Preoperative assessment enables the early diagnosis and successful treatment of lymphedema

Preventive Analgesic Efficacy of Nefopam in Acute and Chronic Pain After Breast Cancer Surgery: A Prospective, Double-Blind, and Randomized Trial

Breast cancer surgery is known to cause severe acute postoperative pain, which can persist for a long time. We administered nefopam preventively to patients undergoing lumpectomy with axillary lymph node dissection or sentinel lymph node biopsy, and evaluated its efficacy on acute and chronic postoperative pain.Enrolled patients were assigned to the nefopam (n = 41) or the control (n = 42) group. Before initiating the operation, 20 mg of nefopam was given to the patients of the nefopam group, and normal saline was used in the control group. Ketorolac was given at the end of surgery, and meloxicam was prescribed in the postoperative period to all patients in both groups. Pain was assessed using a numerical rating scale (NRS), and the rescue analgesic drug was given when the NRS was >5. Implementation of postoperative chemotherapy, radiotherapy (RT), or hormone therapy was evaluated.The NRS of postoperative pain was significantly lower in the nefopam than in the control group in the postanesthetic care unit (4.5 ± 2.2 vs 5.7 ± 1.5, respectively; P = 0.01), at postoperative 6 h (3.0 ± 1.6 vs 4.5 ± 1.3, respectively; P < 0.001), and at postoperative 24 h (3.1 ± 1.1 vs 3.8 ± 1.5, respectively; P = 0.01) with reduced use of rescue analgesic drugs. Significantly fewer patients suffered from chronic postoperative pain in the nefopam than in the control group at postoperative 3 months (36.6% vs 59.5%, P = 0.04). Considering only the cohort without postoperative adjuvant RT, the difference in the proportion of patients reporting chronic pain increased (23.5% in the nefopam group vs 61.5% in the control group, P = 0.04).Preventive nefopam was helpful in reducing the acute postoperative pain, with reduced use of rescue analgesic drugs, and it contributed to reduced occurrence of chronic pain at postoperative 3 months after breast cancer surgery.

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

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

Differences in limb volume trajectories after breast cancer treatment

PURPOSE

Approximately 20 % of patients develop lymphedema (LE) following breast cancer (BC) surgery. An evaluation of distinct trajectories of volume change may improve our ability to diagnose LE sooner. The purposes of this study were to identify subgroups of women with distinct trajectories of limb volume changes following BC surgery and to evaluate for phenotypic differences among these classes.

METHODS

In this prospective longitudinal study, 380 women were enrolled prior to unilateral BC surgery. Upper limb bioimpedance was measured preoperatively and serially for 1 year postoperatively. Resistance ratios (RRs) were calculated. A RR of >1 indicates affected limb volume > unaffected limb volume. Latent class growth analysis (LCGA) was used to identify classes of women with distinct postoperative RR trajectories. Differences among classes were evaluated using analyses of variance and chi-square analyses.

RESULTS

Three distinct classes were identified as follows: RR <0.95 (37.9 %), RR ~1.00 (46.8 %), and RR >1.05 (15.3 %). Patients in the RR >1.05 class were more likely to have diabetes (p = 0.036), were more likely to have BC on their dominant side (p < 0.001), had higher RR ratios at the preoperative and 1-month assessments (p < 0.001), and were more likely to be diagnosed with LE (p < 0.001).

CONCLUSIONS

LCGA is a useful analytic technique to identify subgroups of women who may be at higher risk for the development of LE, based on trajectories of limb volume change after BC surgery.

IMPLICATIONS FOR CANCER SURVIVORS

Assessment of preoperative and 1-month bioimpedance RRs may allow for the earlier identification of patients who are at higher risk for the development of LE.

Complex Decongestive Lymphatic Therapy With or Without Vodder II Manual Lymph Drainage in More Severe Chronic Postmastectomy Upper Limb Lymphedema: A Randomized Noninferiority Prospective Study

CONTEXT

Complex decongestive lymphatic therapy (CDT) has been the method of choice in conservative management of lymphedema. Although effective, it is time consuming and manual lymph drainage (MLD) usually requires skilled therapists.

OBJECTIVES

The purpose of this study was to compare the reduction in edema volume in more advanced (≥20% limb volume difference) postmastectomy arm lymphedema achieved by compression bandaging (CB) and physical exercises vs. the same management augmented by an additional 30 minutes of MLD (Vodder II method).

METHODS

Sixty postmastectomy women were randomly assigned to either the CB group or the CDT group. Of those, 51 women (26 within the CB group) completed 26 weeks of therapy (two weeks of the intensive phase and six months of the maintenance phase).

RESULTS

A decrease of limb volume (15.6% in the CB group and 13.8% in the CDT group), edema volume (47.2% and 47.4%, respectively), and limb-related volume change (14.7% and 12.5%) during the intensive phase were observed. This improvement remained constant in both groups after six months of maintenance therapy. The health-related quality of life (measured by the Lymphedema Questionnaire) similarly showed improvement in both groups, with a high level of treatment satisfaction.

CONCLUSION

These results indicate that parallel (immediate and delayed) results may be obtained by CDT without the use of Vodder MLD and CB may be an essential part of lymphedema management.

Complexities of Adherence and Post-Cancer Lymphedema Management

Breast cancer survivors are at increased risk for breast cancer-related lymphedema (BCRL), a chronic, debilitating, condition that is progressive and requires lifelong self-management. Up to 40% of 3 million breast cancer survivors in the US will develop BCRL, which has no cure, is irreversible, and requires self-management with regimens that may include multiple components. The complexities of treatment can negatively affect adherence to BCRL self-management which is critical to preventing progressive swelling and infection. The aim of this review of contemporary literature published from 2005-2015 is to examine the complexities of BCRL self-management, to identify adherence-focused studies relevant to BCRL, and to summarize barriers to self-management of BCRL. Six electronic indices were searched from which 120 articles were retrieved; 17 were BCRL-focused; and eight met inclusion criteria. Seventeen of 120 articles identified barriers to self-management of BCRL such as complexities of treatment regimens, symptom burden, balance of time for treatment and life demands, and lack of education and support; however, only eight studies included outcome measures of adherence to BCRL treatment regimens with a subsequent improvement in reduced limb volumes and/or perceptions of self-efficacy and self-regulation. A major limitation is the few number of rigorously developed outcome measures of BCRL adherence. In addition, randomized studies are needed with larger sample sizes to establish adequate levels of evidence for establishing best practice standards for improving adherence to BCRL self-management treatment regimens.

