicopathologic features related to BCRL, Fisher’s exact test or Chi-squared test were carried out for categorical variables; the Wilcoxon rank-sum was employed for continuous variables. Factors associated with BCRL occurrence were assessed using a Cox proportional hazards regression model.

Results

En-bloc dissection of the axillary lymph nodes but not the type of breast surgery impacted on BCRL development. Most of BCRL patients had a Luminal A-like neoplasm. The median number of lymph nodes involved by metastatic deposits was significantly higher in BCRL compared to the control group (p = 0.04). Both peritumoral lymphovascular invasion (LVI) and extranodal extension (ENE) of the metastasis had a negative impact on BCRL-free survival (p = 0.01). Specifically, patients with LVI and left side localization harboured 4-fold higher risk of developing BCRL, while right axillary nodes metastases with ENE increased the probability of BCRL compared to ENE-negative patients.

Conclusions

Assessment of LVI and ENE should be integrated with clinical and surgical data to improve BCRL risk stratification.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4851-2) contains supplementary material, which is available to authorized users.

Breast cancer-related lymphedema: risk factors, precautionary measures, and treatments

Breast cancer-related lymphedema (BCRL) is a negative sequela of breast cancer treatment, and well-established risk factors include axillary lymph node dissection (ALND) and regional lymph node radiation (RLNR). BCRL affects approximately 1 in 5 patients treated for breast cancer, and it has a significant negative impact on patients' quality of life after breast cancer treatment, serving as a reminder of previous illness. This paper is a comprehensive review of the current evidence regarding BCRL risk factors, precautionary guidelines, prospective screening, early intervention, and surgical and non-surgical treatment techniques. Through establishing evidence-based BCRL risk factors, researchers and clinicians are better able to prevent, anticipate, and provide early intervention for BCRL. Clinicians can identify patients at high risk and utilize prospective screening programs, which incorporate objective measurements, patient reported outcome measures (PROM), and clinical examination, thereby creating opportunities for early intervention and, accordingly, improving BCRL prognosis. Innovative surgical techniques that minimize and/or prophylactically correct lymphatic disruption, such as axillary reverse mapping (ARM) and lymphatic-venous anastomoses (LVAs), are promising avenues for reducing BCRL incidence. Nonetheless, for those patients with BCRL who remain unresponsive to conservative methods like complete decongestive therapy (CDT), surgical treatment options aiming to reduce limb volume or restore lymphatic flow may prove to be palliative or corrective. It is only through a strong team-based approach that such a continuum of care can exist, and a multidisciplinary approach to BCRL screening, intervention, and research is therefore strongly encouraged.

Diagnosis and Treatment of Edema and Lymphedema in the Cancer Patient

BACKGROUND

Lymphedema occurs commonly in cancer survivors. It is crucial to properly assess cancer patients in order to distinguish lymphedema from general edema and to initiate evidence based treatment.

PURPOSE

To provide evidence based recommendations for screening, evaluating, and treating lymphedema and to establish the role of the nurse in the care of patients with lymphedema.

METHODOLOGY

Comprehensive overview with narrative literature review of evidence based lymphedema diagnosis and treatment.

FINDINGS

Cancer-related edema represents numerous complex conditions. A variety of interventions are needed to address prevention, early detection, patient education, and effective treatment.

CONCLUSION

Lymphedema treatment is complex and multimodal, and is provided by an interdisciplinary team of properly trained professionals. Nurses play a major role in evaluating, treating and educating patients on the signs and symptoms of cancer-related edema and patient self-management.

CLINICAL IMPLICATIONS

Evidence-based assessment and treatment should be initiated early to improve outcomes and quality of life in patients with cancer-related lymphedema.

Comparison of the effectiveness of complex decongestive therapy and compression bandaging as a method of treatment of lymphedema in the elderly

Background

Lymphedema is a chronic condition which significantly lowers the quality of patient life, particularly among elderly populations, whose mobility and physical function are often reduced.

Objectives

The aim of the study was to compare the effectiveness of multi-layer compression bandaging (MCB) and complex decongestive therapy (CDT), and to show that MCB is a cheaper, more accessible and less labor intensive method of treating lymphedema in elderly patients.

