Assessment of volume measurement of breast cancer-related lymphedema by three methods: circumference measurement, water displacement, and dual energy X-ray absorptiometry

Effects of Forearm Resistance Exercises on Breast Cancer-Related Lymphedema Using Segmental Bioelectrical Impedance Analysis: A Pilot Randomized Controlled Trial

Background: Breast cancer-related lymphedema (BCRL) reduces the quality of life of patients and limits their activities of daily living. Even though resistance exercises seemed to be safe in BCRL patients, it was still controversial that resistance exercises improve lymphedema. Therefore, we sought to evaluate the effects of forearm-targeted resistance exercises on BCRL using segmental bioelectrical impedance analysis (BIA). Methods: This study was a pilot-controlled randomized trial, with patients divided into the intervention and the control group. Both groups received 30 min of complete decongestive therapy (CDT) for 2 weeks. In addition, the intervention group received forearm strengthening training including warm-up and cool-down for an extra 20 min, and the control group received stretching exercises. 5 kHz impedance ratios were assessed by segmental BIA before and after treatments. Results: Among the eighteen patients enrolled, ten were assigned to the intervention group, and eight were in the control group. Only the 5 kHz impedance ratio in the forearm segment of the intervention group showed a statistically significant difference. The effect sizes of the groups were 0.71 for the intervention group and 0.93 in the between-group comparison. Conclusions: Forearm resistance exercises in patients with BCRL showed a significant decrease in extracellular fluid in the proximal forearm segment when using segmental BIA. Therefore, we suggest that resistance exercises targeting the forearm might be effective in treating lymphedema.

Limb Volume Measurements: A Comparison of Circumferential Techniques and Optoelectronic Systems against Water Displacement

BACKGROUND

Accurate measurements of limb volumes are important for clinical reasons. We aimed to assess the reliability and validity of two centimetric and two optoelectronic techniques for limb volume measurements against water volumetry, defined as the gold standard.

METHODS

Five different measurement methods were executed on the same day for each participant, namely water displacement, fixed-height (circumferences measured every 5 (10) cm for the upper (lower limb) centimetric technique, segmental centimetric technique (circumferences measured according to proportional height), optoelectronic plethysmography (OEP, based on a motion analysis system), and IGOODI Gate body scanner technology (which creates an accurate 3D avatar).

RESULTS

A population of 22 (15 lower limbs, 11 upper limbs, 8 unilateral upper limb lymphoedema, and 6 unilateral lower limb lymphoedema) participants was selected. Compared to water displacement, the fixed-height centimetric method, the segmental centimetric method, the OEP, and the IGOODI technique resulted in mean errors of 1.2, 0.86, -16.0, and 0.71%, respectively. The corresponding slopes (and regression coefficients) of the linear regression lines were 1.0002 (0.98), 1.0047 (0.99), 0.874 (0.94) and 0.9966 (0.99).

CONCLUSION

The centimetric methods and the IGOODI system are accurate in measuring limb volume with an error of <2%. It is important to evaluate new objective and reliable techniques to improve diagnostic and follow-up possibilities.

Breast Cancer-Related Lymphedema Assessed via Tissue Dielectric Constant Measurements

This review describes the use of tissue dielectric constant (TDC) measurements mainly in the assessment of breast cancer-related lymphedema (BCRL). PubMed, Web of Science, and EMBASE databases were initially searched using criteria that included the terms "dielectric" and "lymphedema." The initial search yielded a total of 131 titles. After removing studies not focused on upper extremity lymphedema, 56 articles remained. These articles, together with relevant articles from their bibliographies, formed the basis of the review. The findings show the potential utility and applications of TDC measurements to help detect and track BCRL, whether present in limbs, breasts, or trunks. It is reported as a non-invasive, simple-to-use method, with each measurement requiring less than 10 seconds, suggesting its practicality and useability as an in-office or in-clinic screening and tracking method. Although there are various ways to quantitatively evaluate lymphedema, most, if not all, are restricted to measurements on limbs. Thus, one significant advantage of the TDC approach is that almost any local region of interest can be effectively measured and tracked, which, for BCRL, could include specific regions of arms or hands, breasts, and truncal areas.

Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidance for the prevention of breast cancer-related arm lymphoedema (BCRAL): international Delphi consensus-based recommendations

Background

Developing strategies to prevent breast cancer-related arm lymphoedema (BCRAL) is a critical unmet need because there are no effective interventions to eradicate it once it reaches a chronic state. Certain strategies such as prospective surveillance programs and prophylactic lymphatic reconstruction have been reported to be effective in clinical trials. However, a large variation exists in practice based on clinician preference, organizational standards, and local resources.

Methods

A two-round international Delphi consensus process was performed from February 27, 2023 to May 25, 2023 to compile opinions of 55 experts involved in the care and research of breast cancer and lymphoedema on such interventions.

Findings

Axillary lymph node dissection, use of post-operative radiotherapy, relative within-arm volume increase one month after surgery, greater number of lymph nodes dissected, and high body mass index were recommended as the most important risk factors to guide selection of patients for interventions to prevent BCRAL. The panel recommended that prospective surveillance programs should be implemented to screen for and reduce risks of BCRAL where feasible and resources allow. Prophylactic compression sleeves, axillary reverse mapping and prophylactic lymphatic reconstruction should be offered for patients who are at risk for developing BCRAL as options where expertise is available and resources allow. Recommendations on axillary management in clinical T1-2, node negative breast cancer patients with 1-2 positive sentinel lymph nodes were also provided by the expert panel. Routine axillary lymph node dissection should not be offered in these patients who receive breast conservation therapy. Axillary radiation instead of axillary lymph node dissection should be considered in the same group of patients undergoing mastectomy.

Interpretation

An individualised approach based on patients' preferences, risk factors for BCRAL, availability of treatment options and expertise of the healthcare team is paramount to ensure patients at risk receive preventive interventions for BCRAL, regardless of where they are receiving care.

Funding

This study was not supported by any funding. RJC received investigator grant support from the Australian National Health and Medical Research Council (APP1194051).

Effects of an early intervention with Hyperbaric Oxygen Treatment on arm lymphedema and quality of life after breast cancer-an explorative clinical trial

PURPOSE

Lymphedema (LE) is a common complication after breast cancer treatment, which negatively affects the quality of life (QOL). Hyperbaric Oxygen Treatment (HBOT) is an established treatment for radiation-induced tissue injury, but evidence of effect on breast cancer-related LE is inconclusive. We aimed to explore effects of HBOT on early breast cancer-related LE and the implications for QOL.

