Intra- and Interrater Reliability and Concurrent Validity of a New Tool for Assessment of Breast Cancer-Related Lymphedema of the Upper Extremity

Ultrasound Examination of Skin, Fasciae and Subcutaneous Tissue: Optimizing Rehabilitation for Secondary Upper Limb Lymphedema

BACKGROUND

Lymphedema represents a frequent cause of disability for patients undergoing oncological treatments and, being a chronic, non-reversible pathology, requires targeted and continuous rehabilitation treatments. To date, the studies available on the use of ultrasound in patients with lymphedema mainly report descriptive data; therefore, with this study, we wanted to describe in a more objective way the typical ultrasound alterations found in these patients, measuring the thickness of the different superficial structures, and defining subcutis echogenicity.

METHODS

14 patients affected by secondary lymphedema of the upper limbs were enrolled in this cross-sectional observational study (12 had breast cancer and 2 with melanoma as their primary diagnosis). All patients were classified as stage II according to the ISL classification. Patients were examined between March and July 2023 with a clinical and an ultrasound evaluation. Ultrasound evaluation was performed following a protocol and took into consideration thickness of the cutis, subcutis, superficial and deep fascia, and subcutis echogenicity.

RESULTS

The cutis of the affected limbs was thicker in the distal anterior region of the arm and throughout the anterior region of the forearm. The subcutaneous tissue was thicker in the posterior region of the distal arm and throughout the forearm, including the dorsum of the hand and excluding only the proximal posterior region of the forearm. Fascial structures did not demonstrate statistically significant differences in thickness between pathological and healthy limbs, despite undergoing significant changes from a qualitative point of view (loss of the trilaminar skin appearance and the development of anechoic areas due to fluid accumulation around the hyperechoic adipose lobule). A statistically significant difference in the echogenicity of subcutaneous tissue was found at the distal anterior region of the arm and at the entire anterior forearm.

CONCLUSIONS

High-resolution ultrasound has been confirmed to be a tool capable of supporting the diagnosis of lymphedema and identifying the most compromised regions of the limb. A tailored rehabilitation plan can be developed based on the non-uniform alterations in subcutaneous tissue, where some areas are affected earlier than others. This compartmentalization should be considered in lymphedema staging and management. Ultrasound may provide early detection of these changes, guiding a more precise therapeutic approach.

Body Mass Index and Breast Cancer-Related Lymphedema: A Retrospective Cohort Study

OBJECTIVE

This study aims to evaluate the association between body mass index (BMI) and the incidence of breast cancer-related lymphedema (BCRL).

METHODS

This retrospective cohort study analyzed data from 1464 breast cancer patients treated at The Third Hospital of Nanchang between 2018 and 2021. Patients were categorized based on BMI (<25, 25 to < 30, ≥ 30 kg/m²). Variables such as axillary lymph node dissection, infections, radiotherapy, and comorbidities were taken into account.

RESULTS

The incidence of BCRL was 23.4%. Higher BMI was associated with increased risk of BCRL, with significant incidence rates observed at 1, 2, and 3 years in the higher BMI groups. Multivariate analysis confirmed BMI as an independent risk factor for BCRL.

CONCLUSION

Elevated BMI is associated with increased BCRL risk and decreased BCRL-free survival, underscoring the significance of weight management in breast cancer care.

Accuracy of Infrared Thermography in Diagnosing Breast Cancer-Related Lymphedema

Background/Objectives: Infrared thermography (IRT) is an imaging technique used in clinical practice to detect changes in skin temperature caused by several dysfunctions, including breast cancer-related lymphedema (BCRL). Thus, the present study aimed to assess the reproducibility and accuracy of IRT in diagnosing BCRL. Methods: This cross-sectional study included participants who underwent a unilateral mastectomy and used indirect volumetry for lymphedema detection. IRT analysis was recorded in four positions, analyzing maximum, mean, and minimum temperatures, as well as the temperature differences between the upper limbs. The analysis encompassed reliability, agreement, accuracy, and the establishment of cut-off points for sensitivity and specificity. A total of 88 upper limbs were included; 176 thermograms were captured, and 1056 regions of interest were analyzed. Results: IRT presented excellent intra- and inter-rater reproducibility and reliability with excellent intraclass correlation coefficient values (0.99 to 1.00). In addition, this assessment reached a sensitivity of 85% and a specificity of 56%; the cut-off point considered a temperature difference of -0.45 °C. Conclusions: IRT was a reliable and reproducible assessment, and the temperature difference between the upper limbs evidenced moderate accuracy. Thus, IRT is recommended as a complementary technique for detecting BCRL.

