Arm lymphoedema after breast cancer

The effect of exercise and educational programs for breast cancer patients on the development of breast cancer-related lymphoedema: secondary endpoint from a randomized controlled trial in the Setouchi Breast Project-10

BACKGROUND

Although the association between higher physical activity and preventive effect on breast-cancer-related lymphoedema (BCRL) has been reported, it is unclear what intervention is optimal. We aimed to investigate the effect of exercise and educational programs on BCRL development.

METHODS

This study was a secondary endpoint analysis from a prospective randomized controlled trial. We enrolled patients with stage 0-III breast cancer from March 2016 to March 2020 and randomly assigned them to the control (n = 111), education (n = 115), or exercise (n = 104) group. As secondary endpoint, we assessed the incidence of and preventive effect on BCRL at 12 months post-intervention.

RESULTS

There were no significant differences in the incidence of BCRL at 12 months post-intervention between the exercise and control groups (9.8% and 10.8%, P = 0.83) and the education and control groups (11.6% and 10.8%, P = 1.00). There were no significant differences in time to BCRL onset from the day of surgery between the exercise and control groups (event rate at 12 months: 20.7% and 17.2%, log-rank, P = 0.54) and the education and control groups (18.8% and 17.2%, log-rank, P = 0.57). The multivariable analyses indicated that axillary dissection and obesity significantly increased the risk of BCRL [hazard ratio (HR): 2.36, 95% confidence interval (CI) 1.52-3.67 and HR: 1.68, 95% CI 1.07-2.63, respectively].

CONCLUSIONS

The intervention did not decrease the risk of BCRL, and axillary dissection and obesity were the risk factors of BCRL.

TRIAL REGISTRATION NUMBER

UMIN000020595 at UMIN Clinical Trial Registry.

Non-contrast magnetic resonance lymphography (NCMRL) in cancer-related secondary lymphedema: acquisition technique and imaging findings

Cancer-related secondary lymphedema (LE) is a widespread issue, which markedly affects patients' quality of life. Its diagnosis is mainly clinical since there is no consensus on the best imaging technique that should be used to assess this pathology. Even if lymphedema treatment has been traditionally conservative and mainly based on compressive bandages and decongestive therapy, new surgical techniques are proving their effectiveness in the management of the disease and made proper assessment and characterization of lymphedema necessary. In this scenario, non-contrast magnetic resonance lymphography (NCMRL) is acquiring an increasing role, as a non-invasive imaging technique, useful for the analysis of LE. NCMRL is an effective tool in diagnosis confirmation, in providing information about the structural changes of the affected limbs, in grading this disorder, and provides a guide for LE management and treatment planning. This article aims to provide an overview of the literature regarding this examination, analyzing the acquisition technique, the interpretation of the imaging findings and their usefulness, the advantages and limits of this technique, to help the radiologist approach this relatively new investigation in cases of cancer-related LE.

Examining Obesity in Lymphedema: A Retrospective Study of 178 New Patients with Suspected Lymphedema at a Canadian Hospital-Based Clinic

Purpose: Physiotherapists have an important role to play in the early detection and treatment of lymphedema, a chronic inflammatory condition characterized by excess interstitial protein-rich fluid, which is estimated to affect more than one million Canadians. Obesity has been identified both as an important cause of and as a risk factor for developing lymphedema of various aetiologies. Little is currently known about obesity in Canadians affected by lymphedema. The objective of this study was to report on the prevalence of overweight and obesity in a Canadian lymphedema clinic population and the relationships among BMI; demographic, medical, and lymphedema characteristics; and cellulitis history. Method: We conducted a retrospective electronic record review of the clinical data collected from new patients evaluated for suspected lymphedema at a specialized Canadian hospital-based clinic over a 2-year period. We used descriptive analyses to characterize the sample and one-way analysis of variance and χ2 tests for comparative analyses. Results: Of the 178 patients whose records were reviewed, 36.5% were classified as overweight and 39.3% as obese. Patients with non-cancer diagnoses had a higher mean BMI than those with cancer-related diagnoses (p < 0.001). A higher BMI was associated with a longer time since lymphedema onset (p < 0.001), bilateral lymphedema (p = 0.010), and history of cellulitis (p < 0.001). Conclusions: Obesity is prevalent in the Canadian population with lymphedema and is associated with delayed referral and increased cellulitis rates. Early detection and tailored management strategies are needed to address obesity in patients with lymphedema and the complexities associated with these two related conditions.

