Different physical treatment modalities for lymphoedema developing after axillary lymph node dissection for breast cancer: A review

Lymphoscintigraphy as a Therapeutic Guidance Tool Can Improve Manual Lymphatic Drainage for the Physical Treatment of Patients with Upper Limb Lymphedema: Randomized Clinical Trial

Background: The purpose of this study was to measure the effects of lymphoscintigraphically guided manual lymphatic drainage (LG-MLD) and to compare it with standardized manual lymphatic drainage (St-MLD). Materials and Methods: Fifty-two patients with lymphedema of the upper limb who underwent lymphoscintigraphy were randomly allocated into two groups. Following the phase of physical activity, the control group underwent two phases of St-MLD as the experimental group underwent a first phase of St-MLD followed by a second phase of LG-MLD. Areas of interest were then selected [in particular, dermal backflow (DBF) and axillary lymph nodes (LN)], radioactive activities were quantified for each of these areas. Results: If a first phase of St-MLD increased the LN activity by 28% on average, the findings indicated that for the second phase of DLM, LG-MLD was 19% more efficient than St-MLD in increasing LN activity. If a period of rest does not influence the lymph charge of DBF areas, physical activity leads to an average activity increase of 17%, whereas LG-MLD and St-MLD lead to an activity decrease of 11%. Conclusions: For patients with lymphedema, the findings indicate that MLD can increase the lymphatic flow toward the lymphatic nodes by 28% on average and can decrease the charge in the areas of DBF by 11% on average. Moreover, lymphoscintigraphy can be an important therapeutic tool because LG-MLD significantly increases lymphatic flow by 19% more than St-MLD. Concerning the areas of DBF, the LG-MLD and St-MLD decrease the charge in these areas with the same intensity.

The Effect of Manual Lymph Drainage and Compression Bandaging for Stage 2 Breast Cancer-Related Lymphedema: A Randomized Controlled Trial

Aim: To explore the effect of manual lymph drainage (MLD), compression bandaging (CB), or combined decongestive therapy (CDT), including MLD and CB, on stage 2 breast cancer-related lymphedema (BCRL). Methods: Sixty women with stage 2 BCRL were enrolled. They were randomly divided into the MLD group, the CB group or the CDT group. Each group, respectively, received MLD alone, CB alone, or CDT composed of MLD and CB, for 2 weeks. The volume and the local tissue water (LTW) of affected arms were measured before and after treatment. Arm circumferences were measured at 4 cm interval starting from the wrist to the shoulder with a tape measure. LTW was detected using the (tissue dielectric constant, TDC) method and was expressed as TDC value in two sites on the ventral midpoint of upper arm and forearm. Results: The volume of affected arms in each group after 2-weeks' treatment was lower than their baseline and the difference was statistically significant (p < 0.05). But there was no significant difference in volume change among three groups. The TDC value of the upper arm and forearm in the group CB and the group CDT decreased distinctly compared with baseline (p < 0.05). But the TDC value of the upper arm and forearm after MLD did not change (p > 0.05). Compared with the group MLD and the group CDT, the reduction of the TDC value in the group CB was more significant (p < 0.05). Conclusions: MLD or CB alone could effectively reduce the volume of affected arms for patients with stage 2 BCRL, and CB also could reduce the LTW more significantly. CDT did not seem to show an extra advantage. Therefore, CB may be the first choice for stage 2 BCRL. But for patients who are unwilling or intolerant to CB, MLD can be selected.

Advances in the prevention and treatment of breast cancer-related lymphedema

PURPOSE

Breast cancer-related lymphedema (BCRL) represents a lifelong risk for breast cancer survivors and once acquired becomes a lifelong burden. This review summarizes current BCRL prevention and treatment strategies.

FINDINGS

Risk factors for BCRL have been extensively studied and their identification has affected breast cancer treatment practice, with sentinel lymph node removal now standard of care for patients with early stage breast cancer without sentinel lymph node metastases. Early surveillance and timely management aim to reduce BCRL incidence and progression, and are further facilitated by patient education, which many breast cancer survivors report not having adequately received. Surgical approaches to BCRL prevention include axillary reverse mapping, lymphatic microsurgical preventative healing (LYMPHA) and Simplified LYMPHA (SLYMPHA). Complete decongestive therapy (CDT) remains the standard of care for patients with BCRL. Among CDT components, facilitating manual lymphatic drainage (MLD) using indocyanine green fluorescence lymphography has been proposed. Intermittent pneumatic compression, nonpneumatic active compression devices, and low-level laser therapy appear promising in lymphedema management. Reconstructive microsurgical techniques such as lymphovenous anastomosis and vascular lymph node transfer are growing surgical considerations for patients as well as liposuction-based procedures for addressing fatty fibrosis formation from chronic lymphedema. Long-term self-management adherence remains problematic, and lack of diagnosis and measurement consensus precludes a comparison of outcomes. Currently, no pharmacological approaches have proven successful.

CONCLUSION

Progress in prevention and treatment of BCRL continues, requiring advances in early diagnosis, patient education, expert consensus and novel treatments designed for lymphatic rehabilitation following insults.

Patient-Reported Symptoms of Late Toxicity in Patients With Breast Cancer Treated With Hypofractionated Radiation Therapy and the Association With Quality of Life

PURPOSE

Our purpose was to assess the prevalence of patient-reported symptoms of local late toxicity in patients with irradiated breast cancer and determine the association between late toxicity and quality of life.

METHODS

Within the prospective Utrecht cohort for Multiple BReast cancer intErvention studies and Long-term evaluation cohort, a survey on self-reported late toxicity was sent to all patients with breast cancer with ≥12 months interval since radiation therapy treated with curative intent. Patients were treated with hypofractionated radiation therapy of 40 Gy/15 fractions or 42.5 Gy/16 fractions, with or without a simultaneous integrated boost. Symptoms of late toxicity were evaluated on a 4-point Likert scale. Late toxicity was defined as moderate-severe breast or chest wall pain combined with at least 1 other mild-severe late toxicity symptom, that is, breast or arm/hand lymphedema, firmness of the breast, or impaired arm movement. Physical, role, and social functioning were measured before, during, and after the late toxicity survey using the European Organization for Research and Treatment of Cancer Quality of Life Core questionnaire-C30 and compared with a Dutch normative population.

RESULTS

In the study, 1613/2248 patients (72%) were included. Of those, 16% (n = 265) reported late toxicity. The median time interval between radiation therapy and survey was 38 months (interquartile range, 21-55). Moderate/severe firmness of the breast, chest wall pain, and breast pain were reported by, respectively, 18% (n = 295), 14% (n = 225), and 10% (n = 140) of all patients. Physical, role, and social functioning were below the clinical threshold (ie, clinically relevant impairment) in 13% to 52% of patients with late toxicity and 2% to 26% of patients without late toxicity. Patients with late toxicity significantly more often received analgesics, physiotherapy, and lymphedema therapy compared with patients without late toxicity.

CONCLUSIONS

This study provided insight into the prevalence of patient-reported late toxicity after hypofractionated radiation therapy and the influence of late toxicity on quality of life after breast cancer. These results may help health care professionals to inform their patients about long-term effects of breast cancer treatment including hypofractionated radiation therapy.

Effectiveness of Mobiderm® bandages in the treatment of cancer-related secondary lymphedema: A pilot study

Secondary lymphedema is a clinically incurable disease that commonly occurs following surgical cancer treatment and/or radiation. One of the most common forms of lymphedema treatment is complete decongestive therapy (CDT). This study aimed to investigate the clinical effects of new compression bandages (Mobiderm® bandages) in patients with secondary lymphedema after cancer treatment. This study included 17 patients with ipsilateral limb lymphedema after cancer treatment (one male and 16 female patients; age, 45-80 years). Patients were divided into the Mobiderm® bandage group (n = 9) and classical bandage group (n = 8). The International Society of Lymphology (ISL) stage was also evaluated. Limb circumference was measured at 5 to 6 sites per limb to identify the maximal circumference difference (MCD) between the affected and unaffected limbs. Pre-and posttreatment MCD were analyzed. After intensive CDT, both the Mobiderm® bandage group (1.2 ± 0.56 cm) and classical bandage group (0.85 ± 0.40 cm) had a significant decrease in MCD compared to pretreatment (P < .05). However, in patients with ISL stage 2, the mean MCD decrease rate was greater in the Mobiderm® bandage group (22.82 ± 10.92 %) than in the classical bandage group (12.18 ± 8.1 1%)(P = .045). Both new bandages (Mobiderm® bandages and classical bandages) reduced the circumference of limb edema in patients with secondary lymphedema after cancer treatment. This study findings suggest that Mobiderm® bandages as an alternative modality for controlling ISL stage 2 lymphedema.

