A new soft tissue volume measurement strategy using ultrasonography

Optimal Cut-Off Value for Detecting Breast Cancer-Related Lymphedema Using Ultrasonography

Background: We previously devised an ultrasonographic evaluation to calculate subcutaneous tissue cross-sectional area (△CSA). The reliability and accuracy of this method were demonstrated in healthy individuals and in patients with lymphedema. The purpose of this study was to estimate the optimal cut-off value of the ratio of the △CSA of the involved side (lesion side) to the contralateral side for detecting breast cancer-related lymphedema (BCRL) using ultrasonography. Methods and Results: Ultrasonographic measurements were performed 290 times in 150 patients. BCRLD was defined as a confirmed difference of >2 cm in arm circumference. BCRL confirmed by a clinician (BCRLC) was defined as the patient group that included not only BCRLD but also patients with subcutaneous thickening and abnormal findings on lymphoscintigraphy, even if the difference in arm circumference was <2 cm. The △CSAs of both upper arms and forearms were calculated by measuring the thickness of the subcutaneous tissue at four locations using ultrasonography (superior, medial, inferior, lateral) at 10 cm above the elbow and 10 cm below the elbow. With a 1.35 △CSA ratio as the cut-off value for detecting BCRLD, the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were 0.88, 0.87, and 0.95, respectively. With a 1.20 △CSA ratio as the cut-off value for detecting BCRLC, the sensitivity, specificity, and AUC were 0.92, 0.89, and 0.97, respectively. Conclusions: Our findings suggest that a 1.20 △CSA ratio as determined using ultrasonography, corresponding to a tape measurement of 1.05 cm, can be considered as a diagnostic criterion for lymphedema.

The Clinical Usefulness of Ultrasonographic Measurement Technique in Patients with Lower Extremity Lymphedema

Background: A previous study reported a new ultrasonography (US) measurement technique to evaluate the cross-sectional area (ΔCSA) of lymphedema in the upper extremity. This ΔCSA correlated well with parameters, such as the circumference, volumetry, and bioimpedance analysis (BIA) in healthy people and upper extremity lymphedema patients. This study examined whether a US measurement technique is clinically useful in patients with lymphedema in the lower extremity. Methods and Results: Forty patients diagnosed with unilateral lower extremity lymphedema were enrolled in this study. The subjects' leg circumference, BIA, isokinetic strength, and ΔCSA were examined on the same day. The leg circumference was measured at 15 cm above the knee (AK) and below the knee (BK) crease using a tape measure. BIA was performed by a trained physical therapist, and the data of impedance (Z) at 1 and 5 kHz of each side of the lower limbs and extracellular water (ECW) were used. A fully experienced physician measured soft tissue thickness, the distance between the skin and the fascia of the muscle, three times each at the anterior, medial, posterior, and lateral aspects of the bilateral legs by US at 15 cm AK and BK. The amount of soft tissue in the ΔCSA was calculated using the designed formula from the mean values of the thicknesses. Each parameter was calculated as the ratio of the sound side to the lesion side. The Pearson and Spearman correlation coefficients were used to assess the significance of these parameters. The ratio of ΔCSA measured at 15 cm AK and BK showed strong positive correlations with the circumference difference at the same level (rho = 0.790, p = 0.000, and rho = 0.882, p = 0.000, respectively). In addition, it showed moderate or strong correlations with the ratio of Z at 5 and 1 kHz in the BIA of the lower limbs (AK15, r = -0.511, p = 0.001 and r = -0.497, p = 0.001; BK15, r = -0.780, p = 0.000 and r = -0.756, p = 0.000, respectively). Although ECW and body mass index showed weak positive correlations with the ratio of ΔCSA measured at 15 cm BK, there was no significant correlation between the ratio of ΔCSA and the isokinetic muscle strength. Conclusion: The ΔCSA results showed moderate-to-strong correlations with other conveniently used methods except for the isokinetic muscle strength. As the US ΔCSA technique could measure lymphedema status with a structural consideration, it could also be recommended as a conventional measurement method in patients with upper and lower extremity lymphedema.

Quality of life improvement in breast cancer survivors affected by upper limb lymphedema through a novel multiperspective physical activity methodology: a monocentric pilot study

PURPOSE

Chronic lymphedema causes psychophysical sequelae jeopardizing quality of life (QoL) of breast cancer (BC) survivors, and lack of effective therapies represents a major challenge for healthcare professionals. Structured adapted physical activity (APA) may represent an effective strategy to attenuate cancer treatment-related impairments and improve QoL. Here, we describe the effects of a specific APA intervention based on a novel multiperspective methodology in counteracting lymphedema-related morphofunctional alterations and improving QoL of BC survivors.