METHODS

We invited women with breast cancer treated with surgery, axillary dissection and radiotherapy, who had participated in a randomized controlled trial and who presented with LE 1 year after surgery. In a prospective observational study design, change in LE was assessed with perometry, dual-energy X-ray absorptiometry (DXA) and lymphoscintigraphy, and QOL by validated self-report scales. Participants were offered 40 sessions of HBOT on every weekday for 8 weeks and were followed for 6 months.

RESULTS

Out of 50 eligible participants, 20 women accepted participation. Nineteen women initiated and completed treatment and follow-up. None of the objective measures of LE severity showed consistent changes during the study period, but participants reported significant improvements in QOL (physical functioning, fatigue, insomnia and breast and arm symptoms), with improvements peaking at 6-month follow-up.

CONCLUSION

Participants receiving HBOT experienced improved QOL without consistently significant changes in arm mass, volume or lymphatic drainage. These results call for studies into differential effect in patient sub-groups, and a large-scale, randomized placebo-controlled trial with long-term follow-up to assess the effect of HBOT in patients with soft tissue radiation injuries after breast cancer seems warranted.

TRIAL REGISTRATION

Danish Health and Medicines Authority, EUDRACT no. 2015-000,604-25 Ethical committee of the Capitol Region, No. R96-A6604-14-S22.

Dual X-ray absorptiometry-derived total and regional body volume

BACKGROUND & AIMS

Although dual X-ray absorptiometry (DXA) has been used to determine total body volume, using DXA to determine regional (i.e., arm and leg) volumes needs further assessment. Thus, the aim of the present study is to evaluate the validity of total and regional DXA-derived body volume compared to a traditional method for measuring body volume.

METHODS

A total of 30 males and females (Age: 25.9 ± 4.0 yrs; Height: 1.75 ± 0.10 m; Weight: 70.98 ± 14.02 kg) underwent one whole body DXA scan, underwater weighing, and regional measures of volume via water displacement. Manually created DXA region of interest boxes were used to determine regional DXA body composition. Total body volume was calculated by taking the participant's dry weight and dividing it by the average density from underwater weighing. Linear regression models with body volume from underwater weighing for total body volume and water displacement for regional volume as the dependent variable and DXA lean mass, fat mass, and bone mass as independent variables created total and regional DXA-derived body volume. T-tests assessed DXA-derived body volume to the traditional method of body volume assessment. Regression models were cross-validated using the Repeated k-fold Cross Validation method.

RESULTS

DXA-derived total body volume was not significantly (p = 0.999) different from total body volume measured via total body water displacement. In addition, both arm and leg regional DXA-derived volume was not significantly different (p = 0.999) compared to regional volume measured by regional water displacement. Cross-validation of each model produced R² values of 0.992, 0.923, and 0.932 for total body, arm, and leg, respectively.

CONCLUSIONS

The DXA may be used as valid method for estimating total and regional body volume. Thus, these results expand the DXA's capabilities and potentially allow for a convenient regional four-compartment model with DXA-derived regional volume.

A Software Suite for Limb Volume Analysis Applicable in Clinical Settings: Upper Limb Quantification

In medicine, tridimensional scanning devices produce digital surfaces that replicate the bodies of patients, facilitating anthropometric measurement and limb volume quantification in pathological conditions. Free programs that address this task are not commonly found, with doctors mainly relying on proprietary software. This aspect brings reduced reproducibility of studies and evaluation of alternative measures. A software package made up of three programs has been developed and released together with supporting materials to enhance reproducibility and comparisons between medical centers. In this article, the functions of the programs and steps for volume assessment were introduced together with a pilot study for upper limb volume quantification. This initial experiment aimed to also verify the performance of digital volumes derived from the convex-hull gift-wrapping algorithm and the alternative analysis methods enclosed in the software. Few of these digital volumes are parameter-dependent, requiring a value selection. The experiment was conducted on a small mixed-gender group of young adults without correction for factors like arm dominance or specific physical training. In the sample under investigation, the analysis confirmed the substantial agreement between the clinical and current configurations of digital volumes produced by the package (R ² interval from 0.93 to 0.97, r ranged from 0.965 to 0.984); in addition, as a general consideration, gender appears as a variable that could influence upper limb volume quantification if a single model is built.

Effects of football fitness training on lymphedema and upper-extremity function in women after treatment for breast cancer: a randomized trial

BACKGROUND

Breast cancer survivors are encouraged to be physically active. A recent review suggests that football training is an effective exercise modality for women across the lifespan, positively influencing health variables such as strength, fitness and social well-being. However, football is a contact sport, potentially posing an increased risk of trauma-related injury. Against this backdrop, breast cancer survivors are advised to avoid trauma or injury to the affected or at-risk arm in order to protect against lymphedema onset or exacerbation. The aim of this study was therefore to evaluate the feasibility and safety of Football Fitness training in relation to lymphedema and upper-extremity function after treatment for breast cancer.

MATERIAL AND METHODS

Sixty-eight women aged 18-75 years, who had received surgery for stage I-III breast cancer and completed (neo) adjuvant chemotherapy and/or radiotherapy within five years, were randomized (2:1) to a Football Fitness group (FFG, n = 46) or a control group (CON, n = 22) for twelve months. Secondary analyses using linear mixed models were performed to assess changes in upper-body morbidity, specifically arm lymphedema (inter-arm volume % difference, dual energy X-ray absorptiometry; extracellular fluid (L-Dex), bioimpedance spectroscopy), self-reported breast and arm symptoms (EORTC breast cancer-specific questionnaire (BR23) and upper-extremity function (DASH questionnaire) at baseline, six- and twelve-month follow-up.

RESULTS

We observed similar point prevalent cases of lymphedema between groups at all time points, irrespective of measurement method. At the six-month post-baseline assessment, reductions in L-Dex (extracellular fluid) were found in FFG versus CON. These significant findings were not maintained at the twelve-month assessment. No difference between groups was observed for inter-limb volume difference %, nor any of the remaining outcomes.

CONCLUSION

While superiority of Football Fitness was not observed, the results support that participation in Football Fitness training is feasible and suggests no negative effects on breast cancer-specific upper-body morbidity, including lymphedema.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov. NCT03284567.

Reliability of Jeweler Rings and a Revised Figure-of-Eight Circumference Protocol for the Assessment of Finger and Hand Circumferences

Background: Assessing the circumference of the hand and fingers can be challenging. Therefore, we studied the reliability of jeweler rings and a revised figure-of-eight (figure-8) protocol for the clinical assessment of finger and hand circumference. Methods and Results: Thirteen patients residing in a rehabilitation center were recruited. Inter- and intrarater reliability of the jeweler rings as well as the revised figure-8 protocol were assessed. Jewelers rings were used to assess the circumferences of the middle and ring finger of both hands. The figure-8 method was used to assess the circumference of both hands. Reliability analyses were performed in Statistical Package for the Social Sciences 26 and demonstrated an excellent reliability for the jeweler rings as well as the revised figure-8 protocol, represented by single random measure intraclass correlation coefficient_(2,1) values of at least 0.973 and Cronbach alpha of at least 0.99. Conclusions: Circumference measurements are valid to use; however, reliability issues do exist in clinical practice. Assessing the circumference of fingers with our new jeweler rings protocol and the circumference of the hand by means of a revised figure-8 protocol is highly reliable in a clinical setting.