Manual lymphatic drainage with or without fluoroscopy guidance did not substantially improve the effect of decongestive lymphatic therapy in people with breast cancer-related lymphoedema (EFforT-BCRL trial): a multicentre randomised trial

QUESTIONS

When added to decongestive lymphatic therapy (DLT), what is the effect of fluoroscopy-guided manual lymphatic drainage (MLD) versus traditional MLD or placebo MLD for the treatment of breast cancer-related lymphoedema (BCRL)?

DESIGN

Multicentre, three-arm, randomised controlled trial with concealed allocation, intention-to-treat analysis and blinding of assessors and participants.

PARTICIPANTS

At five hospitals in Belgium, 194 participants with unilateral chronic BCRL were recruited.

INTERVENTION

All participants received standard DLT (education, skin care, compression therapy and exercises). Participants were randomised to also receive fluoroscopy-guided MLD (n = 65), traditional MLD (n = 64) or placebo MLD (n = 65). Participants received 14 sessions of physiotherapy during the 3-week intensive phase and 17 sessions during the 6-month maintenance phase. Participants performed self-management on the other days.

OUTCOME MEASURES

All outcomes were measured: at baseline; after the intensive phase; after 1, 3 and 6 months of maintenance phase; and after 6 months of follow-up. The primary outcomes were reduction in excess volume of the arm/hand and accumulation of excess volume at the shoulder/trunk, with the end of the intensive phase as the primary endpoint. Secondary outcomes included daily functioning, quality of life, erysipelas and satisfaction.

RESULTS

Excess lymphoedema volume decreased after 3 weeks of intensive treatment in each group: 5.3 percentage points of percent excessive volume (representing a relative reduction of 23.3%) in the fluoroscopy-guided MLD group, 5.2% (relative reduction 20.9%) in the traditional MLD group and 5.4% (relative reduction 24.8%) in the placebo MLD group. The effect of fluoroscopy-guided MLD was very similar to traditional MLD (between-group difference 0.0 percentage points, 95% CI -2.0 to 2.1) and placebo MLD (-0.2 percentage points, 95% CI -2.1 to 1.8). Fluid accumulated at the shoulder/trunk in all groups. The average accumulation with fluoroscopy-guided MLD was negligibly less than with traditional MLD (-3.6 percentage points, 95% CI -6.4 to -0.8) and placebo MLD (-2.4 percentage points, 95% CI -5.2 to 0.4). The secondary outcomes also showed no clinically important between-group differences.

CONCLUSION

In patients with chronic BCRL, MLD did not provide clinically important additional benefit when added to other components of DLT.

REGISTRATION

NCT02609724.

A model for self-management of chronic filarial lymphoedema with acute dermato-lymphangio-adenitis

Secondary lymphoedema due to filariasis is a leading cause of morbidity in India. We present a case of a 54-year-old female with lymphatic filariasis for 18 years, with three to four episodes of acute dermato-lymphangio-adenitis (ADLA) every year. The patient had voluntarily restricted social interaction and community participation. A combination of interventions provided in 17 physiotherapy sessions over a period of 20 days showed notable improvement, by reducing limb volume and ADLA episodes and by improving limb shape, functional capacity and quality of life. Interventions included aerobic exercise, decongestion therapy with faradism under pressure and exercises with elevation. This gain was maintained throughout the 8 months of the pandemic. Patient education and counselling along with home programme of self-bandaging and self-limb hygiene played a major role in the recovery of the patient. Self-reliance in management was important because of the pandemic, which restricted the patient from attending the outpatient department.

Patients' Expectations of Physiotherapeutic Treatment for Long-Term Side Effects After Cancer: A Qualitative Study

OBJECTIVE

This study aims to explore the expectations of physiotherapeutic treatment of long-term side effects (LTSEs) after cancer among patients treated in physiotherapy clinics.

METHODS

This a qualitative interview study based on a phenomenological approach. Adult patients with LTSEs after cancer were recruited through The Danish Cancer Society and a private physiotherapy clinic in Denmark. Individual semi-structured interviews were carried out using Microsoft Teams based on an interview guide piloted before the interviews. Interviews were audiotaped and transcribed verbatim. Sampling was conducted with a focus on variation in LTSE. The data were analyzed using Malterud's principles of systematic text condensation and coded in NVivo 12.

RESULTS

2 males and 8 females with an average age of 55.8 years were interviewed for between 40 and 60 minutes from October to November 2020. Four main themes emerged from the interviews1: The importance of the physiotherapist's approach,2 the benefits of meeting patients with similar symptoms,3 the importance of receiving knowledge, and4 patients seeking to maintain their current state more often than aiming to improve their condition.

CONCLUSIONS

Patients consulting a physiotherapy clinic with LTSE after cancer prefer the physiotherapist to have knowledge about cancer and to be emphatic. Furthermore, patients prefer to meet like-minded people and expect support to maintain their current condition rather than improve their condition.

Comparing the experience of individuals with primary and secondary lymphoedema: A qualitative study

BACKGROUND

Lymphoedema is a chronic condition that has significant detrimental impact on patients' quality of life. Secondary lymphoedema often results from anti-tumour treatment, in contrast to primary lymphoedema which is the result of genetic abnormalities that leads to an abnormal development of the lymphatic system.

OBJECTIVE

To describe and compare the experience of individuals with primary and secondary lymphoedema.

METHODS

A total of 19 patients (mean ± standard deviation age: 56.7 ± 16.2 years), 8 with primary and 11 with secondary lymphoedema, participated in this qualitative phenomenological study. Purposeful sampling method was applied. We recruited participants from specialised lymphoedema units of two physical therapy clinics and the Lymphoedema Patient Association in Spain. Data collection methods included unstructured and semi-structured interviews. An inductive thematic analysis was used.

RESULTS

The findings suggest differences between the experience of living with primary or secondary lymphoedema. Also, those with lower extremity lymphoedema have more pain, fatigue, and functional limitations. Three primary themes emerged: "Emotional challenge", "Adapting your life to a new situation," and "lymphoedema management".

CONCLUSIONS

The experience of living with lymphoedema involves aspects of fear, suffering, coping, and management of the disease and differs between secondary and primary causes. However, it seems to be more dependent on its location than its cause.

Effects of weight reduction on the breast cancer-related lymphedema: A systematic review and meta-analysis

Background

Obesity has long been considered a risk factor for breast cancer–related lymphedema (BCRL), but the benefits of weight reduction in managing BCRL have not been clearly established.

Objective

To evaluate the beneficial effects of weight loss interventions (WLIs) on the reduction and prevention of BCRL.

Methods

We conducted a systematic review and meta-analysis by searching the PubMed, Scopus, and Embase databases from their earliest record to October 1st, 2019. We included randomized and non-randomized controlled trials involving adult patients with a history of breast cancer, that compared WLI groups with no-WLI groups, and provided quantitative measurements of lymphedema.

Results

Initial literature search yielded 461 nonduplicate records. After exclusion based on title, abstract, and full-text review, four randomized controlled trials involving 460 participants were included for quantitative analysis. Our meta-analysis revealed a significant between-group mean difference (MD) regarding the volume of affected arm (MD = 244.7 mL, 95% confidence interval [CI]: 145.3–344.0) and volume of unaffected arm (MD = 234.5 mL, 95% CI: 146.9–322.1). However, a nonsignificant between-group MD of −0.07% (95% CI: 1.22–1.08) was observed regarding the interlimb volume difference at the end of the WLIs.

Conclusions

In patients with BCRL, WLIs are associated with decreased volume of the affected and unaffected arms but not with decreased severity of BCRL measured by interlimb difference in arm volume.

•

Weight reduction decreases the volume of both arms in patients with BCRL.

•

Weight reduction does not reduce the severity of BCRL measured objectively.

•

Effects of weight reduction on preventing BCRL are yet unknown.

