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Toro C, Markarian B, Mayrovitz HN. Breast Cancer-Related Lymphedema Assessed via Tissue Dielectric Constant Measurements. Cureus 2024; 16:e59261. [PMID: 38813316 PMCID: PMC11135004 DOI: 10.7759/cureus.59261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/29/2024] [Indexed: 05/31/2024] Open
Abstract
This review describes the use of tissue dielectric constant (TDC) measurements mainly in the assessment of breast cancer-related lymphedema (BCRL). PubMed, Web of Science, and EMBASE databases were initially searched using criteria that included the terms "dielectric" and "lymphedema." The initial search yielded a total of 131 titles. After removing studies not focused on upper extremity lymphedema, 56 articles remained. These articles, together with relevant articles from their bibliographies, formed the basis of the review. The findings show the potential utility and applications of TDC measurements to help detect and track BCRL, whether present in limbs, breasts, or trunks. It is reported as a non-invasive, simple-to-use method, with each measurement requiring less than 10 seconds, suggesting its practicality and useability as an in-office or in-clinic screening and tracking method. Although there are various ways to quantitatively evaluate lymphedema, most, if not all, are restricted to measurements on limbs. Thus, one significant advantage of the TDC approach is that almost any local region of interest can be effectively measured and tracked, which, for BCRL, could include specific regions of arms or hands, breasts, and truncal areas.
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Affiliation(s)
- Carel Toro
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Biura Markarian
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Harvey N Mayrovitz
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Davie, USA
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Johansson K, Blom K, Nilsson-Wikmar L, Brogårdh C. Early Intervention with a Compression Sleeve in Mild Breast Cancer-Related Arm Lymphedema: A 12-Month Prospective Observational Study. Cancers (Basel) 2023; 15:2674. [PMID: 37345010 DOI: 10.3390/cancers15102674] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/03/2023] [Accepted: 05/05/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND In our previous randomized controlled trial (RCT), the progression/no progression of mild breast cancer-related arm lymphedema (BCRL) was examined among women randomized to a compression group (CG) with a compression sleeve (compression class (ccl) 1) or not (NCG) for 6 months. In the present prospective study, BCRL in the CG and NCG was followed for 12 months. METHODS At the end of the RCT, 33 women with mild BCRL were eligible in the CG and 37 in the NCG. The proportional differences in no progression/progression of BCRL were defined as a >2% increase from start of RCT or exceeding 10% in the lymphedema relative volume as measured by the water displacement method. In addition, changes in the lymphedema relative volume and tissue dielectric constant ratio, which measures local tissue water, were examined. At the end of the RCT (i.e., after 6 months), a one-month break of the compression treatment was made in the CG. If the lymphedema relative volume progressed by definition, the compression treatment was resumed and continued, with follow-up of all women at 9 and 12 months. RESULTS A larger proportion of women in the NCG showed progression (57%, 61%, 67%) compared to the CG (16%, 22%, 31%) at 6, 9, and 12 months (p < 0.001, 0.005, 0.012), respectively. Twelve (33%) women in the NCG did not progress at all. No changes of the lymphedema relative volume and local tissue water were found over time at any follow-ups, but were stable on a low level. CONCLUSIONS To avoid the progression of mild BCRL into a chronic issue in the long-term, compression sleeve ccl 1 may be applied immediately after early diagnosis of mild BCRL.
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Affiliation(s)
- Karin Johansson
- Department of Health Sciences, Lund University, 221 00 Lund, Sweden
| | - Katarina Blom
- Department of Health Sciences, Lund University, 221 00 Lund, Sweden
- Physiotherapy Cancer, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Lena Nilsson-Wikmar
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, 141 52 Huddinge, Sweden
| | - Christina Brogårdh
- Department of Health Sciences, Lund University, 221 00 Lund, Sweden
- Department of Neurology, Rehabilitation Medicine, Memory Disorders and Geriatrics, Skåne University Hospital, 221 85 Lund, Sweden
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Cuello Villaverde E, Rambla Tirado E, Cardells Beltrán B, Guerola Soler N. Indirect partial volumetry in breast cancer-related lymphoedema: Distribution of oedema and clinical-diagnostic implications. Rehabilitacion (Madr) 2023; 57:100777. [PMID: 36739629 DOI: 10.1016/j.rh.2022.100777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 10/06/2022] [Accepted: 11/06/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION AND OBJECTIVES Currently, the assessment of lymphoedema related to breast cancer (BCRL) is performed through the global perimeter volumetry. We implemented an additional system with partial measures (hand, forearm, and upper arm) that allows us to approximate the segmental distribution of oedema. We used this measurement tool to determine the oedema distribution and its evolution, as well as its possible impact on clinical assessment. METHODS We carried out a retrospective observational study of the patients referred to our service with suspected BCRL. INCLUSION CRITERIA Unilateral breast cancer, availability of global and partial digital medical record, and follow-up for a minimum of 24 months. Of the 210 selected patients, 190 were considered affected (≥10% excess volume). We analysed at three time points (initial, final, and peak involvement) the oedema distribution and segmental predominance and its relationship with the evolutionary course and the severity of the process. We subsequently examined, at the initial timepoint, the concordance of the global assessment with the partial assessment for the clinical classification of the 210 patients in the initial sample. RESULTS The BCRL oedema was characteristically irregular, with the forearm being the most affected segment and the hand the least affected (RM ANOVA: p<0.001). The irregularity was related to its severity (χ2: p<0.001) and the evolutionary course (Student t-test: p<0.005 for the hand). Overall, disagreement of 46.67% was observed between the clinical classification of the global and partial assessment. CONCLUSIONS This work supports the need to add partial volumetry to the commonly used global assessment.
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Affiliation(s)
- E Cuello Villaverde
- Servicio de Rehabilitación, Consorcio Hospitalario Provincial de Castellón, Castellón, Spain.
| | - E Rambla Tirado
- Servicio de Rehabilitación, Consorcio Hospitalario Provincial de Castellón, Castellón, Spain
| | - B Cardells Beltrán
- Servicio de Rehabilitación, Consorcio Hospitalario Provincial de Castellón, Castellón, Spain
| | - N Guerola Soler
- Servicio de Rehabilitación, Consorcio Hospitalario Provincial de Castellón, Castellón, Spain
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Ochalek K, Gradalski T. Early Detection of Breast Cancer-Related Lymphedema in COVID-19 Pandemic. Lymphat Res Biol 2023; 21:15-19. [PMID: 35833890 DOI: 10.1089/lrb.2021.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: This study aimed at presenting a prospective surveillance model of care delivered at home for women qualified for surgery due to breast cancer under the epidemic-related restrictions. Methods and Results: Women (age ≥18 years, diagnosed with breast cancer, no clinical features of upper limbs lymphedema, and a volume difference between the limbs <5%, not using any prophylactic compression products) will be provided with comprehensive education in the field of self-measurements and lymphedema prevention. The outcome measures include limb volume (circumferential measurements with a tape at 4 cm intervals), simplified protocol of three measurement points combined with the symptoms monitoring (according to the physical section of Lymphedema Quality of Life Inventory [LyQLI]). We propose a new calculation method as the RACI (relative arm circumference increase) in accordance with previous research-RAVI (relative arm volume increase) and the new proposal-the RACD (relative arm circumference difference). According to cylinder formula it can be calculated that 5% increase in limb volume results in ∼2% change in RACI. Regular appointments will be planned at 3, 6, 9, and 12 months after the enrollment. Additional urgent appointments will be arranged after the home or phone "red flags" (an increase circumference by ≥2%, positive pitting test, and any new symptoms) detection. We hypothesize that performing only three measurements combined with the typical symptoms monitoring would be accurate for lymphedema diagnosis based on the RAVI of ≥5%. Moreover, RACI/RACD increments combined with positive symptoms would correlate with RAVI. Conclusions: The new proposal of protocol can be the optimal solution in COVID-19 pandemic.