Symptoms: Lymphedema

Lymphedema is one of the main late effects from breast cancer treatment affecting 3-60% of breast cancer survivors. Primarily occurring in the hand, arm, and/or affected breast, symptoms of lymphedema include swelling, pain, redness, restriction of arm/hand movement, tightness and feelings of fullness. These symptoms not only may limit physical functioning but also negatively affect quality of life, body image, social functioning, and financial status of breast cancer survivors with lymphedema. Unfortunately, there are no standardized methods for prevention, diagnosis, and treatment of breast cancer-related lymphedema. Despite its prevalence and lack of clinical guidelines, lymphedema is one of the most poorly understood, relatively underestimated, and least researched complications of cancer treatment. This chapter reviews the current problem of breast cancer-related lymphedema by investigating prevention and risk reduction strategies, diagnosis, and treatment. In addition, this chapter identifies future research opportunities focusing on prevention and risk reduction strategies, quality of life and physical function, surveillance, patient education, cost, diagnosis, and treatment. Challenges and recommendations for future research in these areas, particularly among underserved populations, are discussed.

3D stereophotogrammetry in upper-extremity lymphedema: An accurate diagnostic method

BACKGROUND

Upper-extremity lymphedema is a frequent complication in patients treated for breast cancer. Current diagnostic methods for the upper-extremity volume measurements are cumbersome or time consuming. The purpose of this study was to assess the validity and reliability of three-dimensional (3D) stereophotogrammetry for volume measurements in patients with upper-extremity lymphedema.

METHOD

Patients with unilateral upper-extremity lymphedema were included. The water displacement volume measurement of both arms was performed using a standardized method. In addition, 3D stereophotogrammetry volume measurements were conducted.

RESULTS

Eleven patients (22 arms) were included. The mean volumes obtained by 3D stereophotogrammetry and water displacement show a high correlation, with a Pearson's correlation coefficient of 0.99 (p = 0.01). The variance calculated by 3D stereophotogrammetry measurements (205 mL) was statistically significant less than that obtained via water displacement measurements (1540 mL) (p < 0.001).

CONCLUSION

3D stereophotogrammetry is an accurate method for measuring upper-extremity volume in patients with lymphedema and gives a lower variance value compared to that of the water displacement measurements. We recommend the use of this method in the diagnosis and follow-up of patients with lymphedema.

Breast cancer-related lymphedema after axillary lymph node dissection: does early postoperative prediction model work?

PURPOSE

Early detection and timely intervention demonstrate the greatest promise of reducing the incidence of late-stage lymphedema in breast cancer patients undergoing axillary lymph node dissection (ALND). A nomogram was developed for predicting the risk of lymphedema (LE) in patients with ALND. This study's aim was to test the early postoperative prediction model for the diagnosis of clinical and subclinical LE after ALND.

METHODS

Patients requiring ALND were identified preoperatively through our LE program database. Measurements using metered tape with bioimpedance spectroscopy (L-Dex U400) were obtained preoperatively (n = 180) and at 3-6-month intervals postoperatively. The 5-year probability of LE after ALND was calculated using the Cleveland Clinic Risk Calculator. The discrimination of the nomogram was assessed by calculating the area under (AUC) the receiver operating characteristic curve.

RESULTS

LE was present in 36.1% (n = 65) of 180 patients with ALND. Of these 65 patients, 22 (12.2%) had clinical LE and 43 (23.9%) had subclinical LE. Statistical analyses showed significant differences in BMI and receipt of radiotherapy between patients with and without LE (p = 0.03 and p = 0.01, respectively). AUC was 0.601, 0.614, and 0.600 for the nomogram using any LE, clinical LE, and subclinical LE patients, respectively.

CONCLUSIONS

The recently created prediction model for the diagnosis of LE in ALND is not accurate in predicting who will develop clinical or subclinical LE. Periodic monitoring of women with ALND is the most effective method to aid in reducing clinical LE incidence through early detection and timely intervention of LE.

Prospective Lymphedema Surveillance in a Clinic Setting

The potential impact of breast cancer-related lymphedema (LE) is quite extensive, yet it often remains under-diagnosed until the later stages. This project examines the effectiveness of prospective surveillance in post-surgical breast cancer patients. A retrospective analysis of 49 out of 100 patients enrolled in a longitudinal prospective study at a Midwestern breast center evaluates: (1) time required for completion of bilateral limb measurements and Lymphedema Breast Cancer Questionnaire (LBCQ); (2) referral to LE management with limb volume increase (LVI) and/or LBCQ symptoms; and (3) cost of LE management at lower LVI (≥5%–≤10%) versus traditional (≥10%). Findings revealed a visit timeframe mean of 40.3 min (range = 25–60); 43.6% of visits were ≤30-min timeframe. Visit and measurement times decreased as clinic staff gained measurement experience; measurement time mean was 17.9 min (range = 16.9–18.9). LBCQ symptoms and LVI were significantly (p < 0.001) correlated to LE referral; six of the nine patients referred (67%) displayed both LBCQ symptoms/LVI. Visits with no symptoms reported did not result in referral, demonstrating the importance of using both indicators when assessing early LE. Lower threshold referral provides compelling evidence of potential cost savings over traditional threshold referral with reported costs of: $3755.00 and $6353.00, respectively (40.9% savings).

