The effectiveness of complete decongestive physiotherapy for the treatment of lymphedema following groin dissection for melanoma

Evidence Mapping of the Treatments for Breast Cancer-related Lymphedema

Women treated for breast cancer are facing a lifetime risk of developing lymphedema, which occurs in up to 40% of this population. There is a lack of evidence and limited knowledge regarding the treatment of breast cancer-related lymphedema (BCRL). The aim of this study was to identify, describe, and organize the currently available evidence in the treatment of BCRL.

METHODS

We conducted an evidence mapping review study according to the methodology proposed by Global Evidence Mapping. We performed a systematic search in Medline, Embase, Central (Cochrane), and Epistemonikos, from 2000-2020. We included studies about all treatment types for BCRL, including surgical and nonsurgical treatment. Results were summarized in narrative and tabular forms.

RESULTS

A total of 240 studies were included in this mapping review, distributed as follows: 147 experimental studies [102 randomized clinical trials (RCTs) and 45 quasi-experimental clinical trials], 48 observational studies (34 prospective and 14 retrospective studies), and 45 systematic reviews (17 of them with metanalysis). Most of the RCTs were on nonsurgical interventions. Only two RCTs addressed surgical intervention.

CONCLUSIONS

In the last 20 years, there were an average of 12 publications per year on the treatment of BCRL. Recently this lack of attention has been partially corrected, as the majority were published in the past 5 years. However, most of them were on nonsurgical interventions. Well-designed RCTs on surgery are needed to measure the effectiveness of the applied interventions.

Associations of Physical Activity and Exercise with Health-related Outcomes in Patients with Melanoma During and After Treatment: A Systematic Review

Purpose:

Although exercise medicine is recommended to counter treatment-related side-effects and improve health-related outcomes of patients affected by different cancers, no specific recommendations exist for patients with melanoma. As a result, we systematically examined the current evidence regarding the effects of physical activity and exercise on objectively-measured and patient-reported outcomes among patients with melanoma.

Methods:

Searches were conducted in PubMed, CINAHL, EMBASE, SPORTDiscus, and Web of Science databases. This review included published data involving physical activity or exercise and objectively-measured or patient-reported outcomes of patients with cutaneous melanoma. The quality of included studies was assessed using the McMaster University Critical Appraisal Tool for Quantitative Studies.

Results:

Six studies including 882 patients with melanoma were included. Studies presented heterogeneity of design with 2 cross-sectional surveys, 2 retrospective analyses, and 2 non-randomized intervention trials. No statistically significant change in quality of life, fatigue, physical function, cardiorespiratory fitness, body composition, psychological distress, cognitive function, or treatment-related side-effects were attributable to physical activity or exercise. Importantly, physical activity or exercise during melanoma treatment or into survivorship did not adversely impact patients/survivors.

Conclusion:

In summary, physical activity or exercise did not adversely impact quality of life, objectively-measured or patient-reported outcomes in patients with melanoma. In addition, there is a paucity of quality studies examining the effects of physical activity or exercise on patients with melanoma throughout the cancer care continuum.

The Lymph-Sparing Quotient: A Retrospective Risk Analysis on Extremity Radiation for Soft Tissue Sarcoma Treatment

Simple Summary

Soft tissue sarcomas, a heterogenous group of tumors with a mesenchymal origin, are mostly located in the extremities and are commonly treated with surgery and radiotherapy. Using opportunities of reducing long-term therapy-related side effects in soft tissue sarcoma treatment is an important task for all physicians involved in soft tissue sarcoma treatment. The extent of lymph-sparing volume in adjuvant radiation therapy of extremity soft tissue sarcoma as a risk factor for lymphedema was analyzed in this study. Patients with a low lymph-sparing volume showed an increased risk of lymphedema in this retrospective study. Maximizing the potential oncologically justifiable lymph-sparing volume should be considered to reduce the risk of high-grade lymphedema when applying RT to extremities.