Comparison of Vectra three-dimensional stereophotogrammetry measurement and tape measurement in the evaluation of perioperative volume change of the lower abdomen in association with lymphatic microsurgery

BACKGROUND

Although microsurgical treatment for lower extremity lymphedema (LEL) can improve lower abdominal morphology, methods to evaluate the volume change of the lower abdomen have yet to be established. This study aimed to determine the accuracy and reproducibility of three-dimensional stereophotogrammetry (3DSM) in measuring the volume change in the lower abdomen.

METHODS

The perioperative volume changes in the lower abdomen were estimated using tape measurement (TM) and 3DSM in 26 patients with LEL. Thirteen patients with suprapubic lymphedema underwent abdominoplasty simultaneously. Each of them underwent multiple lymphaticovenular anastomoses (LVAs), and five of them underwent vascularized lymph node transfer, simultaneously. Thirteen patients with pelvic lymphatic fluid underwent multiple LVAs. Two patients underwent this surgery twice. When assessed on the Internal Society of Lymphology scale, eight patients were Stage I, 10 patients were Stage II, four patients were late Stage II, and four patients were Stage III. The difference between the two measurement methods and reproducibility of each method were analyzed.

RESULTS

During a mean follow-up period of 6 months, all patients had no postoperative complications and their chief complaint improved. The calculated reduction volume between TM and 3DSM showed a high correlation (p < .0001, r = .84). The reduction volume based on TM was significantly larger than 3DSM (991.1 ± 460.3 ml vs. 862.3 ± 333.5 ml, p = .02). The interrater ICC was 0.94 and 0.98 based on TM and 3DSM, respectively.

CONCLUSION

3DSM may be a useful method for assessment of the lower abdominal morphology due to its high accuracy and reproducibility.

Impact of body mass index on long-term surgical outcomes of vascularized lymph node transfer in lymphedema patients

Background

Vascularized lymph node transfer (VLNT) is a surgical procedure with high interest to treat lymphedema. Body mass index (BMI) is a well-described factor that increases the risk of lymphedema, but little is known about its influence on the surgical outcomes of lymphedema patients who undergo VLNT. The aim of this study was to analyze the impact of preoperative BMI on the long-term surgical outcomes after VLNT in lymphedema patients.

Methods

We retrospectively compiled data of patients with International Society of Lymphology (ISL) stage II or III lymphedema who were treated with VLNT from July 2010 to July 2016 at China Medical University Hospital. Preoperative and postoperative demographic and clinical data, such as limb circumference and number of infection episodes were reviewed. Statistical analyses compared circumference reduction rates and infection episode reduction between preoperative BMI categories was done. In addition, prediction of outcomes based on quantitative preoperative BMI was analyzed.

Results

A total of 83 patients met the inclusion criteria. Nine patients (10.8%) were normal weight, 43 (51.8%) were overweight, and 31 (37.3%) were obese. Compared with normal-weight patients, mean circumference reduction rates were significantly lower in overweight (P=0.005) and obese patients (P=0.02), but quantitative BMI was not correlated with circumference reduction rate (P=0.96). However, obese patients had a significantly greater reduction in infection episodes than normal-weight patients (P=0.03). In addition, greater BMI predicted greater reduction in infection episodes after VLNT (P=0.02).

Conclusions

VLNT is an effective surgical treatment, especially for lymphedema patients with higher preoperative BMIs. The results of our study suggest that this procedure considerably decreases the number of postoperative infection episodes per year in obese patients, even though preoperative BMI does not influence circumference reduction rate.

Inter-observer and Intra-observer Variability in Volume Measurements of the Lower Extremity Using Perometer

Background: The swelling of the extremities seen in lymphedema can be measured with many different volumetric devices; however, many methods lack important characteristics including reproducibility and independence from the subjectivity and skill of the operator. The aim of this study was to validate the use of the Perometer^® as a possible standard for volumetric measurement methods based on the inter-observer and intra-observer variability when using a standard method of Perometry^®. Methods and Results: Volumetric measurements were performed on 10 healthy test subjects by 5 individuals (the observers) who had been instructed in the measurement techniques to be used. The inter-observer variability was assessed by having the five observers measure all the test subjects both in the morning and in the early afternoon. The intra-observer variability was examined by having each observer measure all the 10 test subjects 4 times in a row in the aforementioned time frames. A data set was created using the measurements, allowing for the assessment of other parameters including variation of volume between the right and left leg and daily variation in swelling. Statistical measurements were performed using the Statistical Package for the Social Sciences (SPSS), from which it was determined that there was no statistically significant inter-observer (p-value 0.997) and intra-observer variation (p-value 0.995) based on a significance level of >5%. Furthermore, it was observed that a statistically significant difference in volume occurred in the leg volume during the day. Conclusion: It was concluded that the use of the Perometer provides consistent measurements of volume independent of the observer and therefore appears to provide a candidate standard for volumetric measurements.

Lymphedema in survivors of breast cancer

The tremendous improvement of survival in patients with breast cancer can be attributed to several treatment strategies, but these strategies also lead to the occurrence of breast cancer-related lymphedema (BCRL). BRCL is regularly associated with factors such as axillary lymph node dissection and local lymph node radiotherapy and manifests as an increase of >10% in the volume of affected limbs. Being overweight or having obesity (body mass index ≥25 kg/m2), an excessive number of positive lymph nodes (>8) and capsular invasion by a tumor are additional risk factors for lymphedema. It is worth assessing the risk before surgery as this can prevent the occurrence of BCRL at the initial stage of breast cancer management. The clinical utility of many diagnostic tools and lymphedema surveillance allows early stage and even subclinical BCRL to be diagnosed, and allows real-time monitoring of the disease. The early diagnosis of BRCL allows treatment at an early stage, which is beneficial to the reduction of excess limb volume and the improvement of quality of life. At present, the major therapeutic methods of BCRL include complex decongestive therapy, pneumatic compression devices, participating in exercise, microsurgery and liposuction, each of which alleviates lymphedema effectively. No medications for treatment of BRCL have yet been developed. However, the recent findings on the success of molecular therapy in animal models may remedy this deficiency. Furthermore, the volume reduction of swollen limbs without swelling rebound by transplanting autologous stem cells has been successfully reported in some pilot studies, which may provide a new technique for treating BCRL. This review aimed to discuss the pathogenesis, clinical manifestation, risk factors, advantages and disadvantages of diagnostic tools, lymphedema surveillance and the characteristics of traditional and newly emerging BCRL treatments.

