Treatment of breast-cancer-related lymphedema with or without manual lymphatic drainage--a randomized study

Advances in lymphedema: An under-recognized disease with a hopeful future for patients

Lymphedema has traditionally been underappreciated by the healthcare community. Understanding of the underlying pathophysiology and treatments beyond compression have been limited until recently. Increased investigation has demonstrated the key role of inflammation and resultant fibrosis and adipose deposition leading to the clinical sequelae and associated reduction in quality of life with lymphedema. New imaging techniques including magnetic resonance imaging (MRI), indocyanine green lymphography, and high-frequency ultrasound offer improved resolution and understanding of lymphatic anatomy and flow. Nonsurgical therapy with compression, exercise, and weight loss remains the mainstay of therapy, but growing surgical options show promise. Physiologic procedures (lymphovenous anastomosis and vascularized lymph node transfers) improve lymphatic flow in the diseased limb and may reduce edema and the burden of compression. Debulking, primarily with liposuction to remove the adipose deposition that has accumulated, results in a dramatic decrease in limb girth in appropriately selected patients. Though early, there are also exciting developments of potential therapeutic targets tackling the underlying drivers of the disease. Multidisciplinary teams have developed to offer the full breadth of evaluation and current management, but the development of a greater understanding and availability of therapies is needed to ensure patients with lymphedema have greater opportunity for optimal care.

Effects of the Anchor System on Postural Balance of Women Undergoing Breast Cancer Treatment: A Clinical, Randomized, Controlled, and Crossover Trial

OBJECTIVE

Investigate the effects of multisensory training with and without the anchor system on breast cancer survivors' postural balance and self-efficacy of falls.

DESIGN

Clinical randomized, controlled, and crossover trial.

SETTING

Teaching, Research, and Assistance Center in Mastectomized Rehabilitation.

PARTICIPANTS

Eighty breast cancer survivors homogeneously distributed in the groups of adults and elderly affected, or not, by lymphedema.

INTERVENTIONS

Participants were randomized to multisensory training with and without the anchor system involving 3 sessions per week for 12 weeks. After the 4-week washout period, the remaining therapeutic intervention was applied.

MAIN OUTCOME MEASURES

The primary outcome was semi-static and dynamic balance as evaluated by baropodometry and Mini Balance Evaluation Systems Test, and the secondary outcome was self-efficacy of the fall episode as assessed by Falls Efficacy Scale - International in the pre-, post-immediate, and 4-week follow-up period.

RESULTS

Both therapeutic interventions caused positive and significant effects on postural balance and self-efficacy of falls in the immediate period. The multisensory training with the anchor system induced significant functional retention in the short term, related to the clinical effect of small to moderate variation.

CONCLUSIONS

Multisensory training with the anchor system is convenient for postural balance and self-efficacy for falls, regardless of age and upper limb volume, for breast cancer survivors.

Shoulder and scapulothoracic impairments in women with breast cancer-related lymphedema in the upper limb: A cross-sectional study shoulder and breast cancer-related lymphedema

INTRODUCTION

Lymphedema in the upper limb as a complication of breast cancer may lead to shoulder pain and dysfunctions.

OBJECTIVE

To compare the scapular positioning, the shoulder range of motion, and muscle strength among women undergoing treatment for breast cancer with and without lymphedema and a control group.

METHODS

This cross-sectional study evaluated women undergoing treatment for breast cancer (N = 25) and without lymphedema (N = 25), and a control group (N = 25). Static scapular positions and shoulder range of motion were measured by using an inclinometer. The shoulder and periscapular muscle strength were measured by using a hand-held dynamometer and the Disabilities of the Arm, Shoulder, and Hand Questionnaire was applied. Linear regression of the mixed effects model was used to compare the groups.

RESULTS

Both groups of mastectomized women had reduced shoulder range of motion, scapular upward rotation, and muscle strength for shoulder and periscapular muscles compared to the control group. Also, women undergoing treatment for breast cancer with lymphedema had reduced shoulder range of motion, scapular upward rotation, increased anterior tilt, reduced muscle strength of the upper trapezius, and greater upper limb disability compared to women without lymphedema.

CONCLUSION

Women undergoing treatment for breast cancer with lymphedema had even greater shoulder and scapulothoracic impairments when compared to the control group and women without lymphedema.

Effectiveness of manual lymphatic drainage in intensive phase I therapy of breast cancer-related lymphedema-a retrospective analysis

BACKGROUND

The standard therapy for lymphedema of any origin is complex physical decongestive therapy (CDT). It comprises manual lymph drainage (MLD), compression therapy (CT), exercise therapy (ET), skincare, and patient education. Additionally, intermittent pneumatic compression (IPC) can be applied. However, the contribution of MLD to decongestion is repeatedly questioned.

PATIENTS AND METHODS

This study re-analyzes a previous study during a 3-week decongestion period, comparing two different types of compression bandaging at the weekend. Sixty-one patients with unilateral breast cancer-related lymphedema were included. The patients received the same therapy (CDT + IPC) except for the different weekend compression bandaging. MLD was performed twice a day on weekdays. The volume of the affected arm was measured on days 1, 5, 8, 12, 15, 19, and 22. For the analysis, the data of both study groups were pooled.

RESULTS

During the week, the patients showed a significant volume reduction (- 155.23 mL (week 1), - 101.02 mL (week 2), - 61.69 mL (week 3), respectively; p < 0.001 each) with a high effect size. On the weekends without MLD, they showed a slight, but also significant increase (12.08 mL (weekend 1), 8.36 mL (weekend 2), 4.33 mL (weekend 3), respectively; p < 0.001 each) with a medium effect size.

CONCLUSIONS

We showed a strong effect of MLD on volume reduction. Differences from other studies are the larger study population and the more intensive application of MLD. If applied intensively, MLD is strongly decongestive during a 3-week decongestion therapy for breast cancer-related lymphedema.

The Top 100 Most-Cited Articles on the Treatment of Lymphedema

A multitude of articles have been published on lymphedema management. We aim to identify the 100 most-cited articles on the management of lymphedema and perform a bibliometric analysis. In July 2023, a title-specific search was made on the Scopus database using "lymphedema" as the primary search term. The top 100 most-cited articles were reviewed. The top 100 most-cited articles on lymphedema received a mean citation of 81.7 ± 71.9 per article (range of 11.0 to 420.0). The publication dates ranged from 1977 to 2015. Most of the articles were original (63.0%), interventional studies (35.0%), randomized controlled trials (RCTs) (31.0%), and systematic reviews (32.0%). The largest number of articles (31) were found between 2007 and 2011. The top 10 articles' citation counts ranged from 164 to 420 (mean of 244.7 ± 83.9 citations). Five of these 10 articles were published between the years 1990 and 2000. Twenty-five countries contributed to the 100 most-cited articles. The United States produced the most number of articles (n = 32), followed by Italy (n = 11), Sweden, and Turkey, with seven articles each. Four of the top 10 articles were RCTs; the remaining six were systematic, retrospective, and prospective studies. The New England Journal of Medicine published two of these top 10 articles. Retrospective studies had the highest mean citation with 196.5, followed by RCTs with 100.9. We identified the 100 most-cited articles that depict the advancement in treatment methods for lymphedema. This extensive information directory can be an excellent source for further research.

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

PURPOSE

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

FINDINGS

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

CONCLUSION

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

Effect of Manual Lymphatic Drainage on Breast Cancer-Related Postmastectomy Lymphedema: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Manual lymphatic drainage (MLD) is widely used in the treatment of breast cancer-related postmastectomy lymphedema (BCRL). However, the therapeutic benefit of MLD on BCRL remains controversial.

