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

Efficacy of complex decongestive therapy on venous flow, internal saphenous diameter, edema, fat mass of the limbs and quality of life in patients with chronic venous insufficiency: A randomized clinical trial

OBJECTIVE

Demonstrate the effectiveness of complex decongestive therapy (CDT) in patients with chronic venous insufficiency (CVI).

METHODS

A single-blind randomized controlled trial was conducted, where the participants were patients with CVI (n = 21/42) were assigned randomly to an experimental group (n = 11/22) or a control group (n = 9/18). A treatment of CDT (manual lymphatic drainage, intermittent pneumatic presotherapy, bilayer bandage) was applied to the experimental group for 4 weeks 2 days per week and no treatment was applied to the control group. The patients were evaluated at baseline (t0), 1 week after finishing the intervention (t1), and 6 weeks after the intervention (t2). The effectiveness of the treatment on symptoms and quality of life (QoL) (heaviness, pain and Chronic Venous Insufficiency Quality of Life [CIVIQ-20] questionary), edema, venous flow, and impedanciometry measurements was evaluated.

RESULTS

An improvement in the patient's QoL was observed: there was a decrease in symptoms such as heaviness and pain, an increase in the average velocity of the left femoral vein and left internal saphenous vein (ISV), a decrease in the ISV diameter in both extremities and a decrease in body mass index and fat mass in both extremities. These results were maintained when following up at 6 weeks, except for the improvement of QoL.

CONCLUSIONS

CDT treatment improves the CIVIQ-20 and Venous Clinical Severity Scores. It also improves symptoms (pain and heaviness), venous flow velocity (superficial veins and deep veins [common femoral vein, femoral vein, popliteal vein]) and decreases body mass index, fat mass, and ISV diameter.

Effectiveness of complete decongestive therapy for upper extremity breast cancer-related lymphedema: a review of systematic reviews

Breast cancer-related lymphedema (BCRL) remains a challenging condition impacting function and quality of life. Complete decongestive therapy (CDT) is the current standard of care, necessitating a comprehensive review of its impact. This paper presents a systematic review (SR) of SRs on CDT's efficacy in BCRL, and the components of manual lymph drainage (MLD) and exercise. A literature search yielded 13 SRs published between January 2018 and March 2023 meeting inclusion criteria, with varied quality ratings based on the AMSTAR II. A sub-analysis of CDT investigated the within group effect size estimations on volume in different stages of lymphedema. While a moderate quality SR indicated support for CDT in volume reduction, other SRs on the topic were of critically low quality. Larger effect sizes for CDT were found for later stage BCRL. The impact of MLD as a component of CDT demonstrated no additional volume benefit in a mix of moderate to low quality SRs. Similarly, exercise's role in volume reduction in CDT was limited, although it demonstrated some benefit in pain and quality of life. A rapid review of trials published January 2021-March 2023 reinforced these findings. Variability in CDT delivery and outcomes remained. These findings underscore the need to standardize staging criteria and outcome measures in research and practice. Future research should focus on refining interventions, determining clinically important differences in outcomes, and standardizing measures to improve evidence-based BCRL management. Current evidence supports CDT's efficacy in BCRL. MLD and exercise as components of CDT have limited support for volume reduction.

New insights in breast cancer-related lymphedema

Upper limb lymphedema after breast cancer treatment including axillary dissection occurs in almost 20% of women. Its treatment consists of complete decongestive physiotherapy based on low-stretch bandage to reduce volume, followed by elastic compression to maintain it. In this article, we will detail recent data on lymphedema risk factors with possible genetic predisposition, prevention (surgical, compression), manual lymphatic drainage, physical activity, weight, advice, and treatments including gene therapy.

Short-Term Effects Of Dry Heat Treatment (Fluidotherapy) In The Management Of Breast Cancer Related Lymphedema: A Randomized Controlled Study

BACKGROUND

To investigate whether fluidotherapy added to complete decongestive therapy (CDT) would provide additional contribution to edema reduction in patients with breast cancer related lymphedema (BCRL).

MATERIAL AND METHODS

Thirthy-two patients with unilateral BCRL were randomly divided into 2 groups: standard treatment with CDT only (Group 1) and CDT + fluidotherapy (Group 2). All patients underwent phase 1 CDT, which included manual lymphatic drainage, multilayer bandaging, supervised exercises and skin care for a total of 15 sessions, 5 times a week for 3 weeks. Only Group 2 received a total of 15 sessions application of fluidotherapy. Before and after CDT, patients were evaluated for extremity volumes and excess volumes, according to circumferencial measurements of the extremity. Arm pain was evaluated with Visual Analaogue Scale (VAS-Pain).