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Affiliation(s)
- Katarzyna Ochalek
- Faculty of Motor Rehabilitation, Institute of Clinical Rehabilitation, University of Physical Education, Krakow, Poland.,St. Lazarus Hospice, Krakow, Poland
| | - Tomasz Gradalski
- St. Lazarus Hospice, Krakow, Poland.,Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
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Brunelle CL, Taghian AG. Breast Cancer–Related Lymphedema: the Prospective Surveillance Model, Early Intervention Strategies, and Role of Complete Decongestive Therapy. CURRENT BREAST CANCER REPORTS 2023. [DOI: 10.1007/s12609-023-00471-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Blom KY, Johansson KI, Nilsson-Wikmar LB, Brogårdh CB. Early intervention with compression garments prevents progression in mild breast cancer-related arm lymphedema: a randomized controlled trial. Acta Oncol 2022; 61:897-905. [PMID: 35657063 DOI: 10.1080/0284186x.2022.2081932] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Early diagnosis and compression treatment are important to prevent progression in breast cancer-related arm lymphedema (BCRAL). However, some mild BCRAL can be reversible, and therefore, compression treatment may not be needed. The aim of this study was to investigate the proportion of women with mild BCRAL showing progression/no progression of lymphedema after treatment with or without compression garments, differences in changes of lymphedema relative volume (LRV), local tissue water and subjective symptoms during 6 months. Also, adherence to self-care was examined. MATERIAL AND METHODS Seventy-five women diagnosed with mild BCRAL were randomized to a compression group (CG) or noncompression group (NCG). Both groups received self-care instructions, and the CG were treated with a standard compression garment (ccl 1). Women in the NCG who progressed in LRV ≥2%, or exceeded 10% dropped out, and received appropriate treatment. The proportion showing progression/no progression of LRV, and changes in LRV was measured by Water Displacement Method. Changes in local tissue water were measured by Tissue Dielectric Constant (TDC), subjective symptoms by Visual Analogue Scale, and self-care by a questionnaire. RESULTS A smaller proportion of LRV progression was found in the CG compared to the NCG at 1, 2 and 6 months follow-up (p ≤ 0.013). At 6 months, 16% had progression of LRV in the CG, compared to 57% in the NCG, (p = 0.001). Thus, 43% in the NCG showed no progression and could manage without compression. Also, CG had a larger reduction in LRV, at all time-points (p ≤ 0.005), and in the highest TDC ratio, when same site followed, at 6 months (p = 0.025). Subjective symptoms did not differ between the groups, except at 1 month, where the CG experienced more reduced tension (p = 0.008). There were no differences in adherence to self-care. CONCLUSION Early treatment with compression garment can prevent progression in mild BCRAL. Trial registration: ISRCT nr ISRCTN51918431.
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Affiliation(s)
- Katarina Y. Blom
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Physiotherapy Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Karin I. Johansson
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Lena B. Nilsson-Wikmar
- Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, Sweden
| | - Christina B. Brogårdh
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Neurology, Rehabilitation Medicine, Memory Disorders and Geriatrics, Skåne University Hospital, Lund, Sweden
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Al Onazi MM, Campbell KL, Thompson RB, Ghosh S, Mackey JR, Muir A, McNeely ML. Decongestive progressive resistance exercise with an adjustable compression wrap for breast cancer-related lymphoedema (DREAM): protocol for a randomised controlled trial. BMJ Open 2022; 12:e053165. [PMID: 35379618 PMCID: PMC8981291 DOI: 10.1136/bmjopen-2021-053165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Breast cancer-related lymphoedema (BCRL) is a chronic swelling in the arm on the side of the breast cancer surgery, affecting one in five women. Recent studies in BCRL have demonstrated that resistance exercise can improve symptoms and quality of life without worsening lymphoedema. No studies have explored whether combining the principles of progressive resistance exercise training with therapeutic strategies of compression therapy and the decongestive lymphatic exercise sequence are beneficial in reducing arm lymphoedema volume. The aim of this three-arm, provincial randomised controlled trial is to determine the efficacy of a 12-week decongestive progressive resistance exercise (DRE) programme in combination with the one of two types of compression garments compared with standard care. METHODS AND ANALYSIS Sixty women with BCRL will be recruited and randomly assigned to one of the following three groups: (1) Standard care, (2) DRE with use of a daytime compression garment during exercise and (3) DRE with use of an adjustable compression wrap during exercise. The primary outcome is the percentage reduction in arm lymphoedema volume. Secondary outcomes include bioimpedance analysis, muscular strength, shoulder range of motion, physical activity level and health-related quality of life. Exploratory outcomes include evaluating changes in arm tissue composition using MRI and examining outcomes between the two DRE experimental groups. The primary analysis will compare changes between the groups from baseline to week 12 reflecting the end of the randomised control trial period. ETHICS AND DISSEMINATION The trial has received ethics approval from the Health Research Ethics Board of Alberta: Cancer Committee. The study results will be disseminated through scientific peer-reviewed publications, and presented at national and international conferences, and other media portals. The programme protocol will be shared with healthcare professionals and patient groups through clinical workshops and webinars. TRIAL REGISTRATION NUMBER NCT05022823. PROTOCOL VERSION 12 November 2021. ISSUE DATE 26 April 2021.
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Affiliation(s)
- Mona M Al Onazi
- Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| | - Kristin L Campbell
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard B Thompson
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Sunita Ghosh
- Department of Mathematics and Statistical Sciences, University of Alberta, Edmonton, Alberta, Canada
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - John R Mackey
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Anne Muir
- Cancer Rehabilitation Clinic, University of Alberta, Edmonton, Alberta, Canada
| | - Margaret L McNeely
- Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
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Chang CC, Jan WL, Juan CH, Meng NH, Lin BS, Chen HC. Novel Wireless Bioimpedance Device for Segmental Lymphedema Analysis Post Dual-Site Free Vascularized Lymph Node Transfer: A Prospective Cohort Study. SENSORS 2021; 21:s21248187. [PMID: 34960279 PMCID: PMC8707995 DOI: 10.3390/s21248187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 01/02/2023]
Abstract
An innovative wireless device for bioimpedance analysis was developed for post-dual-site free vascularized lymph node transfer (VLNT) evaluation. Seven patients received dual-site free VLNT for unilateral upper or lower limb lymphedema. A total of 10 healthy college students were enrolled in the healthy control group. The device was applied to the affected and unaffected limbs to assess segmental alterations in bioimpedance. The affected proximal limb showed a significant increase in bioimpedance at postoperative sixth month (3.3 [2.8, 3.6], p = 0.001) with 10 kHz currents for better penetration, although the difference was not significant (3.3 [3.3, 3.8]) at 1 kHz. The bioimpedance of the affected distal limb significantly increased after dual-site free VLNT surgery, whether passing with the 1 kHz (1.6 [0.7, 3.4], p = 0.030, postoperative first month; 2.8 [1.0, 4.2], p = 0.027, postoperative third month; and 1.3 [1.3, 3.4], p = 0.009, postoperative sixth month) or 10 kHz current ((1.4 [0.5, 2.7], p = 0.049, postoperative first month; 3.2 [0.9, 6.3], p = 0.003, postoperative third month; and 3.6 [2.5, 4.1], p < 0.001, postoperative sixth month). Bioimpedance alterations on the affected distal limb were significantly correlated with follow-up time (rho = 0.456, p = 0.029 detected at 10 kHz). This bioimpedance wireless device could quantitatively monitor the interstitial fluid alterations, which is suitable for postoperative real-time surveillance.
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Affiliation(s)
- Chang-Cheng Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung 404332, Taiwan; (C.-C.C.); (W.-L.J.)
- School of Medicine, College of Medicine, China Medical University, Taichung 404333, Taiwan
- Institute of Imaging and Biomedical Photonics, National Yang Ming Chiao Tung University, Tainan 711010, Taiwan
| | - Wei-Ling Jan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung 404332, Taiwan; (C.-C.C.); (W.-L.J.)
| | - Cheng-Huei Juan
- Institute of Biomedical Science, China Medical University, Taichung 404333, Taiwan;
| | - Nai-Hsin Meng
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung 404332, Taiwan;
| | - Bor-Shyh Lin
- Institute of Imaging and Biomedical Photonics, National Yang Ming Chiao Tung University, Tainan 711010, Taiwan
- Correspondence: (B.-S.L.); (H.-C.C.); Tel.: +886-6-3032121-57835 (B.S.-L.); +886-4-22052121-1538 (H.-C.C.)
| | - Hung-Chi Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung 404332, Taiwan; (C.-C.C.); (W.-L.J.)
- International Medical Service Center, China Medical University Hospital, Taichung 404332, Taiwan
- Correspondence: (B.-S.L.); (H.-C.C.); Tel.: +886-6-3032121-57835 (B.S.-L.); +886-4-22052121-1538 (H.-C.C.)
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Polomska A, Gousopoulos E, Fehr D, Bachmann A, Bonmarin M, Detmar M, Lindenblatt N. Development and Clinical Validation of the LymphMonitor Technology to Quantitatively Assess Lymphatic Function. Diagnostics (Basel) 2021; 11:diagnostics11101873. [PMID: 34679571 PMCID: PMC8534490 DOI: 10.3390/diagnostics11101873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/17/2021] [Accepted: 10/04/2021] [Indexed: 02/01/2023] Open
Abstract
Current diagnostic methods for evaluating the functionality of the lymphatic vascular system usually do not provide quantitative data and suffer from many limitations including high costs, complexity, and the need to perform them in hospital settings. In this work, we present a quantitative, simple outpatient technology named LymphMonitor to quantitatively assess lymphatic function. This method is based on the painless injection of the lymphatic-specific near-infrared fluorescent tracer indocyanine green complexed with human serum albumin, using MicronJet600TM microneedles, and monitoring the disappearance of the fluorescence signal at the injection site over time using a portable detection device named LymphMeter. This technology was investigated in 10 patients with unilateral leg or arm lymphedema. After injection of a tracer solution into each limb, the signal was measured over 3 h and the area under the normalized clearance curve was calculated to quantify the lymphatic function. A statistically significant difference in lymphatic clearance in the healthy versus the lymphedema extremities was found, based on the obtained area under curves of the normalized clearance curves. This study provides the first evidence that the LymphMonitor technology has the potential to diagnose and monitor the lymphatic function in patients.