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Review of the evidence of lymphedema treatment effect

Lymphedema treatment aims to alleviate symptoms, prevent progression, and reduce risk for skin infection. Mainstream treatment options have been investigated in more than 160 studies. Findings from these studies have been included in at least 1 of more than 20 literature reviews. A critique of these reviews was undertaken to summarize efficacy findings. The quality of the reviews was evaluated, and gaps in the research were identified to better guide clinical practice. Overall, there was wide variation in review methods. The quality of studies included in reviews, in study design and reporting overall, has been poor. Reviews consistently concluded that complex physical therapy is effective at reducing limb volume. Volume reductions were also reported after the use of compression garments, pumps, and manual lymphatic drainage. However, greatest improvements were reported when these treatments formed a combined treatment program. Large, well-designed, evaluated, and reported randomised, controlled trials are needed to evaluate and compare treatments. Consistent outcome measures will allow better quality reviews and meta-analysis in the future.

Thickness of soft tissue of lower extremities measured with magnetic resonance imaging as a new indicator for staging unilateral secondary lower extremity lymphedema

BACKGROUND

Chronic progressive swelling of the lower extremity due to secondary lower extremity lymphedema (LEL) can affect a patient's quality of life, both physically and psychologically. A feasible and reproducible method for detecting and staging LEL will facilitate decision-making about appropriate management strategies.

PURPOSE

To determine whether the thickness of the soft tissues of the lower extremities, measured with magnetic resonance imaging (MRI), could stage unilateral secondary LEL.

MATERIAL AND METHODS

Seventy-two women with unilateral LEL and 22 participants without LEL underwent lower extremity MRI after treatment of uterine malignancies. LEL was classified clinically as stage 0, 1, 2, or 3. On fat-suppressed T2-weighted mid-axial images of calves and thighs, the total thickness of the soft tissue (TT), muscle thickness (MT), subcutaneous tissue thickness (STT), and the differences in TT (DTT), MT (DMT), and STT (DSTT) values and corresponding measurements in the contralateral lower extremity, were obtained and analyzed statistically for staging LEL.

RESULTS

There was a trend for the TT and STT of the affected calf and thigh to increase with increasing LEL stage. These parameters were strongly and moderately correlated with LEL stage, respectively (P < 0.001). Both the DTT and DSTT of the calves or thighs were strongly correlated with LEL stage (P < 0.001). Among the parameters, the DSTT of the calves could best stage LEL, with an area under the receiver operating curve of more than 0.89.

CONCLUSION

The DSTT of the calves could be recommended as an informative indicator for staging LEL.

A Prospective Validation Study of Bioimpedance with Volume Displacement in Early-Stage Breast Cancer Patients at Risk for Lymphedema

BACKGROUND

Although volume displacement (VD) is considered the gold standard for diagnosing breast cancer-related lymphedema, it is inconvenient. We compared bioimpedance (L-Dex) and VD measurements in a prospective cohort of breast cancer patients at risk for lymphedema.

METHODS

Between 2010 and 2014, a total of 223 breast cancer patients were enrolled. Following exclusions (n = 37), 186 received baseline VD and L-Dex; follow-up measurements were performed at 3-6 months intervals for 3 years. At each visit, patients fitted into one of three categories: normal (normal VD and L-Dex); abnormal L-Dex (L-Dex > 10 or increase in 10 from baseline and normal VD); or lymphedema (relative arm volume difference of >10 % by VD ± abnormal L-Dex). Change in L-Dex was plotted against change in VD; correlation was assessed using the Pearson correlation.

RESULTS

At a median follow-up of 18.2 months, 152 patients were normal, 25 had an abnormal L-Dex, and 9 developed lymphedema without a prior L-Dex abnormality. Of the 25 abnormal L-Dex patients, 4 progressed to lymphedema, for a total of 13 patients with lymphedema. Evaluating all time points, 186 patients had 829 follow-up measurements. Sensitivity and specificity of L-Dex compared with VD were 75 and 93 %, respectively. There was no correlation between change in VD and change in L-Dex at 3 months (r = 0.31) or 6 months (r = 0.21).

CONCLUSIONS

VD and bioimpedance demonstrated poor correlation with inconsistent overlap of measurements considered abnormal. Of patients with an abnormal L-Dex, few progressed to lymphedema; most patients with lymphedema did not have a prior L-Dex abnormality. Further studies are needed to understand the clinical significance of bioimpedance.

Swelling among women who need education about leg lymphedema: a descriptive study of lymphedema in women undergoing surgery for endometrial cancer

OBJECTIVES

In addition to hysterectomy and bilateral salpingo-oophorectomy, comprehensive surgical staging for endometrial cancer includes pelvic and para-aortic lymphadenectomy. Clarifying and addressing the morbidity from these surgical procedures is imperative. The goal of this study was to assess the prevalence of lower extremity swelling after surgery for endometrial cancer.

MATERIALS AND METHODS

We performed a descriptive, cross-sectional survey study of women who underwent surgery for endometrial cancer at our institution from 2006 to 2008. Survey information included symptoms, management, and education regarding lymphedema. Demographic information such as race and education was collected in addition to clinical data such as body mass index and age.

RESULTS

Of the 482 patients identified, 440 were determined eligible and 305 (69.3%) responded to the survey with information on lower limb swelling (LLS). Of the 108 (35%) responders who reported swelling, only 68 (22%) participants reported a diagnosis of lower limb lymphedema (LLL). The most commonly experienced symptoms among those who reported LLS were tightness, pain/tenderness, and heaviness. Among those with a diagnosis of LLL, most (60%) stated it affected their daily activities and noted exacerbating factors such as prolonged standing, heat, and walking. The most common therapies used to reduce symptoms included leg elevation (96%), compression stockings (65%), diuretics (46%), massage therapy (35%), and bandaging (25%). There was no association between LLS or LLL diagnosis and body mass index, age, race, and tobacco use. Only 8% of responders reported receiving preoperative education regarding risks for LLS and a desire for more comprehensive education was frequently noted.

CONCLUSIONS

The patient-reported incidence of LLS occurred in approximately 35% of survey participants who underwent surgery for endometrial cancer. However, only 22% reported a diagnosis of LLL. Efforts to obtain the true incidence of LLL and to develop effective educational materials and programs to improve the management of lymphedema are warranted.

