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

Current diagnostic and quantitative techniques in the field of lymphedema management: a critical review

Lymphedema evaluation entails multifaceted considerations for which options continue to evolve and emerge. This paper provides a critical review of the current status of diagnostic and quantitative measures for lymphedema, from traditional and novel bedside assessment tools for volumetric and fluid assessment, to advanced imaging modalities. Modalities are contrasted with regard to empirical support and feasibility of clinical implementation. The manuscript proposes a grid framework for comparing the ability of each modality to quantify specific lymphedema characteristics, including distribution, dysmorphism, tissue composition and fluid content, lymphatic anatomy and function, metaplasia, clinical symptoms, and quality of life and function. This review additionally applies a similar framework approach to consider how well assessment tools support important clinical needs, including: (1) screening, (2) diagnosis and differential diagnosis, (3) individualization of treatment, and (4) monitoring treatment response. The framework highlights which clinical needs are served by an abundance of assessment tools and identifies others that have problematically few. The framework clarifies which tools have greater or lesser empirical support. The framework is designed to assist stakeholders in selecting appropriate diagnostic and surveillance modalities, gauging levels of confidence when applying tools to specific clinical needs, elucidating overarching patterns of diagnostic and quantitative strengths and weaknesses, and informing future investigation.

Non-invasive technology to assess hydration status in advanced cancer to explore relationships between fluid status and symptoms: an observational study using bioelectrical impedance analysis

BACKGROUND

Oral fluid intake decreases in advanced cancer in the dying phase of illness. There is inadequate evidence to support the assessment, and management, of hydration in the dying. Bioelectrical impedance analysis (BIA) is a body composition assessment tool. BIA has the potential to inform clinal management in advanced cancer, by examining the relationships between hydration status and clinical variables.

AIM

BIA was used to determine the association between hydration status, symptoms, clinical signs, quality-of-life and survival in advanced cancer, including those who are dying (i.e. in the last week of life).

MATERIALS AND METHODS

We conducted a prospective observational study of people with advanced cancer in three centres. Advance consent methodology was used to conduct hydration assessments in the dying. Total body water was estimated using the BIA Impedance index (Height - H (m)2 /Resistance - R (Ohms)). Backward regression was used to identify factors (physical signs, symptoms, quality of life) that predicted H2/R. Participants in the last 7 days of life were further assessed with BIA to assess hydration changes, and its relationship with clinical outcomes.

RESULTS

One hundred and twenty-five people participated (males n = 74 (59.2%), females, n = 51 (40.8%)). We used backward regression analysis to describe a statistical model to predict hydration status in advanced cancer. The model demonstrated that 'less hydration' (lower H2/R) was associated with female sex (Beta = -0.39, p < 0.001), increased appetite (Beta = -0.12, p = 0.09), increased dehydration assessment scale score (dry mouth, dry axilla, sunken eyes - Beta = -0.19, p = 0.006), and increased breathlessness (Beta = -0.15, p = 0.03). 'More hydration' (higher H2/R) was associated with oedema (Beta = 0.49, p < 0.001). In dying participants (n = 18, 14.4%), hydration status (H2/R) was not significantly different compared to their baseline measurements (n = 18, M = 49.6, SD = 16.0 vs. M = 51.0, SD = 12.1; t(17) = 0.64, p = 0.53) and was not significantly associated with agitation (rs = -0.85, p = 0.74), pain (rs = 0.31, p = 0.23) or respiratory tract secretions (rs = -0.34, p = 0.19).

CONCLUSIONS

This is the first study to use bioimpedance to report a model (using clinical factors) to predict hydration status in advanced cancer. Our data demonstrates the feasibility of using an advance consent method to conduct research in dying people. This method can potentially improve the evidence base (and hence, quality of care) for the dying. Future BIA research can involve hydration assessment of cancers (according to type and stage) and associated variables (e.g., stage of illness, ethnicity and gender). Further work can use BIA to identify clinically relevant outcomes for hydration studies and establish a core outcome set to evaluate how hydration affects symptoms and quality-of-life in cancer.

BE-WEL trial (breast: evaluation of weight and exercise for lymphoedema) testing weight control and exercise programmes for women with breast cancer related lymphoedema: a feasibility trial

PURPOSE

A combined body weight loss and upper body/arm exercise programme is a potential strategy for managing Breast cancer related lymphoedema (BCRL), but there is limited data on the best method for delivery or its potential efficacy.

METHODS

Fifty-seven women with overweight/obesity and BCRL were randomised to a 12 week supervised (n = 12) or home-based combined weight loss and upper body/arm exercise programme (n = 16), a home-based upper-body arm exercise only programme (n = 17) or standard care (n = 12). Primary outcomes were uptake, retention and changes in weight and change in Relative Arm Volume Increase (RAVI) using analysis of covariance (ANCOVA).

RESULTS

Sixteen percent of women invited joined the study and 49 completed the trial (85% retention). Reductions in weight occurred in the supervised and home-based weight control and exercise programmes; Mean (95% CI) change compared to standard care - 1.68 (- 4.36 to - 1.00), - 2.47(- 4.99 to - 0.04) Kg. Reductions in perometer assessed RAVI were seen in the supervised and home-based combined weight control and arm exercise groups and the weight stable home-based arm exercise only group: mean (95% CI) change compared to standard care - 2.4 (- 5.0 to + 0.4),- 1.8 (- 4.3 to + 0.7), - 2.5(- 4.9 to - 0.05)%.

CONCLUSION

Women with BCRL and overweight and obesity engaged in diet and exercise weight loss programmes. Both weight loss/arm exercise programmes led to modest changes in weight and BCRL. Comparable reductions in BCRL were reported in the weight stable group undertaking arm exercise only. The independent and combined effects of weight loss and exercise on BCRL need further study.

TRIAL REGISTRATION

ISRCTN86789850 https://doi.org/10.1186/ISRCTN86789850 , registered 2011.

Impact of risk factors, early rehabilitation and management of lymphedema associated with breast cancer: a retrospective study of breast Cancer survivors over 5 years

BACKGROUND

Breast cancer-related lymphedema (BCRL) is a potentially disabling and often irreversible consequence of breast cancer treatment, caused by the mechanical incompetence of the lymphatic system, resulting in reduced drainage capacity and functional overload due to an excessive volume of interstitial fluid surpassing the system's transport capacity in the arm. We wanted to determine the impact and explore the differences in independent risk factors for the occurrence of BCRL; incidence of BCRL over a five-year period at the Institute of Oncology Vojvodina in Sremska Kamenica and to answer the research question regarding the influence of the prehabilitation program on the overall incidence of BCRL during the observed five-year period.

METHODS

From 2014 to 2018, a retrospective study was conducted at the Institute of Oncology of Vojvodina in Sremska Kamenica, analyzing female patients who had undergone breast cancer surgery.