Utilization of Noncontrast Magnetic Resonance Lymphangiography for Selection of Effective Surgical Method in Breast Cancer-Related Lymphedema

Background and Objectives: When considering surgery for patients with breast cancer-related lymphedema (BCRL), it is crucial to determine which surgery will be most effective for the patient and establish the indications for each surgery. Our study retrospectively compared the results of preoperative noncontrast MR lymphangiography (NMRL) performed on the lymphedematous limb of patients before surgery, with the aim of analyzing whether preoperative NMRL can be used as a criterion for determining the type of surgery. Materials and Methods: From January 2020 to June 2022, a total of 138 patients with lymphedema underwent surgery at Seoul National University Bundang Hospital. All patients underwent preoperative NMRL imaging and were classified into stages 1-3 based on the MRI severity index using the authors' previous reference. Three types of surgery, LVA, LVA + liposuction, and LVA + VLNT, were conducted on all patients. The effectiveness of the surgery was evaluated one year postoperatively using the interlimb volume difference before and after surgery, the fluid volume of the edematous limb measured by bioimpedance spectroscopy, and the subjective satisfaction of the patients through the Lymph Q questionnaire. Results: In this study, out of a total of 138 patients, 26 (19%) were MRI stage 1, 62 (45%) were stage 2, and 50 (36%) were stage 3. Of the 83 patients who underwent LVA surgery, the greatest decrease in interlimb volume difference was observed in stage 2 patients, and subjective satisfaction was also the most effective in stage 2. In the case of LVA + liposuction patients, a significant volume decrease and a high satisfaction were observed in stage 3 patients. In the case of LVA + VLNT patients, there was no difference in volume decrease according to the stage, but a greater decrease in body fluid volume was observed as the MRI severity index score increased through BIA. Conclusions: In conclusion, this study demonstrates that NMRL imaging is a useful modality for determining the most effective surgical method and predicting the surgical outcome in patients with lymphedema. This highlights the importance of using NMRL in the treatment planning of lymphedema patients.

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.

Integrating Symptoms Into the Diagnostic Criteria for Breast Cancer-Related Lymphedema: Applying Results From a Prospective Surveillance Program

OBJECTIVE

The objectives of this study were to determine whether patients reporting symptoms are more likely to develop lymphedema and to describe the temporal relationship between symptom onset and lymphedema.

METHODS

This was a prospective longitudinal cohort study of 647 women treated for breast cancer and screened for lymphedema using arm volume measurements and subjective questionnaires (n = 647; 2284 questionnaires [median 3.5 per patient, range = 1-24]). Primary study outcome was lymphedema (relative volume change ≥10%). The Kaplan-Meier method was used to estimate cumulative lymphedema incidence. Cox proportional hazards models were used to assess the relationship between symptoms, other risk factors, and lymphedema.

RESULTS

A total of 64 patients (9.9%) developed lymphedema. On multivariable analysis, patients reporting increased arm size (hazard ratio = 3.09, 95% CI = 1.62-5.89) were more likely to progress to lymphedema than those who did not report this symptom. Of those who developed lymphedema, 37 (58%) reported an increased arm size a median of 6.1 months before lymphedema onset (range = 68.6 months before to 50.2 months after lymphedema onset).

CONCLUSION

Patients at risk of lymphedema who report increased arm size might do so prior to lymphedema onset and are at 3 times the risk of lymphedema as patients not reporting this symptom. Even without objective or observable edema, these patients should be followed vigilantly and considered for early intervention. Symptoms should be incorporated into screening and diagnostic criteria for lymphedema.

IMPACT

This study shows that patients at risk for breast cancer-related lymphedema who report increased arm size should be considered at high risk for progression to lymphedema-even without edema on measurement or clinical examination-and should be followed vigilantly, with consideration of early intervention.