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Affiliation(s)
- Anna Polomska
- Swiss Federal Institute of Technology (ETH Zürich), Institute of Pharmaceutical Sciences, Vladimir-Prelog Weg 3, 8093 Zurich, Switzerland;
| | - Epameinondas Gousopoulos
- Department of Plastic and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland; (E.G.); (N.L.)
| | - Daniel Fehr
- Zurich University of Applied Sciences (ZHAW), Institute of Computational Physics, Technikumstrasse 9, 8401 Winterthur, Switzerland; (D.F.); (A.B.); (M.B.)
| | - Andreas Bachmann
- Zurich University of Applied Sciences (ZHAW), Institute of Computational Physics, Technikumstrasse 9, 8401 Winterthur, Switzerland; (D.F.); (A.B.); (M.B.)
| | - Mathias Bonmarin
- Zurich University of Applied Sciences (ZHAW), Institute of Computational Physics, Technikumstrasse 9, 8401 Winterthur, Switzerland; (D.F.); (A.B.); (M.B.)
| | - Michael Detmar
- Swiss Federal Institute of Technology (ETH Zürich), Institute of Pharmaceutical Sciences, Vladimir-Prelog Weg 3, 8093 Zurich, Switzerland;
- Correspondence:
| | - Nicole Lindenblatt
- Department of Plastic and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland; (E.G.); (N.L.)
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Thomis S, Devoogdt N, De Vrieze T, Bechter-Hugl B, Heroes AK, Fourneau I. Relation Between Early Disturbance of lymphatic transport Visualized With Lymphofluoroscopy and Other Clinical Assessment Methods in Patients With Breast Cancer. Clin Breast Cancer 2021; 22:e37-e47. [PMID: 34376347 DOI: 10.1016/j.clbc.2021.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/04/2021] [Accepted: 06/28/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Lymphedema of the upper extremity is one of the most feared complications following breast cancer treatment. Lymphofluoroscopy is a sensitive instrument for detection of lymphedema and visualization of superficial lymphatic transport, thus suitable for early detection. Early detection of lymphedema is important as it can prevent lymphedema to progress into more severe stages and minimalize impact on quality of life and medical costs. OBJECTIVE To determine agreement between the presence of early disturbance of the lymphatic transport and outcome of clinical measurement tools evaluating the development of lymphedema. METHODS A prospective study was conducted in 128 breast cancer patients scheduled for breast cancer surgery. Patients were evaluated before surgery and 1, 3-, 6-, 9-, and 12-months' post-surgery. Cohen's Kappa was used to determine agreement between presence of early disturbance in lymphatic transport and presence of pitting/increased skinfold thickness/increased Percentage Water Content ratio (PWC)/increased arm-hand volume (circumference measures and water displacement). RESULTS For pitting status (Kappa 0.23), for skinfold thickness (Kappa 0.29) and the PWC ratio (Kappa 0.21) a minimal agreement was found. The circumference measurement had a minimal agreement for 5% volume difference (Kappa 0.22) and no agreement for 3% volume difference (Kappa 0.19). Sensitivity was weak for all clinical assessments. The specificity was excellent for pitting status, skinfold thickness, PWC ratio, and for 5% volume difference. For 3% a high specificity was found. CONCLUSION The clinical tools assessed in this study were not able to predict an early disturbance of the lymphatic transport seen on lymphofluoroscopy.
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Affiliation(s)
- Sarah Thomis
- Department of Vascular Surgery, UZ Leuven - University Hospitals Leuven, Centre for Lymphedema, Leuven, Belgium; Department of Cardiovascular Sciences, Research unit Vascular Surgery, KU Leuven - University of Leuven, Leuven, Belgium.
| | - Nele Devoogdt
- Department of Vascular Surgery, UZ Leuven - University Hospitals Leuven, Centre for Lymphedema, Leuven, Belgium; Department of Rehabilitation Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Tessa De Vrieze
- Department of Rehabilitation Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Beate Bechter-Hugl
- Department of Vascular Surgery, UZ Leuven - University Hospitals Leuven, Centre for Lymphedema, Leuven, Belgium
| | - An-Kathleen Heroes
- Department of Vascular Surgery, UZ Leuven - University Hospitals Leuven, Centre for Lymphedema, Leuven, Belgium
| | - Inge Fourneau
- Department of Vascular Surgery, UZ Leuven - University Hospitals Leuven, Centre for Lymphedema, Leuven, Belgium; Department of Cardiovascular Sciences, Research unit Vascular Surgery, KU Leuven - University of Leuven, Leuven, Belgium
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11
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Havens LM, Brunelle CL, Gillespie TC, Bernstein M, Bucci LK, Kassamani YW, Taghian AG. Use of technology to facilitate a prospective surveillance program for breast cancer-related lymphedema at the Massachusetts General Hospital. Mhealth 2021; 7:11. [PMID: 33634194 PMCID: PMC7882272 DOI: 10.21037/mhealth-19-218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 04/29/2020] [Indexed: 11/06/2022] Open
Abstract
Breast cancer-related lymphedema (BCRL) is a negative sequela of breast cancer (BC) caused by trauma to the lymphatic system during surgery or radiation to the axillary lymph nodes. BCRL affects approximately one in five patients treated for BC, and patients are at a lifelong risk for BCRL after treatment. Early diagnosis of BCRL may prevent its progression and reduce negative effects on quality of life, necessitating comprehensive prospective screening. This paper provides an overview of technology that may be used as part of a BCRL screening program, including objective measures such as perometry, bioimpedance spectroscopy, tissue tonometry, and three-dimensional optical imaging. Furthermore, this paper comprehensively reviews the technology incorporated into the established prospective screening program at Massachusetts General Hospital. Our prospective screening program consists of longitudinal measurements via perometry, symptoms assessment, and clinical examination by a certified lymphedema therapist (CLT) as needed. Discussion about use of perometry within the screening program and incorporation of arm volume measurements into equations to determine change over time and accurate diagnosis is included [relative volume change (RVC) and weight-adjusted change (WAC) equations]. Use of technology throughout the program is discussed, including a HIPPA-compliant online research database, the patient's electronic medical record, and incorporation of BCRL-related symptoms [BC and lymphedema symptom experience index (BCLE-SEI) survey]. Ultimately, both subjective and objective data are used to inform BCRL diagnosis and treatment by the CLT. In conclusion, the role of technology in facilitating BCRL screening is indispensable, and the continued development of objective assessment methods that are not only reliable and valid, but also cost-effective and portable will help establish BCRL screening as the standard of care for patients treated for BC.
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Affiliation(s)
- Lauren M. Havens
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Cheryl L. Brunelle
- Department of Physical and Occupational Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - Tessa C. Gillespie
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Madison Bernstein
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Loryn K. Bucci
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Yara W. Kassamani
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Alphonse G. Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
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Rafn BS, Singh CA, Midtgaard J, Camp PG, McNeely ML, Campbell KL. Self-Managed Surveillance for Breast Cancer-Related Upper Body Issues: A Feasibility and Reliability Study. Phys Ther 2020; 100:468-476. [PMID: 32043126 DOI: 10.1093/ptj/pzz181] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Early identification of breast cancer-related upper body issues is important to enable timely physical therapist treatment. OBJECTIVE This study evaluated the feasibility and reliability of women performing self-managed prospective surveillance for upper body issues in the early postoperative phase as part of a hospital-based physical therapy program. DESIGN This was a prospective, single-site, single-group feasibility and reliability study. METHODS Presurgery arm circumference measurements were completed at home and at the hospital by participants and by a physical therapist. Instruction in self-measurement was provided using a video guide. After surgery, all circumference measurements were repeated along with self-assessment and therapist assessment for shoulder flexion and abduction active range of motion. Feasibility was determined by recruitment/retention rates and participant-reported ease of performing self-measurements (1 [very difficult] to 10 [very easy]). Reliability was determined as intrarater reliability, interrater reliability, and agreement. RESULTS Thirty-three women who were 53.4 (SD = 11.4) years old participated, with recruitment and retention rates of 79% and 94%, respectively. Participant-reported ease of measurement was 8.2 (SD = 2.2) before surgery and 8.0 (SD = 1.9) after surgery. The intrarater reliability and interrater reliability were excellent before surgery (intraclass correlation coefficient [ICC] ≥ 0.94; 95% confidence interval = 0.87-0.97) and after surgery (ICC ≥ 0.91; 95% confidence interval = 0.76-0.96). Agreement between self-assessed and therapist-assessed active shoulder flexion (κ = 0.79) and abduction (κ = 0.71) was good. LIMITATIONS Further testing is needed using a prospective design with a longer follow-up to determine whether self-managed prospective surveillance and timely treatment can hinder the development of chronic breast cancer-related upper body issues. CONCLUSIONS Self-measured arm circumference and shoulder range of motion are reliable, and their inclusion in a hospital-based program of prospective surveillance for upper body issues seems feasible. This approach may improve early detection and treatment.