RESULTS

The study included 150 breast cancer patients who developed secondary lymphedema following surgery with the mean age of 59.2 ± 11.3 years. Fluctuations in hospitalization rates were observed over the five-year period, with the highest number of admissions in 2014 (24.0%) and a decline in 2018 (14.0%). The most common surgical procedure performed was left quadrantectomy (24.0%), followed by right quadrantectomy (20.0%) and left amputation (15.3%). The mean number of removed lymph nodes was 15.2 ± 6.1, with no statistically significant association between the number of removed lymph nodes and the manifestation of secondary lymphedema. The severity of secondary lymphedema varied based on patient age, with a higher incidence of moderate and severe lymphedema observed in patients aged 61 years and older. Patients who underwent radical surgery were more likely to experience severe lymphedema compared to those who had conservative surgery, although this difference was not statistically significant.

CONCLUSION

In our study, the type of surgery, elapsed time since surgery, and the number of removed lymph nodes were not influencing factors for the occurrence of BCRL. However, concerning its severity, a greater number of systemic therapy modalities combined with radiotherapy were associated with a more frequent occurrence of mild and moderate BCRL. Also, the severity of BCRL varied among different age groups, with a higher incidence of moderate and severe lymphedema observed in patients aged 61 years and older. Ultimately, improving the quality of life for individuals affected by secondary lymphedema remains a crucial goal in the field of oncology.

Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidance for the prevention of breast cancer-related arm lymphoedema (BCRAL): international Delphi consensus-based recommendations

Background

Developing strategies to prevent breast cancer-related arm lymphoedema (BCRAL) is a critical unmet need because there are no effective interventions to eradicate it once it reaches a chronic state. Certain strategies such as prospective surveillance programs and prophylactic lymphatic reconstruction have been reported to be effective in clinical trials. However, a large variation exists in practice based on clinician preference, organizational standards, and local resources.

Methods

A two-round international Delphi consensus process was performed from February 27, 2023 to May 25, 2023 to compile opinions of 55 experts involved in the care and research of breast cancer and lymphoedema on such interventions.

Findings

Axillary lymph node dissection, use of post-operative radiotherapy, relative within-arm volume increase one month after surgery, greater number of lymph nodes dissected, and high body mass index were recommended as the most important risk factors to guide selection of patients for interventions to prevent BCRAL. The panel recommended that prospective surveillance programs should be implemented to screen for and reduce risks of BCRAL where feasible and resources allow. Prophylactic compression sleeves, axillary reverse mapping and prophylactic lymphatic reconstruction should be offered for patients who are at risk for developing BCRAL as options where expertise is available and resources allow. Recommendations on axillary management in clinical T1-2, node negative breast cancer patients with 1-2 positive sentinel lymph nodes were also provided by the expert panel. Routine axillary lymph node dissection should not be offered in these patients who receive breast conservation therapy. Axillary radiation instead of axillary lymph node dissection should be considered in the same group of patients undergoing mastectomy.

Interpretation

An individualised approach based on patients' preferences, risk factors for BCRAL, availability of treatment options and expertise of the healthcare team is paramount to ensure patients at risk receive preventive interventions for BCRAL, regardless of where they are receiving care.

Funding

This study was not supported by any funding. RJC received investigator grant support from the Australian National Health and Medical Research Council (APP1194051).

Early Detection of Breast Cancer-Related Lymphedema: Accuracy of Indocyanine Green Lymphography Compared with Bioimpedance Spectroscopy and Subclinical Lymphedema Symptoms

Introduction: The reported incidences of breast cancer-related lymphedema (LE) affecting the arms vary greatly. Reason for this variability includes different diagnostic techniques used across studies. In the current study, we compared the accuracy of indocyanine green lymphography (ICG_L) and bioimpedance spectroscopy (BIS) in detecting LE before presentation of clinical signs. Methods and Results: Patients with no initial detectable signs of clinical LE of their arms after axillary lymph node dissection or removal of >5 lymph nodes on sentinel lymph node biopsy were included. Subclinical LE was defined as BIS values outside the normal range [(≥7 units (or >10 units)] or a 7-unit (or 10 unit) change between two measurements. We tracked ICG_L and BIS measurements for 133 potentially affected arms (n = 123). ICG_L detected signs of lymphatic flow disruption in 63 arms (47%). Based on the BIS value of 7 units, 60 arms (45%) had values outside the normal range. When using ICG_L-identified LE cases as true positives, BIS had a 54% accuracy (area under the curve [AUC] = 0.54) in detecting LE. Accuracy was 61% for subclinical LE symptoms when compared with ICG_L (AUC = 0.62). Both BIS and subclinical LE symptoms had <0.70 AUC-receiver characteristic operator curve, suggesting that BIS and development of subclinical LE symptoms are not adequate for identifying patients with subclinical LE. Conclusion: ICG_L is a reliable diagnostic tool for detecting early signs of lymphatic flow disruption in subclinical LE. Utilizing ICG_L to diagnose subclinical LE followed by a personalized treatment plan may provide patients the best chance of preventing disease progression.

Bioelectrical impedance analysis in patients with breast cancer-related lymphedema before and after lymphaticovenular anastomosis

OBJECTIVE

Bioelectrical impedance analysis (BIA) as a measure of lymphedema has been gaining popularity because of its measurement simplicity and noninvasiveness. This study was performed to investigate the effectiveness of BIA for assessment of the outcomes of lymphaticovenular anastomosis (LVA) in patients with breast cancer-related lymphedema.

METHODS

This study involved 25 patients with unilateral breast cancer-related lymphedema who underwent LVA. Segmental multifrequency BIA and conventional circumferential volume measurement were performed preoperatively and 6 months postoperatively from June 2018 to June 2021 at Hiroshima University Hospital International Center for Lymphedema. The patients' clinicopathological data, operative details, and preoperative and postoperative BIA results were investigated.

RESULTS

Segmental multifrequency BIA and circumferential volume measurement were strongly correlated in the lymphedema-affected upper limb both before and after LVA. The interlimb volume, interlimb extracellular water ratio (r = 0.784; P < .001), and interlimb extracellular water/total body water ratio were positively correlated (r = 0.612; P < .01), whereas the phase angle was negatively associated (r = -0.556; P < .01).

CONCLUSIONS

Segmental multifrequency BIA can be a useful tool for assessing the severity of lymphedema and monitoring the outcomes of LVA.

Practice patterns of physical therapists and physical therapist assistants treating patients with breast cancer related lymphedema

Clinical Practice Guidelines (CPGs) aim to improve patient outcomes through implementation of proven interventions and decrease variation in practices. The relevance of this article is to describe the current state practice of physical therapists who diagnose and treat patients with Breast Cancer Related Lymphedema (BCRL). It also provides a description of physical therapist-reported adherence to the BCRL CPG recommendations which establishes the need for implementation interventions to improve adherence.

PURPOSE

The purpose of this study is to describe practice patterns of physical therapists (PT) and physical therapist assistants (PTA) who treat patients with breast cancer-related lymphedema and determine if they are adherent to best evidence recommendations for lymphedema diagnosis and intervention.

METHODS

An electronic survey to collect practice pattern data of PTs and PTAs who treat patients with BCRL was distributed. A descriptive and quantitative statistical analysis was performed.