Lymphatic mapping and lymphedema surgery in the breast cancer patient

Upper limb lymphedema can be an unfortunate sequela following the oncologic treatment of breast cancer. The surgical treatment of lymphedema has had a recent renewed clinical interest paralleling innovative descriptions of surgical techniques and imaging modalities. In addition, an improved understanding of the physiology and pathophysiology of lymphedema has allowed improved translation to the clinical condition. Various surgical options exist to decrease the symptom-burden of upper limb lymphedema, including vascularized lymph node (VLN) transfer, lymphovenous bypass (LVB), liposuction, lymphatic grafting, and excisional procedures. Modern imaging techniques help to improve the consistency and accuracy of these surgical treatment options. A multi-modal treatment plan utilizing non-operative and surgical therapies has the potential to improve various factors related to overall patient quality of life. This review details all of the current operative treatment strategies and modern imaging modalities used in the treatment of lymphedema.

Agreement between dual energy X-ray absorptiometry and opto-electronic volumetry for measurement of forearm volume

BACKGROUND

Lymphedema is commonly assessed by measuring the increase in volume of the affected region using methods that are not only accurate and sensitive but also applicable for use in clinical practice. Opto-electronic volumetry (Perometer™) is a rapid and convenient technique recommended as a reference method for this purpose, while the use of dual-energy X-ray absorptiometry is becoming more common. We report here a method agreement study between DXA and perometry for the measurement of forearm volume.

METHODS

Perometric measurements were performed on both whole arms, in the horizontal plane, of a group of healthy young participants. Perometric data were obtained for 4 and 5 mm slices between the malleoli to the anticubital fossa crease. The DXA-measured masses (bone mineral, fat, and lean) for the same forearm region were obtained using recently published algorithms. Perometric and DXA-measured volumes were compared using correlation and limits of agreement analysis.

RESULTS

DXA-computed volumes were highly and significantly correlated (r=0.986; p<0.0001) with those measured by perometry. The mean bias between the methods was extremely small; 0.7% underestimation by DXA with limits of agreement of 6.3 to -7.7% (DXA-perometry).

CONCLUSIONS

This study has demonstrated a high degree of concordance between DXA computed limb volumes and those measured by the reference method of perometry. The relatively small limits of agreement suggest that these methods can be used interchangeably.

Factors associated with fear of lymphedema after treatment for breast cancer

PURPOSE/OBJECTIVES

To identify demographic and treatment characteristics associated with postoperative fear of lymphedema.

DESIGN

Prospective cohort study.

SETTING

Outpatient breast clinic at a comprehensive cancer center in the northeastern United States.

SAMPLE

324 patients undergoing treatment for unilateral breast cancer.

METHODS

Women with breast cancer were prospectively screened for lymphedema (relative volume change of 10% or greater) preoperatively and every three to eight months postoperatively via Perometer arm volume measurements. Fear was simultaneously evaluated via questionnaire. Multivariate linear mixed-effects regression models were used to identify factors associated with mean postoperative fear score and to plot the average fear score over time within axillary surgery type subgroups.

MAIN RESEARCH VARIABLES

Postoperative fear of lymphedema.

FINDINGS

Higher preoperative fear score (p < 0.0001), younger age at diagnosis (p = 0.0038), and axillary lymph node dissection (ALND) (p < 0.0001) were significantly associated with higher mean postoperative fear score. The average fear score changed nonlinearly over time (p < 0.0001), decreasing from preoperative to 24 months postoperative and leveling thereafter.

CONCLUSIONS

Preoperative fear, younger age at diagnosis, and ALND may contribute to postoperative fear of lymphedema.

IMPLICATIONS FOR NURSING

Individualized education that begins preoperatively, continues throughout treatment, and is re-emphasized 24 months postoperatively may help minimize fear of lymphedema.

Impact of adjuvant taxane-based chemotherapy on development of breast cancer-related lymphedema: results from a large prospective cohort

Taxane-based chemotherapy for the treatment of breast cancer is associated with fluid retention in the extremities; however, its association with development of breast cancer-related lymphedema is unclear. We sought to determine if adjuvant taxane-based chemotherapy increased risk of lymphedema or mild swelling of the upper extremity. 1121 patients with unilateral breast cancer were prospectively screened for lymphedema with perometer measurements. Lymphedema was defined as a relative volume change (RVC) of ≥10 % from preoperative baseline. Mild swelling was defined as RVC 5- <10 %. Clinicopathologic characteristics were obtained via medical record review. Kaplan-Meier and Cox proportional hazard analyses were performed to determine lymphedema rates and risk factors. 29 % (324/1121) of patients were treated with adjuvant taxane-based chemotherapy. The 2-year cumulative incidence of lymphedema in the overall cohort was 5.27 %. By multivariate analysis, axillary lymph node dissection (ALND) (p < 0.0001), higher body mass index (p = 0.0007), and older age at surgery (p = 0.04) were significantly associated with increased risk of lymphedema; however, taxane chemotherapy was not significant when compared to no chemotherapy and non-taxane chemotherapy (HR 1.14, p = 0.62; HR 1.56, p = 0.40, respectively). Chemotherapy with docetaxel was significantly associated with mild swelling on multivariate analysis in comparison to both no chemotherapy and non-taxane chemotherapy groups (HR 1.63, p = 0.0098; HR 2.15, p = 0.02, respectively). Patients who receive taxane-based chemotherapy are not at an increased risk of lymphedema compared to patients receiving no chemotherapy or non-taxane adjuvant chemotherapy. Those treated with docetaxel may experience mild swelling, but this does not translate into subsequent lymphedema.

Normal values for segmental bioimpedance spectroscopy in pediatric patients

INTRODUCTION

Localized limb edema is a clinically relevant sign in diseases such as post-thrombotic syndrome and lymphedema. Quantitative evaluation of localized edema in children is mainly done by measuring the absolute difference in limb circumference, which includes fat and fat-free mass. Bioimpedance spectroscopy (BIS) provides information on the fluid volume of a body segment. Our objective was to determine normal ranges for segmental (arm and leg) BIS measurements in healthy children. Additionally, we determined the normal ranges for the difference in arm and ankle circumference and explored the influence of handedness and the correlation between techniques.