Heavy-load resistance exercise during chemotherapy in physically inactive breast cancer survivors at risk for lymphedema: a randomized trial

Background: Due to long-standing concerns that heavy-load lifting could increase the risk of developing lymphedema, breast cancer survivors have been advised to refrain from resistance exercise with heavy loads. This study prospectively evaluated the effect of heavy-load resistance exercise on lymphedema development in women receiving chemotherapy for breast cancer.Material and Methods: Physically inactive women receiving adjuvant chemotherapy for breast cancer (n = 153) were randomized to a HIGH (supervised, multimodal exercise including heavy-load resistance exercise: 85-90% 1 repetition maximum [RM], three sets of 5-8 repetitions) versus LOW (pedometer and one-on-one consultations) 12-week intervention. Outcomes (baseline, 12 and 39 weeks) included lymphedema status (extracellular fluid [bioimpedance spectroscopy] and inter-arm volume % difference [dual-energy X-ray absorptiometry], lymphedema symptoms [numeric rating scale 0-10]), upper-extremity strength (1 RM), and quality of life domains (EORTC- BR23). Linear mixed models were used to evaluate equivalence between groups for lymphedema outcomes (equivalence margins for L-Dex, % difference and symptoms scale: ±5, ±3% and ±1, respectively). Superiority analysis was conducted for muscle strength and quality of life domains.Results: Postintervention equivalence between groups was found for extracellular fluid (0.4; 90% CI -2.5 to 3.2) and symptoms of heaviness (-0.2; -0.6 to 0.2), tightness (-0.1; -0.8 to 0.6) and swelling (0.2; -0.4 to 0.8). Nonequivalence was found for inter-arm volume % difference (-3.5%; -17.3 to 10.3) and pain (-0.7; -1.3 to 0), favoring HIGH. Strength gains were superior in the HIGH versus LOW group (3 kg; 1 to 5, p < .05). Further, clinically relevant reductions in breast (-11; -15 to -7) and arm (-6; -10 to -1) symptoms were found in the HIGH group.Conclusion: Findings suggest that physically inactive breast cancer survivors can benefit from supervised heavy-load resistance exercise during chemotherapy without increasing lymphedema risk. Trial registration: ISRCTN13816000.

Palpation of Increased Skin and Subcutaneous Thickness, Tissue Dielectric Constant, and Water Displacement Method for Diagnosis of Early Mild Arm Lymphedema

Background: Early diagnosis of mild lymphedema and treatment are important to prevent its progress. The tissue dielectric constant (TDC), measuring local tissue water in the skin and upper subcutis, has neither been related to the water displacement method (WDM) nor been used to diagnose mild arm lymphedema in patients at risk. Our aims were to evaluate TDC and WDM in combination with palpation, examine the association between TDC and WDM measurements, and compare lymphedema-related factors. Methods and Results: Seventy-two women treated for breast cancer were diagnosed with mild arm lymphedema using skin palpation in combination with TDC from fixed measurement sites (threshold ratio for upper arm ≥1.45 and forearm ≥1.3) and/or WDM (lymphedema relative volume [LRV]: ≥5% to ≤8%). Results revealed that 32 (45%) women were diagnosed by TDC only, 19 (26%) by WDM only, and 21 (29%) by both TDC and WDM. TDC ratios exceeding the threshold were most frequently identified on the medial site of the arm, proximal and distal to the antecubital fossa. TDC and WDM were negatively associated; LRV (r = -0.545, p < 0.001). The women diagnosed by TDC only were diagnosed earlier after surgery (p = 0.003) and had a lower LRV (1.3%) than those diagnosed by WDM only (6.3%) or both TDC and WDM (6.2%; p < 0.001). Conclusions: TDC and WDM can be used together for early diagnosis of arm lymphedema, but TDC is the most valid method, determining the diagnosis earlier after surgery and at a lower arm volume than WDM.

Heavy-Load Lifting: Acute Response in Breast Cancer Survivors at Risk for Lymphedema

Purpose

Despite a paucity of evidence, prevention guidelines typically advise avoidance of heavy lifting in an effort to protect against breast cancer–related lymphedema. This study compared acute responses in arm swelling and related symptoms after low- and heavy-load resistance exercise among women at risk for lymphedema while receiving adjuvant taxane-based chemotherapy.

Methods

This is a randomized, crossover equivalence trial. Women receiving adjuvant taxane-based chemotherapy for breast cancer who had undergone axillary lymph node dissection (n = 21) participated in low-load (60%–65% 1-repetition maximum, two sets of 15–20 repetitions) and heavy-load (85%–90% 1-repetition maximum, three sets of 5–8 repetitions) upper-extremity resistance exercise separated by a 1-wk wash-out period. Swelling was determined by bioimpedance spectroscopy and dual-energy x-ray absorptiometry, with breast cancer–related lymphedema symptoms (heaviness, swelling, pain, tightness) reported using a numeric rating scale (0–10). Order of low- versus heavy-load was randomized. All outcomes were assessed before, immediately after, and 24 and 72 h after exercise. Generalized estimating equations were used to evaluate changes over time between groups, with equivalence between resistance exercise loads determined using the principle of confidence interval inclusion.

Results

The acute response to resistance exercise was equivalent for all outcomes at all time points irrespective of loads lifted, with the exception of extracellular fluid at 72 h after exercise with less swelling after heavy loads (estimated mean difference, −1.00; 95% confidence interval, −3.17 to 1.17).

Conclusions

Low- and heavy-load resistance exercise elicited similar acute responses in arm swelling and breast cancer–related lymphedema symptoms in women at risk for lymphedema receiving adjuvant taxane-based chemotherapy. These represent important preliminary findings, which can be used to inform future prospective evaluation of the long-term effects of repeated exposure to heavy-load resistance exercise.

Communicating vessels volumeter to measure upper extremity lymphedema after breast cancer: reliability and criterion validity compared to the gold standard

BACKGROUND

The traditional overflow method for measuring limb volume remains the gold standard, but many disadvantages still inhibit its routine use in clinical practice.

OBJECTIVE

To assess the intra-rater and inter-rater reliability and criterion validity of the 'communicating vessels volumeter' (CVV) for volume measurement of lymphedematous upper extremities (LUE) by using the overflow volumeter (OV) as the reference standard.

METHODS

Twelve LUE of 12 women undergoing mastectomy for breast cancer were measured three times each by three raters using both methods, totaling 216 volume measurements. Criterion validity was estimated by 33 volume measurements of one cylinder of known volume by three raters using both methods, totaling 198 measurements.