Abstract

Radiation therapy (RT) for extremity soft tissue sarcoma is associated with lymphedema risk. In this study, we analyzed the influence of lymph-sparing volume on the lymphedema occurrence in patients who received adjuvant extremity RT. The lymph-sparing quotient (LSQ) was calculated by dividing the lymph-sparing volume by the total extremity volume with double weightingfor the narrowest lymph-sparing region. A total of 34 patients were enrolled in this analysis. The median applied total radiation dose was 66.3 Gy in 36 fractions. Acute lymphedema appeared in 12 patients (35%). Most of them (n = 8) were lymphedema grade 1 and five patients had grade 2 to 3 lymphedema. Chronic lymphedema appeared in 22 patients (65%). 17 of these patients had at least a grade 2 lymphedema. In 13 of 14 patients with an LSQ ≤ 0.2 and 11 of 20 patients with an LSQ > 0.2, an acute or chronic lymphedema ≥ grade 2 was observed. A Kaplan–Meier Analysis of the two groups with the endpoint of a two-year lymph edema-free survival (=2-YLEFS) was estimated with an univariate, significant result (2-YLEFS LSQ ≤ 0.2 vs. LSQ > 0.2: 0% vs. 39%; p = 0.006; hazard ratio LSQ ≤ 0.2 vs. > 0.2 2-YLEFS 2.822 (p = 0.013); 95% confidence interval (CI): 1.24–6.42). Maximizing the potential oncologically-justifiable lymph-sparing volume should be considered to reduce the risk of high-grade lymphedema when applying RT to extremities.

Is the Effect of Complex Decongestive Therapy the Same for Primary and Secondary Lower Lymphedema?

Background: The aim was to compare edema and quality of life (QOL) after complex decongestive therapy (CDT) in two types of lymphedema: primary lower limb lymphedema (PLL) and secondary lower limb lymphedema (SLL). Methods and Results: Participants with PLL (n = 20) and SLL (n = 20) were recruited in this prospective single-blinded study. Patients in both groups were treated with CDT for 4 weeks 5 days a week. The amount of edema in their lower extremities was assessed by circumference measurement. The QOL for the patients was evaluated by a Lymphedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphedema (Lymph-ICF-LL) before and immediately following the therapy. There was no significant difference in the volume reductions between the two groups (p > 0.05). Overall initial QOL was significantly lower in patients with PLL than in patients with SLL scores. Post-CDT differed significantly between PLL and SLL groups, QOL was significantly lower for patients with PLL than for patients with SLL scores (p < 0.05). When the changes in both groups were examined, it was found that their QOL increased after the treatment (p < 0.05). Conclusions: While there was no difference in the amount of edema in both groups, the results of patients with SLL were more positive than patients with PLL in terms of QOL. Lymphedema therapists should approach patients with different therapeutic considerations specific to each type of lymphedema before using CDT in clinical practice.

Effectiveness and Safety of Complete Decongestive Therapy of Phase I: A Lymphedema Treatment Study in the Greek Population

Background

Lymphedema is a chronic condition caused by a failure in the lymphatic system that most commonly occurs in the limbs. Complete decongestive therapy (CDT) is the gold standard for lymphedema management.

Objective

To evaluate the effectiveness and safety of complete decongestive therapy (CDT) of phase I in the Greek population with lymphedema.

Methods

The patients’ demographic and clinical characteristics were recorded. CDT was implemented in all patients for 20 sessions in a four-week treatment period. The edema’s (excess volume (EV) and percent of excess volume (PEV)) measurements were carried out four times in the treatment period, whereas the percent reduction of excess volume (PREV) was calculated at the end of phase I. Moreover, we recorded every infection, trauma of skin, and pain of limb during the treatment.

Results

One-hundred five patients with lymphedema were enrolled in the present study, of whom 31.4% had upper limb lymphedema and 68.6% had lower limb lymphedema. All patients with upper limb lymphedema had a secondary type while the corresponding proportion of patients with lower limb lymphedema was 58.3%. A significant reduction (p<0.001) between the pre-treatment and post-treatment values of EV and PEV was found for both upper and lower limb lymphedema. For patients with upper limb lymphedema, the average PREV was 66.5% (interquartile range, 57.3%-80.6%), whereas for patients with lower limb lymphedema, a 71.5% (interquartile range, 64.5%-80.7%) median value was measured. No side effects from the treatment were recorded during CDT.

Conclusion

The proper treatment of the CDT phase I ensures safety and a great reduction in edema in patients with lymphedema that predispose the success of phase II of CDT.