RESULTS

Twenty-six percent of respondents read the American Physical Therapy Association sponsored lymphedema diagnosis clinical practice guideline (CPG) and 20% read the lymphedema intervention CPG. Lymphoscintigraphy was the only diagnosis or intervention tool with a significant difference in use between therapists who read versus did not read the CPGs. Adherence to "should do" recommendations was variable: bioimpedance (18.2%), volume calculation (49.3%), ultrasound (0%), patient reported outcome tools (64.9%), compression garments (43.9%), exercise (87.2%), and compression bandaging (56.8%).

CONCLUSIONS

There is variability in adherence to recommendations for both the lymphedema diagnosis and intervention CPGs. Interventions to improve implementation and adherence to CPG recommendations are warranted.

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.

Overview of Lymphedema for Physicians and Other Clinicians: A Review of Fundamental Concepts

Lymphedema has historically been underrated in clinical practice, education, and scholarship to the detriment of many patients with this chronic, debilitating condition. The mechanical insufficiency of the lymphatic system causes the abnormal accumulation of protein-rich fluid in the interstitium, which triggers a cascade of adverse consequences such as fat deposition and fibrosis. As the condition progresses, patients present with extremity heaviness, itchiness, skin infections, and, in later stages, dermal fibrosis, skin papillomas, acanthosis, and other trophic skin changes. Correspondingly, lymphedema results in psychological morbidity, including anxiety, depression, social avoidance, and a decreased quality of life, encompassing emotional, functional, physical, and social domains. For this review, we conducted a literature search using PubMed and EMBASE and herein summarize the evidence related to the fundamental concepts of lymphedema. This article aims to raise awareness of this serious condition and outline and review the fundamental concepts of lymphedema.

Prediction of breast cancer-related lymphedema by dermal backflow detected with near-infrared fluorescence lymphatic imaging

PURPOSE

Mild breast cancer-related lymphedema (BCRL) is clinically diagnosed as a 5%-10% increase in arm volume, typically measured no earlier than 3-6 months after locoregional treatment. Early BCRL treatment is associated with better outcomes, yet amid increasing evidence that lymphedema exists in a latent form, treatment is typically delayed until arm swelling is obvious. In this study, we investigated whether near-infrared fluorescence lymphatic imaging (NIRF-LI) surveillance could characterize early onset of peripheral lymphatic dysfunction as a predictor of BCRL.

METHODS

In a prospective, longitudinal cohort/observational study (NCT02949726), subjects with locally advanced breast cancer who received axillary lymph node dissection and regional nodal radiotherapy (RT) were followed serially, between 2016 and 2021, before surgery, 4-8 weeks after surgery, and 6, 12, and 18 months after RT. Arm volume was measured by perometry, and lymphatic (dys) function was assessed by NIRF-LI.

RESULTS

By 18 months after RT, 30 of 42 study subjects (71%) developed mild-moderate BCRL (i.e., ≥ 5% arm swelling relative to baseline), all manifested by "dermal backflow" of lymph into lymphatic capillaries or interstitial spaces. Dermal backflow had an 83% positive predictive value and 86% negative predictive value for BCRL, with a sensitivity of 97%, specificity of 50%, accuracy of 83%, positive likelihood ratio of 1.93, negative likelihood ratio of 0.07, and odds ratio of 29.00. Dermal backflow appeared on average 8.3 months, but up to 23 months, before the onset of mild BCRL.

CONCLUSION

BCRL can be predicted by dermal backflow, which often appears months before arm swelling, enabling early treatment before the onset of edema and irreversible tissue changes.

The effect of a self-management lymphedema education program on lymphedema, lymphedema-related symptoms, patient compliance, daily living activities and patient activation in patients with breast cancer-related lymphedema: A quasi-experimental study

PURPOSE

This study was undertaken to determine the effects of self-management lymphedema education program (SMLEP) on lymphedema, lymphedema-related symptoms, patient compliance, activities of daily living (ADL) and patient activation in patients with breast cancer-related lymphedema (BCRL).

METHODS

A quasi-experimental design without a control group was used to conduct this study in a lymphedema center of a university hospital in Ankara. A total of 44 patients with BCRL participated in the study. Patients (n = 44) received a SMLEP in the form of face-to-face sessions and information booklet at the beginning of the study. Patients were evaluated for upper extremity (UE) volume, and they were followed for 12 months. UE volume, symptom severity, physical function, patient compliance, ADL and patient activity level were measured at the beginning and end of the study.

RESULTS

A significant reduction was found in the UE volume (P = 0.000; ES = -0.79) and swelling and numbness symptom scores (P = 0.016; ES = - 0.26; P = 0.002; ES = -0.45, respectively). In addition, a significant increase was found in patient compliance (P = 0.001; ES = -0.29), ADL (P = 0.018; ES = -0.16) and patient activity level (P = 0.000; ES = -0.39) compared to those at the baseline.

CONCLUSION

The present study results showed that SMLEP reduced UE volume and lymphedema-related symptoms. In addition, results demonstrated its effectiveness on patient compliance and activity level, and independent performance of ADL. The results suggest that SMLEP is an effective approach in long-term lymphedema self-management.

Diagnostic Criteria for Breast Cancer-Related Lymphedema of the Upper Extremity: The Need for Universal Agreement

With advances in breast cancer treatments and resultant increased survival rates, emphasis has been placed on post-treatment complications such as breast cancer-related lymphedema (BCRL), a chronic, negative sequela of breast cancer treatment. Accurate BCRL diagnosis necessitates longitudinal screening beginning at preoperative baseline. Prospective screening programs incorporating symptoms, objective measurements and clinical examination allow for early detection, early intervention, and improved BCRL prognosis. Currently, varied diagnostic criteria for BCRL exist, and this lack of consensus leads to variation in diagnostic and screening practices across institutions. This review outlines current diagnostic tools, including subjective and objective measurement methods and clinical examination. The merits of different criteria are evaluated and recommendations are made regarding measurement tools and diagnostic criteria for BCRL. Ultimately, the BCRL diagnostic process should be universalized and combine objective measurements, clinical evaluation, and symptoms assessment, and adhere to the best practices of the measurement tools used.

Prevention of Breast Cancer-Related Lymphedema

Tremendous progress has been made over the past several decades in the treatment of breast cancer. Mortality and recurrence rates continue to decline. Our ability to tailor patient- and tumor-specific treatments has rapidly advanced. The vast majority of our patients can safely have breast conservation. Unfortunately, for many patients, survivorship is burdened by ongoing quality-of-life issues. Most breast cancer patients are asymptomatic at presentation, and the onus is on us to preserve this. Surgery, radiation, and systemic therapy can result in long-term toxicities that can be amplified with multimodality approaches. We must strive to apply minimally effective therapies rather than a maximally tolerated approach. Breast cancer-related lymphedema (BCRL) is a particularly dreaded chronic complication. This review strives to give the reader a better understanding of BCRL and shed light on wisely choosing an integration of treatment modalities that minimizes BCRL risk. Key literature on emerging concepts is highlighted.