METHODS

Healthy children aged 1-18 years were recruited. The ratio of extracellular fluid content between contralateral limbs (estimated as the inter-arm and inter-leg extracellular impedance ratio), and the ratio of extracellular to intracellular fluid content for each limb (estimated as the intracellular to extracellular impedance ratio) were determined with a bioimpedance spectrometer. Arm and ankle circumference was determined with a Gulick II tape.

RESULTS

We recruited 223 healthy children (48 infants, 54 preschoolers, 66 school-aged children, and 55 teenagers). Normal values for arm and leg BIS measurements, and for the difference in arm and ankle circumference were estimated for each age category. No influence of handedness was found. We found a statistically significant correlation between extracellular impedance ratio and circumference difference for arms among teenagers.

CONCLUSION

We determined normal BIS ranges for arms and legs and for the difference in circumference between arms and between ankles in children. There was no statistically significant correlation between extracellular impedance ratio and difference in circumference, except in the case of arms in adolescents. This may indicate that limb circumference measures quantities other than fluid, challenging the adequacy of this technique to determine the presence of localized edema in most age groups.

Normal values for segmental bioimpedance spectroscopy in pediatric patients

Introduction

Localized limb edema is a clinically relevant sign in diseases such as post-thrombotic syndrome and lymphedema. Quantitative evaluation of localized edema in children is mainly done by measuring the absolute difference in limb circumference, which includes fat and fat-free mass. Bioimpedance spectroscopy (BIS) provides information on the fluid volume of a body segment. Our objective was to determine normal ranges for segmental (arm and leg) BIS measurements in healthy children. Additionally, we determined the normal ranges for the difference in arm and ankle circumference and explored the influence of handedness and the correlation between techniques.

Methods

Healthy children aged 1-18 years were recruited. The ratio of extracellular fluid content between contralateral limbs (estimated as the inter-arm and inter-leg extracellular impedance ratio), and the ratio of extracellular to intracellular fluid content for each limb (estimated as the intracellular to extracellular impedance ratio) were determined with a bioimpedance spectrometer. Arm and ankle circumference was determined with a Gulick II tape.

Results

We recruited 223 healthy children (48 infants, 54 preschoolers, 66 school-aged children, and 55 teenagers). Normal values for arm and leg BIS measurements, and for the difference in arm and ankle circumference were estimated for each age category. No influence of handedness was found. We found a statistically significant correlation between extracellular impedance ratio and circumference difference for arms among teenagers.

Conclusion

We determined normal BIS ranges for arms and legs and for the difference in circumference between arms and between ankles in children. There was no statistically significant correlation between extracellular impedance ratio and difference in circumference, except in the case of arms in adolescents. This may indicate that limb circumference measures quantities other than fluid, challenging the adequacy of this technique to determine the presence of localized edema in most age groups.

Comparison of multi-frequency bioimpedance with perometry for the early detection and intervention of lymphoedema after axillary node clearance for breast cancer

The importance of early detection of lymphoedema by arm volume measurements before surgery and repeated measurements after surgery in women undergoing axillary node clearance (ANC) in order to enable early intervention is recognised. A prospective multi-centre study was performed which studied the difference between multi-frequency bioimpedance electrical analysis (BIS) and perometer arm measurement in predicting the development of lymphoedema. Women undergoing ANC underwent pre-operative and regular post-operative measurements of arm volume by both methods. The primary endpoint is the incidence of lymphoedema (≥10 % arm volume increase compared to contralateral arm by perometer) at 2 and 5 years after ANC. The threshold for intervention in lymphoedema was also assessed. Out of 964 patients recruited, 612 had minimum 6 months follow-up data. Using 1-month post-operative measurements as baseline, perometer detected 31 patients with lymphoedema by 6 months (BIS detected 53). By 6 months, 89 % of those with no lymphoedema reported at least one symptom. There was moderate correlation between perometer and BIS at 3 months (r = 0.40) and 6 months (r = 0.60), with a sensitivity of 73 % and specificity of 84 %. Univariate and multivariate analyses revealed a threshold for early intervention of ≥5 to <10 % (p = 0.03). Threshold for early intervention to prevent progression to lymphoedema is ≥5 to <10 % but symptoms alone do not predict lymphoedema. The modest correlation between methods at 6 months indicates arm volume measurements remain gold standard, although longer term follow-up is required.

Prevention and management of lymphedema after breast cancer treatment

Lymphedema of the arm after breast cancer treatment continues to challenge clinicians worldwide. In this review, we examine the main modalities, both nonsurgical and surgical, to prevent and treat this as yet incurable condition.

The impact of breast cancer-related lymphedema on the ability to perform upper extremity activities of daily living

We sought to assess the association of breast cancer-related lymphedema (BCRL) with the ability to perform upper extremity activities of daily living (ADL) in our patient population. 324 breast cancer patients who had received treatment for unilateral breast cancer at our institution between 2005 and 2014 were prospectively screened for lymphedema. Bilateral arm measurements were performed pre-operatively and during post-operative follow-up using a Perometer. Patients completed an extensive quality of life (QOL) questionnaire at the time of each study assessment. Lymphedema was defined as a relative volume change (RVC) of ≥10% from the patient's pre-operative baseline measurement. Linear regression models were used to evaluate the relationship between post-operative arm function score (as a continuous variable) and RVC, demographic, clinical, and QOL factors. By multivariate analysis, greater fear of lymphedema (p < 0.0001), more pain (p < 0.0001), body mass index >25 (p = 0.0015), mastectomy (p = 0.0001), and having an axillary node dissection (p = 0.0045) were all associated with lower functional scores. Higher emotional well-being score (p < 0.0001) and adjuvant chemotherapy (p = 0.0005) were associated with higher post-operative functional score. Neither low-level volume changes (5-10 % RVC) nor BCRL (RVC ≥10 %) were associated with ability to perform upper extremity ADL as measured by self-report (p = 0.99, p = 0.79). This prospective study demonstrates that low-level changes in arm volume (RVC 5-10 %) as well as clinically significant BCRL (RVC ≥10 %) did not impact the self-reported ability to use the affected extremity for ADL. These findings may help to inform clinicians and patients on the importance of prospective screening for lymphedema and QOL which enables early detection and intervention.