Changes in Indocyanine Green Lymphography Patterns after Physical Treatment in Secondary Upper Limb Lymphedema

Indocyanine green (ICG) lymphography is used to evaluate the lymphatic function before and after pneumatic compression or post-manual lymphatic drainage. The aim of this study was to ascertain the changes in the fluoroscopic pattern produced by the provision of complex physical therapy. This prospective analytic (pretest-posttest) study was conducted in 19 patients with upper lymphedema secondary to breast cancer. Nine patients were excluded due to ICG found after 3 weeks. The ICG patterns were analyzed under basal conditions and after three weeks of treatment. After the treatment, 45% of the patients presented tracer remains in the affected limb, and this finding was significantly related to time of the lymphedema development. In one subject, the patterns remain unchanged or cannot be defined. Three of the ten patients observed present the worsening of at least 1 of the patterns and in the rest of the subjects, six cases, the improvement of the patterns is observed. In 60% of the cases, the most severe pattern reversed towards slight (splash) cases, and moderate cases reversed towards a slight case in 70% of cases. Therefore, after treatment with complex physical therapy, the pathological patterns observed in the pretest, which evolved positively, reverted their severity toward milder disease patterns or towards normality.

Electronic Moxibustion for Breast Cancer-Related Lymphedema: A Pilot Clinical Trial

This is a preliminary study to investigate the feasibility of electronic moxibustion in breast cancer patients with upper limb lymphedema. As current treatment options for lymphedema are unsatisfactory and time consuming, there have been attempts to manage symptoms using integrative treatments. Electronic moxibustion was developed to compensate for the shortcomings of conventional moxibustion and is widely used in clinical practice. However, there have been no studies on using electronic moxibustion in breast cancer-related lymphedema. To investigate the feasibility of electronic moxibustion in treating breast cancer-related lymphedema, this study included subjects who completed primary cancer treatment at least 6 months ago and had more than 10 mm difference in arm circumference of upper limbs. All subjects were assigned to the treatment group. Subjects were treated with 16 sessions (30 minutes/session) of electronic moxibustion for 8 weeks followed by 4 weeks of follow-up. For outcome measures, upper limb circumferences, shoulder range of motion, bioimpedance analysis, and quality of life questionnaire were assessed. All 10 subjects completed the study. The effective index showed 38.21% reduction after treatment ( P = .0098) and 29.35% ( P = .0039) after 4 weeks of follow-up compared to the baseline. The reduction of lymphedema was most prominent at 10 cm above the elbow crease, where the mean reduction of circumference difference was 7.5 mm ( P = .0430) and continued to improve after treatment (mean reduction of 8.3 mm, P = .0156). There was significant improvement in shoulder range of motion only in flexion and internal rotation at week 9. There were 7 adverse events, and most were irrelevant to the treatment. Only 1 participant had a mild burn on the acupuncture point. Here, we demonstrate for the first time that electronic moxibustion treatment is a feasible treatment for breast cancer-related lymphedema. Electronic moxibustion may reduce differences in upper limb circumference and improve shoulder range of motion. A future comparative clinical trial is needed to confirm the clinical efficacy of this treatment.

A mapping study and recommendations for a joint NGO (Think Pink) and Bahrain Government Breast Cancer project

AIMS

Breast cancer within the region continues to present challenges to the healthcare services. Strategies to shed light on clinical gaps could better support country-specific circumstances. The aims of the mapping study were to identify the gaps in the evidence base, for the management of breast cancer with relevance to Bahrain and the Gulf Region. In parallel, focusing on areas and directions of research, which are compatible with international and local clinical interests. It was envisaged that the mapping project would expose not only opportunities to improve support to the community but also illustrate the possible engagement of a government entity and a Nongovernment Organization in a private-public partnership.

METHOD

An extensive literature review of local and international publications from the period between 1979 and 2015 was undertaken. Searches were conducted using free-text terms, singularly or combined, with no limiters, to provide unrestricted retrieval of available English studies.

RESULTS

A total of 326 citations were identified, which after deduplication provided 277 unique citations of which included 236 studies within 13 different categories, relevant to breast cancer within the Gulf Cooperation Council (GCC).

CONCLUSION

Contextualizing gaps in literature and, therefore, providing evidence-based decisions, not only support the enduser, but better support the country-specific challenges and burdens to healthcare. Three broad but key areas were identified after mapping of the literature, covering:screening and mammography, knowledge translation and dissemination, and lymphoedema postsurgical resection. Similar mapping projects could be undertaken by other national NGO's to better support the government and solidify the framework for a public-private partnership.

Compression Vest Treatment for Symptomatic Breast Edema in Women Treated for Breast Cancer: A Pilot Study

Background: Lymphedema of the breast/chest wall after breast cancer treatment is often associated with pain and reduced quality of life. We conducted a pilot study to evaluate whether the use of a compression vest reduced symptoms of breast/chest wall edema in breast cancer patients. Methods and Results: This single-center study included patients (n = 25) with symptomatic breast/chest wall edema with a pain score of ≥3 on the Numerical Rating Scales (range 1-10). The patients were instructed to wear a compression vest (Lymphatrex, Class II) for 6 months. Wilcoxon signed-rank tests were used to compare differences in patient-reported pain intensity/severity. Analyses included all patients with available data. In total, 17 (68%) continued to wear their vests for 6 months, whereas the other 8 withdrew prematurely. At baseline, median pain severity (4.9, interquartile range [IQR] 3.6-6.0) and pain interference (4.3, IQR 2.1-5.9) scores were significantly higher compared with pain scores after wearing the compression vest for 6 months (1.8 IQR 1.0-4.8 and 1.4 IQR 0.9-4.4, resp.). Patient-reported breast/chest wall swelling decreased from 92% (n = 22) at baseline to 71% (n = 12) at 6 months. The prevalence of moderate/severe patient-reported breast/chest wall pain declined from 63% (n = 15) at baseline to 18% (n = 3) at 6 months. Physical, emotional, and social functioning improved over time and was comparable to scores of the Dutch reference population. Conclusion: The results of this pilot study suggest that a compression vest could be an acceptable and effective treatment option for patients with painful breast/chest wall edema. In compliant patients, swelling and pain was significantly reduced.

A comprehensive approach to rehabilitation interventions following breast cancer treatment - a systematic review of systematic reviews

BACKGROUND

Breast cancer (BC) is the most common type of cancer in women worldwide. Post-treatment, patients suffer from side effects and have various rehabilitation needs, which means that individualization is fundamental for optimal rehabilitation. This systematic review (SR) of SRs aims to evaluate the current evidence on rehabilitation interventions in female patients following BC treatment.

METHODS

Full-text SRs published in English from 2009 were searched in Embase, PubMed, Cinahl Complete, PsycINFO, AMED, SCOPUS, and Cochrane Library.

INCLUSION CRITERIA

SRs of randomized or non-randomized controlled trials investigating the effects of rehabilitation interventions in women following BC treatment. All outcomes were considered. Methodological quality was evaluated using the AMSTAR 2 tool and interrater agreement was evaluated. Out of 1269 citations retrieved, 37 SRs were included.

RESULTS

Five rehabilitation areas were identified: exercise and physical activity (PA), complementary and alternative medicine (CAM), yoga, lymphoedema treatment, and psychosocial interventions. The most solid evidence was found in exercise/PA and yoga. Exercise interventions improved outcomes such as shoulder mobility, lymphoedema, pain, fatigue and quality of life (QoL). Effects of yoga were shown on QoL, anxiety, depression, sleep disturbance, fatigue and gastrointestinal symptoms. The effect of CAM was shown on nausea, pain, fatigue, anger and anxiety but these results need to be interpreted with caution because of low methodological quality in included studies in the SRs. Among the lymphoedema treatments, positive effects were seen for resistance training on volume reduction and muscle strength and psychosocial interventions such as cognitive behavioural therapy had positive effects on QoL, anxiety, depression and mood disturbance.

CONCLUSIONS

This SR of SRs show solid positive effects of exercise/PA and yoga for women following BC treatment, and provides extended knowledge of the effects of CAM, yoga, lymphoedema treatment and psychosocial interventions. It is evident that more than one intervention could have positive effects on a specific symptom and that the effects depend not only on intervention type but also on how and when the intervention is provided. The results can be used as a foundation for individualized rehabilitation and aid health care professionals in meeting patients' individual needs and preferences.

TRIAL REGISTRATION

PROSPERO ( CRD42017060912 ).

Diagnosis and Treatment of Edema and Lymphedema in the Cancer Patient

BACKGROUND

Lymphedema occurs commonly in cancer survivors. It is crucial to properly assess cancer patients in order to distinguish lymphedema from general edema and to initiate evidence based treatment.