OBJECTIVE

The aim of this study was to analyze the efficacy of MLD for BCRL.

METHOD

Four electronic databases were systematically searched for trials comparing MLD and no MLD treatment as options for BCRL. Comparative treatment results included reduction of upper extremity limb volume with subgroup analysis by the number and duration of treatments.

RESULTS

A total of 457 patients were included in the analysis. There was no significant difference in the amount of upper extremity edema between the MLD treatment and control or no MLD groups ( P = .11). However, when the treatment course was ≥20 sessions, there was a significant reduction in the upper extremity volume ( P = .03). There was also a significant reduction in the upper extremity volume when treatment duration was >2 weeks ( P = .03).

CONCLUSION

Manual lymphatic drainage treatment statistically did not reduce the upper extremity limb volume of BCRL, but upper extremity volume was reduced at statistically significant levels when treatment number were ≥20 sessions or the duration of treatment was >2 weeks.

IMPLICATION FOR PRACTICE

Reduction in upper limb volume is dependent on the number and duration of treatments. When treatment number were ≥20 sessions, or the duration of treatment was >2 weeks, reduction of upper limb volume was statistically achieved. Manual lymphatic drainage treatment can be clinically recommended to treat BCRL according to these parameters.

Self-managed physical activity in breast cancer survivors: A scoping review

OBJECTIVE

Breast cancer survivors (BCS) experience many issues of rehabilitative concern due to the treatments they have undergone. Given the chronicity of these outcomes, the increasing number of survivors, and the positive results obtained by supervised exercise, professionals should consider offering self-managed physical activity (PA) programs to this population. Our aim was to map the currently available evidence about self-care rehabilitation for BCS.

METHODS

Medline, CINAHL, and Cochrane databases were searched for primary literature. Scoping review methodological frameworks were used to tackle the heterogeneity of the topic. Studies investigating self-managed PA interventions prescribed to adult BCS were included.

RESULTS

One hundred-eight studies were included, with sample sizes ranging from 6 to 692 patients. Information was systematically collected in tables displaying study design, type of PA, duration and recommended frequency, professional leading the study, type of supervision, initial training, strategies used to help patients integrate self-care into their daily lives, and self-managed PA efficacy. Tables were produced for every oncological side effect that BCS might experience: lymphedema, arthralgia, cancer-related fatigue, a decline in physical parameters, treatment-related cardiotoxicity, peripheral neurotoxicity, and a possible decline in the quality of life.

CONCLUSIONS

Self-managed PA has the potential to improve BCS oncological issues. Professionals can adopt many strategies to support patients and empower them with long-lasting self-care competencies. This scoping review provided a comprehensive and easy-to-consult overview of self-managed PA interventions for BCS. We also provided recommendations for future primary studies and secondary synthesis.

The prevention and treatment of breast cancer- related lymphedema: A review

Background

Breast cancer- related lymphedema (BCRL) affects about 3 to 5 million patients worldwide, with about 20,000 per year in the United States. As breast cancer mortality is declining due to improved diagnostics and treatments, the long-term effects of treatment for BCRL need to be addressed.

Methods

The American Society of Breast Surgeons Lymphatic Surgery Working Group conducted a large review of the literature in order to develop guidelines on BCRL prevention and treatment. This was a comprehensive but not systematic review of the literature. This was inclusive of recent randomized controlled trials, meta-analyses, and reviews evaluating the prevention and treatment of BCRL. There were 25 randomized clinical trials, 13 systemic reviews and meta-analyses, and 87 observational studies included.

Results

The findings of our review are detailed in the paper, with each guideline being analyzed with the most recent data that the group found evidence of to suggest these recommendations.

Conclusions

Prevention and treatment of BCRL involve a multidisciplinary team. Early detection, before clinically apparent, is crucial to prevent irreversible lymphedema. Awareness of risk factors and appropriate practice adjustments to reduce the risk aids are crucial to decrease the progression of lymphedema. The treatment can be costly, time- consuming, and not always effective, and therefore, the overall goal should be prevention.

Does Manual Lymphatic Drainage Add Value in Reducing Suprafascial Fluid Accumulation and Skin Elasticity in Patients With Breast Cancer-Related Lymphedema?

OBJECTIVE

The purpose of this study was to investigate the effectiveness of fluoroscopy-guided manual lymph drainage (MLD) versus that of traditional and placebo MLD, when added to decongestive lymphatic therapy (DLT) for the treatment of breast cancer-related lymphedema (BCRL) (EFforT-BCRL trial), on the suprafascial accumulation of lymphatic fluid and skin elasticity.

METHODS

In this multicenter, 3-arm, double-blind, randomized controlled trial (EFforT-BCRL trial), 194 participants (mean age = 61 [SD = 10] years) with unilateral BCRL were recruited. All participants received standardized DLT (education, skin care, compression therapy, exercises) and were randomized to fluoroscopy-guided, traditional, or placebo MLD. Participants received 60 min/d of treatment during the 3-week intensive phase and 18 sessions of 30 minutes during the 6-month maintenance phase. During this phase, participants were instructed to wear a compression garment, to perform exercises, and to perform a self-MLD procedure once daily. This study comprises secondary analyses of the EFforT-BCRL trial. Outcomes were the amount of fluid accumulation in the suprafascial tissues (local tissue water, extracellular fluid, and thickness of the skin and subcutaneous tissue) and skin elasticity at the level of the arm and trunk. Measurements were performed at baseline; after intensive treatment; after 1, 3, and 6 months of maintenance treatment; and after 6 months of follow-up.

RESULTS

At the level of the arm, there was a significant improvement over time in the 3 groups for most of the outcomes. At the level of the trunk, no remarkable improvement was noted within the individual groups. No significant interaction effects (between-group differences) were present. Only skin elasticity at the level of the arm, evaluated through palpation, showed a significant interaction effect.

CONCLUSION

All 3 groups showed similar improvements in response to DLT regardless of the type of MLD that was added. The effect of the addition of MLD to other components of DLT for reducing local tissue water and extracellular fluid or skin thickness and for improving skin elasticity and fibrosis in participants with chronic BCRL was limited.

IMPACT

Although MLD has been applied all over the world for many years, evidence regarding its added value in reducing arm volume in patients with BCRL is lacking. These results show that adding MLD to other components of DLT has limited value in reducing local tissue water and extracellular fluid or skin thickness and in improving skin elasticity and fibrosis in patients with chronic BCRL. To date, there is no clinical indication to continue including time-consuming MLD in physical therapist sessions for patients with chronic BCRL.

The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment

BACKGROUND

Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature. The goal of this study was to assess experts' opinions on the available literature on lymphedema while following the Delphi methodology.

METHODS

In December of 2019, the American Venous Forum created a working group tasked to develop a consensus statement regarding current practices for the diagnosis and treatment of lymphedema. A panel of experts was identified by the working group. The working group then compiled a list of clinical questions, risk factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions that met the criteria for consensus were included in the list. Using a modified Delphi methodology, six questions that received between 60% and 80% of the votes were included in the list for the second round of analysis. Consensus was reached whenever >70% agreement was achieved.