RESULTS

Seventeen patients in Group 1 and 15 patients in Group 2 completed the study. Patients' demographic data and volume measurements were similar at the beginning of the treatment. Limb volumes of both groups were significantly reduced after treatment (P < .001 for both group). Pain significantly decreased (P = .001 for both group). No adverse reactions were recorded. The mean change in volume measurements and VAS-Pain scores of patients in CDT+fluidotherapy group before and after treatment were significantly higher than those in only CDT group (P = .028, P = .020 respectively).

CONCLUSION

Fluidotherapy added to CDT reduced pain and edema severity more than standard CDT in the patients with BCRL. As a noninvasive, novel, and effective method, fluidotherapy may be a promising treatment modality for the treatment of lymphedema.

Development of a core outcome set for breast cancer-related lymphedema: a Delphi study

PURPOSE

For breast cancer survivors (BCS) living with breast cancer-related lymphedema (BCRL), what outcome domains (OD) should be measured to assess the burden of the disease and efficacy of interventions? A Core Outcome Set (COS) that promotes standardized measurement of outcomes within the constraints of time influenced by work environments is essential for patients and the multidisciplinary professionals that manage and research BCRL.

METHODS

Using Delphi methodology, a multidisciplinary group of BCRL experts (physical and occupational therapists, physicians, researchers, physical therapist assistants, nurses, and massage therapist) completed two waves of online surveys. BCRL expert respondents that completed the first survey (n = 78) had an average of 26.5 years in practice, whereas, respondents who completed the second survey (n = 33) had an average of 24.9 years. ODs were included in the COS when consensus thresholds, ranging from 70% to 80%, were met.

RESULTS

A total of 12 ODs made up the COS. Reaching a minimum consensus of 70%; volume, tissue consistency, pain, patient-reported upper quadrant function, patient-reported health-related quality of life, and upper extremity activity and motor control were recommended at different phases of the BCRL continuum in a time-constrained environment. Joint function, flexibility, strength, sensation, mobility and balance, and fatigue met an 80% consensus to be added when time and resources were not constrained.

CONCLUSION

The COS developed in this study thoroughly captures the burden of BCRL. Using this COS may reduce selective reporting, inconsistency in clinical use, and variability of reporting across interdisciplinary healthcare fields, which manage or research BCRL.

The Role of Inflammation in Lymphedema: A Narrative Review of Pathogenesis and Opportunities for Therapeutic Intervention

Lymphedema is a chronic and progressive disease of the lymphatic system characterized by inflammation, increased adipose deposition, and tissue fibrosis. Despite early hypotheses identifying lymphedema as a disease of mechanical lymphatic disruption alone, the progressive inflammatory nature underlying this condition is now well-established. In this review, we provide an overview of the various inflammatory mechanisms that characterize lymphedema development and progression. These mechanisms contribute to the acute and chronic phases of lymphedema, which manifest clinically as inflammation, fibrosis, and adiposity. Furthermore, we highlight the interplay between current therapeutic modalities and the underlying inflammatory microenvironment, as well as opportunities for future therapeutic development.

[Update of indications and techniques for the management of lymphedema after breast cancer surgery]

OBJECTIVES

Upper limb lymphedema secondary to breast cancer treatment is the leading cause of lymphedema in France. Despite improved surgical practices and de-escalation of radiotherapy, the risk of lymphedema after breast cancer still affects 5-20% of patients, with this variation depending on the measurement method used and the population studied. Lymphedema has a negative impact on quality of life and body image, and their possible occurrence remains a major concern for all women treated for breast cancer. The Sénologie Commission of the Collège national des gynécologues et obstétriciens français (CNGOF) asked four specialists in breast surgery or lymphology to prepare a summary on the prevention, medical and surgical management of lymphedema after breast cancer treatment, and to discuss the medical and surgical innovations currently being evaluated.

METHODS

This synthesis was based on national and international guidelines on the management of upper limb lymphedema after breast surgery and a recent review of the literature focusing on the years 2020-2023.