PURPOSE

To provide evidence based recommendations for screening, evaluating, and treating lymphedema and to establish the role of the nurse in the care of patients with lymphedema.

METHODOLOGY

Comprehensive overview with narrative literature review of evidence based lymphedema diagnosis and treatment.

FINDINGS

Cancer-related edema represents numerous complex conditions. A variety of interventions are needed to address prevention, early detection, patient education, and effective treatment.

CONCLUSION

Lymphedema treatment is complex and multimodal, and is provided by an interdisciplinary team of properly trained professionals. Nurses play a major role in evaluating, treating and educating patients on the signs and symptoms of cancer-related edema and patient self-management.

CLINICAL IMPLICATIONS

Evidence-based assessment and treatment should be initiated early to improve outcomes and quality of life in patients with cancer-related lymphedema.

Acupuncture for breast cancer-related lymphedema: a randomized controlled trial

PURPOSE

Approximately 20% of breast cancer survivors develop breast cancer-related lymphedema (BCRL), and current therapies are limited. We compared acupuncture (AC) to usual care wait-list control (WL) for treatment of persistent BCRL.

METHODS

Women with moderate BCRL lasting greater than six months were randomized to AC or WL. AC included twice weekly manual acupuncture over six weeks. We evaluated the difference in circumference and bioimpedance between affected and unaffected arms. Responders were defined as having a decrease in arm circumference difference greater than 30% from baseline. We used analysis of covariance for circumference and bioimpedance measurements and Fisher's exact to determine the proportion of responders.

RESULTS

Among 82 patients, 73 (89%) were evaluable for the primary endpoint (36 in AC, 37 in WL). 79 (96%) patients received lymphedema treatment before enrolling in our study; 67 (82%) underwent ongoing treatment during the trial. We found no significant difference between groups for arm circumference difference (0.38 cm greater reduction in AC vs. WL, 95% CI - 0.12 to 0.89, p = 0.14) or bioimpedance difference (1.06 greater reduction in AC vs. WL, 95% CI - 5.72 to 7.85, p = 0.8). There was also no difference in the proportion of responders: 17% AC versus 11% WL (6% difference, 95% CI - 10 to 22%, p = 0.5). No severe adverse events were reported.

CONCLUSIONS

Our acupuncture protocol appeared to be safe and well tolerated. However, it did not significantly reduce BCRL in pretreated patients receiving concurrent lymphedema treatment. This regimen does not improve upon conventional lymphedema treatment for breast cancer survivors with persistent BCRL.

Clinical effectiveness of decongestive treatments on excess arm volume and patient-centered outcomes in women with early breast cancer-related arm lymphedema: a systematic review

OBJECTIVE

To identify the effect of decongestive lymphedema treatment on excess arm volume or patient-centered outcomes in women presenting within either 12 months or a mean nine months of developing arm lymphedema following breast cancer treatment.

INTRODUCTION

Lymphedema is a common consequence of breast cancer treatment requiring life-long treatment to reduce symptoms and prevent complications. Currently, evidence to inform the optimal decongestive lymphedema treatment package is lacking.

INCLUSION CRITERIA

The review included studies on women who received lymphedema treatment within either 12 months or a mean of nine months of developing unilateral breast cancer-related arm lymphedema. The intervention was any decongestive lymphedema treatment delivered with the purpose of reducing arm lymphedema, compared to another form of lymphedema treatment (whether self or practitioner-administered), placebo or no treatment. The clinical outcome was excess arm volume; patient-centered outcomes were health-related quality of life, arm heaviness, arm function, patient-perceived benefit and satisfaction with treatment. Experimental study designs were eligible, including randomized and non-randomized controlled trials, quasi-experimental, prospective and retrospective before and after studies were considered.

METHODS

A three-step search strategy was utilized to find published and unpublished studies. The search identified studies published from the inception of each database to July 6, 2016. Reference lists were scanned to identify further eligible studies. Studies were critically appraised using appropriate standardized critical appraisal instruments from the Joanna Briggs Institute. Details describing each study and treatment results regarding outcomes of interest were extracted from papers included in the review using appropriate standardized data extraction tools from the Joanna Briggs Institute. Due to heterogeneity in included studies, results for similar outcome measures were not pooled in statistical meta-analysis. A narrative and tabular format was used to synthesize results from identified and included studies.

RESULTS

Seven studies reporting results for outcomes of interest were critically appraised and included in the review: five randomized controlled trials and two descriptive (uncontrolled) studies. Reported outcomes included excess arm volume (five studies), health-related quality of life (three studies), arm heaviness (one study), arm function (two studies) and patient-perceived benefit (two studies). There was some evidence that decongestive treatments were effective for women presenting within either 12 months or a mean of nine months of developing breast cancer-related arm lymphedema, but the wide range of data prevented comparison of treatment findings which limited our ability to answer the review questions.

CONCLUSIONS

Weak evidence (grade B) for the impact of decongestive lymphedema treatment on women with early lymphedema (i.e. less than 12 months duration of BCRL symptoms) did not allow any conclusions to be drawn about the most effective treatment to be offered when these women first present for treatment. Findings provided no justification to support change to current practice.Future primary research needs to focus on the most effective treatment for women when they first present with lymphedema symptoms, e.g. treatment provided within 12 months of developing symptoms. Studies should be adequately powered and recruit women exclusively with less than 12 months duration of breast cancer-related lymphedema symptoms, provide longer follow-up to monitor treatment effect over time, with comparable treatment protocols, outcome measures and reporting methods.

Effects of Kinesio Taping on breast cancer-related lymphedema: A meta-analysis in clinical trials

BACKGROUND

Lymphedema is known as a secondary complication of breast cancer treatment, caused by reduction on lymphatic flow and lymph accumulation on interstitial space. The Kinesio Taping (KT) has become an alternative treatment for lymphedema volume reduction. The objective of the study was to evaluate the literature through a systematic review on KT effects on lymphedema related to breast cancer.

METHODS

Search strategies were performed by the following keywords: "Kinesio Taping," "Athletic Tape," "Cancer," "Neoplasm," "Lymphedema," and "Mastectomy" with derivations and different combinations. The following databases were accessed: SCIELO, LILACS, MEDLINE via PubMed, and PEDro, between 2009 and 2016. Studies published in English, Portuguese, and Spanish were considered for inclusion. The studies' methodological quality was assessed by the PEDro scale.

RESULTS

Seven studies were identified by the search strategy and eligibility. All of them showed positive effect in reducing lymphedema (perimeter or volume) before versus after treatment. However, with no effects comparing the KT versus control group or others treatments (standardized mean difference = 0.04, confidence interval 95%: -0.24; 0.33), the average score of the PEDro scale was 4.71 points.

CONCLUSIONS

KT was effective on postmastectomy lymphedema related to breast cancer; however, it is not more efficient than other treatments.

Optimizing post-acute care in breast cancer survivors: a rehabilitation perspective

Breast cancer (BC) is the most common malignancy and a leading cause of morbidity and mortality in women worldwide. Therapeutic advances and improved survival rates of women with BC have implications for long-term impact on disability, psychological function and quality of life (QoL), which may be amenable to rehabilitation. The focus of rehabilitation is on managing disability, reducing sequelae and symptoms, and enhancing participation and societal reintegration, to achieve the highest possible independence and the best QoL. Rehabilitation interventions should be considered early for maintaining functional capacity and reducing the risk of losing important abilities or independence and should be individualized depending on disease phase, functional deficits, personal requirements and specific goals. A number of interventions have been trialled to support rehabilitation input for women with BC, which include physical therapy, psychological interventions (psychotherapy, cognitive behavioral training) and others. Multidisciplinary rehabilitation and uni-disciplinary interventions such as physical therapy have been shown to be beneficial in reducing disability, and improving participation and QoL. There is a need for comprehensive assessment of health domains in BC patients using a standardized framework and a common language for describing the impact of disease at different levels, using the International Classification of Functioning, Disability and Health core sets. This will provide more detailed information on the needs of these patients, so more efficient and targeted rehabilitation interventions can be provided.