METHODS

BC survivors with chronic moderate/severe lymphedema attending the Cancer Rehabilitation Center in Florence were assessed before and after 8-week APA. The protocol consisted of both APA specialist-supervised and self-leaded sessions using a tailor-designed proprioceptive board. Body mass index, bioimpedance parameters, indirect upper limb volume measurement, and ultrasonography were performed. Wrist flexion/extension and hand strength functional tests were also executed. QoL, depression/anxiety and pain intensity were evaluated by ULL27, HADS, distress thermometer and NRS questionnaires, respectively.

RESULTS

Although bioimpedance, ultrasound and volumetric measures remained mostly unchanged, wrist mobility, pain perception, depression, and QoL were all significantly ameliorated after APA.

CONCLUSIONS

Our findings suggest that a multidisciplinary treatment approach involving APA professionals should be employed in the management of BC-related lymphedema to improve patient psychophysical outcomes and QoL.

The efficacy of different bandaging methods in patients with breast cancer-related lymphedema: A prospective, randomized study

Objectives

The aim of this study was to evaluate the comparative efficacy of 3MTM CobanTM 2 layer system and conventional multi-layer short-stretch bandaging in terms of volume reduction, ultrasonographic measurements, functional status, and quality of life (QoL) in the treatment of patients with breast cancer-related lymphedema (BCRL).

Patients and methods

This prospective, single-blind, randomized study included a total of 60 BCRL patients (60 females; mean age 54.9±9.6 years; range, 30 to 73 years). The patients were randomly allocated to Group 1 (n=30) and Group 2 (n=30). Both groups received complex decongestive therapy (CDT) including skin care, lymphedema exercises, and manual lymphatic drainage (MLD) combined with traditional multi-layer short-stretch bandaging five times per week for three weeks in Group 1 and with 3MTM CobanTM 2 layer system bandaging two times per week for three weeks in Group 2. Differences in volumes, excess volumes, ultrasonographic measurements, QoL, and functional assessment scores were evaluated at baseline, after three weeks of intensive treatment period, and at two months of follow-up. Functional status was evaluated by the Quick Disability of Arm Shoulder and Hand Questionnaire (Q-DASH), while the QoL was assessed using the Turkish version of Lymphedema Quality of Life Questionnaire-Arm (LYMQOL-Arm). The duration and easiness of applying bandages by physiotherapists and comfortableness of bandages according to patients and physiotherapists were also evaluated using a questionnaire.

Results

The demographic and clinical properties were similar between the groups. There were significant improvements in the volumes, excess volumes, ultrasonographic measures, functional scores, and QoL scores in both groups at the end of treatment. The improvements were sustained at two months of follow-up.

Conclusion

The 3MTM CobanTM 2 layer bandaging as a part of CDT twice a week for a period of three weeks can significantly reduce the volume and improve the disability and impaired QoL, similar to conventional short-stretch multi-layer bandages. In addition, treatment with this layer system enables a time-efficient, easy, and comfortable application of bandaging with increased mobility of the upper extremity.

The Clinical Usefulness of Lymphedema Measurement Technique Using Ultrasound

Background: We previously invented a new technique to measure the cross-sectional area of soft tissue of a limb (ΔCSA) with lymphedema using ultrasonography. The measurement correlated strongly with both circumference and volumetry in normal subjects. The purpose of this study was to measure the reliability and accuracy of the method in patients with lymphedema. Methods and Results: Ultrasonography was performed on both arms of 69 female patients diagnosed with stage ≥1 lymphedema related to advanced breast cancer. At 10 cm above elbow (AE) and below elbow (BE), soft-tissue thicknesses at various locations were measured by two examiners. Subcutaneous tissue stiffness was also obtained by measuring thickness differences of soft tissue when applying minimal and maximal pressure to the skin (compliance) and its ratio to the initial thickness (compliance ratio). ΔCSA showed a strong positive correlation with circumference (r = 0.758 to 0.951), and a moderate negative correlation with Z at 5 Hz (r = -0.326 to -0.486). Intra- and interclass coefficients of all ultrasonography measurements were moderate to excellent (0.623-0.990). Compliance measured at 10 cm BE on the lesion side was significantly higher than on the normal side (p < 0.001), and compliance measured at 10 cm AE showed no difference between the two sides (p = 0.653). Conversely, compliance ratios measured at 10 cm AE and BE on the lesion side were significantly lower than on the normal side (p < 0.001). Conclusion: Thus, ΔCSA using ultrasonography could be a particularly viable option for determining status in lymphedema patients.