RESULTS

The panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema. Consensus was also reached that clinical examination is adequate for diagnosing lymphedema and that all patients with chronic venous insufficiency (C3-C6) should be treated as lymphedema patients. No consensus was reached regarding routine clinical practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool. However, the panel came to consensus regarding the importance of quantifying edema in all patients (93.6% in favor). In terms of treatment, consensus was reached favoring the regular use of compression garments to reduce lymphedema progression (89.4% in favor, 10.6% against; mean score of 79), but the use of Velcro devices as the first line of compression therapy did not reach consensus (59.6% in favor vs 40.4% against; total score of 15). There was agreement that sequential pneumatic compression should be considered as adjuvant therapy in the maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of 85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean score of 27). Most of the panel agreed that manual lymphatic drainage should be a mandatory treatment modality (70.2% in favor), but the panel was split in half regarding the proposal that reductive surgery should be considered for patients with failed conservative treatment.

CONCLUSION

This consensus process demonstrated that lymphedema experts agree on the majority of the statements related to risk factors for lymphedema, and the diagnostic workup for lymphedema patients. Less agreement was demonstrated on statements related to treatment of lymphedema. This consensus suggests that variability in lymphedema care is high even among the experts. Developers of future practice guidelines for lymphedema should consider this information, especially in cases of low-level evidence that supports practice patterns with which the majority of experts disagree.

Evidence-Based Practice Guideline for the Management of Lymphedema Proposed by the Japanese Lymphedema Society

Background: Secondary lymphedema mostly occurs as an aftereffect of cancer treatment, and it is estimated that 100,000-150,000 patients are affected in Japan. An estimated 3500 patients, develop lymphedema of the lower and upper extremities each year secondary to uterine and breast cancer treatment. Medical reimbursement was first instituted in April 2008 by the Ministry of Health, Labour and Welfare in Japan. Since 2008, we have developed guidelines regarding treatment options for patients with lymphedema based on scientific evidence. This is the third edition of the guidelines established by the Japanese Lymphedema Society (JLES), published in 2018. The JLES Practice Guideline-Making Committee (PGMC) developed 21 clinical questions (CQs). Methods and Results: A review of these 15 CQs was performed in accordance with the methodology for establishing clinical guidelines. The 15 recommendations for each of these CQs were developed and discussed until consensus by the PGMC was reached. Moreover, outside members who had no involvement in these guidelines evaluated the contents using the Appraisal of Guidelines for Research and Evaluation (AGREE) II reporting checklist. Conclusion: These guidelines have been produced for the adequate management of lymphedema by doctors and other medical staff on the lymphedema management team of medical institutes, including nurses, physical technicians, and occupational therapists.

Pilot Study of Anti-Th2 Immunotherapy for the Treatment of Breast Cancer-Related Upper Extremity Lymphedema

Recent studies suggest that Th2 cells play a key role in the pathology of secondary lymphedema by elaborating cytokines such as IL4 and IL13. The aim of this study was to test the efficacy of QBX258, a monoclonal IL4/IL13 neutralizing antibody, in women with breast cancer-related lymphedema (BCRL). We enrolled nine women with unilateral stage I/II BCRL and treated them once monthly with intravenous infusions of QBX258 for 4 months. We measured limb volumes, bioimpedance, and skin tonometry, and analyzed the quality of life (QOL) using a validated lymphedema questionnaire (Upper Limb Lymphedema 27, ULL-27) before treatment, immediately after treatment, and 4 months following treatment withdrawal. We also obtained 5 mm skin biopsies from the normal and lymphedematous limbs before and after treatment. Treatment was well-tolerated; however, one patient with a history of cellulitis developed cellulitis during the trial and was excluded from further analysis. We found no differences in limb volumes or bioimpedance measurements after drug treatment. However, QBX258 treatment improved skin stiffness (p < 0.001) and improved QOL measurements (Physical p < 0.05, Social p = 0.01). These improvements returned to baseline after treatment withdrawal. Histologically, treatment decreased epidermal thickness, the number of proliferating keratinocytes, type III collagen deposition, infiltration of mast cells, and the expression of Th2-inducing cytokines in the lymphedematous skin. Our limited study suggests that immunotherapy against Th2 cytokines may improve skin changes and QOL of women with BCRL. This treatment appears to be less effective for decreasing limb volumes; however, additional studies are needed.

Physical therapies in the decongestive treatment of lymphedema: A randomized, non-inferiority controlled study

OBJECTIVE

To assess whether the treatment with intermittent pneumatic compression plus multilayer bandages is not inferior to classical trimodal therapy with manual lymphatic drainage in the decongestive lymphedema treatment.

STUDY DESIGN

Randomized, non-inferiority, controlled study to compare the efficacy of three physical therapies' regimens in the Decongestive Lymphatic Therapy.

PARTICIPANTS

194 lymphedema patients, stage II-III with excess volume > 10% were stratified within upper and lower limb and then randomized to one of the three treatment groups. Baseline characteristics were comparable between the groups.

INTERVENTION

all patients were prescribed 20 sessions of the following regimens: Group A (control group): manual lymphatic drainage + Intermittent Pneumatic Compression + Bandages; Group B: pneumatic lymphatic drainage + Intermittent Pneumatic Compression + Bandages; and Group C: only Intermittent Pneumatic Compression + Bandages.

END-POINT

Percentage reduction in excess volume (PREV).

RESULTS

All patients improved after treatment. Global mean of PREV was 63.9%, without significant differences between the groups. The lower confidence interval of the mean difference in PREV between group B and group A, and between group C and group A were below 15%, thus meeting the non-inferiority criterion. Most frequent adverse events were discomfort and lymphangitis, without differences between groups. A greater baseline edema, an upper-limb lymphedema and a history of dermatolymphangitis were independent predictive factors of worse response in the multivariate analysis.

CONCLUSIONS

Decongestive lymphatic therapy performed only with intermittent pneumatic compression plus bandages is not inferior to the traditional trimodal therapy with manual lymphatic drainage. This approach did not increase adverse events.

Retrograde Manual Lymphatic Drainage following Vascularized Lymph Node Transfer to Distal Recipient Sites for Extremity Lymphedema: A Retrospective Study and Literature Review

BACKGROUND

Vascularized lymph node transfer is an efficacious treatment for extremity lymphedema. This study investigated the outcome of retrograde manual lymphatic drainage for vascularized lymph node transfer to distal recipient sites.

METHODS

Lymphedema patients who underwent either complete decongestive therapy or vascularized lymph node transfer between 2013 and 2018 were retrospectively included. Retrograde manual lymphatic drainage was started with intermittent manual compression and the assistance of a sphygmomanometer and proximal-to-distal massage of the limb 1 month postoperatively. Outcomes evaluations used the circumferential reduction rate and the Lymphedema-Specific Quality-of-Life Questionnaire. Outcomes of vascularized lymph node transfer to proximal versus distal recipient sites in the literature between 2006 and 2018 were also compared.

RESULTS

One hundred thirty-eight unilateral extremity lymphedema patients, including 68 patients in the complete decongestive therapy group and 70 patients in the vascularized lymph node transfer group, were included. The mean circumferential reduction rate of 38.9 ± 2.5 percent in the vascularized lymph node transfer group was statistically greater than the 13.2 ± 10.1 percent rate in the complete decongestive therapy group (p = 0.01). At a mean follow-up of 36 months, the improvement of overall Lymphedema-Specific Quality-of-Life Questionnaire score from 3.8 ± 0.3 to 7.5 ± 1.8 in the vascularized lymph node transfer group was statistically greater than that in the complete decongestive therapy group (from 4.7 ± 0.9 to 5.0 ± 1.9; p < 0.01). In total, 536 lymphedema patients who underwent 548 vascularized lymph node transfers in 23 published articles were reviewed; the distal recipient-site group was found to have more efficacious results than the proximal recipient-site group.