Systematic Review of Occupational Therapy and Adult Cancer Rehabilitation: Part 1. Impact of Physical Activity and Symptom Management Interventions

This article is the first part of a systematic review of evidence for the effectiveness of cancer rehabilitation interventions within the scope of occupational therapy that address the activity and participation needs of adult cancer survivors. This article focuses on the importance of physical activity and symptom management. Strong evidence supports the use of exercise for cancer-related fatigue and indicates that lymphedema is not exacerbated by exercise. Moderate evidence supports the use of yoga to relieve anxiety and depression and indicates that exercise as a whole may contribute to a return to precancer levels of sexual activity. The results of this review support inclusion of occupational therapy in cancer rehabilitation and reveal a significant need for more research to explore ways occupational therapy can positively influence the outcomes of cancer survivors. Part 2 of the review also appears in this issue.

Lower Extremity Lymphedema Management after Gynecologic Cancer Surgery: A Review of Current Management Strategies

Lymphedema can be described as an accumulation of protein-rich fluid in interstitial spaces. It affects patients in multiple aspects. Gynecologic cancer survivors might experience lower extremity lymphedema after cancer surgery or treatment. In literature, most of the studies have been performed on upper extremity lymphedema. As gynecologic cancer malignancies have increased in the recent years, treatment options and related complications have been gaining attention in studies. In this manner, this review focused on the management of lower extremity lymphedema after gynecologic surgery. Studies indicated that the incidence of lower extremity lymphedema ranges between 2.4% and 41% after pelvic lymph node dissection in patients with gynecologic malignancies. Thus, management of lower extremity lymphedema in patients after gynecologic cancer surgery is an important issue. Complex decongestive therapy method is still the gold standard of lymphedema management. Controlling, evaluating, and preventing the risk factors are also substantial points; hence, it is very important to provide accurate knowledge in the management of lower extremity lymphedema.

[What physiotherapeutic method for the treatment of post-mastectomy lymphedema is the most effective?]

We have undertaken the search for the publications of interest in the following databases: Scopus, Web of Science, MedLine, The Cochrane Library, CyberLeninka, and Russian science citation index. In addition, we evaluated the effectiveness of the physical agents and procedures having different mechanisms of action of the known factors responsible for the development of post-mastectomy lymphedema. Such agents and procedures include self-massage, manual lymphatic drainage, therapeutic physical exercises, compression bandaging, wearing elastic compression garments, Kinesio Tex taping, pneumatic compression, ultrasonic, electrostatic, extracorporeal shock wave therapy, electrical muscle stimulation, microcurrent and low-intensity laser therapy. These methods and products were used by the authors of selected publications either separately or in the combined modes taking into consideration the significant differences between effects of the application of individual techniques. The results of the treatment are presented for different time periods, either in absolute units (cm or ml) in the majority of the cases or in relative units (%) only in part of them without information concerning the statistical significance of the results obtained. There is thus far neither the universal classification of post-mastectomy lymphedema nor the generally accepted approaches to its diagnostics and treatment. Therefore, it is impossible to give an unambiguous answer as regards the effectiveness of one or another method for the diagnostics and treatment of this condition. The author of the present article observed 172 patients at the age of 56.8±9.7 years suffering from late grade I-IV lymphedema treated with the use of local low-intensity low-frequency electric and magnetic therapy in the combination with pneumatic compression applied during 15 days. The results of the treatment were evaluated using water and impedance plethysmography. Within 4 weeks after the onset of therapy, the volume of the upper limb decreased on the average for all stages of lymphedema by 37.7±9.3% under effect of pneumatic compression alone, by 49.5±10.7% under the influence of its combination with electrotherapy, by 59.9±5.4% under the action of the combination of pneumatic compression with magnetotherapy, and by 76.3±7.3% after the application of all the three techniques together (p<0.05). Electrical neurostimulation of the blood vessels and skeletal muscles proved especially effective for the treatment of I-II grade lymphedema while magnetic therapy was most efficient for the management of grade III-IV lymphedema. The proposed method of combined physiotherapy looks very encouraging for the treatment of late lymphedema but does not completely solve all problems pertaining to the management of this pathological condition.

Satisfaction with a therapeutic sleeve for arm lymphedema secondary to breast cancer treatment: Controlled crossover trial

Highlights

Secondary lymphedema is a late iatrogenic side effect of breast cancer treatment.Despite multimodal decongestive therapy in their daily life breast cancer survivors with lymphedema have few alternatives but to use a compressive sleeve.Concerned with the well-known low compliance to the daily use of traditional sleeves, we conducted a comparative study to evaluate the subjective assessment of an innovative class 1 compression sleeve.We concluded that the PRADEX^® sleeve, not being worse in its compressive efficacy, is much better with regard to patient comfort.

Abstract

Secondary arm lymphedema is a feared late iatrogenic side effect of breast cancer survivors with a negative impact on patient's self-image and quality of life. Its reported incidence is extremely variable, from 6% to 80%, as well as the effectiveness of the multimodal decongestive lymphedema therapy.In their daily life breast cancer survivors with lymphedema have few alternatives but to use a compressive sleeve. Concerned with the well-known low compliance to the daily use of traditional sleeves, we conducted a comparative study in a subgroup of our patients with lymphedema secondary to breast cancer treatment for the subjective assessment of PRADEX^®, an innovative class 1 compression sleeve. Secondarily, we aimed to assess the non-inferiority of PRADEX^® regarding subjective and objective measures of the severity of lymphedema.We studied 46 women with grade 1 secondary arm lymphedema, who used their usual sleeve and PRADEX^® daily for 2 weeks each, in a crossover design.The new therapeutic sleeve was classified as having a better design and a better usability and comfort (more comfortable, thinner, fresher, softer, more flexible, comfortable, resistant to dirt and easier to dress and to wear). Women's subjective opinion about the severity of lymphedema favored their usual sleeve in detriment of PRADEX^®, but this subjective feeling was contradicted by objective measurements of different perimeters of the arm at the beginning and at the end of the study.We concluded that the PRADEX^® sleeve, not being worse in its compressive therapeutic efficacy, is much better with regard to patient comfort.

Current Treatments for Breast Cancer-Related Lymphoedema: A Systematic Review

Background and objective: Breast cancer-related lymphoedema (BCRL) is a disabling complication with long term impact on quality on life after breast cancer treatment. Its management remains a major challenge for patients and health care professionals; the goal of this overview was to summarize effects of different treatment strategies for patients with BCRL. Methods: A thorough search was undertaken to allow a systematic review or meta-analysis of treatments for BCRL. Two investigators independently selected studies and abstracted the data. Results: Combined physical therapy (CPT) with different combinations of surgery, oral pharmaceuticals, low-level laser therapy, weight reduction, mesenchymal stem cell therapy, kinesio tex taping, and acupuncture might be effective in reducing lymphoedema, but exercise demonstrated no obvious benefit. The results of direct comparisons showed CPT might be more effective than standard physiotherapy (ST). Manual lymphatic drainage (MLD) may not offer additional benefits to ST for swelling reduction, but could facilitate compression bandaging. MLD seemed to have similar effects with self-administered simple lymphatic drainage (SLD) or using an intermittent pneumatic compression pump (IPC). IPC might also not be associated with additional effectiveness for CPT. Efficacy of stem cell therapy vs. compression sleeve or CPT, as well as the effects of daflon and coumarin could not be established. Conclusion: Although many treatments for BCRL might reduce lymphoedema volume, their effects were not well established. The quality of many of the original studies in the included reviews was not optimal, so that in future randomized control trials are a high priority.

Are compression corsets beneficial for the treatment of breast cancer-related lymphedema? New opportunities in physiotherapy treatment - a preliminary report

Introduction

Treatment of secondary lymphedema still remains an important medical issue. Treatment response is characterized by periodic remission rather than complete recovery. Compression methods currently used as part of complete decongestive therapy vary considerably in efficacy. Manual drainage, bandaging, and compression pumps are ineffective in everyday practice. Positive results have increasingly been reported where compression garments have been used as part of the treatment. This pilot study demonstrates a beneficial effect following the use of compression corsets in the treatment of edema in breast cancer-related lymphedema (BCRL).

Material

A total of 35 women with BCRL were enrolled. Of these, 29 patients completed the study.

Methods

Ultrasound (B-mode) was used to evaluate lymphedema in the side of the chest after mastectomy. This test was performed three times at a specific site on the operated side and symmetrically on the opposite side. Subsequently, patients were fit with an appropriate compression corset. The data were then statistically analyzed.