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Affiliation(s)
- Bolette S Rafn
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Chiara A Singh
- Department of Physical Therapy, Surrey Memorial Hospital, Fraser Health, Surrey, British Columbia, Canada
| | - Julie Midtgaard
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark; and University Hospitals' Centre for Health Research, Rigshospitalet, Copenhagen, Denmark
| | - Pat G Camp
- Department of Physical Therapy, University of British Columbia; Centre for Heart and Lung Innovation, University of British Columbia; and St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Margaret L McNeely
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kristin L Campbell
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Wesbrook Mall, Vancouver, British Columbia V6T 1Z3, Canada
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Svensson BJ, Dylke ES, Ward LC, Black DA, Kilbreath SL. Screening for breast cancer–related lymphoedema: self-assessment of symptoms and signs. Support Care Cancer 2019; 28:3073-3080. [DOI: 10.1007/s00520-019-05083-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 09/16/2019] [Indexed: 01/09/2023]
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Rafn BS, McNeely ML, Camp PG, Midtgaard J, Campbell KL. Self-Measured Arm Circumference in Women With Breast Cancer Is Reliable and Valid. Phys Ther 2019; 99:240-253. [PMID: 30289500 DOI: 10.1093/ptj/pzy117] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/21/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Prospective surveillance by physical therapists enables early detection and treatment of breast cancer-related lymphedema (BCRL). Strategies to increase access to prospective surveillance could reduce the burden of BCRL on patients and the health system. One potential solution is self-managed surveillance that does not require in-person assessment by a specialized physical therapist. OBJECTIVE The objective was to develop and test the reliability and validity of a written and video-supported protocol for women with breast cancer to self-measure arm circumference. DESIGN This was a cross-sectional reliability and validity study. RESULTS The intrarater reliability between CIRself_home and CIRself_lab and the interrater reliability between CIRself_lab and CIRther was high to excellent for both arms in both groups (intraclass correlation coefficient ≥0.86). VOLself_lab correlated strongly with VOLper (r ≥ 0.95), demonstrating excellent validity. Participants reported strong intention, self-efficacy, and positive attitude toward the performance of self-managed surveillance for BCRL, which was not perceived to increase worry about having or getting BCRL. METHODS Participants with (n = 20) and without (n = 21) BCRL completed self-measurement of arm circumference on both arms at home (CIRself_home) and at the lab (CIRself_lab) (intrarater reliability). The CIRself_lab was subsequently compared to measures performed by a specialized physical therapist (CIRther) (interrater reliability). To test validity, arm volume calculated from the self-measurements (VOLself_lab) was compared to perometry measurements (VOLper). Participants completed a questionnaire to assess attitudes for performing self-managed surveillance for BCRL. LIMITATIONS These findings need to be replicated in a clinical setting to confirm the reliability and acceptability of self-managed surveillance for BCRL among women newly diagnosed with breast cancer. CONCLUSIONS Self-measured arm circumference is reliable and valid among women with and without BCRL. Self-managed surveillance for BCRL can support self-efficacy without increasing anxiety.
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Affiliation(s)
- Bolette S Rafn
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Margaret L McNeely
- Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| | - Pat G Camp
- Department of Physical Therapy, Centre for Heart Lung Innovation, University of British Columbia
| | - Julie Midtgaard
- Department of Public Health, University of Copenhagen, and Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kristin L Campbell
- Department of Physical Therapy, University of British Columbia, 212-2177 Wesbrook Mall Vancouver, Vancouver, British Columbia V6T 1Z3, Canada
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15
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Manirakiza A, Irakoze L, Shui L, Manirakiza S, Ngendahayo L. Lymphoedema After Breast Cancer Treatment is Associated With Higher Body Mass Index: A Systematic Review and Meta-Analysis. East Afr Health Res J 2019; 3:178-192. [PMID: 34308212 PMCID: PMC8279288 DOI: 10.24248/eahrj-d-19-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 10/07/2019] [Indexed: 11/25/2022] Open
Abstract
Background: Excess body weight has been identified as an important risk factor for lymphoedema following breast cancer treatment, however it remains unclear how much risk increases as weight increases. We conducted a meta-analysis to assess the relationship between body mass index (BMI) and risk of lymphoedema in breast cancer patients, and to estimate the level of risk by BMI category. Methods: We conducted a systematic search of all articles published through May 2018 in PubMed and the Cochrane library. Studies that included data on BMI and lymphoedema in breast cancer patients were included in the meta-analysis. We compared risk of lymphoedema in BMI groups as: BMI<25 versus BMI≥25, BMI<25 versus BMI≥30, BMI≥25 to <30 versus BMI≥30, BMI<30 versus BMI≥30, BMI<25 versus BMI≥25 to BMI<30. Results: After exclusion of ineligible studies, 57 studies were included in the meta-analysis. The mean difference in BMI between patients with lymphoedema compared to those without lymphoedema was 1.7 (95% CI, 1.3–2.2). Compared to patients with a BMI<25, risk of lymphoedema was higher in those with a BMI >25 to <30 (odds ratio [OR] 1.3; 95% CI, 1.2 to 1.5), a BMI≥25 (OR 1.7; 95% CI, 1.5 to 1.9), or a BMI≥30 (OR 1.9; 95% CI, 1.6 to 2.4). Compared to patients with a BMI of >25 to <30, risk of lymphoedema was higher in patients with a BMI>30 (OR 1.5; 95% CI,1.4 to 1.8). Conclusion: Excess body weight is a risk factor for lymphoedema following treatment of breast cancer, with the magnitude of risk increasing across higher categories of BMI.
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Affiliation(s)
- Astère Manirakiza
- Department of Oncology, Karuzi Fiftieth Hospital, Karuzi, Burundi.,Department of Oncology, University Hospital Centre of Kamenge, Bujumbura, Burundi
| | - Laurent Irakoze
- Department of Endocrinology, First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Lin Shui
- Department of Oncology, West China Medical Center, Sichuan University, Chengdu, China
| | - Sébastien Manirakiza
- Faculty of Medicine, University of Burundi, Bujumbura, Burundi.,Department of Radiology, University Hospital Centre of Kamenge, Bujumbura, Burundi
| | - Louis Ngendahayo
- Faculty of Medicine, University of Burundi, Bujumbura, Burundi.,Department of Pathology, University Hospital Centre of Kamenge, Bujumbura, Burundi
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16
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Ochalek K, Partsch H, Gradalski T, Szygula Z. Do Compression Sleeves Reduce the Incidence of Arm Lymphedema and Improve Quality of Life? Two-Year Results from a Prospective Randomized Trial in Breast Cancer Survivors. Lymphat Res Biol 2018; 17:70-77. [PMID: 30339481 DOI: 10.1089/lrb.2018.0006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In a previous randomized controlled trial it has been demonstrated that arm compression sleeves worn immediately after breast cancer surgery, including axillary lymph node removal in addition to physical therapy are able to reduce the occurrence of early postoperative swelling and of arm lymphedema up to 1 year and to improve quality of life. The aim of the present investigation was to check the further development of the arm swelling in patients using compression sleeves or not, and to compare the quality of life in women treated due to breast cancer 2 years after surgery. MATERIALS AND METHODS Twenty from originally 23 patients who still wore their compression sleeves (15 mmHg) and 21 from 22 patients who had been randomized into the control group without compression could be seen after one more year. Arm volume measurements were performed and quality of life (QLQ-C30 and QLQ-BR23 questionnaires) was assessed. RESULTS Three from 20 patients in the compression group (CG) and 6 from 21 without compression showed arm lymphedema, defined by an increase of the arm volume exceeding 10% compared with the preoperative values. Significant improvement of several quality of life parameters were found in the CG. CONCLUSION Light compression sleeves worn for 2 years are not only able to reduce the incidence of early postoperative edema and of lymphedema, but also lead to a significant improvement of important quality-of-life parameters like physical functioning, fatigue, pain, arm and breast symptoms, and future perspectives.
