Prevention and management of lymphedema after breast cancer treatment

Further Insight in Selecting the Ideal Vein for Lymphaticovenous Anastomosis: Utilizing the Venturi Effect

BACKGROUND

The functional and dilated lymphatic vessel and veins with minimal backflow and pressure are considered ideal for lymphaticovenous anastomosis (LVA). How to select the ideal vein remains to be determined. This study aimed to provide further insight into selecting the ideal vein.

METHODS

This is a retrospective study evaluating 166 limbs with lymphedema with a minimal follow-up period of 12 months. The surgical approach included side-to-end LVA, including 1 group with a non-Venturi LVA and another with a small branch draining into a major vein (Venturi LVA). Preoperative and 1, 3, 6, and 12 months postoperative limb volume, circumference, reduction volume, and ratio were evaluated.

RESULTS

The postoperative volume reduction was significant for both groups when compared with their respective preoperative volume. When compared between the 2 groups, the Venturi LVA had a significantly higher reduction volume and ratio at postoperative 1 month (240.82 ± 260.73 cm³ versus 364.27 ± 364.08 cm³, 6.13 ± 5.62% versus 8.77 ± 6.64%; P < 0.05) and 3 months (289.19 ± 291.42 cm³ versus 432.50 ± 395.04 cm³, 7.31 ± 6.39% versus 10.55 ± 6.88%; P < 0.05) However, the reduction volume and ratio was not significant by months 6 and 12.

CONCLUSIONS

This study provides further insight into selecting the ideal vein for LVA. By using a small vein draining into the main vein, valves play a role in reducing backflow. Furthermore, the Venturi effect allows significantly enhanced drainage, especially in the initial period after surgery. The effect slowly plateaus after few months, ultimately having a similar outcome of reduction at 12 months.

Myogenic microRNAs as Therapeutic Targets for Skeletal Muscle Mass Wasting in Breast Cancer Models

Breast cancer is the type of cancer with the highest prevalence in women worldwide. Skeletal muscle atrophy is an important prognostic factor in women diagnosed with breast cancer. This atrophy stems from disrupted skeletal muscle homeostasis, triggered by diminished anabolic signalling and heightened inflammatory conditions, culminating in an upregulation of skeletal muscle proteolysis gene expression. The importance of delving into research on modulators of skeletal muscle atrophy, such as microRNAs (miRNAs), which play a crucial role in regulating cellular signalling pathways involved in skeletal muscle protein synthesis and degradation, has been recognised. This holds true for conditions of homeostasis as well as pathologies like cancer. However, the determination of specific miRNAs that modulate skeletal muscle atrophy in breast cancer conditions has not yet been explored. In this narrative review, we aim to identify miRNAs that could directly or indirectly influence skeletal muscle atrophy in breast cancer models to gain an updated perspective on potential therapeutic targets that could be modulated through resistance exercise training, aiming to mitigate the loss of skeletal muscle mass in breast cancer patients.

The anti-proliferative effects of a frankincense extract in a window of opportunity phase ia clinical trial for patients with breast cancer

PURPOSE

Boswellic acids, active components of frankincense, suppress tumor proliferation in vitro with a strong clinical trial safety profile in patients with inflammatory diseases. We performed a Phase Ia window of opportunity trial of Boswellia serrata (B. serrata) in patients with breast cancer to evaluate its biologic activity and safety.

METHODS

Patients with invasive breast cancer were treated pre-operatively with B. Serrata (2400 mg/day PO) until the night before surgery for a median of 11 days (SD 6 days; range: 5-23 days). Paraffin-embedded sections from pretreatment diagnostic core biopsies and post-treatment surgical excisions were evaluated using a tunnel assay and immunohistochemistry staining with Ki-67 antibodies. A non-intervention retrospective control arm consisting of core and surgical tissue specimens from untreated patients was used to compare patients treated with B. Serrata. The change in proliferation and apoptosis between diagnostic core specimens and surgical specimens was compared between the control and treatment groups using a two-tailed paired t-test.

RESULTS

Twenty-two patients were enrolled, of which 20 received treatment, and 18 had sufficient tissue for IHC. There was an increase in percent change in proliferation from core biopsy to surgical excision in the control group (n = 18) of 54.6 ± 21.4%. In the B. serrata-treated group there was a reduction in proliferation between core biopsy and excision (n = 18) of 13.8 ± 11.7%. This difference was statistically significant between the control and B. serrata-treated groups (p = 0.008). There was no difference in change in apoptosis. There were no serious adverse events related to the drug.

CONCLUSION

Boswellia serrata inhibited breast cancer proliferation and was well-tolerated in a Phase Ia window of opportunity trial.