Conclusion

After the surgical treatment of breast cancer, lymphatic fluid reservoirs may form at the side of the chest. The use of carefully selected compression corsets is an effective treatment for BCRL. Corsets are an important item, which we recommend should be included in compression clothing sets. We anticipate this finding will form the foundation for further work on the use of modern compression garments for the treatment of BCRL as well as contribute to the limited number of published reports that exist on the subject.

Relevance of low-pressure compression corsets in physiotherapeutic treatment of patients after mastectomy and lymphadenectomy

There is no fully effective treatment for secondary lymphedema. In patients with breast cancer, lymphedema may present immediately after axillary dissection or years later. It typically occurs in a limb (such as an arm), but it can also occur in the torso, especially in breast cancer patients. It is, therefore, essential to prevent or minimize the condition. The currently used compression therapy has varying efficiency. Thus, researchers are still looking for better solutions, especially for primary prevention. The aim of this study was to find whether compression corsets therapy with a class I compression garment could prevent truncal lymphedema on the operated side in females who underwent mastectomy and axillary lymph node dissection as the standard of care for breast cancer treatment without subsequent reconstruction. We also investigated whether this therapy is efficient in prevention and treatment of truncal lymphedema in patients who underwent mastectomy and additional radiotherapy, and finally whether this method could be implemented for pain reduction strategies in this treatment group. The study was carried out in 50 randomly selected breast cancer patients classified by the oncologist as candidates for surgery. The final study was completed in 37 patients who underwent mastectomy and lymphadenectomy. The study group was randomly divided into two subgroups: subgroup G (received compression corsets 1 month following the surgery) and subgroup K (control) in which the patients underwent no physiotherapeutic treatment. The size of truncal lymphedema was measured using ultrasound in presentation B. Measurements were carried out symmetrically on both sides of the chest wall. The patients were examined four times. The follow-up was for 7 months in total. After the second measurement, a randomly selected subgroup of patients received properly fitted compression corsets, which they had to wear throughout the study, whereas the control subgroup had no physiotherapy treatment. The results were statistically analyzed. In both subgroups, we analyzed the reduction of pain using a visual analog scale. The results strongly suggest that when properly fitted, class I compression corsets not only are an effective treatment for lymphedema but also could be used for antiedematous prevention in patients who underwent removal of axillary lymph nodes as well as radiotherapy. Results of these studies have also confirmed that the use of compression corsets could reduce pain associated with surgical treatment of breast cancer.

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

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of complete decongestive therapy and a home program for patients with post mastectomy lymphedema

[Purpose] Post mastectomy lymphedema is common among breast cancer survivors. It leads to physical discomfort and functional impairment. Rehabilitation forms the mainstay of treatment and is multidisciplinary. [Subjects and Methods] Sixty post mastectomy patients were allocated randomly and assigned to either a conventional treatment group (n=30) or a complete decongestive therapy (CDT) group (n=30). The conventional treatment group received manual lymphatic drainage, wore a low elastic compression garment, received glenohumeral mobilization, and performed deep breathing exercises, and the complete decongestive therapy group received CDT from a trained physiotherapist and a daily home program along with the conventional treatment, 5 days a week for 6 weeks. [Results] Arm circumference measurements were taken at five levels: the wrist, mid forearm, elbow, mid-upper arm, and axilla. The upper extremity function was evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and pain was assessed using the visual analogue scale. Measurements were taken at baseline, and at 4th and 6th weeks after the start of intervention. Within and between group comparisons showed significant improvements in the CDT group. [Conclusion] Complete decongestive therapy and a home program assists breast cancer related lymphedema survivors in regaining their lost functions. It also helps to improve their independence in daily activities, reduce their need for caregivers, and thereby improving their quality of life. Therefore, the results of this study showed that the CDT with a home program is an effective treatment for reducing post mastectomy lymphedema.

Review of the evidence of lymphedema treatment effect

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

Manual lymphatic drainage for lymphedema following breast cancer treatment

BACKGROUND

More than one in five patients who undergo treatment for breast cancer will develop breast cancer-related lymphedema (BCRL). BCRL can occur as a result of breast cancer surgery and/or radiation therapy. BCRL can negatively impact comfort, function, and quality of life (QoL). Manual lymphatic drainage (MLD), a type of hands-on therapy, is frequently used for BCRL and often as part of complex decongestive therapy (CDT). CDT is a fourfold conservative treatment which includes MLD, compression therapy (consisting of compression bandages, compression sleeves, or other types of compression garments), skin care, and lymph-reducing exercises (LREs). Phase 1 of CDT is to reduce swelling; Phase 2 is to maintain the reduced swelling.

OBJECTIVES

To assess the efficacy and safety of MLD in treating BCRL.

SEARCH METHODS

We searched Medline, EMBASE, CENTRAL, WHO ICTRP (World Health Organization's International Clinical Trial Registry Platform), and Cochrane Breast Cancer Group's Specialised Register from root to 24 May 2013. No language restrictions were applied.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) or quasi-RCTs of women with BCRL. The intervention was MLD. The primary outcomes were (1) volumetric changes, (2) adverse events. Secondary outcomes were (1) function, (2) subjective sensations, (3) QoL, (4) cost of care.

DATA COLLECTION AND ANALYSIS

We collected data on three volumetric outcomes. (1) LE (lymphedema) volume was defined as the amount of excess fluid left in the arm after treatment, calculated as volume in mL of affected arm post-treatment minus unaffected arm post-treatment. (2) Volume reduction was defined as the amount of fluid reduction in mL from before to after treatment calculated as the pretreatment LE volume of the affected arm minus the post-treatment LE volume of the affected arm. (3) Per cent reduction was defined as the proportion of fluid reduced relative to the baseline excess volume, calculated as volume reduction divided by baseline LE volume multiplied by 100. We entered trial data into Review Manger 5.2 (RevMan), pooled data using a fixed-effect model, and analyzed continuous data as mean differences (MDs) with 95% confidence intervals (CIs). We also explored subgroups to determine whether mild BCRL compared to moderate or severe BCRL, and BCRL less than a year compared to more than a year was associated with a better response to MLD.

MAIN RESULTS

Six trials were included. Based on similar designs, trials clustered in three categories.(1) MLD + standard physiotherapy versus standard physiotherapy (one trial) showed significant improvements in both groups from baseline but no significant between-groups differences for per cent reduction.(2) MLD + compression bandaging versus compression bandaging (two trials) showed significant per cent reductions of 30% to 38.6% for compression bandaging alone, and an additional 7.11% reduction for MLD (MD 7.11%, 95% CI 1.75% to 12.47%; two RCTs; 83 participants). Volume reduction was borderline significant (P = 0.06). LE volume was not significant. Subgroup analyses was significant showing that participants with mild-to-moderate BCRL were better responders to MLD than were moderate-to-severe participants.(3) MLD + compression therapy versus nonMLD treatment + compression therapy (three trials) were too varied to pool. One of the trials compared compression sleeve plus MLD to compression sleeve plus pneumatic pump. Volume reduction was statistically significant favoring MLD (MD 47.00 mL, 95% CI 15.25 mL to 78.75 mL; 1 RCT; 24 participants), per cent reduction was borderline significant (P=0.07), and LE volume was not significant. A second trial compared compression sleeve plus MLD to compression sleeve plus self-administered simple lymphatic drainage (SLD), and was significant for MLD for LE volume (MD -230.00 mL, 95% CI -450.84 mL to -9.16 mL; 1 RCT; 31 participants) but not for volume reduction or per cent reduction. A third trial of MLD + compression bandaging versus SLD + compression bandaging was not significant (P = 0.10) for per cent reduction, the only outcome measured (MD 11.80%, 95% CI -2.47% to 26.07%, 28 participants).MLD was well tolerated and safe in all trials.Two trials measured function as range of motion with conflicting results. One trial reported significant within-groups gains for both groups, but no between-groups differences. The other trial reported there were no significant within-groups gains and did not report between-groups results. One trial measured strength and reported no significant changes in either group.Two trials measured QoL, but results were not usable because one trial did not report any results, and the other trial did not report between-groups results.Four trials measured sensations such as pain and heaviness. Overall, the sensations were significantly reduced in both groups over baseline, but with no between-groups differences. No trials reported cost of care.Trials were small ranging from 24 to 45 participants. Most trials appeared to randomize participants adequately. However, in four trials the person measuring the swelling knew what treatment the participants were receiving, and this could have biased results.