Avoiding the Swell: Advances in Lymphedema Prevention, Detection, and Management

Lymphedema is a feared complication of cancer treatments that negatively affects survivors' quality of life. The true incidence of lymphedema is difficult to determine given its long latency period. As the number of survivors of cancer is increasing in the United States, lymphedema is poised to be a major health concern. The most noteworthy risk factor for lymphedema is comprehensive lymph node dissection. The last 2 decades have witnessed a dramatic shift in cancer treatment in an attempt to systematically de-escalate therapeutic interventions, specifically seeking to shift treatment away from routine lymph node dissection in favor of sentinel node biopsy or radiation strategies, thereby reducing the risk for lymphedema while maintaining survival outcomes. A growing body of robust evidence supports prospective screening and thereby a prospective surveillance model (PSM) for early diagnosis and intervention for the prevention and treatment of lymphedema. Finally, investigators are actively evaluating the effectiveness of contemporary surgical procedures in ameliorating the symptoms and disability of patients with lymphedema and reducing the risk of future episodes of cellulitis, with outcomes of surgery significantly better than with conservative therapy alone. In this article, we review the current data surrounding these initiatives.

Three Decades of Bioelectrical Impedance Spectroscopy in Lymphedema Assessment: An Historical Perspective

Bioelectrical impedance spectroscopy (BIS) is a technology that is widely used for the assessment of body composition. The method is based on the measurement of the electrical resistance of the body or a body region that can be quantitatively related to the amount of water in the tissues. Lymphedema is characterized, at least in its early stages, as an accumulation of lymph, an extracellular fluid. In the late 1980s, it was recognized that it might be possible to adapt BIS protocols to measure this increase in lymph volume. Subsequently, the use of BIS for the early detection of breast cancer-related lymphedema was demonstrated in the early 1990s, with BIS reference values indicative of lymphedema published in 2001. The subsequent two decades have seen BIS become a widely accepted method for lymphedema assessment. This review traces the evolution of the BIS technique since its inception and presents the current state of the art, with particular emphasis on utility in clinical practice.

Fluid Shifts Induced by Physical Therapy in Lower Limb Lymphedema Patients

Complete decongestive therapy (CDT), a physical therapy including manual lymphatic drainage (MLD) and compression bandaging, is aimed at mobilizing fluid and reducing limb volume in lymphedema patients. Details of fluid shifts occurring in response to CDT are currently not well studied. Therefore, we investigated fluid shifts before, during and after CDT. Thirteen patients (3 males and 10 females, aged 57 ± 8.0 years, 167.2 ± 8.3 cm height, 91.0 ± 23.4 kg weight) diagnosed with stage II leg lymphedema participated. Leg volume, limb and whole-body fluid composition (total body water (limbTBW/%TBW), extracellular (limbECF/%ECF) and intracellular (limbICF/%ICF fluid), as well as ECF/ICF and limbECF/limbICF ratios were determined using perometry and bioelectrical impedance spectroscopy. Plasma volume, proteins, osmolality, oncotic pressure and electrolytes were assessed. Leg volume (p < 0.001), limbECF (p = 0.041), limbICF (p = 0.005) and limbECF/limbICF decreased over CDT. Total leg volume and limbTBW were correlated (r = 0.635). %TBW (p = 0.001) and %ECF (p = 0.007) decreased over time. The maximum effects were seen within one week of CDT. LimbICF (p = 0.017), %TBW (p = 0.009) and %ICF (p = 0.003) increased post-MLD, whereas ECF/ICF decreased due to MLD. Plasma volume increased by 1.5% post-MLD, as well as albumin and the albumin-to-globulin ratio (p = 0.005 and p = 0.049, respectively). Our results indicate that physical therapy leads to fluid shifts in lymphedema patients, with the greatest effects occurring within one week of therapy. Fluid shifts due to physical therapy were also reflected in increased plasma volume and plasma protein concentrations. Perometry, in contrast to bioelectrical impedance analysis, does not seem to be sensitive enough to detect small fluid changes caused by manual lymphatic drainage.

Standardization of lower extremity quantitative lymphedema measurements and associated patient-reported outcomes in gynecologic cancers

Practice changing standardization of lower extremity lymphedema quantitative measurements with integrated patient reported outcomes will likely refine and redefine the optimal risk-reduction strategies to diminish the devastating limb-related dysfunction and morbidity associated with treatment of gynecologic cancers. The National Cancer Institute (NCI), Division of Cancer Prevention brought together a diverse group of cancer treatment, therapy and patient reported outcomes experts to discuss the current state-of-the-science in lymphedema evaluation with the potential goal of incorporating new strategies for optimal evaluation of lymphedema in future developing gynecologic clinical trials.

The Effects of Thermal Water Physical Exercise in Patients with Lower Limb Chronic Venous Insufficiency Monitored by Bioimpedance Analysis

BACKGROUND

Lower limb chronic venous diseases (CVD) lead to possible edema. The aim of the present investigation was to study the effect of thermal aquatic standardize exercise on lower limb edema control in CVD patients assessed by bioimpedance analysis (BIA).

METHODS

Seventeen patients (34 legs) affected by CVD clinical class CEAP C3, 4c, Ep, As, Pr were included. All the cohort performed a standardized exercise protocol in thermal water environment for a total of five sessions. BIA, leg volume, and heart rate at rest were measured.

RESULTS

After the five exercise sessions, BIA showed a significant percentage of extracellular water (ECW) reduction from 42.1 ± 5.8 to 41.24 ± 5.5%; p < 0.001. Moreover, an improvement of resistance (p < 0.0009) and reactance (p < 0.009) was assessed. At the same time, the leg volume reduction rate was 15.7%, p <0.0001. A moderate-strong correlation was found between % ECW and leg volume variation (R = 0.59, p < 0.01). Finally, a significant HR at rest reduction was recorded, p < 0.0001.

CONCLUSION

The investigated exercise protocol significantly affects the lower limb volume, and BIA parameters related to the tissue drainage improvement. The correlation founded between the ECW rate and volume variations suggest the possible use of BIA as a biomarker for monitoring the treatments aimed to reduce edema in CVD.

An infrared 3D scanning device as a novel limb volume measurement tool in breast cancer patients

Abstract

Background

Lymphedema is a common complication of breast cancer treatment that affects one in five breast cancer survivors, yet there is no reliable method to detect lymphedema in the subclinical range. The objective of this study was to determine the feasibility and reliability of using an infrared 3D scanning device (ISD) as a peri-operative limb volume measurement tool.

Methods

Fifteen patients were analyzed based on inclusion criteria. Peri-operative measurements were obtained using tape measure and an ISD. Volumes were calculated using a standard algorithm for tape measure and a custom algorithm for ISD measurements. Linear regression models were used to assess ISD and tape measurement volume and circumference correlation. One-way ANOVA was used to compare change in percent difference at set time points post-operatively (2–3 weeks, 4–6 weeks, and 7–12 weeks) for both ISD and tape measure. t tests for unequal variances with the Bonferroni correction were performed among these groups.