A comprehensive overview on the surgical management of secondary lymphedema of the upper and lower extremities related to prior oncologic therapies

Secondary lymphedema of the upper and lower extremities related to prior oncologic therapies, including cancer surgeries, radiation therapy, and chemotherapy, is a major cause of long-term morbidity in cancer patients. For the upper extremities, it is most commonly associated with prior oncologic therapies for breast cancer, while for the lower extremities, it is most commonly associated with oncologic therapies for gynecologic cancers, urologic cancers, melanoma, and lymphoma. Both non-surgical and surgical management strategies have been developed and utilized, with the primary goal of all management strategies being volume reduction of the affected extremity, improvement in patient symptomology, and the reduction/elimination of resultant extremity-related morbidities, including recurrent infections. Surgical management strategies include: (i) ablative surgical methods (i.e., Charles procedure, suction-assisted lipectomy/liposuction) and (ii) physiologic surgical methods (i.e., lymphaticolymphatic bypass, lymphaticovenular anastomosis, vascularized lymph node transfer, vascularized omental flap transfer). While these surgical management strategies can result in dramatic improvement in extremity-related symptomology and improve quality of life for these cancer patients, many formidable challenges remain for successful management of secondary lymphedema. It is hopeful that ongoing clinical research efforts will ultimately lead to more complete and sustainable treatment strategies and perhaps a cure for secondary lymphedema and its devastating resultant morbidities.

Mechanisms of lymphatic regeneration after tissue transfer

Introduction

Lymphedema is the chronic swelling of an extremity that occurs commonly after lymph node resection for cancer treatment. Recent studies have demonstrated that transfer of healthy tissues can be used as a means of bypassing damaged lymphatics and ameliorating lymphedema. The purpose of these studies was to investigate the mechanisms that regulate lymphatic regeneration after tissue transfer.

Methods

Nude mice (recipients) underwent 2-mm tail skin excisions that were either left open or repaired with full-thickness skin grafts harvested from donor transgenic mice that expressed green fluorescent protein in all tissues or from LYVE-1 knockout mice. Lymphatic regeneration, expression of VEGF-C, macrophage infiltration, and potential for skin grafting to bypass damaged lymphatics were assessed.

Results

Skin grafts healed rapidly and restored lymphatic flow. Lymphatic regeneration occurred beginning at the peripheral edges of the graft, primarily from ingrowth of new lymphatic vessels originating from the recipient mouse. In addition, donor lymphatic vessels appeared to spontaneously re-anastomose with recipient vessels. Patterns of VEGF-C expression and macrophage infiltration were temporally and spatially associated with lymphatic regeneration. When compared to mice treated with excision only, there was a 4-fold decrease in tail volumes, 2.5-fold increase in lymphatic transport by lymphoscintigraphy, 40% decrease in dermal thickness, and 54% decrease in scar index in skin-grafted animals, indicating that tissue transfer could bypass damaged lymphatics and promote rapid lymphatic regeneration.

Conclusions

Our studies suggest that lymphatic regeneration after tissue transfer occurs by ingrowth of lymphatic vessels and spontaneous re-connection of existing lymphatics. This process is temporally and spatially associated with VEGF-C expression and macrophage infiltration. Finally, tissue transfer can be used to bypass damaged lymphatics and promote rapid lymphatic regeneration.

Impact of aggressive decongestion on the maintenance phase in combined physical therapy for lower extremity lymphedema

OBJECTIVES

To evaluate the impact of initial aggressive decongestion (Phase 1) on the maintenance phase of complex physical therapy (CPT).

MATERIALS AND METHODS

We reviewed 27 patients with unilateral and 3 patients with bilateral lower extremity lymphedema who started CPT between April, 2009 and October, 2010. Twelve patients elected to undergo in-hospital Phase 1 (Group I), while the other 18 started CPT on an outpatient-basis without having Phase 1 (Group O). The extremity volume was assessed at the beginning of CPT, and then 3 and 6 months later.

RESULTS

A significant reduction in extremity volume was achieved in each group after 6 months of CPT: from 9049 ± 1912 mL at the beginning to 7771 ± 1486 mL (p = 0.0033) in group I; and from 7370 ± 1392 mL to 7036 ± 1241 mL (p = 0.0200) in group O. However, after 6 months, extremity volume reduction (-845 ± 1283 mL in group I vs. -404 ± 370 mL in group O; p = 0.7672) and volume reduction rates (-23.6 ± 22.7% in group I vs. -46.4 ± 52.2% in group O; p = 0.2564) did not differ significantly between the groups.

CONCLUSION

Phase 1 did not have a significant impact on the maintenance phase in terms of control of the extremity volume for at least 6 months after the induction of CPT.