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Affiliation(s)
- Katarzyna Ochalek
- 1 Department of Clinical Rehabilitation, Faculty of Motor Rehabilitation, University of Physical Education, Krakow, Poland.,2 Lymphoedema Clinic, St. Lazarus Hospice, Krakow, Poland
| | - Hugo Partsch
- 3 Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | | | - Zbigniew Szygula
- 4 Department of Physiotherapy, State University of Applied Sciences in Nowy Sacz, Nowy Sacz, Poland
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17
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Sun F, Hall A, Tighe MP, Brunelle CL, Sayegh HE, Gillespie TC, Daniell KM, Taghian AG. Perometry versus simulated circumferential tape measurement for the detection of breast cancer-related lymphedema. Breast Cancer Res Treat 2018; 172:83-91. [PMID: 30062571 DOI: 10.1007/s10549-018-4902-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Despite increasing emphasis on screening and early intervention for breast cancer-related lymphedema (BCRL), there is marked heterogeneity in diagnostic methodology, including for volumetric measures. This retrospective study compared two volumetric modalities, perometry and simulated circumferential tape measurement (anatomic- and interval-based), for BCRL detection. METHODS Between 2005 and 2017, 287 female patients with unilateral breast cancer were prospectively screened for BCRL by perometry and the relative volume change (RVC) formula. Circumferential measurement was performed by sampling at five anatomic landmark-based points or 4-cm intervals from pairs of perometer arm diameter measurements. Volumetric conversion was by a frustum model. The Bland-Altman method was used to compare segmental volume differences. Confusion matrix analysis was performed for each circumferential measurement technique against perometry. RESULTS Median follow-up was 34.7 months over 4 postoperative visits. There was no difference in total arm volume comparing any of the circumferential measurement techniques to perometry. Landmark-based methods significantly underestimated upper arm volume (mean difference - 207 mL [- 336, - 78 mL]) and overestimated forearm volume (mean difference + 170 mL [+ 105, + 237 mL]). Landmark-based methods had greater sensitivity and specificity compared to 4-cm interval methods for detection of both RVC ≥ 10 and 5-10%. Landmark-based methods were comparable to perometry for detection of RVC ≥ 10%, but sensitivity was only 63.2-66.7% for RVC 5-10%. CONCLUSIONS This hypothesis-generating study suggested the superiority of anatomic landmark-based circumferential tape measurement compared to interval-based methods, while generating questions about the underestimation of upper arm volume and overestimation of forearm volume of circumferential tape measurement compared to perometry.
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Affiliation(s)
- Fangdi Sun
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA.
| | - Alexander Hall
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA
| | - Megan P Tighe
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA
| | - Cheryl L Brunelle
- Department of Physical and Occupational Therapy, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA
| | - Hoda E Sayegh
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA
| | - Tessa C Gillespie
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA
| | - Kayla M Daniell
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA, 02114, USA
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18
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Gerber LH, Hodsdon B, Comis LE, Chan L, Gallin JI, McGarvey CL. A Brief Historical Perspective of Cancer Rehabilitation and Contributions From the National Institutes of Health. PM R 2018; 9:S297-S304. [PMID: 28942904 DOI: 10.1016/j.pmrj.2017.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 11/17/2022]
Abstract
People who have cancer diagnoses often need care throughout their lives through all stages of their illness. These stages include diagnosis, primary treatment, survivorship, and end of life. The management of people with cancer, now a common and chronic illness with long-term survival improving, is complex, challenging, and rapidly changing. Rehabilitation for people with cancer diagnoses is a new specialty and is charged with providing care throughout the trajectory of illness and wellness to maximize potential for function and mitigate disability. Rehabilitation interventions include the application of physical and occupational therapeutics, speech and language interventions, and physical medicine in order to help patients reach their individual goals and to promote life satisfaction. The Department of Rehabilitation in the Clinical Center of the National Institutes of Health has pioneered this field through research and clinical care models over the past 40 years. Staff of this department has supported clinical research investigators at the National Institutes of Health in their exploration of new treatments using chemotherapies, surgery, radiation, and psychosocial interventions. They have also engaged in research specific to rehabilitation to devise and improve functional outcome measures, design exercise interventions, devise orthotics, and prosthetic devices for adaptation to functional loss. Collectively, the staff has published widely in oncology textbooks and professional journals in order to share findings and improve the quality of cancer rehabilitation treatment across the continuum of care.
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Affiliation(s)
- Lynn H Gerber
- Department of Medicine, Inova Fairfax Medical Campus, Inova Health System, Fairfax, VA; 4400 University Dr., MS 2G7, George Mason University, Fairfax, VA 22030(∗).
| | - Bonnie Hodsdon
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD(†)
| | - Leora Ellen Comis
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD(‡)
| | - Leighton Chan
- Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD(§)
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19
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Brunelle CL, Swaroop MN, Skolny MN, Asdourian MS, Sayegh HE, Taghian AG. Hand Edema in Patients at Risk of Breast Cancer-Related Lymphedema: Health Professionals Should Take Notice. Phys Ther 2018; 98:510-517. [PMID: 29361079 PMCID: PMC6692642 DOI: 10.1093/ptj/pzy007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 01/17/2018] [Indexed: 11/14/2022]
Abstract
BACKGROUND There is little research on hand edema in the population at risk for breast cancer-related lymphedema (BCRL). OBJECTIVES Study aims included reporting potential importance of hand edema (HE) as a risk factor for progression of edema in patients treated for breast cancer at risk for BCRL, reporting risk factors for BCRL, and reporting treatment of HE. DESIGN/METHODS This was a retrospective analysis of 9 patients treated for breast cancer in Massachusetts General Hospital's lymphedema screening program who presented with isolated HE. Limb volumes via perometry, BCRL risk factors, and HE treatment are reported. RESULTS Edema was mostly isolated to the hand. Three patients had arm edema >5% on perometry; and 2 of these had edema outside the hand on clinical examination. Patients were at high risk of BCRL with an average of 2.9/5 known risk factors. Arm edema progressed to >10% in 2 high-risk patients. Treatment resulted in an average hand volume reduction of 10.2% via perometry and improvement upon clinical examination. LIMITATIONS The small sample size and lack of validated measures of subjective data were limitations. CONCLUSIONS In this cohort, patients with HE carried significant risk factors for BCRL. Two out of 9 (22%), both carrying ≥4/5 risk factors, progressed to edema >10%. Isolated HE may be a prognostic factor for edema progression in patients treated for breast cancer at risk for BCRL. Further research is warranted.
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Affiliation(s)
- Cheryl L Brunelle
- Department of Physical and Occupational Therapy, Massachusetts General Hospital, Boston, Massachusetts
| | - Meyha N Swaroop
- Department of Radiation Oncology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Melissa N Skolny
- Department of Radiation Oncology, Massachusetts General Hospital, and Harvard Medical School
| | - Maria S Asdourian
- Department of Radiation Oncology, Massachusetts General Hospital, and Harvard Medical School
| | - Hoda E Sayegh
- Department of Radiation Oncology, Massachusetts General Hospital, and Harvard Medical School
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 (USA),Address all correspondence to Dr Taghian at:
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20
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Yang EJ, Kim SY, Lee WH, Lim JY, Lee J. Diagnostic Accuracy of Clinical Measures Considering Segmental Tissue Composition and Volume Changes of Breast Cancer-Related Lymphedema. Lymphat Res Biol 2018; 16:368-376. [PMID: 29338541 PMCID: PMC6104249 DOI: 10.1089/lrb.2017.0047] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: If we use only volumetry for measuring lymphedema, we could underdiagnose lymphedema with characteristics of biomechanical changes without definite volume change, especially in the medial forearm. Methods and Results: In total, 158 breast cancer patients participated in this study. Arm volume was measured by water displacement volumetry, and segmental volumes were calculated from circumferences by using the truncated cone method. Subcutaneous ultrasound echogenicities were assessed on the medial side of the upper arm and forearm of both arms and graded by subcutaneous echogenicity grade (SEG) and revised SEG (rSEG). The standards for diagnosing secondary lymphedema were according to the volume change and clinical stage. Sensitivity, specificity, receiver-operating characteristic (ROC) curve, and area under the curve (AUC) were used. Analysis of ROC curves yielded AUCs of 0.875–0.933 (p < 0.001). Volume differences in each segment were significantly different among the grades by SEG. The highest AUC was found for volume difference (AUC = 0.919, 95% confidence interval [CI] = 0.860–0.978) in the upper arm near the elbow; however, in the medial forearm, the highest AUC was found for rSEG (AUC = 0.948, 95% CI = 0.923–0.965 in the proximal forearm; AUC = 0.940, 95% CI = 0.923–0.965 in the distal forearm). Conclusions: Our findings support the use of SEG by ultrasound in the assessment of lymphedema, especially in the medial region of the forearm. Subcutaneous ultrasound echogenicities may improve the accuracy of diagnosis of lymphedema in the forearm.