Results

There is a positive linear correlation (R² = 0.8518) between absolute volume measurements by the ISD and tape measure. Analyses over 2–10 weeks post-operatively showed that the ISD was able to detect volume changes in both the unaffected and the affected arm. Furthermore, the affected arm tended to have a greater increase in volume in the majority of patients, indicating these patients could be at risk for lymphedema.

Conclusions

Technology utilizing infrared 3D scanners can reliably measure limb volume pre- and post-treatment similarly to tape measure in a small sample of patients. Further research using 3D scanning technology with a longer follow up is warranted.

Increases in arm volume predict lymphoedema and quality of life deficits after axillary surgery: a prospective cohort study

Background

Lymphoedema develops after axillary clearance (ANC) in 25% of patients. This prospective, multi-centre study compared multi-frequency bioimpedance spectroscopy (BIS) with arm volume measurement to: (1) determine which test has better diagnostic accuracy, (2) identify factors predicting development of lymphoedema, and its effect on quality-of-life.

Methods

Participants (N = 1100) underwent measurements pre and post-ANC surgery for breast cancer. Relative arm volume increase (RAVI) of >10% diagnosed lymphoedema. Predictors of lymphoedema were determined using logistic regression. Optimal diagnostic method was assessed using diagnostic accuracy. Quality-of-life was assessed using the FACT B + 4 questionnaire.

Results

Lymphoedema was diagnosed in 22.8% women using RAVI > 10%, 45.6% using BIS criteria, while 24.5% underwent compression sleeve application by 24 months. BMI > 30 was an independent factor for both development (p = 0.005) and progression (p = 0.015) of lymphoedema. RAVI at 1 month, BMI > 30 and number of involved nodes contributed to a novel scoring model to predict lymphoedema by 36 months. Larger decreases in QoL scores post-surgery occurred in lymphoedema patients (p < 0.001). Progression to moderate lymphoedema occurred in 15% patients after sleeve application.

Conclusions

RAVI measurement was the best diagnostic tool for lymphoedema. BIS alone is not appropriate for lymphoedema screening or diagnosis. BMI > 30 predicted lymphoedema diagnosis and progression.

The impact of radiation on lymphedema: a review of the literature

Radiation therapy (RT) is a common adjunct therapy in oncology. However, it carries a significant risk of lymphedema when utilized in some anatomic locations. Recent studies have provided insight into lymphedema pathophysiology, diagnostic techniques, and RT. This review will examine the role of RT in upper and lower extremity lymphedema. Radiation's role in increasing the risk of lymphedema through decreased lymphatic proliferation potential, interstitial fibrosis compressing lymphatic vessels, and mechanical insufficiency of the lymphatic system will be reviewed.

Lymphedema in survivors of breast cancer

The tremendous improvement of survival in patients with breast cancer can be attributed to several treatment strategies, but these strategies also lead to the occurrence of breast cancer-related lymphedema (BCRL). BRCL is regularly associated with factors such as axillary lymph node dissection and local lymph node radiotherapy and manifests as an increase of >10% in the volume of affected limbs. Being overweight or having obesity (body mass index ≥25 kg/m2), an excessive number of positive lymph nodes (>8) and capsular invasion by a tumor are additional risk factors for lymphedema. It is worth assessing the risk before surgery as this can prevent the occurrence of BCRL at the initial stage of breast cancer management. The clinical utility of many diagnostic tools and lymphedema surveillance allows early stage and even subclinical BCRL to be diagnosed, and allows real-time monitoring of the disease. The early diagnosis of BRCL allows treatment at an early stage, which is beneficial to the reduction of excess limb volume and the improvement of quality of life. At present, the major therapeutic methods of BCRL include complex decongestive therapy, pneumatic compression devices, participating in exercise, microsurgery and liposuction, each of which alleviates lymphedema effectively. No medications for treatment of BRCL have yet been developed. However, the recent findings on the success of molecular therapy in animal models may remedy this deficiency. Furthermore, the volume reduction of swollen limbs without swelling rebound by transplanting autologous stem cells has been successfully reported in some pilot studies, which may provide a new technique for treating BCRL. This review aimed to discuss the pathogenesis, clinical manifestation, risk factors, advantages and disadvantages of diagnostic tools, lymphedema surveillance and the characteristics of traditional and newly emerging BCRL treatments.

Feasibility of Bioimpedance Analysis to Assess the Outcome of Complex Decongestive Therapy in Cancer Treatment-Related Lymphedema

Background: Cancer treatment-related lymphedema (CTRL) affects patients physically, psychologically and emotionally, and remains a significant quality of life issue among patients with cancer. Reliable methods to measure changes in lymphedema are required for early detection, acute intensive treatment, and long-term management. Here, we evaluated the use of bioimpedance analysis (BIA) as a tool to measure lymphedema before and after treatment.

Patients and Methods: Patients with CTRL who were admitted to a secondary university hospital between October 2017 and July 2018 for complex decongestive therapy (CDT) were eligible for this prospective cohort study. Circumferential measure (CM) and BIA were used to evaluate lymphedema at admission (initial) and before discharge (follow-up, FU). Volume was calculated from the CM using the truncated cone formula. The inter-limb ratios (ILRs) of the circumference, volume, and impedance were also calculated as the unaffected limb to affected limb. Each parameter before and after treatment and correlations between parameters also were analyzed.

Results: A total of 29 patients (12 upper- and 17 lower-extremity CTRL) completed were included in this analysis. Absolute value and the ILRs of circumference, volume or impedance, and extracellular water/total body water (ECW/TBW) were significantly improved at FU (p < 0.01, p < 0.05). The initial and FU absolute values, ILRs, ECW/TBW correlated significantly with each other (p < 0.01, p < 0.05). The cutoff values of ECW/TBW for moderate and severe degree of CTRL were 0.3855 and 0.3955, respectively. The changes of ILRs between initial and FU assessments were significantly different among three groups according to lymphedema severity (p < 0.01, p < 0.05).

Conclusions: BIA data correlates significantly with clinical measurement, and therefore can be a practical tool in monitoring outcome measure after lymphedema treatment. In addition, BIA is more sensitive to subtle changes in lymphedema, and therefore can be useful for the long-term maintenance of lymphedema.

Variation in Measurement Results Using Bioimpedance Spectroscopy to Determine Extracellular Fluid of Upper Extremity

Background: The L-Dex U400 is a recently developed measurement device to aid in the clinical assessment of unilateral lymphedema. Until now, little is known about variation in measurement results of the L-Dex U400. The aim of this study was to determine variation in measurement results in determining extracellular fluid of the arm with the L-Dex U400 under different measurement conditions on 2 days and to determine the reliability of these measurements in healthy subjects. Methods and Results: Thirty participants were included. Participants were measured on 2 days, 2 weeks apart. Each day they were measured six times, 1st basic measurement, 2nd after a 10-minute rest period, 3rd second observer, 4th after drinking 200 mL of coffee and rest for 30 minutes on the examination couch, 5th after 30 minutes of cycling on an exercise bike at 50 W and 50-60 rounds per minute, and 6th after a 10-minute rest period. The variance due to participants was 68% of the total variance and 32% was error variance. Lin's concordance coefficient (CCC), a reliability measure, ranged from 0.935 (first day, 1st and 2nd measurement of observer 1) to 0.517 (first and second day after a 10-minute rest period after cycling). In two CCCs, the lower limits of the 95% confidence interval were higher than 0.750. Repeatability coefficient was smallest for the basic observations on day 2 (4.6) and largest after cycling (8.0). Conclusions: Clinical decision-making based on L-Dex U400 measurements should be regarded with caution because of moderate reliability.