Effects of physical exercise on breast cancer-related secondary lymphedema: a systematic review

PURPOSE

The aim of this systematic review is to assess the effect of different types of exercise on breast cancer-related lymphedema (BCRL) in order to elucidate the role of exercise in this patient group.

METHODS

A systematic data search was performed using PubMed (December 2016). The review is focused on the rehabilitative aspect of BCRL and undertaken according to the PRISMA statement with Levels of Evidence (LoE) assessed.

RESULTS

11 randomized controlled trials (9 with LoE 1a and 2 with LoE 1b) that included 458 women with breast cancer in aftercare were included. The different types of exercise consisted of aqua lymph training, swimming, resistance exercise, yoga, aerobic, and gravity-resistive exercise. Four of the studies measured a significant reduction in BCRL status based on arm volume and seven studies reported significant subjective improvements. No study showed adverse effects of exercise on BCRL.

CONCLUSION

The evidence indicates that exercise can improve subjective and objective parameters in BCRL patients, with dynamic, moderate, and high-frequency exercise appearing to provide the most positive effects.

Investigation of Shape with Patients Suffering from Unilateral Lymphoedema

This study investigates the use of a 3D depth sensing camera for analysing the shape of lymphoedematous arms, and seeks to identify suitable metrics for monitoring lymphoedema clinically. A fast, simple protocol was developed for scanning upper limb lymphoedema, after which a robust data pre- and post-processing framework was built that consistently and quickly identifies arm shape and volume. The framework was then tested on 24 patients with mild unilateral lymphoedema, who were also assessed using tape measurements. The scanning protocol developed led to scanning times of about 20–30 s. Shape related metrics such as circumference and circularity were used to distinguish between affected and healthy arms (p ≤ 0.05). Swelling maps were also derived to identify the distribution of oedema on arms. Topology and shape could be used to monitor or even diagnose lymphoedema using the provided framework. Such metrics provide more detailed information to a lymphoedema specialist than solely volume. Although tested on a small cohort, these results show promise for further research into better diagnostics of lymphoedema and for future adoption of the proposed methods across lymphoedema clinics.

Magnetic Resonance Imaging-Based Assessment of Breast Cancer-Related Lymphoedema Tissue Composition

OBJECTIVES

The aim of this study was to propose a magnetic resonance imaging acquisition and analysis protocol that uses image segmentation to measure and depict fluid, fat, and muscle volumes in breast cancer-related lymphoedema (BCRL). This study also aims to compare affected and control (unaffected) arms of patients with diagnosed BCRL, providing an analysis of both the volume and the distribution of the different tissue components.

MATERIALS AND METHODS

The entire arm was imaged with a fluid-sensitive STIR and a 2-point 3-dimensional T1W gradient-echo-based Dixon sequences, acquired in sagittal orientation and covering the same imaging volume. An automated image postprocessing procedure was developed to simultaneously (1) contour the external volume of the arm and the muscle fascia, allowing separation of the epifacial and subfascial volumes; and to (2) separate the voxels belonging to the muscle, fat, and fluid components. The total, subfascial, epifascial, muscle (subfascial), fluid (epifascial), and fat (epifascial) volumes were measured in 13 patients with unilateral BCRL. Affected versus unaffected volumes were compared using a 2-tailed paired t test; a value of P < 0.05 was considered to be significant. Pearson correlation was used to investigate the linear relationship between fat and fluid excess volumes. The distribution of fluid, fat, and epifascial excess volumes (affected minus unaffected) along the arm was also evaluated using dedicated tissue composition maps.