LAY SUMMARY

If you are at risk of lymphedema and you feel as though your arm size has increased, you might develop lymphedema, and you are at 3 times the risk of lymphedema as patients not reporting this symptom. Even without measurable or observable edema, you should be followed vigilantly and consider early intervention.

Features, Predictors, and Treatment of Breast Cancer-related Lymphedema

Purpose of review

Breast cancer-related lymphedema (BCRL) is a common sequelae among breast cancer survivors. This review provides updated information on recent studies to prevent, diagnose, and actively treat women with BCRL.

Recent findings

In total, 63 articles were identified from 2015 and 2020 that assessed incidence, risk factors, surveillance, measurement and definition, treatment, and awareness of BCRL. Depending on the approach and timing of assessment, BCRL incidence rates ranged from 9.1% to 39%. Modified radical mastectomy, number of positive lymph nodes, and postoperative complications were linked to BCRL risk, in addition to chemotherapy, radiation, axillary lymph node dissection, advanced cancer stage, and higher body mass index. Early detection showed favorable BCRL outcomes (e.g., severity, symptoms). Exercise, self-management, complete decongestive therapy, bandaging, and surgery had positive effects on BCRL outcomes.

Summary

Numerous gaps exist within BCRL literature, such as the value of self-reported surveillance options to identify BCRL early, measurement strategies, and definitions of BCRL. In terms of policies, efforts are needed to educate providers, patients, payers, and legislators about the need for consensus to reduce the burden of BCRL in women being treated for breast cancer.

Effect of Home-Based Exercise and Weight Loss Programs on Breast Cancer-Related Lymphedema Outcomes Among Overweight Breast Cancer Survivors: The WISER Survivor Randomized Clinical Trial

Importance

To our knowledge, no randomized clinical trials have assessed the effects of the combination of weight loss and home-based exercise programs on lymphedema outcomes.

Objective

To assess weight loss, home-based exercise, and the combination of weight loss and home-based exercise with clinical lymphedema outcomes among overweight breast cancer survivors.

Design, Setting, and Participants

This randomized clinical trial (Women in Steady Exercise Research [WISER] Survivor clinical trial ) of 351 overweight breast cancer survivors with breast cancer-related lymphedema (BCRL) was conducted in conference rooms at academic and community hospitals and in the homes of participants from March 12, 2012, to May 28, 2016; follow-up was conducted for 1 year from the start of the intervention. Statistical analysis by intention to treat was performed from September 26, 2018, to October 28, 2018.

Interventions

A 52-week, home-based exercise program of strength/resistance training twice per week and 180 minutes of walking per week, a weight loss program of 20 weeks of meal replacements and 52 weeks of lifestyle modification counseling, and a combination of the home-based exercise and weight loss programs.

Main Outcomes and Measures

The 12-month change in the percentage of interlimb volume difference.

Results

Of 351 participants, 90 were randomized to the control group (facility-based lymphedema care with no home-based exercise or weight loss intervention), 87 to the exercise intervention group, 87 to the weight loss intervention group, and 87 to the combined exercise and weight loss intervention group; 218 (62.1%) were white, 122 (34.8%) were black, and 11 (3.1%) were of other races or ethnicities. Median time since breast cancer diagnosis was 6 years (range, 1-29 years). Mean (SD) total upper extremity score changes from the objective clinical evaluation were -1.40 (11.10) in the control group, -2.54 (13.20) in the exercise group, -3.54 (12.88) in the weight loss group, and -3.84 (10.09) in the combined group. Mean (SD) overall upper extremity score changes from the self-report survey were -0.39 (2.33) in the control group, -0.12 (2.14) in the exercise group, -0.57 (2.47) in the weight loss group, and -0.62 (2.38) in the combined group. Weight loss from baseline was -0.55% (95% CI, -2.22% to 1.11%) in the control group, -8.06% (95% CI, -9.82% to 6.29%) in the combined group, -7.37% (95% CI, -8.90% to -5.84%) in the weight loss group, and -0.44% (95% CI, -1.81% to 0.93%) in the exercise group.

Conclusions and Relevance

Study results indicate that weight loss, home-based exercise, and combined interventions did not improve BCRL outcomes; a supervised facility-based program of exercise may be more beneficial than a home-based program for improving lymphedema outcomes.

Trial Registration

ClinicalTrials.gov identifier: NCT01515124.