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Affiliation(s)
- Eun Joo Yang
- 1 Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital , Seongnam-si, Korea
| | - Seoung Yeon Kim
- 2 Department of Rehabilitation Medicine, Seoul National University Hospital , Jongno-gu, Korea
| | - Woo Hyung Lee
- 2 Department of Rehabilitation Medicine, Seoul National University Hospital , Jongno-gu, Korea
| | - Jae-Young Lim
- 1 Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital , Seongnam-si, Korea
| | - Jaebong Lee
- 2 Department of Rehabilitation Medicine, Seoul National University Hospital , Jongno-gu, Korea.,3 Medical Research Collaborating Center, Seoul National University Bundang Hospital , Seongnam-si, Korea
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Hidding JT, Beurskens CHG, van der Wees PJ, Bos WCAM, Nijhuis-van der Sanden MWG, van Laarhoven HWM. Changes in volume and incidence of lymphedema during and after treatment with docetaxel, doxorubicin, and cyclophosphamide (TAC) in patients with breast cancer. Support Care Cancer 2017; 26:1383-1392. [PMID: 29127528 PMCID: PMC5876252 DOI: 10.1007/s00520-017-3907-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 09/25/2017] [Indexed: 01/18/2023]
Abstract
Purposes The purposes of this study were to investigate the incidence of lymphedema in patients with breast cancer during and after adjuvant treatment with docetaxel, doxorubicin, and cyclophosphamide (TAC), to identify predictors for development of lymphedema, and to describe consequences in daily life in relation to lymphedema. Methods This is a prospective study with measurements before chemotherapy (T0), during chemotherapy before cycle 2 (T1), cycle 4 (T2), and 1 month after completion of treatment (T3). Volume change was monitored using tape measurements. Lymphedema was defined as ≥ 10% volume difference. Linear mixed-effect models were estimated to analyze differences in arm volume and consequences in daily life (total score and domain scores of the Lymph-International Classification of Functioning (ICF) questionnaire) over time and to identify treatment and patient characteristics as predictors for changes in volume. Results Forty-eight patients completed all measurements. Volume did not change during TAC treatment. One month after treatment, volume was significantly increased compared to T0-T2, and 12 patients (25%) had developed lymphedema. Axillary lymph node dissection was associated with lymphedema (ES 2.9, 95% CI 0.02–5.7; p < 0.05). In patients with and without lymphedema, 1 month after completion (T3), the Lymph-ICF questionnaire showed significant limitations in physical function compared to T0-T2. In patients with lymphedema at T3, a significant association between volume and total score on the Lymph-ICF questionnaire on physical function and mobility activities was observed. Conclusions One month after treatment in 12 patients (25%), volume difference increased over 10%. Axillary lymph node dissection was predictive for development of lymphedema. All patients, but more patients with lymphedema, perceived difficulties in activities in daily life after treatment.
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Affiliation(s)
- Janine T Hidding
- Department of Orthopedics, Section of Physical Therapy, Radboud University Medical Center, Nijmegen, The Netherlands. .,Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Geert Grooteplein Noord 21, 6525 EZ, Nijmegen, The Netherlands.
| | - Carien H G Beurskens
- Department of Orthopedics, Section of Physical Therapy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philip J van der Wees
- Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Geert Grooteplein Noord 21, 6525 EZ, Nijmegen, The Netherlands
| | - Wilmy C A M Bos
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maria W G Nijhuis-van der Sanden
- Department of Orthopedics, Section of Physical Therapy, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Geert Grooteplein Noord 21, 6525 EZ, Nijmegen, The Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.,Academic Medical Center, Department of Medical Oncology, University of Amsterdam, Amsterdam, The Netherlands
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22
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Svensson BJ, Dylke ES, Ward LC, Kilbreath SL. Segmental Bioimpedance Informs Diagnosis of Breast Cancer-Related Lymphedema. Lymphat Res Biol 2017; 15:349-355. [PMID: 28956701 DOI: 10.1089/lrb.2017.0030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Detection of lymphedema, particularly its mild stage, is clinically challenging. The aim of this study was to determine whether segmental bioimpedance spectroscopy (BIS) provided additional information to whole arm BIS in assessing women with or at risk of lymphedema following breast cancer. METHODS AND RESULTS Participants (n = 66), aged 61.6 ± 10.5 years (mean ± standard deviation [SD]), were grouped according to lymphedema status: (1) at-risk (n = 24) had no indicators of lymphedema and (2) lymphedema (n = 42) were suspected to be developing lymphedema or had previously met lymphedema diagnostic criteria and undergone treatment. For each upper limb, impedance was measured for the whole arm, hand and four 10 cm segments of the arm, commencing at the ulnar styloid. Interlimb impedance ratios for corresponding locations were calculated and compared to previously determined, normatively based thresholds based on 2SD and 3SD above the mean. Segmental BIS classified 19% more women with lymphedema than 3SD whole arm thresholds and the same number as 2SD whole arm thresholds. Segmental BIS identified localized lymphedema and patterns in lymphedema distribution that were undetectable by whole arm BIS. Neither 3SD whole arm nor segmental BIS thresholds found lymphedema where it was not present; however, 2SD whole arm thresholds alone classified one woman in the at-risk group as having lymphedema. CONCLUSION Segmental BIS classified as many or more cases of lymphedema than whole arm BIS thresholds without finding lymphedema where it was likely not present while also providing additional information regarding the distribution of lymphedema within the limb.
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Affiliation(s)
- Brenda J Svensson
- 1 Faculty of Health Sciences, The University of Sydney , Sydney, Australia .,2 Occupational Therapy Department, Lourdes Hospital and Community Health Service , Dubbo, Australia
| | - Elizabeth S Dylke
- 1 Faculty of Health Sciences, The University of Sydney , Sydney, Australia
| | - Leigh C Ward
- 1 Faculty of Health Sciences, The University of Sydney , Sydney, Australia .,3 School of Chemistry and Molecular Biosciences, The University of Queensland , Brisbane, Australia
| | - Sharon L Kilbreath
- 1 Faculty of Health Sciences, The University of Sydney , Sydney, Australia
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Levenhagen K, Davies C, Perdomo M, Ryans K, Gilchrist L. Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of the American Physical Therapy Association. Phys Ther 2017; 97:729-745. [PMID: 28838217 PMCID: PMC5803775 DOI: 10.1093/ptj/pzx050] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 05/01/2017] [Indexed: 01/20/2023]
Abstract
The Oncology Section of the American Physical Therapy Association (APTA) developed a clinical practice guideline to aid the clinician in diagnosing secondary upper quadrant cancer-related lymphedema. Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in the diagnostic process. Overall clinical practice recommendations were formulated based on the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility. In an effort to maximize clinical applicability, recommendations were based on the characteristics as to the location and stage of a patient's upper quadrant lymphedema.
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Affiliation(s)
- Kimberly Levenhagen
- Saint Louis University, Doisy College of Health Sciences, Department of Physical Therapy & Athletic Training, St Louis, Missouri
| | - Claire Davies
- Rehabilitation Services Baptist Health Lexington, Lexington, Kentucky
| | - Marisa Perdomo
- University of Southern California, Division of Biokinesiology and Physical Therapy, Los Angeles, California
| | - Kathryn Ryans
- Doctor of Physical Therapy Program, Mercy College, Dobbs Ferry, New York
| | - Laura Gilchrist
- St Catherine University, Doctor of Physical Therapy Program, 601 25th Avenue South, Minneapolis, MN 55454
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Levenhagen K, Davies C, Perdomo M, Ryans K, Gilchrist L. Diagnosis of Upper-Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of APTA. REHABILITATION ONCOLOGY 2017; 35:E1-E18. [PMID: 28748128 PMCID: PMC5497787 DOI: 10.1097/01.reo.0000000000000073] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The Oncology Section of APTA developed a clinical practice guideline to aid the clinician in diagnosing secondary upper-quadrant cancer-related lymphedema. METHODS Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in their diagnostic process. Overall, clinical practice recommendations were formulated on the basis of the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility. RECOMMENDATIONS In an effort to make these clinically applicable, recommendations were based on the characteristics as to the location and stage of a patient's upper-quadrant lymphedema.
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Affiliation(s)
- Kimberly Levenhagen
- Department of Physical Therapy & Athletic Training, Doisy College of Health Sciences, Saint Louis University, St Louis, MO
| | - Claire Davies
- Certified Lymphedema Therapist-Lymphology Association of North America (CLT-LANA), Rehabilitation Services, Baptist Health Lexington, Lexington, KY
| | - Marisa Perdomo
- Certified Lymphedema Therapist-Foldi (CLT-Foldi), Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA
| | - Kathryn Ryans
- Doctor of Physical Therapy Program, Mercy College, Dobbs Ferry, NY
| | - Laura Gilchrist
- Doctor of Physical Therapy Program, St Catherine University, Minneapolis, MN
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Diagnostic Methods, Risk Factors, Prevention, and Management of Breast Cancer-Related Lymphedema: Past, Present, and Future Directions. CURRENT BREAST CANCER REPORTS 2017; 9:111-121. [PMID: 28894513 DOI: 10.1007/s12609-017-0237-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Breast cancer-related lymphedema (BCRL) is a chronic, adverse, and much feared complication of breast cancer treatment, which affects approximately 20% of patients following breast cancer treatment. BCRL has a tremendous impact on breast cancer survivors, including physical impairments and significant psychological consequences. The intent of this review is to discuss recent studies and analyses regarding the risk factors, diagnosis, prevention through early screening and intervention, and management of BCRL. RECENT FINDINGS Highly-evidenced risk factors for BCRL include axillary lymph node dissection, lack of reconstruction, radiation to the lymph nodes, high BMI at diagnosis, weight fluctuations during and after treatment, subclinical edema within and beyond 3 months after surgery, and cellulitis in the at-risk arm. Avoidance of potential risk factors can serve as a method of prevention. Through establishing a screening program by which breast cancer patients are measured pre-operatively and at follow-ups, are objectively assessed through a weight-adjusted analysis, and are clinically assessed for signs and symptoms, BCRL can be tracked accurately and treated effectively. Management of BCRL is done by a trained professional, with research mounting towards the use of compression bandaging as a first line intervention against BCRL. Finally, exercise is safe for breast cancer patients with and without BCRL and does not incite or exacerbate symptoms of BCRL. SUMMARY Recent research has shed light on BCRL risk factors, diagnosis, prevention, and management. We hope that education on these aspects of BCRL will promote an informed, consistent approach and encourage additional research in this field to improve patient outcomes and quality of life in breast cancer survivors.