RESULTS

Total arm, epifascial, epifascial fluid, and epifascial fat volumes were significantly different (P < 0.0005), with greater volume in the affected arms. The increase in epifascial volume (globally, 94% of the excess volume) constituted the bulk of the lymphoedematous swelling, with fat comprising the main component. The total fat excess volume summed over all patients was 2.1 times that of fluid. Furthermore, fat and fluid excess volumes were linearly correlated (Pearson r = 0.75), with the fat excess volume being greater than the fluid in 11 subjects. Differences in muscle compartment volume between affected and unaffected arms were not statistically significant, and contributed only 6% to the total excess volume. Considering the distribution of the different tissue excess volumes, fluid accumulated prevalently around the elbow, with substantial involvement of the upper arm in only 3 cases. Fat excess volume was generally greater in the upper arm; however, the relative increase in epifascial volume, which considers the total swelling relative to the original size of the arm, was in 9 cases maximal within the forearm.

CONCLUSIONS

Our measurements indicate that excess of fat within the epifascial layer was the main contributor to the swelling, even when a substantial accumulation of fluid was present. The proposed approach could be used to monitor how the internal components of BCRL evolve after presentation, to stratify patients for treatment, and to objectively assess treatment response. This methodology provides quantitative metrics not currently available during the standard clinical assessment of BCRL and shows potential for implementation in clinical practice.

Evaluation of the Upper Limb Lymphatic System: A Prospective Lymphoscintigraphic Study in Melanoma Patients and Healthy Controls

BACKGROUND

Current research on the upper limb lymphatic system mainly studies breast cancer patients with unilateral lymphedema. Without preoperative lymphoscintigraphy, the contralateral limb is used as a control, assuming that it is functionally intact. Few lymphoscintigraphic studies investigate patients before any axillary surgery. The purpose of this study was to evaluate, through lymphoscintigraphy, the preoperative condition of the upper limb lymphatic system in melanoma patients and healthy controls.

METHODS

Two groups were studied: the study group (16 patients with trunk/upper limb melanoma candidates for axillary sentinel lymph node biopsy) and the control group (10 healthy volunteers). All subjects underwent upper limb lymphoscintigraphy. Lymphoscintigraphic images were classified into three patterns based on the tracer appearance time in the axillary nodes. Type I, 20 minutes; type II, 60 minutes; and type III, 120 minutes. Statistical analysis was used to assess the relationship between lymphoscintigraphic patterns and clinical variables and to compare patterns of distribution.

RESULTS

Lymphoscintigraphic patterns were asymmetric in 37.5 percent (study group) and 50 percent (control group). Type III was the most common pattern. There was no significant association between lymphoscintigraphic patterns and considered clinical variables. There was no significant difference in the lymphoscintigraphic pattern distribution of the two groups (p = 0.870).

CONCLUSION

The authors' findings show wide differences and an often "slow" tracer appearance time in patients with intact lymphatic system, questioning the use of contralateral limb as control and transportation time greater than 30 minutes as criteria for identification of lymphatic alterations.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, IV.

The effect of prophylactic lymphovenous anastomosis and shunts for preventing cancer-related lymphedema: a systematic review and meta-analysis

BACKGROUND

Lymphedema is one of the most dreaded side effects to any cancer treatment involving lymphadenectomy. Progressed lymphedema is adversely complex and currently there is no widely acknowledged curative treatment. Therefore recent focus has shifted to risk reduction and prevention. It has been hypothesized that bypassing lymphatic vessels to veins prophylactically, could minimize the lymphatic dysfunction seen following lymphadenectomy.

METHODS

To investigate this possible future treatment modality, we performed a systematic meta-analysis of studies treating patients with prophylactic lymphovenous analysisstomosis (LVA) for the prevention of secondary lymphedema following lymphadenectomy. A systematic search yielded 12 articles included in the qualitative analysis and four of these were further eligible to be included in the quantitative analysis.

RESULTS

We found that patients treated with prophylactic LVA had a significant reduction in lymphedema incidence (Relative risk: 0.33, 95%CI: 0.19 to 0.56) when compared to patients receiving no prophylactic treatment (P < 0.0001).