Individualising breast cancer treatment to improve survival and minimise complications in older women: a research programme including the PLACE RCT

Background

Over 44,000 women are diagnosed with breast cancer annually in the UK. The research comprised three workstreams (WSs) focused on older women.

Maximising survival

WS1 – to identify the role of older women’s and surgeons’ preferences in cancer treatment decisions and whether comorbidity or fitness for surgery has an impact on survival.

Minimising complications

WS2 – to assess multifrequency bioimpedance (BEA) compared with perometry in identifying women predisposed to develop lymphoedema after axillary node clearance (ANC) surgery. WS3 – to assess, in women at risk of lymphoedema, whether or not applying compression garments prevents the onset of lymphoedema.

Design

WS1 – a prospective, consecutive cohort of surgical consultations with women aged ≥ 70 years with operable breast cancer. Interviews and questionnaire surveys of surgeons’ and women’s perceptions of responsibility for treatment decisions (Controlled Preference Score), effects related to survival and secondary outcomes. WS2 – women undergoing ANC for cancer in 21 UK centres underwent baseline and subsequent BEA, and perometer arm measurements and quality-of-life (QoL) assessments. WS3 – a randomised controlled trial testing standard versus applying graduated compression garments to the affected arm, for 1 year, in WS2 patients developing arm swelling.

Setting

Breast outpatient clinics in hospitals with specialist lymphoedema clinics.

Participants

WS1 – patients aged ≥ 70 years with newly diagnosed, operable, invasive breast cancer. WS2 – women with node-positive cancer scheduled to undergo ANC. WS3 – WS2 participants developing a 4–9% increase in arm volume.

Interventions

WS1 – observational study. WS2 – observational study. WS3 – application of graduated compression garments to affected arm, compared with standard management, for 1 year.

Outcomes

WS1 – self-report and clinically assessed health, QoL, complications and survival. WS2 – perometer and bioimpedance spectroscopy (BIS) measurements, QoL and health utility; and sensitivity and specificity of BIS for detecting lymphoedema compared with perometer arm measurements; in addition, a health economics assessment was performed. WS3 – time to the development of lymphoedema [≥ 10% relative arm-volume increase (RAVI)] from randomisation.

Results

WS1 – overall, 910 women were recruited, but numbers in the substudies differ depending on consent/eligibility. In a study of patient/surgeon choice, 83.0% [95% confidence interval (CI) 80.4% to 85.6%] had surgery. Adjusting for health and choice, only women aged > 85 years had reduced odds of surgery [odds ratio (OR) 0.18, 95%CI 0.07 to 0.44]. Patient role in treatment decisions made no difference to receipt of surgery. A qualitative study of women who did not have surgery identified three groups: ‘patient declined’, ‘patient considered’ and ‘surgeon decided’. In a survival substudy, adjusting for tumour stage, comorbidity and functional status, women undergoing surgery had one-third the hazard of dying from cancer. Serious complications from surgery were low and not predicted by older age. In a substudy of the effect of surgical decision-making on HRQoL, 59 (26%) received preferred treatment decision-making style. In multivariate analyses, change in HRQoL was associated neither with congruence (p = 0.133) nor with receipt of surgery (p = 0.841). In a substudy of receipt of chemotherapy in women aged ≥ 65 years, adjusting for tumour characteristics, health measures and choice, women aged ≥ 75 years had reduced odds of chemotherapy (OR 0.06, 95%CI 0.02 to 0.16). WS2 – lymphoedema by 24 months was detected in 21.4% of women by perometry (24.4% sleeve application) and in 39.4% by BIS. Perometer and BIS measurements correlated at 6 months (r = 0.61). Specificity for sleeve application was greater for perometry (94% CI 93% to 96%) at 24 months, as was a positive predictive value of 59% (95% CI 48% to 68%). Lymphoedema diagnosis reduced QoL scores. Sleeve application in the absence of RAVI of > 9% did not improve QoL or symptoms. A composite definition of lymphoedema was developed, comprising a 9% cut-off point for perometer and self-reported considerable swelling. Diagnostic accuracy was ≥ 94% at 6, 12 and 24 months. WS3 – the PLACE (Prevention of Lymphoedema After Clearance of External compression) trial recruited 143 patients, but recruitment was slow and closed early on the advice of the Independent Data Monitoring Committee. A qualitative substudy identified a number of barriers to recruitment.

Conclusions

Half of older patients felt that they influenced decisions about their treatment. No relationship between decision preference being fulfilled and HRQoL in elderly patients diagnosed with cancer occurred, and older age did not predict complications. Primary surgery reduced the hazard of dying of cancer by two-thirds, independent of age, health and tumour characteristics. Women aged ≥ 75 years have reduced odds of receiving chemotherapy. Lymphoedema (along with a BMI of > 30 kg/m2, cigarette smoking and chemotherapy) reduces QoL. Changes in arm volume of > 9% predicted lymphoedema requiring and benefiting from sleeve application. The PLACE trial qualitative work provides a number of insights into problems of recruitment that were specific to this trial (stigma of compression garments) but that are also generalisable to other RCTs.

Limitations

Both WS1 and WS2 were large, multicentre, UK cohort, observational studies. The WS3 PLACE trial has not reported yet but closed with approximately half of the patients originally planned.

Future work

Research producing objective measures for sleeve prescription in the NHS is required.

Trial registration

Current Controlled Trials ISRCTN48880939.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 7, No. 5. See the NIHR Journals Library website for further project information. Additional support for WS1 came from a Breast Cancer Campaign Grant and a NIHR Postdoctoral Fellowship. ImpediMed (Carslbad, CA, USA;www.impedimed.com) provided bioimpedance L-Dex®machines and electrodes for the study and Sigvaris provided the external compression garments free of charge for the (PLACE) trial.