Comparisons of Manual Tape Measurement and Morphomics Measurement of Patients with Upper Extremity Lymphedema

Lymphedema is a debilitating condition characterized by swelling from lymph fluid exceeding transport capacity. A gold standard for arm measurement is not established, and measurement methods vary. This study evaluates the comparability of the tape measure and Analytic Morphomics in deriving limb circumference measurements in patients with upper extremity lymphedema.

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.

Computed tomography-based quantitative assessment of lower extremity lymphedema following treatment for gynecologic cancer

Objective

To develop an algorithmic quantitative skin and subcutaneous tissue volume measurement protocol for lower extremity lymphedema (LEL) patients using computed tomography (CT), to verify the usefulness of the measurement techniques in LEL patients, and to observe the structural characteristics of subcutaneous tissue according to the progression of LEL in gynecologic cancer.

Methods

A program for algorithmic quantitative analysis of lower extremity CT scans has been developed to measure the skin and subcutaneous volume, muscle compartment volume, and the extent of the peculiar trabecular area with a honeycombed pattern. The CT venographies of 50 lower extremities from 25 subjects were reviewed in two groups (acute and chronic lymphedema).

Results

A significant increase in the total volume, subcutaneous volume, and extent of peculiar trabecular area with a honeycombed pattern except quantitative muscle volume was identified in the more-affected limb. The correlation of CT-based total volume and subcutaneous volume measurements with volumetry measurement was strong (correlation coefficient: 0.747 and 0.749, respectively). The larger extent of peculiar trabecular area with a honeycombed pattern in the subcutaneous tissue was identified in the more-affected limb of chronic lymphedema group.

Conclusion

CT-based quantitative assessments could provide objective volume measurements and information about the structural characteristics of subcutaneous tissue in women with LEL following treatment for gynecologic cancer.

High-resolution 3D volumetry versus conventional measuring techniques for the assessment of experimental lymphedema in the mouse hindlimb

Secondary lymphedema is a common complication of cancer treatment characterized by chronic limb swelling with interstitial inflammation. The rodent hindlimb is a widely used model for the evaluation of novel lymphedema treatments. However, the assessment of limb volume in small animals is challenging. Recently, high-resolution three-dimensional (3D) imaging modalities have been introduced for rodent limb volumetry. In the present study we evaluated the validity of microcomputed tomography (μCT), magnetic resonance imaging (MRI) and ultrasound in comparison to conventional measuring techniques. For this purpose, acute lymphedema was induced in the mouse hindlimb by a modified popliteal lymphadenectomy. The 4-week course of this type of lymphedema was first assessed in 6 animals. In additional 12 animals, limb volumes were analyzed by μCT, 9.4 T MRI and 30 MHz ultrasound as well as by planimetry, circumferential length and paw thickness measurements. Interobserver correlation was high for all modalities, in particular for μCT analysis (r = 0.975, p < 0.001). Importantly, caliper-measured paw thickness correlated well with μCT (r = 0.861), MRI (r = 0.821) and ultrasound (r = 0.800). Because the assessment of paw thickness represents a time- and cost-effective approach, it may be ideally suited for the quantification of rodent hindlimb lymphedema.

The effect of mechanical massage on early outcome after total knee arthroplasty: a pilot study

[Purpose] The aim of this study was to evaluate the efficacy of mechanical massage via Endermologie^® after total knee arthroplasty in reducing edema and pain and improving knee range of motion, in the early postoperative period. [Subjects and Methods] Eighteen patients with knee edema following total knee arthroplasty were randomly assigned to the intervention group (n=8) or the control group (n=10). The intervention group received mechanical massage therapy using Endermologie^® and the control group received conventional physical therapy for 20 minutes a day, 5 times a week from the seventh day postsurgery. Clinical assessments included active knee flexion and extension range of motion, knee pain using a numeric rating scale, the operated limb circumference, the soft tissue cross-sectional area using ultrasonography, the extracelluar fluid volume, and single frequency bioimpedance analysis at 5 kHz using bioelectrical impedance spectroscopy. [Results] Both groups showed significant reduction in edema and pain, and improvement in active knee flexion at the end of treatment. There were no significant inter-group differences before or after treatment. [Conclusion] Mechanical massage could be an alternative way of managing knee edema after total knee arthroplasty in early postoperative recovery.