Weight lifting in patients with lower-extremity lymphedema secondary to cancer: a pilot and feasibility study

OBJECTIVE

To assess the feasibility of recruiting and retaining cancer survivors with lower-limb lymphedema into an exercise intervention study. To develop preliminary estimates regarding the safety and efficacy of this intervention. We hypothesized that progressive weight training would not exacerbate leg swelling and that the intervention would improve functional mobility and quality of life.

DESIGN

Before-after pilot study with a duration of 5 months.

SETTING

University of Pennsylvania.

PARTICIPANTS

Cancer survivors with a known diagnosis of lower-limb lymphedema (N=10) were directly referred by University of Pennsylvania clinicians. All 10 participants completed the study.

INTERVENTION

Twice weekly slowly progressive weight lifting, supervised for 2 months, unsupervised for 3 months.

MAIN OUTCOME MEASURES

The primary outcome was interlimb volume differences as measured by optoelectronic perometry. Additional outcome measures included safety (adverse events), muscle strength, objective physical function, and quality of life.

RESULTS

Interlimb volume differences were 44.4% and 45.3% at baseline and 5 months, respectively (pre-post comparison, P=.70). There were 2 unexpected incident cases of cellulitis within the first 2 months. Both resolved with oral antibiotics and complete decongestive therapy by 5 months. Bench and leg press strength increased by 47% and 27% over 5 months (P=.001 and P=.07, respectively). Distance walked in 6 minutes increased by 7% in 5 months (P=.01). No improvement was noted in self-reported quality of life.

CONCLUSIONS

Recruitment of patients with lower-limb-lymphedema into an exercise program is feasible. Despite some indications that the intervention may be safe (eg, a lack of clinically significant interlimb volume increases over 5 mo), the unexpected finding of 2 cellulitic infections among the 10 participants suggests additional study is required before concluding that patients with lower-extremity lymphedema can safely perform weight lifting.

Manipulative therapy of secondary lymphedema in the presence of locoregional tumors

BACKGROUND

Complete decongestive therapy (CDT), including manual lymphatic drainage (MLD) is a manipulative intervention of documented benefit to patients with lymphedema (LE). Although the role of CDT for LE is well described, to the authors' knowledge there are no data regarding its efficacy for patients with LE due to tumor masses in the draining anatomic bed. Traditionally, LE therapists are wary of providing therapy to such patients with 'malignant' LE for fear of exacerbating the underlying cancer, and that the obstruction will render therapy less effective. In the current study, the authors' experience providing CDT for such patients is discussed.

METHODS

Cancer survivors with LE were referred to therapists at 2 Atlanta-area clinics. CDT consists of treatment (Phase 1) and maintenance phases (Phase 2). During Phase 1, the patient undergoes manipulative therapy and bandaging daily until the LE reduction plateaus; at that point, Phase 2 (self-care) begins. At the beginning and end of Phase 1, LE is quantified and differences in girth volume calculated. The results for patients completing Phase 1 therapy for LE in the presence of locoregional masses were compared with results for patients with LE in the absence of such disease. Both volume reduction of the affected limb and number of treatments to plateau were analyzed.

RESULTS

Between January 2004, and March 2007, LE of 82 limbs in 72 patients was treated with CDT and Phase 1 was completed. The median number of treatments to plateau was 12 (range, 4-23 treatments); the median limb volume reduction was 22% (range, -23 to 164%). Nineteen limbs (16 patients) with associated chest wall/axillary or pelvic/inguinal tumors had nonsignificant difference in LE reduction (P = .75) in the presence of significantly more sessions to attain plateau (P = .0016) compared with 63 limbs in 56 patients without such masses.

CONCLUSIONS

Patients with LE may obtain relief with CDT regardless of whether they have locoregional disease contributing to their symptoms. However, it will likely take longer to achieve that effect. Manipulative therapy of LE should not be withheld because of persistent or recurrent disease in the draining anatomic bed.

Lymphedema: a comprehensive review

BACKGROUND

Lymphedema is a chronic, debilitating condition that has traditionally been seen as refractory or incurable. Recent years have brought new advances in the study of lymphedema pathophysiology, as well as diagnostic and therapeutic tools that are changing this perspective.

OBJECTIVE

To provide a systematic approach to evaluating and managing patients with lymphedema.

METHODS

We performed MEDLINE searches of the English-language literature (1966 to March 2006) using the terms lymphedema, breast cancer-associated lymphedema, lymphatic complications, lymphatic imaging, decongestive therapy, and surgical treatment of lymphedema. Relevant bibliographies and International Society of Lymphology guidelines were also reviewed.