CONCLUSION

Vascularized lymph node transfer to a distal recipient site with standard retrograde manual lymphatic drainage significantly improved circumferential reduction rates and Lymphedema-Specific Quality-of-Life Questionnaire scores.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Manual Lymphedema Drainage for Reducing Risk for and Managing Breast Cancer-Related Lymphedema After Breast Surgery: A Systematic Review

OBJECTIVE

To examine the effects of manual lymphatic drainage (MLD) on reducing the risk of and managing breast cancer-related lymphedema (BCRL).

DATA SOURCES

The electronic databases ScienceDirect, Scopus, PubMed, and CINAHL were searched for articles published in the English language from January 2000 to June 2020.

STUDY SELECTION

A total of 518 articles were retrieved. After the removal of duplicates, 472 articles remained, 433 of which were excluded based on title and abstract consideration. Thereafter, 39 studies were further inspected, and 27 articles were excluded because they were not randomized controlled trials, did not measure BCRL, and/or were an incomplete study. Ten studies were included for the final review.

DATA EXTRACTION

Data from the 10 studies were extracted and compiled into a summary table.

DATA SYNTHESIS

Based on the results of this systematic review, it cannot be concluded that MLD helps reduce the risk of BCRL for women after breast surgery. Regarding the effect of MLD on managing BCRL, the findings indicate that MLD alone or MLD combined with other treatments was likely to give similar benefits in terms of reducing arm volume for women diagnosed with BCRL.

CONCLUSION

Scientific evidence to support the benefits of MLD on preventing or reducing BCRL remains unclear. More rigorous studies to confirm findings on the effectiveness of MLD are needed.

Tissue Engineering Strategies for Cancer-Related Lymphedema

Tissue engineering has witnessed remarkable advancement in various fields of medicine and has the potential of revolutionizing the management of lymphedema. Combining approaches of biotechnology with the evolving understanding of lymphangiogenesis may offer promising treatment modalities for patients suffering from lymphedema. The strategies to lymphatic vessels tissue engineer can be grouped into four main categories: Delivery of chemokines, cytokines, and other growth factors to induce lymphangiogenesis; cell-based approach using lymphatic endothelial cells or stem-cells; scaffold-based tissue engineering; or a combination of these. This review will summarize the current approach to cancer-related lymphedema and advances in lymphatic tissue engineering strategies and the challenges facing the regeneration of lymphatic vasculature, particularly in an oncologic setting.

Breast edema, from diagnosis to treatment: state of the art

Introduction

Breast edema can arise from different etiologies; however, it is mostly seen after breast conserving surgery and/or radiotherapy. Combining breast conserving surgery and radiotherapy can cause damage to the lymphatic system and reactions to surrounding tissues, which can lead to breast edema; hereby, the breast size can increase by more than one cup size. Swelling of the breast is not the only criterion associated with breast edema. Other common criteria found in literature are peau d’orange, heaviness of the breast, skin thickening, breast pain, redness of the skin, hyperpigmented skin pores and a positive pitting sign. Despite the benefits of breast conserving surgery, breast edema can be uncomfortable, and can negatively influence quality of life in suffering patients. In contrast to lymphedema of the arm, which is well known in clinical practice and in research, breast edema is often underestimated and far less explored in literature. Currently, many aspects still need to be reviewed.

Purpose and importance to practice

This masterclass aims at providing the state of the art of breast edema for all health care workers and researchers involved in the treatment and monitoring of breast cancer patients. It includes current and future perspectives on its diagnosis, longitudinal course and treatment. Furthermore, recommendations for clinical practice and future research are discussed.

Clinical implications

It is recommended to closely monitor those patients in whom breast edema symptoms do not decline within 6 months after termination of radiotherapy and provide them with the appropriate therapy. Since evidence concerning the treatment of breast edema is currently lacking, we recommend the complex decongestive therapy (CDT) to the utmost extent, by analogy with the lymphedema treatment of the extremities. This treatment involves skin care, exercise therapy and compression. Additionally, all patients should be informed about the normal course of breast edema development.

Future research priorities

A consensus should be reached among clinicians and researchers concerning the definition, assessment methods and best treatment of breast edema. Furthermore, high quality studies are necessary to prove the effectiveness of the CDT for breast edema.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40945-021-00103-4.

Prevention of Breast Cancer-Related Lymphedema

Tremendous progress has been made over the past several decades in the treatment of breast cancer. Mortality and recurrence rates continue to decline. Our ability to tailor patient- and tumor-specific treatments has rapidly advanced. The vast majority of our patients can safely have breast conservation. Unfortunately, for many patients, survivorship is burdened by ongoing quality-of-life issues. Most breast cancer patients are asymptomatic at presentation, and the onus is on us to preserve this. Surgery, radiation, and systemic therapy can result in long-term toxicities that can be amplified with multimodality approaches. We must strive to apply minimally effective therapies rather than a maximally tolerated approach. Breast cancer-related lymphedema (BCRL) is a particularly dreaded chronic complication. This review strives to give the reader a better understanding of BCRL and shed light on wisely choosing an integration of treatment modalities that minimizes BCRL risk. Key literature on emerging concepts is highlighted.

Lymphatic Tissue Engineering: A Further Step for Successful Lymphedema Treatment

BACKGROUND

 Secondary lymphedema, caused by oncologic surgery, radiation, and chemotherapy, is one of the most relevant, nononcological complications affecting cancer survivors. Severe functional deficits can result in impairing quality of life and a societal burden related to increased treatment costs. Often, conservative treatments are not sufficient to alleviate lymphedema or to prevent stage progression of the disease, as they do not address the underlying etiology that is the disruption of lymphatic pathways. In recent years, lymphatic surgery approaches were revolutionized by advances in microsurgical technique. Currently, lymphedema can effectively be treated by procedures such as lymphovenous anastomosis (LVA) and lymph node transfer (LNT). However, not all patients have suitable lymphatic vessels, and lymph node harvesting is associated with risks. In addition, some data have revealed nonresponders to the microsurgical techniques.

METHODS

 A literature review was performed to evaluate the value of lymphatic tissue engineering for plastic surgeons and to give an overview of the achievements, challenges, and goals of the field.

RESULTS

 While certain challenges exist, including cell harvesting, nutrient supply, biocompatibility, and hydrostatic properties, it is possible and desirable to engineer lymph nodes and lymphatic vessels. The path toward clinical translation is considered more complex for LNTs secondary to the complex microarchitecture and pending final mechanistic clarification, while LVA is more straight forward.

CONCLUSION

 Lymphatic tissue engineering has the potential to be the next step for microsurgical treatment of secondary lymphedema. Current and future researches are necessary to optimize this clinical paradigm shift for improved surgical treatment of lymphedema.

Manual lymphatic drainage for lymphedema in patients after breast cancer surgery: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Studies have shown that manual lymphatic drainage (MLD) has a beneficial effect on lymphedema related to breast cancer surgery. However, whether MLD reduces the risk of lymphedema is still debated. The purpose of this systematic review and meta-analysis was to summarize the current evidence to assess the effectiveness of MLD in preventing and treating lymphedema in patients after breast cancer surgery.

METHODS

From inception to May 2019, PubMed, EMBASE, and Cochrane Library databases were systematically searched without language restriction. We included randomized controlled trials (RCTs) that compared the treatment and prevention effect of MLD with a control group on lymphedema in breast cancer patients. A random-effects model was used for all analyses.