Easy Volumeter in Detection of Breast Cancer-Related Lymphedema: A Validity Study

Aim and Hypothesis: The standard volumeter is heavy and fragile, and using the same volumeter for different patients can result in hygiene problems. These disadvantages point to the need for the development of a new model of volumeter. The new volumeter put forward in this study is lighter, smaller, sturdier, and easier to clean, while also having its own scale. In this study, the validity of this newly designed volumeter is investigated. Materials and Methods: In the first step, the volume of standard cylinders was measured thrice using a standard volumeter and an easy-measurement volumeter, after which a total of 30 arm volumes of 15 volunteers were measured. In the final stage, the arms of 28 patients with breast cancer-related lymphedema were measured once with both volumeters and the mean results were compared. Results: There was a high degree of consistency between the measured volumes of cylinders of known volume when measured with a standard volumeter and the "Easy volumeter." The measured mean volumes with the two volumeters were assessed with paired sample t-test, resulting in a significance (p value) of 0.927, indicating no difference between the measurements of the two volumeters. The variance of measurement of the devices was assessed with a Levene's test, and the significance (p value) was obtained as 0.981. Based on this result, the null hypothesis cannot be rejected, meaning that there is no difference in the variances of measurements of the two volumeters. Likewise, a paired sample t-test was used to evaluate the differences between the mean measurements of the healthy volunteers group, and no difference was detected between the mean arm volumes measured with each volumeter (significance=0.105). The measurements between the two volumeters were also consistent in the lymphedema patient group (involved arm significance = 0.842 and normal arm significance = 0.075). Conclusion: Our study revealed the validity of the newly designed "Easy Volumeter" for the measurement of arm volumes, indicating its appropriateness for use in daily practice.

Tackling the diversity of breast cancer related lymphedema: Perspectives on diagnosis, risk assessment, and clinical management

Breast cancer related lymphedema (BCRL) develops as a consequence of surgical treatment and/or radiation therapy in a significant number of breast cancer patients. The etiology of this condition is multifactorial and has not yet been completely elucidated. Risk factors include high body mass index, radical surgical procedures (i.e. mastectomy and axillary lymph node dissection), number of lymph nodes removed and number of metastatic lymph nodes, as well as nodal radiation, and chemotherapy. However, these predisposing factors explain only partially the BCRL occurrence, suggesting the possible involvement of individual determinants. Despite the implementation of conservative approaches, BCRL still remains in a proportion of cases an incurable and progressive condition with major physical and psychological implications. To date, diagnostic methods and staging systems lack uniformity, leading to a possible underestimation of the real incidence of this condition, decreasing early detection and thus the possibility of an effective treatment. Several preventive and therapeutic options are available, both conservative and surgical, but are not included in a standardized intervention protocol, tailored on patient's specific characteristics. In this review, we provide a comprehensive overview of the current state-of-knowledge of BCRL management, novel advantages in the assessment of pre-operative evaluation and risk prediction and discuss strengths and weaknesses of diagnostic and treatment strategies currently accessible in clinical practice.

Correlation of L-Dex Bioimpedance Spectroscopy with Limb Volume and Lymphatic Function in Lymphedema

Background: Bioimpedance spectroscopy (BIS) is an established tool for the measurement of extracellular fluid in lymphedema. This study assesses the validity of BIS measurements using the l-Dex^® for evaluating the effectiveness of interventions to treat lymphedema. Measurements are correlated with limb volume, assessment of pitting edema, physiologic measures of lymphatic function, and response to surgical intervention. Three l-Dex BIS metrics are compared. Methods and Results: This retrospective study of prospectively collected data identified consecutive patients with lymphedema. l-Dex BIS measurements, limb volume measurements using perometry, transport index (TI) evaluation using radioisotope lymphoscintigraphy, staging using indocyanine green (ICG) fluorescent lymphography, and clinical evaluation of degree of pitting edema were compared to examine correlations. l-Dex BIS metrics included the l-Dex ratio, absolute difference between the affected and unaffected extremities, and their unadjusted ratio. The study included 26 patients with 70 sets of evaluations. There were significant correlations between the l-Dex ratio and limb volume ratio (LVR) using perometry, the degree of pitting edema, TI evaluation using lymphoscintigraphy, and staging using ICG lymphography. Of the l-Dex BIS metrics, the l-Dex ratio correlated most closely with all measures (ρ = 0.71-0.94, p < 0.0001). Following complete decongestive therapy, the mean decrease in the l-Dex ratio was 48.3% whereas the corresponding mean reduction in limb volume was 13.8% (ρ = 0.19; p = 0.65); subsequent physiological surgery including lymphovenous bypass and vascularized lymph node transfer resulted in an average reduction in l-Dex ratio of 36.1% and mean limb volume reduction of 25.2% (ρ = 0.38; p = 0.27). Conclusions: L-Dex BIS measurements demonstrate face, construct, and criterion validity, and correlate with clinical assessment, LVR, physiologic measures of lymphatic function, and response to conservative and surgical intervention. The L-Dex ratio correlates most closely with all measures and is the recommended metric when using BIS.

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.

Bioelectrical impedance analysis; a new method to evaluate lymphoedema, fluid status, and tissue damage after gynaecological surgery - A systematic review

The aim of this descriptive review is to summarise the current knowledge of non-invasive bioelectrical impedance analysis (BIA) used with gynaecological surgical patients in regard to postoperative development of lymphoedema and determination of perioperative fluid balance, and as a prognostic factor in cancer mortality and a predictor of postoperative complications. The databases PubMed, MEDLINE, Scopus Web of Science, the Cochrane Library, and reference lists of selected articles were searched for relevant articles published during the period January 2008-April 2018. Only papers published in English were retrieved. Thirty-seven articles were evaluated. Where gynaecological studies were lacking, studies with a study population from neighbouring clinical fields were used instead. Studies on the clinical use of BIA with gynaecological surgical patients were divided into three categories: the postoperative development of lower limb lymphoedema (n = 7), perioperative hydration measuring (n = 3), and the BIA parameter phase angle as a prognostic factor in cancer survival and as predictive for postoperative complications (n = 6). Of these 16 studies only three used a pure gynaecological study population. Three different methods of BIA were used in these articles: single frequency-BIA, multifrequency-BIA and bioimpedance spectroscopy. BIA was found to detect lymphoedema with a sensitivity of 73% and a specificity of 84%. Studies indicated that BIA was able to detect lower limb lymphoedema at an early stage even before it became clinically detectable. During postoperative hydration measurements, an increase in extracellular fluid volume and extracellular fluid volume in relation to total body fluid volume, as well as a decrease in phase angle, were associated with higher frequencies of postoperative complications. Moreover, low values for the phase angle have been associated with increased mortality in cancer patients. However, the number of studies in this field was limited. From our review, BIA seems to be a useful tool for use in the clinical setting of the gynaecological surgical patient. The theoretical approach of using bioelectrical impedance values to measure the fluid distribution in the body compartments offers wide opportunities in the clinical setting. However, so far, all studies have set up cut-off limits within the study population, and reference values for a general population need to be defined. There are also rather few studies on a gynaecological study population. Hence, there is a need for further studies within gynaecological surgery focusing on early detection of lower limb lymphoedema, perioperative fluid balance, and postoperative complications in order to establish the value of BIA in clinical praxis.

Preventing Breast Cancer-Related Lymphedema in High-Risk Patients: The Impact of a Structured Surveillance Protocol Using Bioimpedance Spectroscopy

Purpose

We evaluated the impact of structured surveillance using bioimpedance spectroscopy (BIS) to reduce the rate of chronic breast cancer-related lymphedema (BCRL) in high-risk patients undergoing axillary lymph node dissection (ALND).