RESULTS

In the United States, the populations primarily affected by lymphedema are patients undergoing treatment of malignancy, particularly women treated for breast cancer. A thorough evaluation of patients presenting with extremity swelling should include identification of prior surgical or radiation therapy for malignancy, as well as documentation of other risk factors for lymphedema, such as prior trauma to or infection of the affected limb. Physical examination should focus on differentiating signs of lymphedema from other causes of systemic or localized swelling. Lymphatic dysfunction can be visualized through lymphoscintigraphy; the diagnosis of lymphedema can also be confirmed through other imaging modalities, including CT or MRI. The mainstay of therapy in diagnosed cases of lymphedema involves compression garment use, as well as intensive bandaging and lymphatic massage. For patients who are unresponsive to conservative therapy, several surgical options with varied proven efficacies have been used in appropriate candidates, including excisional approaches, microsurgical lymphatic anastomoses, and circumferential suction-assisted lipectomy, an approach that has shown promise for long-term relief of symptoms.

CONCLUSIONS

The diagnosis of lymphedema requires careful attention to patient risk factors and specific findings on physical examination. Noninvasive diagnostic tools and lymphatic imaging can be helpful to confirm the diagnosis of lymphedema or to address a challenging clinical presentation. Initial treatment with decongestive lymphatic therapy can provide significant improvement in patient symptoms and volume reduction of edematous extremities. Selected patients who are unresponsive to conservative therapy can achieve similar outcomes with surgical intervention, most promisingly suction-assisted lipectomy.

Lymphedema therapy reduces the volume of edema and pain in patients with breast cancer

BACKGROUND

Despite recent advances in breast-conserving surgery, upper-extremity lymphedema remains a problem for patients after the treatment of breast cancer. This study examines the results of a protocol of therapy for lymphedema in breast cancer patients.

METHODS

A total of 135 patients with lymphedema after breast cancer treatment were provided a protocol of complete decongestive therapy (CDT). This involved manual lymphatic drainage, compression garments, skin care, and range-of-motion exercises. Therapy was divided into an induction phase involving twice-weekly therapy for 8 weeks and maintenance therapy individualized to patient needs. Absolute volume and percentage of volume of lymphedema was compared before and after treatment. Also assessed was the degree of chronic pain and the need for pain medication.

RESULTS

Mean initial lymphedema volume was 709 mL, and the percentage of lymphedema was 31%. The induction phase of CDT reduced this to 473 mL and 18%, respectively. Before therapy, 76 patients had chronic pain and 41 required oral pain medication. CDT reduced this to 20 and 11, respectively. The degree of pain was also assessed on a numerical scale from 0 to 10. Those patients with chronic pain initially rated their pain at an average of 6.9. After treatment, this was reduced to 1.1.

CONCLUSIONS

Lymphedema continues to be a problem for patients with breast cancer. A program of lymphedema therapy can reduce the volume of edema and reduce pain in this population.

Evaluation and Management of the Fat Leg Syndrome

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Discuss the initial evaluation of a patient presenting with lower extremity enlargement. 2. Distinguish underlying medical conditions causing lower extremity enlargement, including lymphedema and lipedema. 3. Discuss appropriate management and treatment for patients presenting with these conditions.

BACKGROUND

Given the epidemic of obesity in the United States, many patients will consult the plastic surgeon with complaints of lower extremity enlargement secondary to "fat legs." In addition to cosmetic disfigurement, some patients may suffer from underlying medical conditions that are responsible for their symptoms. Knowledge of these other causes, including lymphedema and a disorder of abnormal fat deposition known as lipedema, ensures appropriate management and/or surgical treatment for affected patients.

METHODS

Initial evaluation for lower extremity enlargement should include a discussion of pertinent medical history and a focused physical examination for findings that might indicate a pathologic underlying cause. When indicated, patients should undergo additional testing, including radiologic studies, to confirm their diagnoses.

RESULTS

For those patients found to have lymphatic dysfunction, conservative management, such as massage therapy, use of compression garments, and limb elevation, should be initially recommended. Excisional or suction-assisted lipectomy may be considered in patients who fail conservative therapy. More extensive consultation with the plastic surgeon is recommended for patients seeking aesthetic improvement in contour and shape of large legs without a specified underlying abnormality.

CONCLUSIONS

Patients with lower extremity enlargement may present to the plastic surgeon unsure of the specific cause of their deformity. A broad differential diagnosis exists for their presentation, which can be narrowed by using the common features and unique manifestations of the conditions.