Patients and methods

The study included 103 patients (85 women and 18 men) aged ≥60 years, with unilateral lower limb lymphedema. The subjects were divided into two groups: 50 treated with CDT and 53 with MCB. Pre- and post-treatment BMI, and average and maximum circumference of the edematous extremities were analyzed.

Results

Reduction in swelling in both groups was achieved after 15 interventions. Both therapies demonstrated similar efficacy in reducing limb volume and circumference, but MCB showed greater efficacy in reducing the maximum circumference.

Conclusion

Compression bandaging is a vital component of CDT. Maximum lymphedema reduction during therapy and maintaining its effect cannot be achieved without it. It also demonstrates its effectiveness as an independent method, which can reduce therapy cost and accessibility.

Nonoperative Treatment of Lymphedema

Complex decongestive therapy is the mainstay of lymphedema (LE) therapy. It consists of two phases: an intensive volume reduction phase, principally involving low-stretch bandages and manual lymph drainage (MLD), followed by compression garment use to maintain the reduction achieved. Adjunctive treatments include the use of a sequential gradient pump, LE-specific exercises, skin and nail care, as well as risk-reduction precautions. Herein the techniques are described and the evidence for their effectiveness is reviewed.

Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement

Objective Medical compression stockings are a standard, non-invasive treatment option for all venous and lymphatic diseases. The aim of this consensus document is to provide up-to-date recommendations and evidence grading on the indications for treatment, based on evidence accumulated during the past decade, under the auspices of the International Compression Club. Methods A systematic literature review was conducted and, using PRISMA guidelines, 51 relevant publications were selected for an evidence-based analysis of an initial 2407 unrefined results. Key search terms included: 'acute', CEAP', 'chronic', 'compression stockings', 'compression therapy', 'lymph', 'lymphatic disease', 'vein' and 'venous disease'. Evidence extracted from the publications was graded initially by the panel members individually and then refined at the consensus meeting. Results Based on the current evidence, 25 recommendations for chronic and acute venous disorders were made. Of these, 24 recommendations were graded as: Grade 1A (n = 4), 1B (n = 13), 1C (n = 2), 2B (n = 4) and 2C (n = 1). The panel members found moderately robust evidence for medical compression stockings in patients with venous symptoms and prevention and treatment of venous oedema. Robust evidence was found for prevention and treatment of venous leg ulcers. Recommendations for stocking-use after great saphenous vein interventions were limited to the first post-interventional week. No randomised clinical trials are available that document a prophylactic effect of medical compression stockings on the progression of chronic venous disease (CVD). In acute deep vein thrombosis, immediate compression is recommended to reduce pain and swelling. Despite conflicting results from a recent study to prevent post-thrombotic syndrome, medical compression stockings are still recommended. In thromboprophylaxis, the role of stockings in addition to anticoagulation is limited. For the maintenance phase of lymphoedema management, compression stockings are the most important intervention. Conclusion The beneficial value of applying compression stockings in the treatment of venous and lymphatic disease is supported by this document, with 19/25 recommendations rated as Grade 1 evidence. For recommendations rated with Grade 2 level of evidence, further studies are needed.

Use of compression garments by women with lymphoedema secondary to breast cancer treatment

PURPOSE

This aim of this study was to determine the use of compression garments by women with lymphoedema secondary to breast cancer treatment and factors which underpin use.

METHODS

An online survey was distributed to the Survey and Review group of the Breast Cancer Network Australia. The survey included questions related to the participants' demographics, breast cancer and lymphoedema medical history, prescription and use of compression garments and their beliefs about compression and lymphoedema. Data were analysed using principal component analysis and multivariable logistic regression.

RESULTS

Compression garments had been prescribed to 83% of 201 women with lymphoedema within the last 5 years, although 37 women had discontinued their use. Even when accounting for severity of swelling, type of garment(s) and advice given for use varied across participants. Use of compression garments was driven by women's beliefs that they were vulnerable to progression of their disease and that compression would prevent its worsening. Common reasons given as to why women had discontinued their use included discomfort, and their lymphoedema was stable. Participant characteristics associated with discontinuance of compression garments included their belief that (i) the garments were not effective in managing their condition, (ii) experienced mild-moderate swelling and/or (iii) had experienced swelling for greater than 5 years.