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Measurement Properties of Instruments for Measuring of Lymphedema: Systematic Review. Phys Ther 2016; 96:1965-1981. [PMID: 27340195 DOI: 10.2522/ptj.20150412] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 06/15/2016] [Indexed: 02/09/2023]
Abstract
BACKGROUND Lymphedema is a common complication of cancer treatment, resulting in swelling and subjective symptoms. Reliable and valid measurement of this side effect of medical treatment is important. PURPOSE The purpose of this study was to provide best evidence regarding which measurement instruments are most appropriate in measuring lymphedema in its different stages. DATA SOURCES The PubMed and Web of Science databases were used, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. STUDY SELECTION Clinical studies on measurement instruments assessing lymphedema were reviewed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) scoring instrument for quality assessment. DATA EXTRACTION Data on reliability, concurrent validity, convergent validity, sensitivity, specificity, applicability, and costs were extracted. DATA SYNTHESIS Pooled data showed good intrarater intraclass correlation coefficients (ICCs) (.89) for bioimpedance spectroscopy (BIS) in the lower extremities and high intrarater and interrater ICCs for water volumetry, tape measurement, and perometry (.98-.99) in the upper extremities. In the upper extremities, the standard error of measurement was 3.6% (σ=0.7%) for water volumetry, 5.6% (σ=2.1%) for perometry, and 6.6% (σ=2.6%) for tape measurement. Sensitivity of tape measurement in the upper extremities, using different cutoff points, varied from 0.73 to 0.90, and specificity values varied from 0.72 to 0.78. LIMITATIONS No uniform definition of lymphedema was available, and a gold standard as a reference test was lacking. Items concerning risk of bias were study design, patient selection, description of lymphedema, blinding of test outcomes, and number of included participants. CONCLUSIONS Measurement instruments with evidence for good reliability and validity were BIS, water volumetry, tape measurement, and perometry, where BIS can detect alterations in extracellular fluid in stage 1 lymphedema and the other measurement instruments can detect alterations in volume starting from stage 2. In research, water volumetry is indicated as a reference test for measuring lymphedema in the upper extremities.
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Shah C, Arthur DW, Wazer D, Khan A, Ridner S, Vicini F. The impact of early detection and intervention of breast cancer-related lymphedema: a systematic review. Cancer Med 2016; 5:1154-62. [PMID: 26993371 PMCID: PMC4924374 DOI: 10.1002/cam4.691] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 02/05/2016] [Accepted: 02/08/2016] [Indexed: 01/18/2023] Open
Abstract
Breast cancer-related lymphedema (BCRL) has become an increasingly important clinical issue as noted by the recent update of the 2015 NCCN breast cancer guidelines which recommends to "educate, monitor, and refer for lymphedema management." The purpose of this review was to examine the literature regarding early detection and management of BCRL in order to (1) better characterize the benefit of proactive surveillance and intervention, (2) clarify the optimal monitoring techniques, and (3) help better define patient groups most likely to benefit from surveillance programs. A Medline search was conducted for the years 1992-2015 to identify articles addressing early detection and management of BCRL. After an initial search, 127 articles were identified, with 13 of these studies focused on early intervention (three randomized (level of evidence 1), four prospective (level of evidence 2-3), six retrospective trials (level of evidence 4)). Data from two, small (n = 185 cases), randomized trials with limited follow-up demonstrated a benefit to early intervention (physiotherapy, manual lymphatic drainage) with regard to reducing the rate of chronic BCRL (>50% reduction) with two additional studies underway (n = 1280). These findings were confirmed by larger prospective and retrospective series. Several studies were identified that demonstrate that newer diagnostic modalities (bioimpedance spectroscopy, perometry) have increased sensitivity allowing for the earlier detection of BCRL. Current data support the development of surveillance programs geared toward the early detection and management of BCRL in part due to newer, more sensitive diagnostic modalities.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas W Arthur
- Department of Radiation Oncology, Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - David Wazer
- Department of Radiation Oncology, Tufts University School of Medicine, Boston, Massachusetts.,Department of Radiation Oncology, Brown University, Providence, Rhode Island
| | - Atif Khan
- Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Sheila Ridner
- School of Nursing, Vanderbilt University, Nashville, Tennessee
| | - Frank Vicini
- Michigan Healthcare Professionals/21st Century Oncology, Farmington Hills, Michigan
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Johnson KC, DeSarno M, Ashikaga T, Dee J, Henry SM. Ultrasound and Clinical Measures for Lymphedema. Lymphat Res Biol 2015; 14:8-17. [PMID: 26574872 DOI: 10.1089/lrb.2015.0001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Treatment for breast cancer has increased patient survivorship exponentially over the past few decades. With increased survivorship, more women are living with the longstanding effects of breast cancer treatment, such as lymphedema. Patients, health care providers, and payers depend on practical and efficient clinical measures to accurately diagnose and monitor disease progression or regression. However, current clinical measures do not include objective measures that assess lymphedetamous tissue accurately. This study compared current measures to a novel use of ultrasound (US) imaging to quantify tissue texture. METHODS AND RESULTS Seventeen women diagnosed with lymphedema completed self-report questionnaires and then were tested twice by two lymphedema physical therapists who measured edema, fibrosis, and limb volume differences. One therapist measured subjects' limbs using US imaging and derived measures of entropy and average pixel intensity. Volume measures were consistent between therapists (p < 0.01) but palpation was not (0.01 < p < 0.72). Therapists' measures correlated better to subjects' self-report of edema (0.01 < p > 0.32) as compared to fibrosis (0.23 < p > 0.90). US measures were reliable (Cronbachs's α = 0.7 and 0.91 for entropy and API, respectively). Entropy measures demonstrated significant differences between subjects' involved versus uninvolved forearms (p = 0.03). CONCLUSIONS Therapists were not consistent with each other when rating edema or fibrosis; however, they were consistent when measuring limb volume differences. US measures (entropy) demonstrated a significant difference between involved and uninvolved. US imaging, as a tool to quantify subcutaneous tissues, holds promise to be a safe, mobile, and effective method to measure lymphedema tissue texture.
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Affiliation(s)
- Kristine C Johnson
- 1 Department of Rehabilitation and Movement Science, University of Vermont , Burlington, Vermont
| | - Mike DeSarno
- 2 Department of Biostatistics, University of Vermont , Burlington, Vermont
| | - Taka Ashikaga
- 2 Department of Biostatistics, University of Vermont , Burlington, Vermont
| | - Justine Dee
- 1 Department of Rehabilitation and Movement Science, University of Vermont , Burlington, Vermont
| | - Sharon M Henry
- 1 Department of Rehabilitation and Movement Science, University of Vermont , Burlington, Vermont
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Abstract
Lymphedema is one of the main late effects from breast cancer treatment affecting 3-60% of breast cancer survivors. Primarily occurring in the hand, arm, and/or affected breast, symptoms of lymphedema include swelling, pain, redness, restriction of arm/hand movement, tightness and feelings of fullness. These symptoms not only may limit physical functioning but also negatively affect quality of life, body image, social functioning, and financial status of breast cancer survivors with lymphedema. Unfortunately, there are no standardized methods for prevention, diagnosis, and treatment of breast cancer-related lymphedema. Despite its prevalence and lack of clinical guidelines, lymphedema is one of the most poorly understood, relatively underestimated, and least researched complications of cancer treatment. This chapter reviews the current problem of breast cancer-related lymphedema by investigating prevention and risk reduction strategies, diagnosis, and treatment. In addition, this chapter identifies future research opportunities focusing on prevention and risk reduction strategies, quality of life and physical function, surveillance, patient education, cost, diagnosis, and treatment. Challenges and recommendations for future research in these areas, particularly among underserved populations, are discussed.