CONCLUSION

Prophylactic LVA in relation to lymphadenectomy shows promising results, however because of the low number of eligible studies and method heterogeneity between studies, there is an urgent need for uniformly high quality studies, before the treatment can be concluded effective.

Preoperative Lymphedema-Related Risk Factors in Early-Stage Breast Cancer

BACKGROUND

Prolongation of survival in patients with breast cancer due to early diagnosis and modern methods of treatment has turned the attention on lymphedema, which is the most important morbidity secondary to the treatment of the disease. Determination of lymphedema and related risk factors in patients before a surgical intervention may provide protection for patients and early treatment. The aim of this study was to determine the presence of lymphedema before surgery by bioimpedance analysis in patients with breast cancer and to establish risk factors associated with lymphedema.

PATIENTS AND METHODS

A total of 277 patients who were diagnosed as having breast cancer, were planned to undergo a surgical intervention, and had no clinical lymphedema were included in the study. The presence of lymphedema was evaluated with clinical examination, measurement of arm circumference, and bioimpedance analysis.

RESULTS

Lymphedema was found in 59 (21.3%) patients with no detected differences in arm circumferences. A significant relationship was found between the presence of lymphedema and body mass index (BMI), number of positive lymph nodes, and capsule invasion of the tumor (p = 0.001, p = 0.003, p = 0.002, respectively). Multiple regression analysis revealed that BMI and the number of positive lymph nodes were independent variables (p = 0.024, p = 0.002). ROC curve analysis resulted in an increased risk of preoperative lymphedema when the number of positive lymph nodes was ≥8. Correlation analysis revealed a positive correlation between the number of positive lymph nodes and L-dex score (p = 0.001, r = 0.219).

CONCLUSION

Preoperative bioimpedance analysis demonstrated that ∼1/5 of the patients had subclinical lymphedema. Preoperative subclinical lymphedema is associated with obesity and the number of positive lymph nodes, and thus, treatment of the axilla in patients who are preoperatively detected to have subclinical lymphedema should be revised.

Comparisons Between Cancer-Related and Noncancer-Related Lymphedema: An Overview of New Patients Referred to a Specialized Hospital-Based Center in Canada

BACKGROUND

Lymphedema is an irreversible inflammatory condition caused by accumulated lymph fluid and is associated with chronic swelling and increased risk of cellulitis. Our objectives were to: (1) describe the patient population referred to a Canadian lymphedema center and (2) compare lymphedema characteristics between patients with cancer and patients with noncancer diagnoses.

METHODS AND RESULTS

A retrospective cohort study was conducted of new patients referred for suspected lymphedema to a hospital-based center over a 2-year period. The mean age of the patients (n = 429) was 61.4 years; 85% were female and 81% had a history of cancer. Lymphedema characteristics were primary (7%) versus secondary (92%); upper body (51%) versus lower body (45%); unilateral (74%) versus bilateral (25%); and history of cellulitis (22%). Patients with noncancer diagnoses (n = 82) were more likely than patients with cancer diagnoses (n = 347) to have a history of cellulitis (44% vs. 17%), to have bilateral (61% vs. 16%) and lower limb (89% vs. 37%) lymphedema, and to experience a long delay between symptom onset and referral (14.0 vs. 3.5 years) (p < 0.001).

CONCLUSION

Most patients referred to our lymphedema center were female with a history of cancer. However, patients with noncancer diagnoses were more likely to have bilateral lower body lymphedema with an important history of cellulitis; this subgroup is at great risk of missed and delayed diagnoses in the medical setting and of experiencing long-term issues with mobility, recurrent hospitalizations, and poor quality of life.

Endothelial Cell Responses to Biomechanical Forces in Lymphatic Vessels

SIGNIFICANCE

Lymphatic vessels are important components of the cardiovascular and immune systems. They contribute both to the maintenance of normal homeostasis and to many pathological conditions, such as cancer and inflammation. The lymphatic vasculature is subjected to a variety of biomechanical forces, including fluid shear stress and vessel circumferential stretch.

RECENT ADVANCES

This review will discuss recent advances in our understanding of biomechanical forces in lymphatic vessels and their role in mammalian lymphatic vascular development and function.