RESULTS

Measurement time was short with both CVV and OV. The intraclass correlation coefficient_3,1 was high for both CVV and OV in intra-rater (0.99 vs 0.99) and inter-rater (0.99 vs 0.99) analyses. The bias between methods was low (7.50mL; 0.40%) and the limits of agreement were narrow (-5.80 to 6.50%). The volumes were statistically equal with a strong correlation (R²=0.98) between methods. CVV was more accurate than OV (0.00 vs 0.02%) in cylinder measurements.

CONCLUSION

The high intra-rater and inter-rater reliability rates of CVV were comparable to those of OV, and the volumes resulting from LUE measurements were statistically equal in the two methods. Criterion validity rates indicated that CVV measurements were closer to the actual value of the cylinder than those obtained with the OV.

Intra- and Interrater Reliability and Concurrent Validity of a New Tool for Assessment of Breast Cancer-Related Lymphedema of the Upper Extremity

OBJECTIVE

The goal of this study was to develop and assess intra- and interrater reliability and validity of a clinical evaluation tool for breast cancer-related lymphedema, for use in the context of outcome evaluation in clinical trials.

DESIGN

Blinded repeated measures observational study.

SETTING

Outpatient research laboratory.

PARTICIPANTS

Breast cancer survivors with and without lymphedema (N=71).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The assessment of intraclass correlation coefficients (ICCs) for the Breast Cancer-Related Lymphedema of the Upper Extremity (CLUE) standardized clinical evaluation tool.

RESULTS

Intrarater reliability for the CLUE tool was ICC: 0.88 (95% confidence interval [95% CI], 0.71-0.96). Interrater reliability for the CLUE tool was ICC: 0.90 (95% CI, 0.79-0.95). Concurrent validity of the CLUE score (Pearson r) was 0.79 with perometric interlimb difference and 0.53 with the Norman lymphedema overall score.

CONCLUSIONS

The CLUE tool shows excellent inter- and intrarater reliability. The overall CLUE score for the upper extremity also shows moderately strong concurrent validity with objective and subjective measures. This newly developed clinical, physical assessment of upper extremity lymphedema provides standardization and a single score that accounts for multiple constructs. Next steps include evaluation of sensitivity to change, which would establish usefulness to evaluate intervention efficacy.

Validity and Reliability of Three-Dimensional Imaging for Measuring Breast Cancer-Related Lymphedema in the Upper Limb: A Cross-Sectional Study

Background: In the past, measurement of upper limb lymphedema was done by water displacement (WD), which is frequently cited as the gold standard. For various reasons, however, the use of WD is restricted in clinical settings. A more precise and easy-to-use method would be favorable. The high precision of three-dimensional (3D) imaging in comparison to WD has already been reported for healthy subjects. The aim of this study is to determine the validity and reliability of 3D imaging by comparing it to the WD method in women with unilateral upper limb lymphedema. Methods and Results: Thirty-nine women with unilateral breast cancer-related lymphedema (BCRL) were included, of which 37 completed two volume measurement techniques (3D and WD) on the BCRL and contralateral healthy arm. Slightly larger volumes were measured by the WD method in healthy arms (+9.8 mL; p = 0.058) and also in BCRL arms (+18.5 mL; p < 0.001). All measurements were performed twice by the same researcher to evaluate reliability. There was no significant difference between the two measurements for healthy arms (p = 0.323) or BCRL arms (p = 0.807) in 3D imaging. Bland-Altman plots showed a high limit of agreement between the single measurements. 3D imaging had a high intrarater reliability (Intraclass Correlation Coefficient = 0.999). Conclusion: Results show that 3D imaging is an innovative method for measuring upper limb volume in BCRL patients. Even though image processing is time consuming, 3D imaging combines high reproducibility with high precision. By software automation, this technique could easily be integrated into clinical routine. It is for this reason that we would recommend implementing the Vectra 3D imaging technique for measurement of BCRL.

Adipose-derived regenerative cells and fat grafting for treating breast cancer-related lymphedema: Lymphoscintigraphic evaluation with 1 year of follow-up

BACKGROUND

Breast cancer-related lymphedema (BCRL) is a feared late complication. Treatment options are lacking at present. Recent studies have suggested that mesenchymal stromal cells can alleviate lymphedema. Herein, we report the results from the first human pilot study with adipose-derived regenerative cells (ADRCs) for treating BCRL with 1 year of follow-up.

MATERIAL AND METHODS

We included 10 patients with BCRL. ADRCs were injected directly into the axillary region together with a scar-releasing fat grafting procedure. Primary endpoint was change in arm volume. Secondary endpoints were change in patient-reported outcomes, changes in lymph flow, and safety.

RESULTS

During follow-up, no significant change in volume was noted. Patient-reported outcomes improved significantly with time. Five patients reduced their use of conservative management. Quantitative lymphoscintigraphy did not improve on the lymphedema-affected arms. ADRCs were well tolerated, and only minor transient adverse events related to liposuction were noted.

CONCLUSIONS

In this pilot study, a single injection of ADRCs improved lymphedema based on patient-reported outcome measures, and there were no serious adverse events during the follow-up period. Lymphoscintigraphic evaluation showed no improvement after ADRC treatment. There was no change in excess arm volume. Results of this trial need to be confirmed in randomized clinical trials.

Quantitative comparison between the laser scanner three-dimensional method and the circumferential method for evaluation of arm volume in patients with lymphedema

OBJECTIVE

Several methods are used to evaluate arm volumes. The most commonly used methods are water displacement and the circumferential method (CM), but these techniques have some limitation in application in clinical settings and accuracy. Recently, the laser scanner three-dimensional (LS3D) method was successfully proposed as a valid method for volume measurements of the upper limb in healthy individuals. The aim of the study was to compare, in terms of intraobserver and interobserver reliability, the CM and LS3D method to measure the upper limb in a group of women with upper limb lymphedema.

METHODS

There were 200 women with upper limb lymphedema (mean age, 64 ± 9 years; body mass index, 24.72 ± 2.94 kg/m²) involved in this study. Arm measurements were obtained with both the CM and LS3D method. Statistical analysis was conducted to compare the CM and LS3D method.

RESULTS

Both the CM and LS3D method have a satisfactory level of agreement, but we found some statistically significant differences in terms of some measurements (both circumferential and volume measurements).

CONCLUSIONS

The data obtained in this study indicate that the LS3D method could represent a reliable, valid method to measure arm circumferences and volumes in arms with lymphedema, suitable for daily clinical use. It combines precision, reproducibility, and ease of use with the possibility of measuring geometric parameters and shape information of scanned limbs.