Methods

From April 2010 through November 2016, 93 patients who underwent ALND were prospectively monitored with BIS using L-Dex. Intervention for an L-Dex increase of >10 consisted of applying an over the counter (OTC) sleeve followed by re-evaluation after 4 weeks. The utilization of complex decongestive physiotherapy (CDP) represented a surrogate for chronic BCRL.

Results

Median follow-up was 24 months. 55% of patients received taxane-based chemotherapy, 24% received some form of axillary irradiation (includes additional fields or high tangents) and 66% had an elevated body mass index (BMI) with the median number of nodes removed being 19. Overall, 75% of these patients had at least one additional high-risk feature (taxane chemotherapy, axillary radiation, elevated BMI), 48% had at least two, and 6% had all. Thirty-three patients (35.4%) developed an elevated L-Dex score with only 10 (10.8%) requiring CDP (30.3% of those undergoing treatment with sleeve). At last follow-up, only three patients (3%) had unresolved BCRL.

Conclusion

The results of this analysis support previous data regarding prospective BCRL surveillance and early intervention using BIS. With this approach, only 3% of patients have chronic BCRL.

Diagnostic accuracy of bioimpedance spectroscopy in patients with lymphedema: A retrospective cohort analysis

BACKGROUND

Bioimpedance spectroscopy (BIS) is used by healthcare specialists to diagnose lymphedema. BIS measures limb fluid content by assessing tissue resistance to the flow of electric current. However, there is debate regarding the validity of BIS in diagnosing early lymphedema. Indocyanine green (ICG) lymphography has been established as the most accurate diagnostic modality to date for lymphedema diagnosis. In this retrospective study, we test the sensitivity, specificity, and diagnostic accuracy of BIS in diagnosing lymphedema by referencing its results with ICG lymphography.

METHODS

Patients presented to the University of Iowa Lymphedema Center from 2015 to 2017 were evaluated with a standardized protocol that included history and physical examination, a validated lymphedema-specific quality-of-life assessment (LYMQOL), circumference -measurement-based index, BIS, and ICG lymphography. Diagnostic accuracy of BIS was assessed using ICG lymphography as a reference test.

RESULTS

Fifty-eight patients had positive ICG lymphography results, which confirmed the diagnosis of lymphedema. ICG lymphographic findings consistently correlated with clinical examination, LYMQOL evaluation, and lymphedema indices. By contrast, BIS demonstrated a false-negative rate of 36% - 21 out of 58 patients had normal BIS readings, but a positive ICG lymphography result. The 21 false-negative results occurred in patients with early-stage disease. Sensitivity and specificity for BIS were 0.64 and 1, respectively.

CONCLUSION

BIS carries an excessively high rate of false-negative results to be dependably used as a diagnostic modality for lymphedema. ICG lymphography highly correlates with other tracking modalities, and it remains the most reliable tool for diagnosing lymphedema.

Edema Areas of Calves Measured with Magnetic Resonance Imaging as a Novel Indicator for Early Staging of Lower Extremity Lymphedema

BACKGROUND

Staging of lower extremity lymphedema (LEL) is difficult in clinical work. The excellent soft tissue contrast of magnetic resonance imaging (MRI) enables soft tissue changes to be feasibly and reproducibly characterized and distinguished.

AIM

To determine whether cross-section areas of edema calves measured with MRI could be useful for staging of the LEL.

MATERIALS AND METHODS

We recruited 138 participants who were clinically diagnosed with LEL: 61 unilateral and 77 bilateral LEL. Two legs underwent different stages of LEL. Fourteen characters are diagnosed without LEL; we assumed them as stage 0; age-matched 54, 59, and 54 lower extremities had the LEL, which are classified as stages 1, 2, and 3, respectively. On fat-suppressed T2-weighted mid-axial images of calves, the total area of the soft tissue (TA), muscle area (MA), and the water area (WA) of subcutaneous tissue of the bilateral claves were measured and analyzed statistically for staging of LEL. The difference of TA (DTA) of the unilateral LEL was also analyzed.

RESULT

TA and DTA showed statistical differences among each stage (p < 0.0001), except that it was challenged in making off stages 0 and 1 (p > 0.05). No significant difference was found among four stages of LEL in MA. WA was able to display the perfect sensitivity to lymphedema appearance (p < 0.0001, sensitivity = 100%).

CONCLUSION

The WA of the calves could be suggested as a specific indicator for diagnosis of LEL. TA and DTA are the secondary indicators for staging of LEL.

Segmental Bioimpedance Informs Diagnosis of Breast Cancer-Related Lymphedema

BACKGROUND

Detection of lymphedema, particularly its mild stage, is clinically challenging. The aim of this study was to determine whether segmental bioimpedance spectroscopy (BIS) provided additional information to whole arm BIS in assessing women with or at risk of lymphedema following breast cancer.

METHODS AND RESULTS

Participants (n = 66), aged 61.6 ± 10.5 years (mean ± standard deviation [SD]), were grouped according to lymphedema status: (1) at-risk (n = 24) had no indicators of lymphedema and (2) lymphedema (n = 42) were suspected to be developing lymphedema or had previously met lymphedema diagnostic criteria and undergone treatment. For each upper limb, impedance was measured for the whole arm, hand and four 10 cm segments of the arm, commencing at the ulnar styloid. Interlimb impedance ratios for corresponding locations were calculated and compared to previously determined, normatively based thresholds based on 2SD and 3SD above the mean. Segmental BIS classified 19% more women with lymphedema than 3SD whole arm thresholds and the same number as 2SD whole arm thresholds. Segmental BIS identified localized lymphedema and patterns in lymphedema distribution that were undetectable by whole arm BIS. Neither 3SD whole arm nor segmental BIS thresholds found lymphedema where it was not present; however, 2SD whole arm thresholds alone classified one woman in the at-risk group as having lymphedema.

CONCLUSION

Segmental BIS classified as many or more cases of lymphedema than whole arm BIS thresholds without finding lymphedema where it was likely not present while also providing additional information regarding the distribution of lymphedema within the limb.

Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of the American Physical Therapy Association

The Oncology Section of the American Physical Therapy Association (APTA) developed a clinical practice guideline to aid the clinician in diagnosing secondary upper quadrant cancer-related lymphedema. Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in the diagnostic process. Overall clinical practice recommendations were formulated based on the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility. In an effort to maximize clinical applicability, recommendations were based on the characteristics as to the location and stage of a patient's upper quadrant lymphedema.

Diagnosis of Upper-Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of APTA

INTRODUCTION

The Oncology Section of APTA developed a clinical practice guideline to aid the clinician in diagnosing secondary upper-quadrant cancer-related lymphedema.

METHODS

Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in their diagnostic process. Overall, clinical practice recommendations were formulated on the basis of the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility.

RECOMMENDATIONS

In an effort to make these clinically applicable, recommendations were based on the characteristics as to the location and stage of a patient's upper-quadrant lymphedema.