CONCLUSION

The prescription of compression garments for lymphoedema is highly varied and may be due to lack of underpinning evidence to inform treatment.

Manual lymphatic drainage and quality of life in patients with lymphoedema and mixed oedema: a systematic review of randomised controlled trials

Purpose

To assess the impact of manual lymphatic drainage (MLD) on the health-related quality of life (HRQoL) of adults with lymphoedema or mixed oedema, through a systematic review of randomised controlled trials (RCTs).

Methods

MEDLINE, EMBASE, PsycINFO, CENTRAL, the Cochrane Database of Systematic Reviews and ClinicalTrials.gov were searched to identify RCTs evaluating HRQoL after a MLD intervention compared to non-MLD interventions (PROSPERO 2016:CRD42016042255). We extracted the effect of the interventions on the HRQoL (primary outcome) as well as data on volume and functional changes, and adverse events when available (secondary outcomes).

Results

Eight studies were eligible. The studies were heterogeneous in the aetiology of oedema, schemes of MLD applied, additional treatments offered with MLD, length of follow-up, instruments used to assess HRQoL and interventions offered to the control group. Five studies included patients with breast cancer-related arm lymphoedema; one study reported increased HRQoL among patients randomised to the MLD group. The two RCTs that involved patients with leg mixed oedema due to chronic venous insufficiency did not find between-group differences in the overall HRQoL. One trial included patients with hand oedema from systemic sclerosis and showed higher HRQoL in the group that received MLD. No studies reported reductions in HRQoL, or severe adverse events after MLD. The small numbers of patients analysed in all studies may have resulted in lack of power to detect between-group differences in HRQoL.

Conclusions

The effect of MLD on the HRQoL of patients with chronic oedema is unclear.

Electronic supplementary material

The online version of this article (10.1007/s11136-018-1796-5) contains supplementary material, which is available to authorized users.

Clinical effectiveness of decongestive treatments on excess arm volume and patient-centered outcomes in women with early breast cancer-related arm lymphedema: a systematic review

OBJECTIVE

To identify the effect of decongestive lymphedema treatment on excess arm volume or patient-centered outcomes in women presenting within either 12 months or a mean nine months of developing arm lymphedema following breast cancer treatment.

INTRODUCTION

Lymphedema is a common consequence of breast cancer treatment requiring life-long treatment to reduce symptoms and prevent complications. Currently, evidence to inform the optimal decongestive lymphedema treatment package is lacking.

INCLUSION CRITERIA

The review included studies on women who received lymphedema treatment within either 12 months or a mean of nine months of developing unilateral breast cancer-related arm lymphedema. The intervention was any decongestive lymphedema treatment delivered with the purpose of reducing arm lymphedema, compared to another form of lymphedema treatment (whether self or practitioner-administered), placebo or no treatment. The clinical outcome was excess arm volume; patient-centered outcomes were health-related quality of life, arm heaviness, arm function, patient-perceived benefit and satisfaction with treatment. Experimental study designs were eligible, including randomized and non-randomized controlled trials, quasi-experimental, prospective and retrospective before and after studies were considered.

METHODS

A three-step search strategy was utilized to find published and unpublished studies. The search identified studies published from the inception of each database to July 6, 2016. Reference lists were scanned to identify further eligible studies. Studies were critically appraised using appropriate standardized critical appraisal instruments from the Joanna Briggs Institute. Details describing each study and treatment results regarding outcomes of interest were extracted from papers included in the review using appropriate standardized data extraction tools from the Joanna Briggs Institute. Due to heterogeneity in included studies, results for similar outcome measures were not pooled in statistical meta-analysis. A narrative and tabular format was used to synthesize results from identified and included studies.

RESULTS

Seven studies reporting results for outcomes of interest were critically appraised and included in the review: five randomized controlled trials and two descriptive (uncontrolled) studies. Reported outcomes included excess arm volume (five studies), health-related quality of life (three studies), arm heaviness (one study), arm function (two studies) and patient-perceived benefit (two studies). There was some evidence that decongestive treatments were effective for women presenting within either 12 months or a mean of nine months of developing breast cancer-related arm lymphedema, but the wide range of data prevented comparison of treatment findings which limited our ability to answer the review questions.