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A systematic review of axillary web syndrome (AWS). J Cancer Surviv 2015; 9:576-98. [PMID: 25682072 DOI: 10.1007/s11764-015-0435-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 01/27/2015] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Axillary web syndrome (AWS) can result in early post-operative and long-term difficulties following lymphadenectomy for cancer and should be recognised by clinicians. This systematic review was conducted to synthesise information on AWS clinical presentation and diagnosis, frequency, natural progression, grading, pathoaetiology, risk factors, symptoms, interventions and outcomes. METHODS Electronic searches were conducted using Cochrane, Pubmed, MEDLINE, CINAHL, EMBASE, AMED, PEDro and Google Scholar until June 2013. The methodological quality of included studies was determined using the Downs and Black checklist. Narrative synthesis of results was undertaken. RESULTS Thirty-seven studies with methodological quality scores ranging from 11 to 26 on a 28-point scale were included. AWS diagnosis relies on inspection and palpation; grading has not been validated. AWS frequency was reported in up to 85.4 % of patients. Biopsies identified venous and lymphatic pathoaetiology with five studies suggesting lymphatic involvement. Twenty-one studies reported AWS occurrence within eight post-operative weeks, but late occurrence of greater than 3 months is possible. Pain was commonly reported with shoulder abduction more restricted than flexion. AWS symptoms usually resolve within 3 months but may persist. Risk factors may include extensiveness of surgery, younger age, lower body mass index, ethnicity and healing complications. Low-quality studies suggest that conservative approaches including analgesics, non-steroidal anti-inflammatory drugs and/or physiotherapy may be safe and effective for early symptom reduction. CONCLUSIONS AWS appears common. Current evidence for the treatment of AWS is insufficient to provide clear guidance for clinical practice. IMPLICATIONS FOR CANCER SURVIVORS Cancer survivors should be informed about AWS. Further investigation is needed into pathoaetiology, long-term outcomes and to determine effective treatment using standardised outcomes.
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Czerniec SA, Ward LC, Meerkin JD, Kilbreath SL. Assessment of segmental arm soft tissue composition in breast cancer-related lymphedema: a pilot study using dual energy X-ray absorptiometry and bioimpedance spectroscopy. Lymphat Res Biol 2015; 13:33-9. [PMID: 25668060 DOI: 10.1089/lrb.2014.0033] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Changes in arm soft tissue composition, especially increased adipose tissue, has been found in advanced, non-pitting breast cancer-related lymphedema (BCRL). The aim of this study was to examine whether these changes were localized to any particular region of the arm and whether they occurred in lymphedema which still pitted to pressure. Secondary aims were to explore relationships between arm segment volumes, bioimpedance spectroscopy (BIS) measurements of extracellular fluid (ECF), and dual-energy X-ray absorptiometry (DXA) measurements of tissue composition. METHODS AND RESULTS Nine women with unilateral BCRL participated. The dominant arm was affected in 4 women, and all presented with lymphedema that pitted to pressure. Arm volume was calculated from circumferences by the truncated cone method, ECF was determined with BIS and fat and lean tissue content measured by DXA. BIS and DXA measurements for women with lymphedema were made of the whole arm and also of four 10 cm-segments measured from the ulnar styloid at the wrist. Whole arm DXA data were compared to those of 45 women of similar age and body mass index without lymphedema. All women with lymphedema had a significantly larger absolute fat mass in their affected arm compared to their unaffected arm, (median difference between arms 146.9 g). The forearm segment 10 - 20 cm proximal to the wrist had the highest median inter-limb fat difference of all four arm segments. CONCLUSIONS The soft tissue composition changes associated with BCRL may occur in the presence of pitting and predominantly affect the proximal forearm.
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Shaitelman SF, Cromwell KD, Rasmussen JC, Stout NL, Armer JM, Lasinski BB, Cormier JN. Recent progress in the treatment and prevention of cancer-related lymphedema. CA Cancer J Clin 2015; 65:55-81. [PMID: 25410402 PMCID: PMC4808814 DOI: 10.3322/caac.21253] [Citation(s) in RCA: 156] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
This article provides an overview of the recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema. Lymphedema incidence by tumor site is evaluated. Measurement techniques and trends in patient education and treatment are also summarized to include current trends in therapeutic and surgical treatment options as well as longer-term management. Finally, an overview of the policies related to insurance coverage and reimbursement will give the clinician an overview of important trends in the diagnosis, treatment, and management of cancer-related lymphedema.
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Johnson KC, Kennedy AG, Henry SM. Clinical Measurements of Lymphedema. Lymphat Res Biol 2014; 12:216-21. [DOI: 10.1089/lrb.2014.0019] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kristine C. Johnson
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont
| | - Amanda G. Kennedy
- Department of Clinical and Translational Science, University of Vermont, Burlington, Vermont
| | - Sharon M. Henry
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont
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Prospective surveillance of breast cancer-related lymphoedema in the first-year post-surgery: feasibility and comparison of screening measures. Support Care Cancer 2014; 23:1549-59. [DOI: 10.1007/s00520-014-2504-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 10/31/2014] [Indexed: 10/24/2022]
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Smoot B, Paul SM, Aouizerat BE, Elboim C, Levine JD, Abrams G, Hamolsky D, Neuhaus J, Schmidt B, West C, Topp K, Miaskowski C. Side of cancer does not influence limb volumes in women prior to breast cancer surgery. Lymphat Res Biol 2014; 12:189-93. [PMID: 24834791 DOI: 10.1089/lrb.2013.0038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Understanding normal volume asymmetry is essential for accurate assessment of limb volume changes following breast cancer (BC) treatment in which lymphatic function is disrupted. The purposes of this study were to evaluate for differences in dominant and nondominant limb volumes and to evaluate for interactions between the effects of dominance and side of cancer on limb volume. METHODS AND RESULTS This study evaluated preoperative limb volumes of 397 women enrolled in a prospective, longitudinal study of neuropathic pain and lymphedema. Volume was calculated from circumference. Limb resistance was measured with bioimpedance. Women were dichotomized into two groups: those whose cancer was on their dominant side and those whose cancer was on their nondominant side. Analyses of variance were used to evaluate for differences. In 47%, BC occurred on the side of the dominant limb. Except for the 30 to 40 centimeter (cm) limb volume segment, a main effect of dominance was found for all measures. The volume of the dominant limb was significantly greater than that of the nondominant limb. No main effects were found for side of cancer. A statistically significant interaction was found only at the 0 to 10 cm limb volume segment. CONCLUSIONS Prior to BC treatment, the dominant limb demonstrated lower bioimpedance resistance (-2.09%) and greater total limb volume (1.12%) than the nondominant limb. Segmental volume differences were greatest at the proximal forearm segment (2.31%) and least at the proximal arm segment (0.21%). This study provides evidence that preoperative volume assessment is important due to normal variability associated with limb dominance.
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Affiliation(s)
- Betty Smoot
- 1 Department of Physical Therapy and Rehabilitation Science, University of California San Francisco , San Francisco, California
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BREAST CANCER EDGE TASK FORCE OUTCOMES: Assessment Measures of Secondary Lymphedema in Breast Cancer Survivors. REHABILITATION ONCOLOGY 2014. [DOI: 10.1097/01893697-201432010-00005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ancukiewicz M, Miller CL, Skolny MN, O'Toole J, Warren LE, Jammallo LS, Specht MC, Taghian AG. Comparison of relative versus absolute arm size change as criteria for quantifying breast cancer-related lymphedema: the flaws in current studies and need for universal methodology. Breast Cancer Res Treat 2012; 135:145-52. [PMID: 22710706 DOI: 10.1007/s10549-012-2111-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 05/23/2012] [Indexed: 12/01/2022]
Abstract
The purpose of this article is to evaluate arm measurements of breast cancer patients to critically assess absolute change in arm size compared to relative arm volume change as criteria for quantifying breast cancer-related lymphedema (BCRL). We used pre-operative measurements of 677 patients screened for BCRL before and following treatment of unilateral breast cancer at Massachusetts General Hospital between 2005 and 2008 to model the effect of an absolute change in arm size of 200 mL or 2 cm compared to relative arm volume change. We also used sequential measurements to analyze temporal variation in unaffected arm volume. Pre-operative arm volumes ranged from 1,270 to 6,873 mL and correlated strongly (Kendall's τ = 0.55) with body mass index (BMI). An absolute arm volume change of 200 mL corresponded to relative arm volume changes ranging from 2.9 to 15.7 %. In a subset of 45 patients, modeling of a 2-cm change in arm circumference predicted relative arm volume changes ranging from 6.0 to 9.8 %. Sequential measurements of 124 patients with >6 measurements demonstrated remarkable temporal variation in unaffected arm volume (median within-patient change 10.5 %). The magnitude of such fluctuations correlated (τ = 0.36, P < 0.0001) with pre-operative arm volume, patient weight, and BMI when quantified as absolute volume change, but was independent of these variables when quantified as relative arm volume change (P > .05). Absolute changes in arm size used as criteria for BCRL are correlated with pre-operative and temporal changes in body size. Therefore, utilization of absolute volume or circumference change in clinical trials is flawed because specificity depends strongly on patient body size. Relative arm volume change is independent of body size and should thus be used as the standard criterion for diagnosis of BCRL.
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Affiliation(s)
- Marek Ancukiewicz
- Department of Radiation Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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