RESULTS

A total of 17 RCTs involving 1911 patients were included. A meta-analysis of 8 RCTs, including 338 patients, revealed that MLD did not significantly reduce lymphedema compared with the control group (standardized mean difference (SMD): -0.09, 95% confidence interval (CI): [-0.85 to 0.67]). Subgroup analysis was basically consistent with the main analysis according to the research region, the publication year, the sample size, the type of surgery, the statistical analysis method, the mean age, and the intervention time. However, we found that MLD could significantly reduce lymphedema in patients under the age of 60 years (SMD: -1.77, 95% CI: [-2.23 to -1.31]) and an intervention time of 1 month (SMD: -1.77, 95% CI: [-2.23 to -1.30]). Meanwhile, 4 RCTs including, 1364 patients, revealed that MLD could not significantly prevent the risk of lymphedema (risk ratio (RR): 0.61, 95% CI: [0.29-1.26]) for patients having breast cancer surgery.

CONCLUSIONS

Overall, this meta-analysis of 12 RCTs showed that MLD cannot significantly reduce or prevent lymphedema in patients after breast cancer surgery. However, well-designed RCTs with a larger sample size are required, especially in patients under the age of 60 years or an intervention time of 1 month.

Manual Lymphatic Drainage May Not Have an Additional Effect on the Intensive Phase of Breast Cancer-Related Lymphedema: A Randomized Controlled Trial

Background: Breast cancer-related lymphedema (BCRL) is a potentially debilitating complication of breast cancer and its treatment. The aim of this study was to determine the efficacy of manual lymphatic drainage (MLD) added to multilayer compressive bandage treatment in addition to an exercise program, on arm volume, subjective symptoms, upper limb functions, and health-related quality of life (HRQoL) in patients with BCRL. Methods: This prospective, randomized, single-blind interventional trial involved 54 patients with BCRL. Eligible patients were randomly allocated to a complex decongestive therapy (CDT) group (n = 27) and a standard therapy (ST) group (n = 27). Both groups participated in a 15-session program (every weekday for 3 weeks) that included compressive multilayer bandaging and exercise training. The patients who were allocated to the CDT group received MLD before bandaging in addition to the ST. Bilateral arm circumferences were measured using a measuring tape at six reference points. Subjective symptoms, such as discomfort, heaviness, and swelling severity were measured using a visual analog scale (VAS). Upper limb functions and HRQoL were assessed using the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) and Lymphedema Functioning, Disability, and Health Questionnaire (Lymph-ICF), respectively. Results: The excess arm volume, percent change of excess arm volume, Quick-DASH scores, and Lymph-ICF subscale scores significantly decreased (p < 0.001) in both treatment groups. However, there was no significant difference between the two groups (p > 0.05) in terms of changes in these outcomes. The VAS discomfort (p = 0.015) and VAS heaviness (p = 0.014) scores decreased significantly in the CDT group compared to the ST group. Conclusion: The study findings indicated that both treatment approaches were effective in patients with BRCL. However, no additional effect of MLD was found with regard to percent reduction in arm volume in the intensive treatment period of BRCL.

Comprehensive Decongestive Therapy as a Treatment for Secondary Lymphedema of the Lower Extremity and Quality of Life of Women After Gynecological Cancer Surgery

Background

Lymphedema is a clinical manifestation of lymphatic system failure, caused by an imbalance between the transport capacity of the lymphatic system and the volume of the produced lymph. Lymphedema is complication and significantly worsens quality of life (QoL).

Material/Methods

There were 50 patients diagnosed with secondary lymphedema of the lower extremities after gynecological cancer followed by radiotherapy included in this study. The average age was 57.76 years (standard deviation±10.08). Patients were treated at the Department of Physiotherapy, Balneology and Medical Rehabilitation, in hospital NsP in Bardejov. During therapy, we applied manual lymphatic drainage, instrumental lymphatic drainage, multilayer bandage, vascular gymnastics (with loaded external compression), hydrotherapy, and patient education on the adjustment necessary for a life-long regimen. The circumference of the limb was measured using the Kuhnkes disk method, QoL was assessed using the LYMQOL LEG questionnaire, and for assessment of pain the Visual Analogue Scale (VAS) was used.

Results

After treatment, we found a reduction in lymphedema (P<0.001), an increase in QoL (P<0.001), and a reduction in pain (P<0.001). We found a significant relationship between QoL change and pain in the domains of symptoms, function, and overall QoL (P<0.005). The results showed that reduction of lymphedema was not a significant predictor of QoL (P>0.001).

Conclusions

We found a positive effect in the treatment of secondary lymphedema of the lower extremity on the QoL of women after uterine cancer surgery, and also found that reduction of lymphedema and age were not predictors of improvement in QoL.

Therapeutic Regeneration of Lymphatic and Immune Cell Functions upon Lympho-organoid Transplantation

Lymph nodes (LNs) are secondary lymphoid tissues that play a critical role in filtering the lymph and promoting adaptive immune responses. Surgical resection of LNs, radiation therapy, or infections may damage lymphatic vasculature and compromise immune functions. Here, we describe the generation of functional synthetic lympho-organoids (LOs) using LN stromal progenitors and decellularized extracellular matrix-based scaffolds, two basic constituents of secondary lymphoid tissues. We show that upon transplantation at the site of resected LNs, LOs become integrated into the endogenous lymphatic vasculature and efficiently restore lymphatic drainage and perfusion. Upon immunization, LOs support the activation of antigen-specific immune responses, thus acquiring properties of native lymphoid tissues. These findings provide a proof-of-concept strategy for the development of functional lympho-organoids suitable for restoring lymphatic and immune cell functions.

Identification and Management of Lymphedema in Patients With Breast Cancer

Breast cancer–related lymphedema (BCRL) is a potentially debilitating and often irreversible complication of breast cancer treatment. Risk of BCRL is proportional to the extent of axillary surgery and radiation. Other risk factors include obesity and infections. Given the 5-year survival rate of 90% and its potential impact on the quality of life of survivors of breast cancer, BCRL has become a significant financial burden on the health care system. Minimizing axillary surgery and radiation has been proven to reduce the risk of BCRL. Comprehensive multidisciplinary assessment at the time of initial diagnosis; early referral to physical therapy after surgery; and patient education regarding weight loss, skin, and nail care are cornerstones of the management of early-stage lymphedema. End-stage lymphedema may benefit from referral to a plastic surgeon specializing in lymphedema surgery. In this review, we attempt to review the incidence, risk factors, staging, prevention, and management of this complication of breast cancer treatment. We also describe our multidisciplinary approach for the prevention of this complication at the time of initial diagnosis.

Results of home-based modified combined decongestive therapy in patients with lower extremity lymphedema

Background/aim

The aim of this study is to present the results of modified combined decongestive therapy (CDT) in patients with lower extremity lymphedema (LEL).

Materials and methods

We retrospectively reviewed 95 patients aged 55.84 ± 15.70 years who had been diagnosed with LEL between May 2015 and May 2017. The patients were treated for 4 weeks with modified CDT, including self-manual lymphatic drainage, self-bandaging, decongestive exercises, and skin care.

Results

The mean reduction amounts of edema volume before and after treatment were 296.05, 784.92, and 1038.50 mL for stages 1, 2, and 3 respectively (P = 0.001). There were significant differences between the values before and after treatment in excess extremity volume (EEV) at all stages (P = 0.001). The EEV percentages of the secondary LEL patients were higher than those of the primary LEL patients (P = 0.04). There was no correlation between BMI and treatment response in terms of EEV percentages (r = –0.99; P = 0.36).