CONCLUSIONS

Weak evidence (grade B) for the impact of decongestive lymphedema treatment on women with early lymphedema (i.e. less than 12 months duration of BCRL symptoms) did not allow any conclusions to be drawn about the most effective treatment to be offered when these women first present for treatment. Findings provided no justification to support change to current practice.Future primary research needs to focus on the most effective treatment for women when they first present with lymphedema symptoms, e.g. treatment provided within 12 months of developing symptoms. Studies should be adequately powered and recruit women exclusively with less than 12 months duration of breast cancer-related lymphedema symptoms, provide longer follow-up to monitor treatment effect over time, with comparable treatment protocols, outcome measures and reporting methods.

Complex Decongestive Therapy Enhances Upper Limb Functions in Patients with Breast Cancer-Related Lymphedema

BACKGROUND

We aimed to evaluate the effects of complex decongestive therapy (CDT) on upper extremity functions, the severity of pain, and quality of life. We also searched the impact of the sociodemographic and clinical characteristics on the improvement in upper extremity functions.

METHODS

A total of 37 women with breast cancer-related lymphedema (BCRL) [age, 53.6 ± 11.2 (28-72)] were included in this study. All patients underwent CDT-phase 1 program, including meticulous skin care, manual lymphatic drainage, remedial exercises, and compression bandages. Arm volume was calculated by a formula for truncated cone using circumferential measurements. A baseline questionnaire, including sociodemographic and clinical properties, was used for each patient. Short Form-36 (SF-36), Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and Visual Analog Scale (VAS) for pain and heaviness were used as clinical assessment scales.

RESULTS

The mean of the posttreatment volume of the affected limb was lower compared to pretreatment volume (2741.81 ± 696.85 and 2990.67 ± 745.49, respectively), and the mean percentage change in edema volume was 38.1% ± 26.5%. We observed a statistically significant reduction in pain and heaviness VAS scores and improvement of shoulder mobility among upper extremities with lymphedema (p < 0.001) after CDT. The mean of posttreatment DASH score was lower compared to pretreatment score (37.19 ± 16.01, 49.81 ± 18.84, respectively, p < 0.001). All subgroups of the SF-36 parameters were increased after the CDT application (p < 0.01). Besides being under 65 years old, having a body mass index above 30 and short duration of lymphedema were found to be related to greater improvement in upper extremity functions.

CONCLUSIONS

CDT provides enhancement of upper extremity functions and quality of life in patients with BCRL. The reduction in lymphedema volume, pain, and heaviness and the improvement in shoulder mobility may be the contributed factors.

Preventing Early Postoperative Arm Swelling and Lymphedema Manifestation by Compression Sleeves After Axillary Lymph Node Interventions in Breast Cancer Patients: A Randomized Controlled Trial

CONTEXT

Breast cancer-related lymphedema (LE) remains one of the major long-term complications after surgery. Many reports showed the effectiveness of compression in breast cancer-related LE treatment, but randomized controlled trials evaluating compression garments for postoperative prevention are lacking.

OBJECTIVES

The aim of the study was to evaluate the potential role of light arm compression sleeves for reducing the incidence of early postoperative swelling and of breast cancer-related arm LE.

METHODS

A total of 45 women were pre-operatively randomly assigned to a group with compression of circular-knit sleeves in compression class I (15-21 mm Hg) for daily wearing (compression group [CG]; n = 23) or to a control group without compression (no CG, n = 22). Both groups underwent a standardized physical exercise program. Arm volumes were measured before surgery and one, three, six, nine, and 12 months thereafter.

RESULTS

At one month, postoperative swelling was reduced only in CG. After 12 months, the average change of excess volumes (edema) reached -67.6 mL in the CG vs. +114.5 mL in the no CG (P < 0.001). Significantly less edema was seen in the CG after three, six, nine, and 12 months. No significant difference between groups in health-related quality of life (measured by EORTC QLQ-C30) was observed.

CONCLUSION

Fifteen to 21 mm Hg compression sleeves in combination with physical activity may be a safe and efficient option to prevent postsurgical arm swelling and development of LE.