A systematic review of axillary web syndrome (AWS)

INTRODUCTION

Axillary web syndrome (AWS) can result in early post-operative and long-term difficulties following lymphadenectomy for cancer and should be recognised by clinicians. This systematic review was conducted to synthesise information on AWS clinical presentation and diagnosis, frequency, natural progression, grading, pathoaetiology, risk factors, symptoms, interventions and outcomes.

METHODS

Electronic searches were conducted using Cochrane, Pubmed, MEDLINE, CINAHL, EMBASE, AMED, PEDro and Google Scholar until June 2013. The methodological quality of included studies was determined using the Downs and Black checklist. Narrative synthesis of results was undertaken.

RESULTS

Thirty-seven studies with methodological quality scores ranging from 11 to 26 on a 28-point scale were included. AWS diagnosis relies on inspection and palpation; grading has not been validated. AWS frequency was reported in up to 85.4 % of patients. Biopsies identified venous and lymphatic pathoaetiology with five studies suggesting lymphatic involvement. Twenty-one studies reported AWS occurrence within eight post-operative weeks, but late occurrence of greater than 3 months is possible. Pain was commonly reported with shoulder abduction more restricted than flexion. AWS symptoms usually resolve within 3 months but may persist. Risk factors may include extensiveness of surgery, younger age, lower body mass index, ethnicity and healing complications. Low-quality studies suggest that conservative approaches including analgesics, non-steroidal anti-inflammatory drugs and/or physiotherapy may be safe and effective for early symptom reduction.

CONCLUSIONS

AWS appears common. Current evidence for the treatment of AWS is insufficient to provide clear guidance for clinical practice.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors should be informed about AWS. Further investigation is needed into pathoaetiology, long-term outcomes and to determine effective treatment using standardised outcomes.

Conservative interventions for preventing clinically detectable upper-limb lymphoedema in patients who are at risk of developing lymphoedema after breast cancer therapy

BACKGROUND

Breast cancer-related lymphoedema can be a debilitating long-term sequela of breast cancer treatment. Several studies have investigated the effectiveness of different treatment strategies to reduce the risk of breast cancer-related lymphoedema.

OBJECTIVES

To assess the effects of conservative (non-surgical and non-pharmacological) interventions for preventing clinically-detectable upper-limb lymphoedema after breast cancer treatment.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's (CBCG) Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL, PEDro, PsycINFO, and the World Health Organization (WHO) International Clinical Trials Registry Platform in May 2013. Reference lists of included trials and other systematic reviews were searched.

SELECTION CRITERIA

Randomised controlled trials that reported lymphoedema as the primary outcome and compared any conservative intervention to either no intervention or to another conservative intervention.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed the risk of bias and extracted data. Outcome measures included lymphoedema, infection, range of motion of the shoulder, pain, psychosocial morbidity, level of functioning in activities of daily life (ADL), and health-related quality of life (HRQoL). Where possible, meta-analyses were performed. Risk ratio (RRs) or hazard ratio (HRs) were reported for dichotomous outcomes or lymphoedema incidence, and mean differences (MDs) for range of motion and patient-reported outcomes.

MAIN RESULTS

Ten trials involving 1205 participants were included. The duration of patient follow-up ranged from 2 days to 2 years after the intervention. Overall, the quality of the evidence generated by these trials was low, due to risk of bias in the included trials and inconsistency in the results. Manual lymph drainageIn total, four studies used manual lymph drainage (MLD) in combination with usual care or other interventions. In one study, lymphoedema incidence was lower in patients receiving MLD and usual care (consisting of standard education or exercise, or both) compared to usual care alone. A second study reported no difference in lymphoedema incidence when MLD was combined with physiotherapy and education compared to physiotherapy alone. Two other studies combining MLD with compression and scar massage or exercise observed a reduction in lymphoedema incidence compared to education only, although this was not significant in one of the studies. Two out of the four studies reported on shoulder mobility where MLD combined with exercise gave better shoulder mobility for lateral arm movement (shoulder abduction) and forward flexion in the first weeks after breast cancer surgery, compared to education only (mean difference for abduction 22°; 95% confidence interval (CI) 14 to 30; mean difference for forward flexion 14°; 95% CI 7 to 22). Two of the studies on MLD reported on pain, with inconsistent results. Results on HRQoL in two studies on MLD were also contradictory. Exercise: early versus delayed start of shoulder mobilising exercisesThree studies examined early versus late start of postoperative shoulder exercises. The pooled relative risk of lymphoedema after an early start of exercises was 1.69 (95% CI 0.94 to 3.01, 3 studies, 378 participants). Shoulder forward flexion was better at one and six months follow-up for participants who started early with mobilisation exercises compared to a delayed start (two studies), but no meta-analysis could be performed due to statistical heterogeneity. There was no difference in shoulder mobility or self-reported shoulder disability at 12 months follow-up (one study). One study evaluated HRQoL and reported difference at one year follow-up (mean difference 1.6 points, 95% CI -2.14 to 5.34, on the Trial Outcome Index of the FACT-B). Two studies collected data on wound drainage volumes and only one study reported higher wound drainage volumes in the early exercise group. Exercise: resistance trainingTwo studies compared progressive resistance training to restricted activity. Resistance training after breast cancer treatment did not increase the risk of developing lymphoedema (RR 0.58; 95% CI 0.30 to 1.13, two studies, 358 participants) provided that symptoms are monitored and treated immediately if they occur. One out of the two studies measured pain where participants in the resistance training group reported pain more often at three months and six months compared to the control group. One study reported HRQoL and found no significant difference between the groups. Patient education, monitoring and early interventionOne study investigated the effects of a comprehensive outpatient follow-up programme, consisting of patient education, exercise, monitoring of lymphoedema symptoms and early intervention for lymphoedema, compared to education alone. Lymphoedema incidence was lower in the comprehensive outpatient follow-up programme (at any time point) compared to education alone (65 people). Participants in the outpatient follow-up programme had a significantly faster recovery of shoulder abduction compared to the education alone group.