Conclusion

Our results revealed that home-based modified CDT is more effective in reducing extremity edema volume in secondary LEL than primary LEL. It should be an available method for self-management of LEL at all stages.

Efficacy of self-administered complex decongestive therapy on breast cancer-related lymphedema: a single-blind randomized controlled trial

PURPOSE

After surgery, breast cancer-related lymphedema (BCRL) is a frequent chronic condition. The complex decongestive therapy (CDT) delivered by physiotherapists at hospitals is the state-of-the-art treatment choice. As lymphedema requires continuous management, we designed a 1-month-long course to train women to professionally carry out a self-administered CDT (saCDT) and tested its efficacy while keeping the benefits of CDT.

METHODS

Consecutive patients treated with CDT over a 1-year period at an Italian facility were randomly assigned to either experimental (EXP, saCDT course) or control (CTRL, usual care) group. Women were assessed before, at 1, and 6 months from enrolment. Pain assessed by the numerical pain rating scale (NPRS) was the primary outcome. Arm asymmetry assessed by the excess limb volume (ELV) was the secondary outcome. Outcome variations were compared to their MCID to classify women as improved, stable, or worsened.

RESULTS

Forty-one women were included. The proportion of stable or improved women was significantly different between EXP and CTRL groups at 6 months after enrolment for both arm pain (p = 0.01) and asymmetry (p < 0.01). Noteworthy, only one EXP woman had worsened after 6 months. NPRS significantly decreased in the EXP group only, with a median variation of 2 points. Arm ELV significantly decreased with respect to the baseline value in the EXP group only, with a median reduction of 8%.

CONCLUSIONS

Teaching saCDT to women with BCRL is effective in maintaining or improving the benefits of CDT and can be used as a self-care tool in the management of BCRL.

The addition of self-lymphatic drainage to compression therapy instead of manual lymphatic drainage in the first phase of complex decongestive therapy for treatment of breast cancer-related lymphedema: A randomized-controlled, prospective study

Objectives

The aim of this study was to investigate the effects of adding self-lymphatic drainage (SLD) to compression bandaging (CB) therapy rather than manual lymphatic drainage (MLD) in the first phase of complex decongestive therapy (CDT) on arm edema, quality of life, upper extremity function, and anxiety-depression in patients with breast cancer-related lymphedema (BCRL).

Patients and methods

Between January 2015 and January 2017, a total of 24 patients (mean age 58.9±10.3 years; range, 42 to 83 years) with BCRL were randomly assigned to receive CB or CB plus SLD. The edema of the arm was assessed by volume calculation based on the circumference measurements. The Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH) for upper extremity functions, the Short Form-36 health survey (SF-36) for the quality of life, and the Hospital Anxiety-Depression Scale (HADS) for anxiety and depression were used. The patients were assessed before the treatment, at the end of the treatment, and six months after the treatment.

Results

A significant volume decrease was observed in the affected arm in both groups at the end of the treatment. Statistically significant improvements in the SF-36 and Q-DASH scores were observed in both groups; however, there was no significant change in the HADS-anxiety and depression subscale scores.

Conclusion

Our study results suggest that compression therapy with or without SLD is effective in the treatment of BCRL. However, the addition of SLD to CB in the first phase of CDT rather than MLD seems to provide no additional significant benefit.

Effectiveness of myofascial release after breast cancer surgery in women undergoing conservative surgery and radiotherapy: a randomized controlled trial

PURPOSE

The scars derived from the treatment of breast cancer lead to adverse effects such as fibrosis or retractions of the connective tissue. Myofascial release (MR) seeks to reduce restrictions of the fascial system. Therefore, the aim of this study was to analyze the clinical impact of MR treatment on women survivors of breast cancer.

METHODS

We enrolled 24 women with breast cancer, 13 received myofascial release treatment (MR) and 11, a placebo manual lymphatic drainage treatment (PMLD). Both interventions were administered over a period of 4 weeks. The outcomes studied were pain, shoulder range of motion (ROM), functionality, quality of life (QoL), and depression, immediately after treatment and 1 month later.

RESULTS

After 4 weeks of treatment, only the participants who received MR experienced a significant decrease in pain intensity in the short and midterm (p < 0.05). This therapy also achieved a general improvement in ROM (p < 0.05), except for internal rotation, that persisted 1 month after treatment. Regarding functionality, both therapies achieved the level of significance (p < 0.05), but only MRG sustained the improvement in the midterm. General QoL, assessed with FACT-B, and its physical well-being dimension were significantly improved after MR implementation (p < 0.05), while the emotional dimension and the breast cancer subscale improved only with PMLD (p < 0.05).

CONCLUSIONS

In conclusion, an MR-based treatment shows physical benefits (i.e., overall shoulder movement, functionality, and perceived pain) in women after breast cancer surgery.

TRIAL REGISTRATION

This study is registered on ClinicalTrials.gov NCT03182881.

Manual lymphatic drainage adds no further volume reduction to Complete Decongestive Therapy on breast cancer-related lymphoedema: a multicentre, randomised, single-blind trial

BACKGROUND

We investigated the comparability of Complete Decongestive Therapy (CDT) including manual lymphatic drainage (MLD) vs. without MLD in the management of arm lymphoedema in patients with breast cancer.

METHODS

Patients randomised into either treatment including MLD (T+MLD) or treatment without MLD (T-MLD) received treatment 2×weekly for 4 weeks. The primary outcome was the volume reduction (%) of arm lymphoedema at 7-month follow-up. The secondary outcomes were volume reduction after the end of treatment, circumference of the arm, patient experience of heaviness and tension, and health status.

RESULTS

Despite difficulties enrolling the planned number of patients (160), 77 were randomised and 73 (38 in T+MLD, 35 in T-MLD) completed the trial. In both groups, the volume of lymphoedema decreased significantly, with no difference between groups (1.0% [95% CI, -4.3;2.3%]): the precision in the 95% confidence interval indicates that the efficacy was comparable; the mean (SE) changes at month 7 were -6.8%(1.2) and -5.7% (1.2) in the T+MLD and T-MLD, respectively. There were no statistically significant differences with respect to any of the secondary outcomes. The results were robust and the conclusion was not sensitive even to various alternative assumptions or analytic approaches to data analysis.

CONCLUSION

Manual lymphatic drainage adds no further volume reduction in breast cancer patients.

Effect of Bandage Compliance on Upper Extremity Volume in Patients with Breast Cancer-Related Lymphedema

BACKGROUND

Complex decongestive physiotherapy (CDP) is an effective treatment for patients with breast cancer-related lymphedema (BCRL). Bandaging is an important component of CDP. Although the literature suggests that bandages must be kept on for about 24 hours, some patients cannot tolerate keeping them on for this length of time. Also, it has been observed that limb volume decreased in patients who did not keep bandages on for 24 hours in clinical trials. But there is no evidence that this reduction in time is statistically significant. Our purpose was to compare the effectiveness of bandage compliance for a longer or a shorter period on limb volume in patients with BCRL.

METHODS AND RESULTS

We retroprospectively reviewed the medical records of 39 patients who received CDP. Twenty-eight eligible patients were divided into two groups, group 1 (n = 18) and group 2 (n = 10), according to the average number of hours of bandage compliance, which was 13-24 and 7-12 hours, respectively. The primary outcome was the change in limb volume between groups. The values for the limb volumes showed a statistically significant decrease in both groups. There was no significant difference in volume reduction between the groups.

CONCLUSION

This study shows that keeping bandages on for between about 12 and 24 hours has the same effect on patients with BCRL as receiving CDP.