Diagnosis and Treatment of Edema and Lymphedema in the Cancer Patient

BACKGROUND

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

PURPOSE

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

METHODOLOGY

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

FINDINGS

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

CONCLUSION

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

CLINICAL IMPLICATIONS

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

Diagnostic Accuracy of Clinical Measures Considering Segmental Tissue Composition and Volume Changes of Breast Cancer-Related Lymphedema

Background: If we use only volumetry for measuring lymphedema, we could underdiagnose lymphedema with characteristics of biomechanical changes without definite volume change, especially in the medial forearm.

Methods and Results: In total, 158 breast cancer patients participated in this study. Arm volume was measured by water displacement volumetry, and segmental volumes were calculated from circumferences by using the truncated cone method. Subcutaneous ultrasound echogenicities were assessed on the medial side of the upper arm and forearm of both arms and graded by subcutaneous echogenicity grade (SEG) and revised SEG (rSEG). The standards for diagnosing secondary lymphedema were according to the volume change and clinical stage. Sensitivity, specificity, receiver-operating characteristic (ROC) curve, and area under the curve (AUC) were used. Analysis of ROC curves yielded AUCs of 0.875–0.933 (p < 0.001). Volume differences in each segment were significantly different among the grades by SEG. The highest AUC was found for volume difference (AUC = 0.919, 95% confidence interval [CI] = 0.860–0.978) in the upper arm near the elbow; however, in the medial forearm, the highest AUC was found for rSEG (AUC = 0.948, 95% CI = 0.923–0.965 in the proximal forearm; AUC = 0.940, 95% CI = 0.923–0.965 in the distal forearm).

Conclusions: Our findings support the use of SEG by ultrasound in the assessment of lymphedema, especially in the medial region of the forearm. Subcutaneous ultrasound echogenicities may improve the accuracy of diagnosis of lymphedema in the forearm.

Edema Areas of Calves Measured with Magnetic Resonance Imaging as a Novel Indicator for Early Staging of Lower Extremity Lymphedema

BACKGROUND

Staging of lower extremity lymphedema (LEL) is difficult in clinical work. The excellent soft tissue contrast of magnetic resonance imaging (MRI) enables soft tissue changes to be feasibly and reproducibly characterized and distinguished.

AIM

To determine whether cross-section areas of edema calves measured with MRI could be useful for staging of the LEL.

MATERIALS AND METHODS

We recruited 138 participants who were clinically diagnosed with LEL: 61 unilateral and 77 bilateral LEL. Two legs underwent different stages of LEL. Fourteen characters are diagnosed without LEL; we assumed them as stage 0; age-matched 54, 59, and 54 lower extremities had the LEL, which are classified as stages 1, 2, and 3, respectively. On fat-suppressed T2-weighted mid-axial images of calves, the total area of the soft tissue (TA), muscle area (MA), and the water area (WA) of subcutaneous tissue of the bilateral claves were measured and analyzed statistically for staging of LEL. The difference of TA (DTA) of the unilateral LEL was also analyzed.

RESULT

TA and DTA showed statistical differences among each stage (p < 0.0001), except that it was challenged in making off stages 0 and 1 (p > 0.05). No significant difference was found among four stages of LEL in MA. WA was able to display the perfect sensitivity to lymphedema appearance (p < 0.0001, sensitivity = 100%).

CONCLUSION

The WA of the calves could be suggested as a specific indicator for diagnosis of LEL. TA and DTA are the secondary indicators for staging of LEL.

Clinical assessment of hand oedema: A systematic review

Introduction

Assessment of oedema after trauma or surgery is important to determine whether treatment is effective and to detect change over time. Volumetry is referred to as the ‘gold standard’ method of measuring volume. However, this has practical limitations and other methods are available. The aim of this systematic review was to evaluate the psychometric properties of alternative methods used to assess hand oedema.

Methods

A search of electronic bibliographic databases was undertaken for any studies published in English reporting the psychometric evaluation of a method for measuring hand oedema, in an adult population with hand swelling from surgery, trauma or stroke. The Consensus‐based Standards for the Selection of health Measurement Instruments (COSMIN) checklist was used to evaluate the methodological quality.

Results

Six studies met the inclusion criteria. Three methods were identified assessing hand oedema: perometry, visual inspection and the figure-of-eight tape measure, all were compared to volumetry. Four different psychometric properties were assessed. Studies scored fair or poor on COSMIN criteria. There is low-quality evidence supporting the use of the figure-of-eight tape measure to assess hand volume. The perometer systematically overestimated volume and visual estimation had poor sensitivity and specificity.

Discussion

The figure-of-eight tape measure is the best alternative to volumetry for hand oedema. Benefits include reduced cost and time while having comparable reliability to the ‘gold standard’. Further research is needed to compare methods in patients with greater variability of conditions and with isolated digit oedema. Visual estimation of hand oedema is not recommended.

Practicality of the Lower Extremity Lymphedema Index: Lymphedema Index Versus Volumetry-Based Evaluations for Body-Type-Corrected Lower Extremity Volume Evaluation

BACKGROUND

Volume measurement is one of the most commonly used methods for lower extremity lymphedema (LEL) evaluation because of its objectivity. However, volume comparison between different patients with different body types may be inappropriate because body-type difference seems to significantly affect leg volume (LV).

METHODS

Twenty-seven nonedematous legs of 27 unilateral LEL patients were evaluated. The LEL index was calculated using circumferences and body mass index (BMI), and LV was calculated using a summed truncated cone model. The BMI of the examinees was classified into 3 groups: low BMI (BMI < 20), middle BMI (BMI, 20-25), and high BMI (BMI > 25). The LEL index, LV, LV divided by body surface area (LV/BSA), and LV divided by BMI (LV/BMI) were compared with the corresponding BMI groups.

RESULTS

The mean (SD) LEL index was 218.6 (12.9), and the mean (SD) LV was 4081.3 (835.6) mL. Between the low-, middle-, and high-BMI groups, there were no significant differences in the LEL index [223.2 (11.4), 217.8 (13.3), and 214.6 (14.2), P > 0.5] or in LV/BMI [185.5 (9.2), 179.3 (11.3), and 175.7 (15.8) mL per kg/m, P > 0.3], whereas significant differences were seen in LV [3484.9 (366.0), 3924.4 (342.5), and 5387.7 (1038.4) mL, P < 0.001) and in LV/BSA [2404.3 (236.6), 2539.2 (141.4), and 3106.0 (460.8) mL/m, P < 0.001].

CONCLUSIONS

The LEL index and LV/BMI stayed constant regardless of BMI, whereas LV and LV/BSA significantly increased with increase in BMI. With simplicity of calculation, the LEL index would allow more practical body-type-corrected LV evaluation compared with volumetry-based evaluations.

Arm Volumetry Versus Upper Extremity Lymphedema Index: Validity of Upper Extremity Lymphedema Index for Body-Type Corrected Arm Volume Evaluation

BACKGROUND

Volumetry, measurement of extremity volume, is a commonly used method for upper extremity lymphedema (UEL) evaluation. However, comparison between different patients with different physiques is difficult with volumetry, because body-type difference greatly affects arm volume.