CRITICAL ISSUES

We will highlight the importance of fluid shear stress generated by lymph flow in organizing the lymphatic vascular network. We will also describe how mutations in mechanosensitive genes lead to lymphatic vascular dysfunction.

FUTURE DIRECTIONS

Better understanding of how biomechanical and biochemical stimuli are perceived and interpreted by lymphatic endothelial cells is important for targeting regulation of lymphatic function in health and disease. Important remaining critical issues and future directions in the field will be discussed in this review. Antioxid. Redox Signal. 25, 451-465.

Lymphatic Function in the Early Postoperative Period of Breast Cancer Has No Short-Term Clinical Impact

OBJECTIVE

To evaluate by lymphoscintigraphy the lymphatic function in the preoperative period up to 2 months after surgery for breast cancer, and the relationship between the lymphatic function with clinical features and physical complications.

METHODS

One hundred and five women were studied before and 2 months after surgery to treat breast cancer. On each occasion, inspection and palpation of surgical wound, upper limb circumference, and lymphoscintigraphy were performed. Lymphatic function analysis consisted of velocity of axillary lymph node (LN) visualization; intensity of LN uptake; collateral circulation; dermal backflow; and hepatic uptake.

RESULTS

In the postoperative period, there was a significant worsening of the degree of LN uptake (p = 0.0003) and in the velocity of LN visualization (p = 0.01). No significant differences in dermal backflow (p = 0.4) and collateral circulation (p = 0,07) were observed. There was a significant increase in liver absorption (p = 0.0002). 37.1% of the patients developed seroma, 11.2% dehiscence, and 25.8% infection. No relationship was found between lymphoscintigraphy changes and postoperative complications or clinical characteristics.

CONCLUSION

Lymphoscintigraphy, performed 60 days post surgery for breast cancer, can detect a worsening in lymphatic drainage and some sign of lymphatic changes. These changes are not related to clinical characteristics and physical complications.

Lymphatic mapping and preoperative imaging in the management of post-mastectomy lymphoedema

Early detection and diagnosis of upper extremity lymphoedema in patients after mastectomy and axillary lymph node clearance is important in order to treat disease before it is too advanced to achieve favourable outcomes. Patients with disease refractory to conservative management can be efficiently assessed for diagnosis and surgical intervention using advanced lymphatic imaging techniques. The current paper highlights the more readily available of these: lymphoscintigraphy, indocyanine green (ICG) lymphangiography and immunofluorescence, magnetic resonance lymphangiography (MRL) and computed tomographic lymphangiography in combination or individually. With such techniques, both diagnosis and treatment of lymphoedema has become more readily achieved, with lymphatico-venous and lymphatico-lymphatic anastomosis, and lymph node transfer now increasingly common undertakings.

Functional lymphatic collectors in breast cancer-related lymphedema arm

BACKGROUND

The pathophysiology of breast cancer-related lymphedema (BCRL) is poorly understood. The present study evaluated the lymphatic collectors in the arms of patients with BCRL.

METHODS AND RESULTS

In total, 123 patients with ipsilateral BCRL who had undergone magnetic resonance lymphangiography using gadobenate dimeglumine as a contrast agent were enrolled in this study. Morphological changes and the numbers of collecting lymphatic vessels were recorded. Associations between the number of visualized lymphatic collectors and edema accumulation, subcutis thickness, and the BCRL duration and latency were analyzed. Tortuous and significantly dilated lymphatic collectors were visualized in the lymphedematous arms of 104 patients (85%). The median number of visualized lymphatic collectors was four. The duration of BCRL was weakly but significantly correlated with the number of lymphatic collectors (rs=0.2054, p=0.0226). The differences in the tissue water content and thickness of the subcutis between the bilateral arms demonstrated moderate correlations with the number of collecting lymphatics (rs=0.31 and 0.35, respectively; p<0.01). More lymphatic collectors tended to be seen in more advanced cases. There was no statistical difference in the amount of lymphatic vessels among different breast cancer treatment methods.