Reduction in handgrip strength and electromyographic activity in women with breast cancer

BACKGROUND

Breast cancer survivors have side effects from surgical treatment and adjuvant that may acutely or chronically compromise the musculoskeletal system, resulting in loss of muscle strength.

OBJECTIVE

Handgrip strength and electromyography of the upper limbs and its relationship with dominance in women submitted to surgery for breast cancer.

METHODS

Were evaluated 28 women. The handgrip strength was measured through dynamometer associated with electromyographic, in the muscles: descending trapezius, biceps brachial, triceps brachial, extensor carpi ulnaris, radial extensor carpi and superficial flexor of wrist and fingers.

RESULTS

Reduction in grip strength on the side affected by the surgery, that occurred when the surgery was performed on the non-dominant side. The electromyographic showed significant differences in affected side. This shows the need to consider the affected side by surgery and dominance.

CONCLUSIONS

Decreased grip strength and lower electromyographic activity of upper limb affected by surgery for breast cancer, when the side affected was not the dominant this loss was greater.

A Systematic Review of the Outcomes Used to Assess Upper Body Lymphedema

PURPOSE

To ascertain how change in upper body lymphedema is assessed and understand how clinically significant change is determined.

METHOD

A systematic search of the literature resulted in 55 eligible studies for analysis.

RESULTS

A range of assessment methods, measurement protocols, and outcomes were used in the literature. Of the 21 studies in which thresholds for change were set a priori, 20 different thresholds were reported.

CONCLUSION

How data was measured, analysed and reported was inconsistent across studies. Consensus on a core outcome set with standardised assessment protocols and reporting; and investigation into empirically based minimum important differences (MID) is needed.

Factors associated with professional healthcare advice seeking in women at risk for developing breast cancer-related lymphedema

OBJECTIVES

Approximately 6-20% of breast cancer patients undergoing lymph node surgery will develop lymphedema. At-risk individuals are encouraged to seek professional healthcare advice if symptoms arise. This study aimed to identify cognitive and affective factors associated with professional healthcare advice (PHCA) seeking behavior in women with heightened lymphedema risk.

METHODS

Women with increased lymphedema risk (N=462) completed an online survey measuring cognitive and affective responses to lymphedema risk, including the Illness Perception Questionnaire (Revised), and adherence to seeking PHCA.

RESULTS

Overall, 62% of women reported seeking professional healthcare advice if symptoms arose. Logistic regression analysis indicated that adherence to seeking PHCA if lymphedema symptoms arise was associated with greater illness coherence, belief in the efficacy of seeking PHCA, and lymphedema risk-related emotional distress.

CONCLUSION

Women were more likely to seek PHCA if symptoms arose if they held a coherent understanding of lymphedema and believed in the usefulness of seeking PHCA. For these women, psychological distress associated with lymphedema risk was associated with enhanced adherence to seeking PHCA.

PRACTICE IMPLICATIONS

Health professionals should target lymphedema education to ensure at-risk women have a coherent understanding of lymphedema and that they believe in the effectiveness of seeking PHCA to help manage lymphedema symptoms.

Synergistic Effects of Proprioceptive Neuromuscular Facilitation and Manual Lymphatic Drainage in Patients with Mastectomy-Related Lymphedema

Purpose: Manual lymphatic drainage (MLD) and proprioceptive neuromuscular facilitation (PNF) are potential therapeutic strategies to reduce mastectomy-induced edema. The purpose of this study was to investigate whether the combination of these therapies would induce synergistic effects to treat lymphedema-related complications and to analyze a possible physiological mechanism involved in the observed effects.

Methods: A total of 55 patients diagnosed with mastectomy-induced lymphedema were recruited and randomized into three experimental groups: PNF group (n = 17), MLD group (n = 20), and PNF + MLD group (n = 18). They were subjected to designated rehabilitation program three times a week for 16 weeks. ROM (flexion of the shoulder joint), edema size, arterial blood flow velocity, and degree of pain and depression were measured every 4 weeks over experimental period.

Results: Lymphedema volume, VAS pain scale, and Beck depression scale were decreased in PNF and MLD groups for 16 weeks in a time-dependent manner. In combination, a greater reduction of these variables was observed over 16 weeks compared to each PNF and MLD. While axillary arterial blood circulation rate in the affected extremity was increased in both PNF and PNF + MLD groups over 16 weeks, this value was not increased in MLD group throughout the experimental period. A greater reduction of scales of VAS pain and Beck Depression Inventory (BDI) was observed in PNF + MLD group after the 16 week-treatment, as compared to each PNF and MLD group. Pearson's coefficients test demonstrated that there are significant correlation of depression against pain (r = 0.616, p < 0.01), ROM (r = −0.478, p < 0.01), and lymphedema size (r = 0.492, p < 0.01).

Conclusion: The combination of MLD and PNF induces potent synergistic effects on edema volume, shoulder range of motion (ROM), pain, and depression in patients with lymphedema. In addition, an increased rate of axillary arterial blood flow in PNF-treated patients provide a potential physiological mechanism by which local arterial pulsation in the affected extremity plays a positive role in the treatment of lymphedema. Therefore, it is suggested to incorporate an element of PNF into traditional MLD method to facilitate treatment process for patients with lymphedema.

Alteration of Blood Circulation in the Upper Limb Before and After Surgery for Breast Cancer Associated with Axillary Lymph Node Dissection or Sentinel Lymph Node Biopsy

BACKGROUND

This aim of this study was to assess and compare arterial and venous circulation in women with axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB) before and after breast cancer surgery.

METHODS AND RESULTS

Fifty-two women took part in the study, divided into three groups: those undergoing ALND at levels I, II, and III (ALNDG), with mean age of 56.29 ± 10.85 years old; those undergoing sentinel lymph node biopsy (SLNBG), with mean age of 57.7 ± 7.07 years old; and controls without diagnosis of breast cancer (CG), with mean age of 53.92 ± 8.85 years old. Maximum venous and arterial flow velocities in upper limbs were assessed before and after surgical treatment for breast cancer by means of Doppler ultrasonography (Nicolet Vascular Versalab SE^®). Data normality was assessed by using the Shapiro-Wilk's test, with normally distributed variables being analyzed with analysis of variance (ANOVA) and post hoc Tukey's test or t-test. For variables with non-normal distribution, Kruskal-Wallis' test and post hoc Dunn's test were used at p < 0.05. There was significant difference in the maximum blood flow velocities, both venous (ALNDG) and arterial (SLNBG).

CONCLUSION

The results suggest that ALND and SLNB can interfere with the upper limp blood circulation.

Effectiveness of acupuncture for breast cancer related lymphedema: protocol for a single-blind, sham-controlled, randomized, multicenter trial

BACKGROUND

Although various treatments for breast cancer related lymphedema exist, there is still a need for a more effective and convenient approach. Pilot studies and our clinical observations suggested that acupuncture may be a potential option. This study aims to verify the effectiveness of acupuncture on BCRL and evaluate its safety using a rigorously designed trial.

METHODS/DESIGN

Women who are clinically diagnosed as unilateral BCRL, with a 10% to 40% increase in volume compared to the unaffected arm, will be recruited. Following baseline assessment, participants will be randomized to either the real acupuncture group or sham-acupuncture group at a ratio of 1:1, and given a standard real acupuncture or sham-acupuncture treatment accordingly on both arms followed by the same usual care of decongestive therapy. Volume measurements of both arms will be performed for every participant after each treatment. Data collected at baseline and the last session will be used to calculate the primary outcome and secondary outcomes. Other data will be exploited for interim analyses and trial monitoring. The primary outcome is the absolute reduced limb volume ratio. Secondary outcomes are incidence of adverse events and change in quality of life. A t test or non-parameter test will be used to compare the difference between two groups, and assess the overall effectiveness of acupuncture using the SPSS software (version 12).