METHODS

Seventy arms of 35 participants who had no history of arm edema or breast cancer were evaluated. Arm volume was calculated using a summed truncated cone model, and UEL index was calculated using circumferences and body mass index (BMI). Examinees' BMI was classified into 3 groups, namely, low BMI (BMI, <20 kg/m), middle BMI (BMI, 20-25 kg/m), and high BMI (BMI, >25 kg/m). Arm volume and UEL index were compared with corresponding BMI groups.

RESULTS

Mean (SD) arm volume was 1090.9 (205.5) mL, and UEL index 96.9 (5.6). There were significant differences in arm volume between BMI groups [low BMI vs middle BMI vs high BMI, 945.2 (107.4) vs 1045.2 (87.5) vs 1443.1 (244.4) mL, P < 0.001]. There was no significant difference in UEL index between BMI groups [low BMI vs middle BMI vs high BMI, 97.2 (4.2) vs 96.6 (4.6) vs 96.7 (9.9), P > 0.5].

CONCLUSIONS

Arm volume significantly increased with increase of BMI, whereas UEL index stayed constant regardless of BMI. Upper extremity lymphedema index would allow better body-type corrected arm volume evaluation compared with arm volumetry.

The Use of Noninvasive Imaging Techniques in the Assessment of Secondary Lymphedema Tissue Changes as Part of Staging Lymphedema

Too often, in clinical settings, the diagnosis and evolution of lymphedema is determined by limb circumference measurements and/or volume calculations. Besides the unrecognition of small lymphedemas, these techniques provide little to no information concerning the stage of the lymphedema. This latter is important in choosing appropriate treatment modalities and making an accurate prognosis. Different imaging techniques are described in literature giving insights in tissue changes due to lymphedema. The aim of this article is giving an overview of possible texture changes linked to the different edema stages, visualized with noninvasive imaging procedures like ultrasonography, computed tomography, dual-energy x-ray absorptiometry, or magnetic resonance imaging.

Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of the American Physical Therapy Association

The Oncology Section of the American Physical Therapy Association (APTA) developed a clinical practice guideline to aid the clinician in diagnosing secondary upper quadrant cancer-related lymphedema. Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in the diagnostic process. Overall clinical practice recommendations were formulated based on the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility. In an effort to maximize clinical applicability, recommendations were based on the characteristics as to the location and stage of a patient's upper quadrant lymphedema.

Diagnosis of Upper-Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of APTA

INTRODUCTION

The Oncology Section of APTA developed a clinical practice guideline to aid the clinician in diagnosing secondary upper-quadrant cancer-related lymphedema.

METHODS

Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in their diagnostic process. Overall, clinical practice recommendations were formulated on the basis of the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility.

RECOMMENDATIONS

In an effort to make these clinically applicable, recommendations were based on the characteristics as to the location and stage of a patient's upper-quadrant lymphedema.

Treatment of Breast Cancer-Related Lymphedema with Adipose-Derived Regenerative Cells and Fat Grafts: A Feasibility and Safety Study

Breast cancer‐related lymphedema (BCRL) is a debilitating late complication with a lack of treatment opportunities. Recent studies have suggested that mesenchymal stromal cells can alleviate lymphedema. Herein, we report the results from the first human pilot study with freshly isolated adipose‐derived regenerative cells (ADRC) for treating lymphedema with 6 months follow‐up. Ten BCRL patients were included. ADRC was injected directly into the axillary region, which was combined with a scar‐releasing fat graft procedure. Primary endpoints were change in arm volume. Secondary endpoints were change in patient reported outcome and safety. The study is registered with ClinicalTrials.gov (NCT02592213). During follow‐up, a small volume reduction was noted but was not significant. Five patients reduced their use of conservative management. Patient‐reported outcomes improved significantly over time. ADRCs were well tolerated and only minor transient adverse events related to liposuction were noted. In this pilot study, a single injection of ADRC improved lymphedema based on patient‐reported outcome measures, and there were no serious adverse events in the 6 months follow‐up period. In addition, half of the patients reduced their use of conservative management. ADRC therapy is a promising interventional therapy for alleviating lymphedema, but results need to be confirmed in randomized clinical trials. Stem Cells Translational Medicine2017;6:1666–1672

Reference Values for Assessment of Unilateral Limb Lymphedema with Dual-Energy X-Ray Absorptiometry

INTRODUCTION

The clinical assessment of unilateral limb lymphedema is commonly based on measurements of interlimb volume differences. Reference values for interlimb percentage differences of the volume, fat mass, and lean mass measured with dual-energy X-ray absorptiometry (DXA) scan are, however, not established. The aim of the study was to establish and categorize these reference values in normal limbs.

METHODS AND RESULTS

DXA scans of the normal arms of 167 and normal legs of 196 melanoma patients (aged 18-75 years, body mass index <40), respectively, were performed. The interlimb percentage difference is calculated as follows: ("Limb-of-interest"-contralateral)/contralateral × 100. The interlimb percentage differences for the limb-of-interest were stratified to upper (according to handedness) and lower limbs and categorized as none/mild, moderate, or severe, respectively, based on whether the value is below, in between, or above the two prediction limits. The prediction limits for interlimb total volume percentage difference were 6% and 10%, 0% and 4%, and 3% and 6% for the dominant arm, nondominant arm, and leg, respectively. Further data are given for interlimb percentage differences of regional (upper arm, lower arm, hand, thigh, lower leg, and foot) and total volume, fat mass, and lean mass, respectively.

CONCLUSIONS

The provided clinical reference values allow for identifying and categorizing pathophysiological differences of limbs-of-interest and evaluating tissue composition.

Repeatability of Volume and Regional Body Composition Measurements of the Lower Limb Using Dual-energy X-ray Absorptiometry

Lower limb lymphedema is a dynamic condition in which tissue composition and volume measurements are affected. Various definitions of lower limb lymphedema exist but volume differences between the limbs are widely used. It is therefore necessary to have a readily available noninvasive measurement technique allowing multiple measurements of the lower limbs. This study investigated the repeatability of duplicate volume and regional body composition measurements of the lower limb using the GE Lunar Prodigy dual-energy X-ray absorptiometry (DXA) scanner Prodigy (GE Medical Systems, Madison, WI). Twenty-seven participants (54 limbs), 14 women and 13 men aged 33-71 years with body mass index ranging from 14 to 32 kg/m² were recruited. Duplicate whole-body DXA scans were performed with repositioning between examinations. Regions of interest were manually drawn for the thigh, lower leg, and foot, and total volume was calculated using the density of bone mineral content, fat, and lean mass. The repeatability of the volume of the lower limb and regional thigh and lower leg tissue composition (bone mineral content, fat, and lean mass) was good with intraclass correlation coefficient values of 0.97 to 0.99, and narrow limits of agreement on the Bland-Altman plots. These results confirm DXA to be a highly repeatable method for volume and tissue composition measurements of the lower limb. In a population at risk of lymphedema, DXA offers a clinically readily available noninvasive method allowing multiple measurements of volume and tissue composition on a routine basis, important for diagnosing, monitoring, managing, and researching lymphedema.