AUTHORS' CONCLUSIONS

MLD is safe and may offer additional benefit to compression bandaging for swelling reduction. Compared to individuals with moderate-to-severe BCRL, those with mild-to-moderate BCRL may be the ones who benefit from adding MLD to an intensive course of treatment with compression bandaging. This finding, however, needs to be confirmed by randomized data.In trials where MLD and sleeve were compared with a nonMLD treatment and sleeve, volumetric outcomes were inconsistent within the same trial. Research is needed to identify the most clinically meaningful volumetric measurement, to incorporate newer technologies in LE assessment, and to assess other clinically relevant outcomes such as fibrotic tissue formation.Findings were contradictory for function (range of motion), and inconclusive for quality of life.For symptoms such as pain and heaviness, 60% to 80% of participants reported feeling better regardless of which treatment they received.One-year follow-up suggests that once swelling had been reduced, participants were likely to keep their swelling down if they continued to use a custom-made sleeve.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Effectiveness of postoperative physical therapy for upper-limb impairments after breast cancer treatment: a systematic review

OBJECTIVE

To systematically review the effectiveness of various postoperative physical therapy modalities and timing of physical therapy after treatment of breast cancer on pain and impaired range of motion (ROM) of the upper limb.

DATA SOURCES

We searched the following databases: PubMed/MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, Physiotherapy Evidence Database, and Cochrane. Articles published until October 2012 were included.

STUDY SELECTION

Only (pseudo) randomized controlled trials and nonrandomized experimental trials investigating the effectiveness of passive mobilization, manual stretching, myofascial therapy, and/or exercise therapy and timing of physical therapy after treatment for breast cancer are reviewed. Primary outcomes are pain of the upper limb and/or ROM of the shoulder. Secondary outcomes are decreased shoulder strength, arm lymphedema, limitations in activities of daily living, decreased quality of life, and wound drainage volume. Physical therapy modalities had to be started in the first 6 weeks after surgery.

DATA EXTRACTION

Articles were selected by 2 independent researchers in 3 phases and compared for consensus. First the titles were analyzed, and then the selected abstracts and finally the full texts were reviewed.

DATA SYNTHESIS

Eighteen randomized controlled trials were included in the review. Three studies investigated the effect of multifactorial therapy: 2 studies confirmed that the combination of general exercises and stretching is effective for the treatment of impaired ROM another study showed that passive mobilization combined with massage had no beneficial effects on pain and impaired ROM. Fifteen studies investigated the effectiveness of a single physical therapy modality. One study of poor quality found evidence supporting the beneficial effects of passive mobilization. The only study investigating the effect of stretching did not find any beneficial effects. No studies were found about the effectiveness of myofascial therapy in the postoperative phase. Five studies found that active exercises were more effective than no therapy or information on the treatment of impairments of the upper limb. Three studies supported the early start of exercises for recovery of shoulder ROM, whereas 4 studies supported the delay of exercises to avoid prolonged wound healing.

CONCLUSIONS

Multifactorial physical therapy (ie, stretching, exercises) and active exercises were effective to treat postoperative pain and impaired ROM after treatment for breast cancer. High-quality studies are necessary to determine the effectiveness of passive mobilization, stretching, and myofascial therapy as part of the multifactorial treatment. In addition, the appropriate timing and content of the exercise programs need to be further investigated.

Should a drain be placed in early breast cancer surgery?

BACKGROUND

The current surgical debate has led to a reduction in the extent of surgery performed and thereby to a reduced occurrence of surgical trauma and, over the recent years, reduced seroma formation. This reduction in surgical procedures calls the need for a drain into question.

METHOD

Using Google Scholar and the National Library of Medicine (PubMed), a literature review was performed on systematic reviews and meta-analyses regarding breast cancer surgery ± axillary dissection. Additionally, randomized trials for the time period after the last systematic review were included and evaluated according to the Jadad score.

RESULTS

The search returned 5 systematic reviews, in which a total of 1,075 patients were included (537 cases and 538 controls). Since the last review, no prospective randomized trial meeting the inclusion criteria has been published. The current reviews conclude that insertion of a drain is associated with a longer hospital stay and reduced seroma formation. The data regarding wound infection and drain insertion is inconclusive. The omission of a drain is associated with early discharge, reduced postsurgical pain, and early mobilization, but also with an increase in outpatient seroma aspirations.

CONCLUSION

The omission of a drain is possible in early breast cancer surgery (wide local excision and sentinel node biopsy) with adequate surgical techniques and instruments.

Determining the precision of dual energy x-ray absorptiometry and bioelectric impedance spectroscopy in the assessment of breast cancer-related lymphedema

BACKGROUND

The composition of breast cancer-related lymphedema (BCRL) has been shown to evolve from the initial accumulation of fluid to the development of fibrotic lesions and abnormal fat deposition. Therefore, precise and reliable assessments of BCRL are required to develop accurate staging and management. Although dual energy x-ray absorptiometry (DXA) and bioelectric impedance spectroscopy (BIS) have been used to assess BCRL, no study has evaluated the precision of these two modalities in the same cohort.

METHODS AND RESULTS

We determined the precision of DXA and BIS in lymphedematous (LE) and nonaffected (NA) arms of 24 women with Stage II unilateral BCRL. Precision was calculated from the results of paired bilateral arm measurements obtained from DXA scans measuring fat, lean, and bone mineral masses, BIS measuring extracellular fluid (ECF) and total fluid volume, and circumferential tape measurements (CM) of the arms to calculate the anatomic volume. Precision error was expressed as the root mean square (RMS) of the coefficients of variation (%CV) and standard deviations (SD).

RESULTS

The precisions of DXA and BIS varied from 1.16% (DXA measurements of LE arm total volume) to 1.86% (BIS LE arm total fluid volume) and from 0.95% (DXA lean mass of NA arm) to 1.72% (DXA BMC of NA arm). Precision of CM measures of arm volume were 1.71% CV for LE arm and 2.51% CV for NA arm. The fat and lean masses of the LE arm exceeded the NA arm by about 15% (p<0.0001). ECF and total fluid volume of LE arm was 22.6% and 19% greater than the NA arm (p<0.0001), respectively.

CONCLUSION

For BCRL, these findings suggest that DXA and BIS are two measurement instruments that provide acceptable levels of precision for the measurement of arm lean mass, fat mass and ECF volume, respectively.

Manual lymphatic drainage in chronic venous disease: A duplex ultrasound study

Objectives

To compare the effect of call-up and reabsorption maneuvers of manual lymphatic drainage on blood flow in femoral vein and great saphenous vein in patients with chronic venous disease and healthy controls.

Methods

Forty-one subjects participated in this study (mean age: 42.68(15.23)), 23 with chronic venous disease (chronic venous disease group) with clinical classification C1–5 of clinical-etiological-anatomical-pathological (CEAP) and 18 healthy subjects (control group). Call-up and reabsorption maneuvers were randomly applied in the medial aspect of the thigh. The cross-sectional areas, as well as the peak and the mean blood flow velocity at femoral vein and great saphenous vein, were assessed by Duplex ultrasound at the baseline and during maneuvers. The venous flow volume changes were calculated.

Results

The venous flow volume in femoral vein and great saphenous vein increased during both manual lymphatic drainage maneuvers and in both groups ( P < 0.05). The two maneuvers had a similar effect on femoral vein and great saphenous vein hemodynamics, and in both the chronic venous disease and control groups. As a result of the call-up maneuver, the flow volume augmentations, as a result of call-up maneuver, decreased with the severity of chronic venous disease in those patients measured by the clinical classification of CEAP ( r = −0.64; P = 0.03).

Conclusions

Manual lymphatic drainage increases the venous blood flow in the lower extremity with a magnitude that is independent from the specific maneuver employed or the presence of chronic venous disease. Therefore, manual lymphatic drainage may be an alternative strategy for the treatment and prevention of venous stasis complications in chronic venous disease.

Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes

BACKGROUND

Vascularized groin lymph node flap transfer is an emerging approach to the treatment of postmastectomy upper limb lymphedema. The authors describe the pertinent flap anatomy, surgical technique including different recipient sites, and outcome of this technique.

METHODS

Ten cadaveric dissections were performed to clarify the vascular supply of the superficial groin lymph nodes. Ten patients underwent vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema using the wrist (n=8) or elbow (n=2) as a recipient site. Ten patients who chose to undergo physical therapy were used as controls. Intraoperatively, indocyanine green was injected subcutaneously on the flap margin to observe the lymph drainage. Outcomes were assessed using improvement of circumferential differentiation, reduction rate, and decreased number of episodes of cellulitis.