AUTHORS' CONCLUSIONS

Based on the current available evidence, we cannot draw firm conclusions about the effectiveness of interventions containing MLD. The evidence does not indicate a higher risk of lymphoedema when starting shoulder-mobilising exercises early after surgery compared to a delayed start (i.e. seven days after surgery). Shoulder mobility (that is, lateral arm movements and forward flexion) is better in the short term when starting shoulder exercises earlier compared to later. The evidence suggests that progressive resistance exercise therapy does not increase the risk of developing lymphoedema, provided that symptoms are closely monitored and adequately treated if they occur.Given the degree of heterogeneity encountered, limited precision, and the risk of bias across the included studies, the results of this review should be interpreted with caution.

Bridging the divide between pathogenesis and detection in lymphedema

While our understanding of the lymphatic system has improved substantially in the past few decades, the translation of this knowledge into improved healthcare solutions for patients suffering from secondary lymphedema has been severely limited. The challenge facing clinicians is two-fold. First, there is no reliable, affordable, diagnostic capable of detecting the disease before symptoms of the lymphedema develop and the efficacy of treatment options becomes limited. Second, our understanding of the disease pathogenesis, its risk factors, and the underlying physiologic mechanisms is still in its infancy. These two challenges go hand in hand as limited diagnostic options have hindered our ability to understand lymphedema progression, and the lack of known underlying mechanisms involved in the disease prohibits the development of new diagnostic targets. This review serves to discuss the recent developments in clinical and lab research settings of both lymphedema diagnostic technologies and our understanding of the mechanisms driving disease risk and progression. We will show how these two lines of research are synergistically working with the ultimate goal of improving patient outcomes for those suffering from this horrible disease, identifying key areas of further research that are warranted to move the field forward and provide clinical relief for this neglected patient population.

Recent progress in the treatment and prevention of cancer-related lymphedema

This article provides an overview of the recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema. Lymphedema incidence by tumor site is evaluated. Measurement techniques and trends in patient education and treatment are also summarized to include current trends in therapeutic and surgical treatment options as well as longer-term management. Finally, an overview of the policies related to insurance coverage and reimbursement will give the clinician an overview of important trends in the diagnosis, treatment, and management of cancer-related lymphedema.

Bioelectrical impedance for detecting and monitoring lymphedema in patients with breast cancer. Preliminary results of the florence nightingale breast study group

The aim of this study was to evaluate the efficacy of bioimpedance spectroscopy for the follow-up of patients with lymphedema in Turkey and its benefits in the diagnosis of stage 0, 1, and 2 lymphedema in patients who are under treatment for breast cancer. Thirty-seven female patients with breast cancer who underwent surgical procedures in our Breast Health Centre were followed up for lymphedema using bioimpedance, and clinical measurements were taken for a minimum period of 1 year at 3-month intervals. Patients who had been monitored regularly between November, 2011, and September, 2013, were enrolled to the study. In total, 8 patients developed lymphedema with an overall rate of 21.6%. Among the 8 patients who developed lymphedema, 4 had Stage 2, 1 had Stage 1, and 3 had Stage 0 lymphedema. Stage 0 lymphedema could not be detected with clinical measurements. During the patients' 1-year follow-up period using measurements of bioimpedance, a statistically significant relationship was observed between the occurrence of lymphedema and the disease characteristics. including the number of the extracted and remaining lymph nodes and the region of radiotherapy (p=0.042, p=0.024, p=0.040). Bioimpedance analysis seems to be a practical and reliable method for the early diagnosis of lymphedema. It is believed that regular monitoring of patients in the high-risk group using bioimpedance analyses increases the ability to treat lymphedema.

Lymphedema care for the breast cancer patient: an integrative approach

Lymphedema is a serious complication that involves the accumulation of protein-rich fluid in the interstitial space. Lymphedema is common after treatment for breast cancer, especially for those patients receiving axillary lymph node dissection. Severe lymphedema is associated with serious morbidities such as swelling, fibrosis, decreased function, reduced range of motion, infection, and pain. Here, we discuss a unique, multi-disciplinary approach to effectively manage patients during and after breast cancer therapy. In this approach, patient education and screening are implemented in various departments throughout the health care system, including Physical Therapy and Rehabilitation, Integrative Medicine, and the Breast Care Center, which houses the Lymphedema Clinic. Early patient education and regular screening are combined with aggressive treatment for overt disease to effectively manage lymphedema in the at-risk population.

Development of the lymphoedema genito-urinary cancer questionnaire

The aim of this study was to develop a patient self-report tool to detect symptoms of genital and lower limb lymphoedema in male survivors of genitourinary cancer. The study incorporated the views of patients and subject specialists (lymphoedema and urology) in the design of a patient questionnaire based on the literature. Views on comprehensiveness, relevance of content, ease of understanding and perceived acceptability to patients were collated. The findings informed the development of the next iteration of the questionnaire. The overall view of participants was that the development and application of such a tool was of great clinical value and the Lymphoedema Genito-Urinary Cancer Questionnaire (LGUCQ) has significant potential for further development as a research tool to inform prevalence of this under-reported condition.