RESULTS

From a preventive point of view, the restrictive instructions imposed for a long time (reduction in physical activity or the carrying of loads, air travel, exposure to the sun or cold, etc.) have altered patients' quality of life and should no longer be recommended. A good understanding of risk factors enables us to target preventive actions. Examples include obesity, a sedentary lifestyle, axillary clearance, radiotherapy of the axillary fossa in addition to axillary clearance, total mastectomy, taxanes or anti-HER-2 therapies in the adjuvant phase. Resumption of physical activity, minimally invasive axillary surgery, de-escalation of radiotherapy and breast-conserving surgical procedures have all demonstrated their preventive value. When lymphedema does occur, early management, through complete decongestive physiotherapy, can help reduce its volume and prevent its long-term worsening.

CONCLUSION

Surgical (lymph node transplants, lympho-vascular anastomoses) and medical (prolymphangiogenic growth factors) approaches to lymphedema treatment are numerous, but require long-term evaluation of their efficacy and adverse effects.

Application of complete decongestive therapy after lymphaticovenular anastomosis of the lower limb combined with liposuction-A retrospective study research

BACKGROUND

Complete decongestive therapy (CDT) is a conservative treatment for lymphedema that combines interventions and lifestyle changes. We evaluated the application of CDT after lymphaticovenular anastomosis (LVA) of the lower limb combined with liposuction.

METHODS

A total of 55 patients who underwent LVA of the lower limb combined with liposuction from January 2021 to July 2022 were enrolled in the study. The patients were divided into groups A (n = 24) and B (n = 31) according to whether they adhered to CDT treatment during the 12-month follow-up. Group A was the non-adherence CDT group and Group B was the adherence CDT group. Lower Extremity Lymphedema Index (LELI) and Lymphoedema Functioning, Disability, and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL) were used as prognostic indicators to observe the remission of postoperative lymphedema symptoms in the two groups.

RESULTS

At 6-month and 12-month follow-up, LELI and the score of Lymph-ICF-LL in group B and group A were lower than before the operation (p < .05). The circumference of the affected limb was reduced, and the quality of life was improved in both groups after the operation. The reduction of LELI and Lymph-ICF-LL in group B was higher than in group A, and the difference was statistically significant (p < .05).

CONCLUSION

This study preliminarily proves the effectiveness of CDT after LVA of the lower limb combined with liposuction, which can maintain and strengthen the surgical effect. Further, CDT treatment is still needed after the operation, which is necessary to reduce the circumference of the affected limb and improve patients' quality of life.

Static and Dynamic Imbalance in Patients with Breast Cancer-Related Lymphedema

Background: Breast cancer-related lymphedema (BCRL) was associated with postural imbalance, but the immature knowledge introduced debate about which component of the balance was affected by BCRL in the literature. The aim of this study was to determine the static and dynamic balance of patients with BCRL in comparison with healthy subjects. Methods and Results: This case-control designed study recruited 30 BCRL patients and 30 healthy individuals. The demographic and clinical variables of the subjects were recorded. The static balance stability parameters on four conditions (eyes opened-stable ground, eyes closed-stable ground, eyes opened-unstable ground, eyes closed-unstable ground) and dynamic stability of all participants were evaluated. The values of both stable ground conditions were similar between the groups (p < 0.05). However, values of both eyes opened-unstable ground (p = 0.032) and eyes closed-unstable ground (p = 0.034) conditions were significantly impaired in BCRL in comparison with controls. Besides, comparison of sway area of the opened versus closed eyes conditions on unstable ground (p = 0.036), and movement speed while correcting the center of pressure on unstable ground (with opened and closed eyes, p = 0.014 and p = 0.004 respectively) revealed increased values in the BCRL group. Likewise, the dynamic stability was significantly disrupted in the BCRL group (p = 0.043). Conclusion: Closing eyes did not affect the postural balance in patients with BCRL, whereas the deterioration of ground altered the balance significantly in the BCRL group compared with healthy subjects. We suggest the inclusion of balance exercises and guidance for selection of correct shoes and insoles in routine lymphedema rehabilitation program.