Measurement Properties of Instruments for Measuring of Lymphedema: Systematic Review

BACKGROUND

Lymphedema is a common complication of cancer treatment, resulting in swelling and subjective symptoms. Reliable and valid measurement of this side effect of medical treatment is important.

PURPOSE

The purpose of this study was to provide best evidence regarding which measurement instruments are most appropriate in measuring lymphedema in its different stages.

DATA SOURCES

The PubMed and Web of Science databases were used, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

STUDY SELECTION

Clinical studies on measurement instruments assessing lymphedema were reviewed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) scoring instrument for quality assessment.

DATA EXTRACTION

Data on reliability, concurrent validity, convergent validity, sensitivity, specificity, applicability, and costs were extracted.

DATA SYNTHESIS

Pooled data showed good intrarater intraclass correlation coefficients (ICCs) (.89) for bioimpedance spectroscopy (BIS) in the lower extremities and high intrarater and interrater ICCs for water volumetry, tape measurement, and perometry (.98-.99) in the upper extremities. In the upper extremities, the standard error of measurement was 3.6% (σ=0.7%) for water volumetry, 5.6% (σ=2.1%) for perometry, and 6.6% (σ=2.6%) for tape measurement. Sensitivity of tape measurement in the upper extremities, using different cutoff points, varied from 0.73 to 0.90, and specificity values varied from 0.72 to 0.78.

LIMITATIONS

No uniform definition of lymphedema was available, and a gold standard as a reference test was lacking. Items concerning risk of bias were study design, patient selection, description of lymphedema, blinding of test outcomes, and number of included participants.

CONCLUSIONS

Measurement instruments with evidence for good reliability and validity were BIS, water volumetry, tape measurement, and perometry, where BIS can detect alterations in extracellular fluid in stage 1 lymphedema and the other measurement instruments can detect alterations in volume starting from stage 2. In research, water volumetry is indicated as a reference test for measuring lymphedema in the upper extremities.

A randomized cross-over trial to detect differences in arm volume after low- and heavy-load resistance exercise among patients receiving adjuvant chemotherapy for breast cancer at risk for arm lymphedema: study protocol

Background

In an effort to reduce the risk of breast cancer-related arm lymphedema, patients are commonly advised to avoid heavy lifting, impacting activities of daily living and resistance exercise prescription. This advice lacks evidence, with no prospective studies investigating arm volume changes after resistance exercise with heavy loads in this population. The purpose of this study is to determine acute changes in arm volume after a session of low- and heavy-load resistance exercise among women undergoing adjuvant chemotherapy for breast cancer at risk for arm lymphedema.

Methods/Design

This is a randomized cross-over trial. Participants: Women receiving adjuvant chemotherapy for breast cancer who have undergone axillary lymph node dissection will be recruited from rehabilitation centers in the Copenhagen area. Intervention: Participants will be randomly assigned to engage in a low- (two sets of 15–20 repetition maximum) and heavy-load (three sets of 5–8 repetition maximum) upper-extremity resistance exercise session with a one week wash-out period between sessions. Outcome: Changes in extracellular fluid (L-Dex score) and arm volume (ml) will be assessed using bioimpedance spectroscopy and dual-energy x-ray absorptiometry, respectively. Symptom severity related to arm lymphedema will be determined using a visual analogue scale (heaviness, swelling, pain, tightness). Measurements will be taken immediately pre- and post-exercise, and 24- and 72-hours post-exercise. Sample size: A sample size of 20 participants was calculated based on changes in L-Dex scores between baseline and 72-hours post exercise sessions.

Discussion

Findings from this study are relevant for exercise prescription guidelines, as well as recommendations regarding participating in activities of daily living for women following surgery for breast cancer and who may be at risk of developing arm lymphedema.

Trial registration

Current Controlled Trials ISRCTN97332727. Registered 12 February 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2548-y) contains supplementary material, which is available to authorized users.

The accuracy of breast volume measurement methods: A systematic review

Breast volume is a key metric in breast surgery and there are a number of different methods which measure it. However, a lack of knowledge regarding a method's accuracy and comparability has made it difficult to establish a clinical standard. We have performed a systematic review of the literature to examine the various techniques for measurement of breast volume and to assess their accuracy and usefulness in clinical practice. Each of the fifteen studies we identified had more than ten live participants and assessed volume measurement accuracy using a gold-standard based on the volume, or mass, of a mastectomy specimen. Many of the studies from this review report large (>200 ml) uncertainty in breast volume and many fail to assess measurement accuracy using appropriate statistical tools. Of the methods assessed, MRI scanning consistently demonstrated the highest accuracy with three studies reporting errors lower than 10% for small (250 ml), medium (500 ml) and large (1000 ml) breasts. However, as a high-cost, non-routine assessment other methods may be more appropriate.

Cell-Assisted Lipotransfer Using Autologous Adipose-Derived Stromal Cells for Alleviation of Breast Cancer-Related Lymphedema

: Lymphedema is one of the most frequent side effects following cancer treatment, and treatment opportunities for it are currently lacking. Stem cell therapy has been proposed as a possible novel treatment modality. This study was the first case in which freshly isolated adipose-derived stromal cells were used to treat lymphedema. Treatment was given as a cell-assisted lipotransfer in which 4.07 × 10(7) cells were injected with 10 ml of lipoaspirate in the axillary region. Four months after treatment, the patient reported a great improvement in daily symptoms, reduction in need for compression therapy, and volume reduction of her affected arm. There were no adverse events. The outcome for this patient provides support for the potential use of cellular therapy for lymphedema treatment. We have begun a larger study to further test the feasibility and safety of this procedure (ClinicalTrials.gov Identifier NCT02592213).

SIGNIFICANCE

Lymphedema is a very debilitating side effect of cancer treatment and has very few treatment options. Stem cell therapy has the potential to change the treatment paradigm from a conservative to a more curative approach. Freshly isolated, autologous, adipose-derived stromal cells were combined with a fat-graft procedure to treat lymphedema. The treated patient had great improvement in daily symptoms, a reduced need for compression therapy, and a reduction in arm volume after 4 months. There were no adverse events. The use of cellular therapy for lymphedema treatment is supported by this patient's outcome. A phase II study has begun to further test its feasibility and safety.