RESULTS

A mean 6.2±1.3 groin lymph nodes with consistent pedicles were identified in the cadaveric dissections. After indocyanine injection, the fluorescence was drained from the flap edge into the donor vein, followed by the recipient vein. At a mean follow-up of 39.1±15.7 months, the mean improvement of circumferential differentiation was 7.3±2.7 percent and the reduction rate was 40.4±16.1 percent in the vascularized groin lymph node group, which were statistically greater than those of the physical therapy group (1.7±4.6 percent and 8.3±34.7 percent, respectively; p<0.01 and p=0.02, respectively).

CONCLUSIONS

The superficial groin lymph nodes were confirmed as vascularized with reliable arterial perfusion. Vascularized groin lymph node flap transfer using the wrist or elbow as a recipient site is an efficacious approach to treating postmastectomy upper limb lymphedema.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Lymphedema following treatment for breast cancer: a new approach to an old problem

Lymphedema following treatment for breast cancer can be an irreversible condition with a profound negative impact on quality of life. The lack of consensus regarding standard definitions of clinically significant lymphedema and optimal methods of measurement and quantification are unresolved problems. Inconsistencies persist regarding the appropriate timing of intervention and what forms of treatment should be the standard of care. There are reports that early detection and intervention can prevent progression, however,the Level 1 evidence to support this hypothesis has yet to be generated. To assess these controversies, we propose the implementation of a screening program to detect early lymphedema in conjunction with a randomized, prospective trial designed to generate Level 1 evidence regarding the efficacy of early intervention and appropriate treatment strategies. Collaboration among institutions that manage breast cancer patients is essential to establish a standardized approach to lymphedema and to establish guidelines for best practice.

Clinical outcomes of extracorporeal shock wave therapy in patients with secondary lymphedema: a pilot study

Objective

To investigate the clinical effect of extracorporeal shock wave therapy (ESWT) in patients with secondary lymphedema after breast cancer treatment.

Methods

In a prospective clinical trial, ESWT was performed consecutively 4 times over two weeks in 7 patients who were diagnosed with stage 3 secondary lymphedema after breast cancer treatment. Each patient was treated with four sessions of ESWT (0.056-0.068 mJ/mm², 2,000 impulses). The parameters were the circumference of the arm, thickness of the skin and volume of the arm. We measured these parameters with baseline values before ESWT and repeated the evaluation after each ESWT treatment. Subjective data on skin thickness, edema and sensory impairment were obtained using a visual analogue scale (VAS).

Results

The mean volume of the affected arm after four consecutive ESWT was significantly reduced from 2,332 to 2,144 mL (p<0.05). The circumference and thickness of the skin fold of the affected arm were significantly decreased after the fourth ESWT (p<0.05). The three VAS scores were significantly improved after the fourth ESWT. Almost all patients were satisfied with this treatment and felt softer texture in their affected arm after treatment.

Conclusion

ESWT is an effective modality in the treatment of stage 3 lymphedema after breast cancer treatment. ESWT reduced the circumference and the thickness of arms with lymphedema and satisfied almost all patients with lymphedema. Therefore, this treatment provides clinically favorable outcome to patients with breast cancer-related lymphedema.

Side-to-end Lymphaticovenular anastomosis through temporary lymphatic expansion

OBJECTIVE

The number of bypasses is the most important factor in lymphaticovenular anastomosis (LVA) for lymphedema treatment. Side-to-end (S-E) LVA, which can bypass bidirectional lymph flows via one anastomosis, is considered to be the most efficient bypass, but creation of lateral window to a small lymphatic vessel is technically demanding. To overcome the difficulty, we introduced S-E anastomosis through temporary lymphatic expansion (SEATTLE) procedure in S-E LVA.

METHODS

This was a retrospective observational study set in a teaching hospital. Forty eight lower extremity lymphedema (LEL) patients underwent LVA. S-E LVAs were performed with (SEATTLE group) or without (non-SEATTLE group) temporary lymphatic expansion. S-E LVAs were evaluated to compare anastomosis result in SEATTLE and non-SEATTLE groups.

RESULTS

S-E LVAs resulted in 44 anastomoses in SEATTLE group (n = 25) and 37 anastomoses in non-SEATTLE group (n = 23). LEL index reduction in SEATTLE group was significantly greater than that in non-SEATTLE group (16.5±14.5 vs. 10.9±11.8, P = 0.041). Success rate of S-E LVA in SEATTLE group was significantly higher than that in non-SEATTLE group (95.5% vs 81.1%, P = 0.040). Thirty seven of 44 (84.1%) lymph vessels in SEATTLE group were successfully dilated by temporary lymphatic expansion maneuver. All of 9 failed S-E LVAs used a lymphatic vessel with diameter of 0.35 mm or smaller.

CONCLUSIONS

The SEATTLE procedure facilitates S-E LVA by a simple and easy maneuver. When the diameter of the lymphatic vessel is 0.35 mm or smaller even after the temporary lymphatic expansion maneuver, S-E LVA is not recommended due to relatively high failure rate.

A systematic review of the evidence for complete decongestive therapy in the treatment of lymphedema from 2004 to 2011

OBJECTIVE

To critically analyze the contemporary published research that pertains to the individual components of complete decongestive therapy (CDT), as well as CDT as a bundled intervention in the treatment of lymphedema.

DATA SOURCES

Publications were retrieved from 11 major medical indices for articles published from 2004-2010 by using search terms for lymphedema and management approaches. Literature archives of the authors and reference lists were examined through 2011.

STUDY SELECTION

A research librarian assisted with initial literature searches by using search terms used in the Best Practice for the Management of Lymphoedema, plus expanded terms, for literature related to lymphedema. Authors sorted relevant literature for inclusion and exclusion; included articles were sorted into topical areas for data extraction and assessment of level of evidence by using a published grading system and consensus process. The authors reviewed 99 articles, of which 26 met inclusion criteria for individual studies and 1 case study did not meet strict inclusion criteria. In addition, 14 review articles and 2 consensus articles were reviewed.

DATA EXTRACTION

Information on study design and/or objectives, participants, outcomes, intervention, results, and study strengths and weaknesses was extracted from each article. Study evidence was categorized according to the Oncology Nursing Society Putting Evidence into Practice level of evidence guidelines after achieving consensus among authors.

DATA SYNTHESIS

Levels of evidence were only moderately strong, because there were few randomized controlled trials with control groups, well-controlled interventions, and precise measurements of volume, mobility and/or function, and quality of life. Treatment interventions were often bundled, which makes it difficult to determine the contribution of each individual component of treatment to the outcomes achieved.

CONCLUSIONS

CDT is seen to be effective in reducing lymphedema. This review focuses on original research about CDT as a bundled intervention and 2 individual components, manual lymph drainage and compression bandages. Additional studies are needed to determine the value and efficacy of the other individual components of CDT.

Effects of manual lymphatic drainage on breast cancer-related lymphedema: a systematic review and meta-analysis of randomized controlled trials

Background

Lymphedema is a common complication of axillary dissection for breast cancer. We investigated whether manual lymphatic drainage (MLD) could prevent or manage limb edema in women after breast-cancer surgery.

Methods

We performed a systematic review and meta-analysis of published randomized controlled trials (RCTs) to evaluate the effectiveness of MLD in the prevention and treatment of breast-cancer-related lymphedema. The PubMed, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro), SCOPUS, and Cochrane Central Register of Controlled Trials electronic databases were searched for articles on MLD published before December 2012, with no language restrictions. The primary outcome for prevention was the incidence of postoperative lymphedema. The outcome for management of lymphedema was a reduction in edema volume.

Results

In total, 10 RCTs with 566 patients were identified. Two studies evaluating the preventive outcome of MLD found no significant difference in the incidence of lymphedema between the MLD and standard treatment groups, with a risk ratio of 0.63 and a 95% confidence interval (CI) of 0.14 to 2.82. Seven studies assessed the reduction in arm volume, and found no significant difference between the MLD and standard treatment groups, with a weighted mean difference of 75.12 (95% CI, −9.34 to 159.58).

Conclusions

The current evidence from RCTs does not support the use of MLD in preventing or treating lymphedema. However, clinical and statistical inconsistencies between the various studies confounded our evaluation of the effect of MLD on breast-cancer-related lymphedema.