DISCUSSION

This study will help expand our knowledge about the effectiveness of acupuncture on BCRL, and how acupuncture might be used in the management of this condition. Acupuncture may be a promising complement or alternative to conventional lymphedema treatment methods, if its effectiveness is confirmed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02803736 (Registered on October 31, 2016).

Safety and Efficacy of Massage Therapy for Patients with Cancer

BACKGROUND

As the popularity of complementary/alternative medicine (CAM) grows, patients are incorporating more CAM therapies into their conventional cancer care. Massage therapy, a CAM therapy known primarily for its use in relaxation, may also benefit patients with cancer in other ways. Massage can also be associated with risks in the oncology population. Risks can be minimized and benefits maximized when the clinician feels comfortable discussing CAM with his or her patients. This article reviews and summarizes the literature on massage and cancer to help provide the clinician with information to help facilitate discussions with patients.

METHODS

MEDLINE and CINAHL databases were searched to identify relevant articles. These were reviewed for content and other pertinent references.

RESULTS

Significant information was extracted from these resources to provide this overview of the use of massage for patients with cancer.

CONCLUSIONS

Conventional care for patients with cancer can safely incorporate massage therapy, although cancer patients may be at higher risk of rare adverse events. The strongest evidence for benefits of massage is for stress and anxiety reduction, although research for pain control and management of other symptoms common to patients with cancer, including pain, is promising. The oncologist should feel comfortable discussing massage therapy with patients and be able to refer patients to a qualified massage therapist as appropriate.

Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment

Answer questions and earn CME/CNE Patients with breast cancer commonly use complementary and integrative therapies as supportive care during cancer treatment and to manage treatment-related side effects. However, evidence supporting the use of such therapies in the oncology setting is limited. This report provides updated clinical practice guidelines from the Society for Integrative Oncology on the use of integrative therapies for specific clinical indications during and after breast cancer treatment, including anxiety/stress, depression/mood disorders, fatigue, quality of life/physical functioning, chemotherapy-induced nausea and vomiting, lymphedema, chemotherapy-induced peripheral neuropathy, pain, and sleep disturbance. Clinical practice guidelines are based on a systematic literature review from 1990 through 2015. Music therapy, meditation, stress management, and yoga are recommended for anxiety/stress reduction. Meditation, relaxation, yoga, massage, and music therapy are recommended for depression/mood disorders. Meditation and yoga are recommended to improve quality of life. Acupressure and acupuncture are recommended for reducing chemotherapy-induced nausea and vomiting. Acetyl-L-carnitine is not recommended to prevent chemotherapy-induced peripheral neuropathy due to a possibility of harm. No strong evidence supports the use of ingested dietary supplements to manage breast cancer treatment-related side effects. In summary, there is a growing body of evidence supporting the use of integrative therapies, especially mind-body therapies, as effective supportive care strategies during breast cancer treatment. Many integrative practices, however, remain understudied, with insufficient evidence to be definitively recommended or avoided. CA Cancer J Clin 2017;67:194-232. © 2017 American Cancer Society.

Diagnostic Methods, Risk Factors, Prevention, and Management of Breast Cancer-Related Lymphedema: Past, Present, and Future Directions

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.

Bilateral Changes in Deep Tissue Environment After Manual Lymphatic Drainage in Patients with Breast Cancer Treatment-Related Lymphedema

BACKGROUND

Breast cancer treatment-related lymphedema (BCRL) arises from a mechanical insufficiency following cancer therapies. Early BCRL detection and personalized intervention require an improved understanding of the physiological processes that initiate lymphatic impairment. Here, internal magnetic resonance imaging (MRI) measures of the tissue microenvironment were paired with clinical measures of tissue structure to test fundamental hypotheses regarding structural tissue and muscle changes after the commonly used therapeutic intervention of manual lymphatic drainage (MLD).

METHODS AND RESULTS

Measurements to identify lymphatic dysfunction in healthy volunteers (n = 29) and patients with BCRL (n = 16) consisted of (1) limb volume, tissue dielectric constant, and bioelectrical impedance (i.e., non-MRI measures); (2) qualitative 3 Tesla diffusion-weighted, T₁-weighted and T₂-weighted MRI; and (3) quantitative multi-echo T₂ MRI of the axilla. Measurements were repeated in patients immediately following MLD. Normative control and BCRL T₂ values were quantified and a signed Wilcoxon Rank-Sum test was applied (significance: two-sided p < 0.05). Non-MRI measures yielded significant capacity for discriminating between arms with versus without clinical signs of BCRL, yet yielded no change in response to MLD. Alternatively, a significant increase in deep tissue T₂ on the involved (pre T₂ = 0.0371 ± 0.003 seconds; post T₂ = 0.0389 ± 0.003; p = 0.029) and contralateral (pre T₂ = 0.0365 ± 0.002; post T₂ = 0.0395 ± 0.002; p < 0.01) arms was observed. Trends for larger T₂ increases on the involved side after MLD in patients with stage 2 BCRL relative to earlier stages 0 and 1 BCRL were observed, consistent with tissue composition changes in later stages of BCRL manifesting as breakdown of fibrotic tissue after MLD in the involved arm. Contrast consistent with relocation of fluid to the contralateral quadrant was observed in all stages.

CONCLUSION

Quantitative deep tissue T₂ MRI values yielded significant changes following MLD treatment, whereas non-MRI measurements did not vary. These findings highlight that internal imaging measures of tissue composition may be useful for evaluating how current and emerging therapies impact tissue function.

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

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

Efficacy and safety of Wuling San for treatment of breast-cancer-related upper extremity lymphoedema: study protocol for a pilot trial

INTRODUCTION

Breast-cancer-related upper extremity lymphoedema (BCUL), a common complication of mastectomy, can cause physical discomfort, psychological distress, cosmetic defects, functional disability and chronic recurrent erysipelas in the affected arm(s). It is a challenge to physicians involved in the management of these patients. Wuling San, a classic prescription in Traditional Chinese Medicine used in treating oedema for thousands of years, is reported by many Chinese journals to perform well in BCUL. Therefore, the aim of this study is to verify its efficacy and evaluate its safety using rigorous methodological designs in patients with BCUL.

METHODS AND ANALYSIS

To verify the efficacy and assess the safety of Wuling San over a placebo, this double-blind, randomised, placebo-controlled, multicentre trial will be carried out in three hospitals. A total of 200 eligible patients with BCUL will be randomly allocated, in a ratio of 1:1, to either the experimental medicine group or the placebo group. The primary outcome measure will be the proportion of absolute reduced limb volume, as measured by perometry. The second outcome measure will be the number of participants with adverse events. The assessment will be carried out at the following time points: before enrolment (baseline) and 2, 4, 6 and 8 weeks after treatment.

ETHICS AND DISSEMINATION

This trial will be conducted in accordance with the Declaration of Helsinki and supervised by the institutional review board of the Fourth Affiliated Hospital of Guangxi Medical University (approval number PJK2016088). All patients will receive information about the trial in verbal and written forms and will give informed consent before enrolment. This trial will help to demonstrate whether Wuling San is effective in the treatment of patients with BCUL. The results will be published in peer-reviewed journals or disseminated through conference presentations.

TRIAL REGISTRATION NUMBER

NCT02726477; Pre-results.