CONCLUSIONS

The number of functional remaining lymphatic collectors increases with the prolongation and severity of BCRL. This may imply persistent reactions of lymphatic collectors in response to lymphostasis.

Global abnormalities in lymphatic function following systemic therapy in patients with breast cancer

Background

Breast cancer-related lymphoedema (BCRL) is a result of interaction between several pathophysiological processes, and is not simply a ‘stopcock’ effect resulting from removal of axillary lymph nodes. The aim of this study was to test the hypothesis that there is a constitutional ‘global’ lymphatic dysfunction in patients who develop BCRL.

Methods

Lower-limb lymphoscintigraphy was performed in 30 women who had undergone axillary lymph node dissection at least 3 years previously, of whom 15 had BCRL and 15 did not. No patient had any clinical abnormality of the lower limb. The control group comprised 24 women with no history of cancer or lower-limb lymphoedema. 99mTc-Nanocoll was injected subcutaneously into the first webspace of each foot, followed by whole-body imaging. Scans were reported as abnormal if there was delay in lymph transport or rerouting through skin or deep system. Quantification was expressed as the percentage injected activity accumulating in ilioinguinal nodes.

Results

Mean(s.d.) ilioinguinal nodal accumulation at 150 min was significantly lower in women with BCRL than in those without (2·7(2·5) versus 5·9(4·8) per cent respectively; P = 0·006). Abnormal findings on lower-limb lymphoscintigraphy were observed in 17 of the 30 patients: ten of the 15 women who had BCRL and seven of the 15 who did not. None of the 24 control subjects had abnormal scan findings.

Conclusion

Women with BCRL had reduced lower-limb lymph drainage, supporting the hypothesis of a predisposition to BCRL. A surprisingly high proportion of patients with breast cancer also demonstrated lymphatic dysfunction, despite clinically normal lower limbs. Possible explanations could be a systemic effect of breast cancer or its treatment, or an unidentified association between breast cancer and lymphatic dysfunction. Registration number: ISRCTN84866416 (http://www.isrctn.com).

VEGF-C improves regeneration and lymphatic reconnection of transplanted autologous lymph node fragments: An animal model for secondary lymphedema treatment

Secondary lymphedema occurs after for example breast cancer surgery and radiation in 20–50% of the patients. Due to the poor outcomes of surgical treatments in the past, the therapy often remains symptomatic. However, avascular transplantation of autologous lymph node fragments (LN-Tx) combined with postoperative injections of vascular endothelial growth factor-C (VEGF-C) emerges as a potential surgical therapy. In this study, adult rats underwent LN-Tx to investigate the following parameters of VEGF-C application: time point, location and dosage. Furthermore, the influences of VEGF-C on lymphatic reconnection and transplant regeneration were analyzed. The reconnection was investigated using intradermally injected blue dye and the regeneration was evaluated histologically using hematoxylin-eosin (H&E) staining and immunohistochemistry. The higher dosage enhanced the reconnection rates significantly and showed a statistical tendency of improving regeneration. An application on early postoperative days and the injection into the medial thigh improved the reconnection significantly. However, these variables did not affect the regeneration statistically. This study confirms that LN-Tx combined with lymphatic growth factor VEGF-C is a possible approach in the therapy of secondary lymphedema and shows the important role of VEGF-C application parameters.

Pressing the right buttons: signaling in lymphangiogenesis

Lymphatic vasculature is increasingly recognized as an important factor both in the regulation of normal tissue homeostasis and immune response and in many diseases, such as inflammation, cancer, obesity, and hypertension. In the last few years, in addition to the central role of vascular endothelial growth factor (VEGF)-C/VEGF receptor-3 signaling in lymphangiogenesis, significant new insights were obtained about Notch, transforming growth factor β/bone morphogenetic protein, Ras, mitogen-activated protein kinase, phosphatidylinositol 3 kinase, and Ca2+/calcineurin signaling pathways in the control of growth and remodeling of lymphatic vessels. An emerging picture of lymphangiogenic signaling is complex and in many ways distinct from the regulation of angiogenesis. This complexity provides new challenges, but also new opportunities for selective therapeutic targeting of lymphatic vasculature.