Surveillance recommendations in reducing risk of and optimally managing breast cancer-related lymphedema

Breast cancer survivors are at increased risk for the development of breast cancer-related lymphedema (BCRL), a chronic, debilitating, and disfiguring condition that is progressive and requires lifelong self-management of symptoms. It has been reported that over 40% of the 2.5 million breast cancer survivors in the United States may meet the criteria for BCRL during their lifetimes. Ongoing surveillance, beginning with pre-operative assessment, has been effective in identifying subclinical lymphedema (LE). A prospective model for surveillance is necessary in order to detect BCRL at an early stage when there is the best chance to reduce risk or slow progression. Physical methods for monitoring and assessment, such as circumferential arm measures, perometry, bioimpedance; exercise programs; prophylactic and early-intervention compression garments; and referral for complete decongestive therapy are all interventions to consider in the development of a BCRL surveillance program. In addition, supportive-educative programs and interactive engagement for symptom self-management should also be implemented. The importance of interdisciplinary collaboration is integral to the success of an effective personalized medicine program in breast cancer-related lymphedema surveillance.

Lymphedema

Lymphedema is the chronic, progressive swelling of tissue due to inadequate lymphatic function. Over time, protein-rich fluid accumulates in the tissue, causing it to enlarge. Lymphedema is a specific disease and should not be used as a generic term for an enlarged extremity. The diagnosis is made by evaluating the history and physical examination, and can be confirmed with lymphoscintigraphy. Intervention includes patient education, compression, and, rarely, surgery. Patients are advised to exercise, maintain a normal body mass index, and moisturize/protect the diseased limb from incidental trauma. Conservative management consists of compression regimens. Operative interventions either attempt to address the underlying lymphatic anomaly or the excess tissue. Lymphatic-venous anastomosis and lymph node transfer attempt to create new lymphatic connections to correct the defect. Suction-assisted lipectomy and staged cutaneous/subcutaneous excision reduce the size of the area by removing extra tissues.

The link between lymphedema, breast reconstruction and microsurgery

SUMMARY 

This management perspective will explore the relationship between lymphedema and breast reconstruction surgery. Little data exist, but early reports suggest breast reconstruction may be associated with a lower risk of lymphedema. Theories surrounding this relationship, as well as available data on lymphatic repair theories, will be discussed. In addition, the emerging role of lymphatic surgery to prevent or reverse lymphedema will be discussed. The refinement of advanced microsurgical techniques has resulted in a renewed interest in lymphatic surgery to cure lymphedema. However, efficacy, validation of surgical results, and surgery's ability to eliminate from patients the need for daily compression garments and therapy need further study.

Imaging the lymphatic system

Visualization of the lymphatic system is clinically necessary during diagnosis or treatment of many conditions and diseases; it is used for identifying and monitoring lymphedema, for detecting metastatic lesions during cancer staging and for locating lymphatic structures so they can be spared during surgical procedures. Imaging lymphatic anatomy and function also plays an important role in experimental studies of lymphatic development and function, where spatial resolution and accessibility are better. Here, we review technologies for visualizing and imaging the lymphatic system for clinical applications. We then describe the use of lymphatic imaging in experimental systems as well as some of the emerging technologies for improving these methodologies.

Impact of body mass index and weight fluctuation on lymphedema risk in patients treated for breast cancer

Identifying risk factors for lymphedema in patients treated for breast cancer has become increasingly important, given the current lack of standardization surrounding diagnosis and treatment. Reports on the association of body mass index (BMI) and weight change with lymphedema risk are conflicting. We sought to examine the impact of pre-operative BMI and post-treatment weight change on the incidence of lymphedema. From 2005 to 2011, 787 newly diagnosed breast cancer patients underwent prospective arm volume measurements with a Perometer pre- and post-operatively. BMI was calculated from same-day weight and height measurements. Lymphedema was defined as a relative volume change (RVC) of ≥ 10 %. Univariate and multivariate Cox proportional hazards models were used to evaluate the association between lymphedema risk and pre-operative BMI, weight change, and other demographic and treatment factors. By multivariate analysis, a pre-operative BMI ≥ 30 was significantly associated with an increased risk of lymphedema compared to a pre-operative BMI <25 and 25- <30 (p = 0.001 and p = 0.012, respectively). Patients with a pre-operative BMI 25- <30 were not at an increased risk of lymphedema compared to patients with a pre-operative BMI <25 (p = 0.409). Furthermore, a cumulative absolute weight fluctuation of 10 pounds gained/lost per month post-operatively significantly increased risk of lymphedema (HR: 1.97, p = < 0.0001). In conclusion, pre-operative BMI of ≥ 30 is an independent risk factor for lymphedema, whereas a BMI of 25- <30 is not. Large post-operative weight fluctuations also increase risk of lymphedema. Patients with a pre-operative BMI ≥ 30 and those who experience large weight fluctuations during and after treatment for breast cancer should be considered at higher-risk for lymphedema. Close monitoring or early intervention to ensure optimal treatment of the condition may be appropriate for these patients.

Side of cancer does not influence limb volumes in women prior to breast cancer surgery

BACKGROUND

Understanding normal volume asymmetry is essential for accurate assessment of limb volume changes following breast cancer (BC) treatment in which lymphatic function is disrupted. The purposes of this study were to evaluate for differences in dominant and nondominant limb volumes and to evaluate for interactions between the effects of dominance and side of cancer on limb volume.

METHODS AND RESULTS

This study evaluated preoperative limb volumes of 397 women enrolled in a prospective, longitudinal study of neuropathic pain and lymphedema. Volume was calculated from circumference. Limb resistance was measured with bioimpedance. Women were dichotomized into two groups: those whose cancer was on their dominant side and those whose cancer was on their nondominant side. Analyses of variance were used to evaluate for differences. In 47%, BC occurred on the side of the dominant limb. Except for the 30 to 40 centimeter (cm) limb volume segment, a main effect of dominance was found for all measures. The volume of the dominant limb was significantly greater than that of the nondominant limb. No main effects were found for side of cancer. A statistically significant interaction was found only at the 0 to 10 cm limb volume segment.

CONCLUSIONS

Prior to BC treatment, the dominant limb demonstrated lower bioimpedance resistance (-2.09%) and greater total limb volume (1.12%) than the nondominant limb. Segmental volume differences were greatest at the proximal forearm segment (2.31%) and least at the proximal arm segment (0.21%). This study provides evidence that preoperative volume assessment is important due to normal variability associated with limb dominance.