Risk of Lymphedema and Death after Lymph Node Dissection with Neoadjuvant and Adjuvant Treatments in Patients with Breast Cancer: An Eight-Year Nationwide Cohort Study

Knowledge on the impact of neoadjuvant and adjuvant treatments on post-surgery lymphedema (LE) in patients with breast cancer is limited due to methodological limitations and an insufficient sample size. We investigated the risk of LE in patients going through long-term anticancer treatment regimens using a national cohort from the Korean National Health Insurance Service database from 2011-2013. Incidence rate ratio, Kaplan-Meier analysis, and Cox proportional regression analysis were performed. A total of 39,791 patients were included. While minimal lymph node dissection (SLNB) reduced the risk of LE (hazard ratio [HR] 0.51) as expected, neoadjuvant chemotherapy (NAC) followed by SLNB did not reduce the risk. Adjusting for adjuvant chemotherapy (AC) as time-varying exposure decreased the risk of LE in the SLNB group (HR 0.51), but not the mortality risk (HR 0.861). A longer duration of NAC, especially taxane-based, combined with SLNB reversed the effect and increased risk of LE. The findings highlight the importance of not only early surveillance before and after surgery, but also long-term surveillance during adjuvant treatment by surgeons and oncologists in order to reduce the risk of LE.

Effects of scapulothoracic stabilization exercises on scapular function, posture, and balance in lymphedema after mastectomy: a randomized controlled trial

This study aimed to investigate the effects of scapulothoracic stabilization exercises (SSE) on scapular function, posture, and balance in women with lymphedema after mastectomy. The patients were randomly divided into two groups as complex decongestive physiotherapy (CDP) (n: 12; age: 55.25 ± 8.17 years) and CDP+SSE (n: 13; age: 54.38 ± 9.08 years). While only CDP was applied in the CDP group, CDP and SSE were applied in the CDP+SSE group. Scapulothoracic muscle strength with dynamometer, scapular endurance with Scapular Isometric Compression Test, scapular dyskinesia with Lateral Scapular Slide Test, thoracic posture with inclinometer, general posture with New York Posture Scale, and balance with Mini-BESTest were evaluated before the 3-week treatment phase (TP), after the TP, and after the fifth week of the maintenance phase (MP). Improvements in the lower trapezius muscle strength were found in both groups after the TP (p < .05). In addition, the middle trapezius muscle strength and general posture improved more in the CDP+SSE group than in the CDP group after the TP (p < .05). In the MP, scapulothoracic muscle strength, scapular endurance, and general posture improved more in CDP+SSE group compared to the CDP group (p < .05). In upper extremity lymphedema patients, incorporating additional SSE in CDP may contribute to the improvement of posture and scapular functions.

What do we know about treating breast-cancer-related lymphedema? Review of the current knowledge about therapeutic options

Breast-cancer-related lymphedema (BCRL) is a common consequence of oncological treatment. Its management is a complicated, chronic, and arduous process. Therapeutic options can be divided on non-surgical and surgical methods, although there is still no clear consensus about their effectiveness in preventing or stopping the disease. That brings problems in everyday practice, as there are no guidelines about proper time for starting therapy and no agreement about which management will be beneficial for each patient. The aim of this review is to summarize current knowledge about possible treatment choices, non-surgical so as surgical, indicate knowledge gaps, and try to direct pathways for future studies.

Technical aspects and validation of custom digital algorithms for hand volumetry

BACKGROUND

Establishing baseline measurements on normative data is essential to evaluate standards of care and the impact of clinical or surgical treatments. Hand volume determination is relevant in pathological conditions where the anatomical structures might undergo modifications like post-treatment chronic edema. For example, one of the consequences of breast cancer treatment is the possibility of developing uni-lateral lymphedema on the upper limbs.

OBJECTIVE

Arm and forearm volumetrics are well-studied techniques, whereas hand volumetry computation poses several challenges both from the clinical and digital perspectives. The current work has explored routine clinical and customized digital methodologies for hand volume appraisal on healthy subjects.

METHODS

Clinical hand volumes computed by water displacement or circumferential measurements were compared to digital volumetry calculated from 3D laser scans. Digital volume quantification algorithms exploited the gift wrapping concept or cubic tessellation of acquired 3D shapes. This latter digital technique is parametric, and a calibration methodology to define the resolution of the tessellation has been validated.

RESULTS

Results on a group of normal subjects demonstrated that the volumes computed from digital hand representations extracted by tessellation return values similar to the clinical water displacement volume assessment at low tolerances.

CONCLUSIONS

The current investigation suggested that the tessellation algorithm could be considered a digital equivalent of water displacement for hand volumetrics. Future studies are needed to confirm these results in people with lymphedema.

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.