Effect of various photobiomodulation regimens on breast cancer-related lymphedema: A systematic review and meta-analysis

Breast cancer-related lymphedema (BCRL) is common among patients who have completed their cancer treatment. Although low-level laser therapy (LLLT) has been explored as a treatment option for BCRL, we could not find a regimen that is more effective than others. This meta-analysis aimed to organize existing research and determine the optimal combination of LLLT parameters for BCRL treatment. Studies were collected from four online databases: Embase, Ovid Medline, Cochrane, and Cinahl. The collected studies were reviewed by two of the authors. We focused on the aspects of the treatment area, treatment regimen, and total treatment sessions across the included studies. The comparisons between LLLT and non-LLLT were performed through a meta-analysis. Post-treatment QOL was significantly better in the axillary group. The group treated "three times/week with a laser density of 1.5-2 J/cm2" had significantly better outcomes in terms of swelling reduction, both immediately post-treatment and at 1-3 months follow-ups. The group with > 15 treatment sessions had significantly better post-treatment outcomes regarding reduced swelling and improved grip strength. According to these results, LLLT can relieve the symptoms of BCRL by reducing limb swelling and improving QOL. Further exploration found that a treatment approach targeting the axilla, combined with an increased treatment frequency, appropriate laser density, and extended treatment course, yielded better outcomes. However, further rigorous, large-scale studies, including long-term follow-up, are needed to substantiate this regimen.

Impact of Goreisan components on rat mesenteric collecting lymphatic vessel pumping

BACKGROUND

Goreisan is a traditional herbal formulation with diuretic properties tested as a clinical therapeutic to alleviate lymphedema in Japan. The present study aimed to determine how Goreisan and its five different components affect lymphatic pump function.

METHODS

Mesenteric collecting lymphatics were isolated from anesthetized Sprague-Dawley rats and mounted on resistance-matched glass micropipettes in a 37°C physiological salt solution bath for studies. Diameter was continuously measured to obtain the following lymphatic pump parameters: contraction frequency (CF), end diastolic diameter (EDD), and end systolic diameter (ESD), contraction amplitude (AMP), ejection fraction (EF), and fractional pump flow (FPF). Goreisan and each of its components (Cinnamomi Cortex, Atractylodis Rhizoma, Alismatis Rhizoma, Polyporus, and Poria) were applied to the bath at concentrations of 1-30 μg/mL.

RESULTS

The results show that while Goreisan causes no significant changes to lymphatic pumping, Alismatis Rhizoma and Polyporus each significantly reduce CF and FPF. In addition, rats that received oral administration of Goreisan and Alismatis Rhizoma for 1 week had elevated expression of VEGFR-3 in their mesenteric collecting lymphatics.

CONCLUSIONS

Collectively, the results suggest that some components of Goreisan have a direct, rapid impact on lymphatic pumping. These findings provide new insights but also raise new questions about the therapeutic potential of Goreisan in patients with secondary lymphedema.

Sentinel lymph node biopsy in women over 70: Evaluation of rates of axillary staging and impact on adjuvant therapy in elderly women

BACKGROUND

The 2016 Society of Surgical Oncology Choosing Wisely guidelines recommended against routine sentinel lymph node biopsy in women ≥70 years old with favorable, early-stage breast cancer, as sentinel lymph node biopsy does not decrease recurrence or mortality in these patients. This study's objective was to evaluate the use of sentinel lymph node biopsy and its effect on management in elderly patients.

METHODS

A retrospective analysis of female patients ≥70 years old with stage I-II, clinically node-negative, hormone-receptor positive, HER2-negative disease undergoing upfront breast cancer surgery between 2017 and 2019. Primary outcome was rate of sentinel lymph node biopsy. Secondary outcome was effect of sentinel lymph node biopsy on adjuvant therapy.

RESULTS

In total, 142 patients were included. Median age was 76 (interquartile range 73-81), and 71.8% underwent lumpectomy. On final pathology, 57.7% had invasive ductal carcinoma, and median tumor size was 15 mm (interquartile range 10-24.3). A total of 118 patients (83.1%) underwent sentinel lymph node biopsy; of these, 27 (22.9%) were positive for N1mi (7 patients) or N1a disease (20 patients). On multivariate regression analysis, patients undergoing sentinel lymph node biopsy were more likely to be younger (odds ratio 0.87, 95% confidence interval 0.78-0.95). The major risk factor for sentinel lymph node biopsy positivity was lymphovascular invasion (odds ratio 13.4, 95% confidence interval 4.57-40.1). Patients with sentinel lymph node biopsy positivity were more likely to receive local adjuvant radiation therapy (odds ratio 4.66, 95% confidence interval 1.49-16.8) and tended to receive more adjuvant regional radiation therapy (75.0% if sentinel lymph node biopsy positive compared with 15.3% if sentinel lymph node biopsy negative, P < .001).

CONCLUSION

Despite the 2016 Choosing Wisely guidelines, more than 80% of patients ≥70 years old underwent sentinel lymph node biopsy at our institution. If sentinel lymph node biopsy was positive, this is associated with over 4-fold higher rates of adjuvant radiation therapy.

Long-Term Effects of Breast Cancer Therapy and Care: Calm after the Storm?

Breast cancer is still a lethal disease and the leading cause of death in women, undermining patients' survival and quality of life. Modern techniques of surgery and radiotherapy allow for the obtaining of good results in terms of survival, however they cause long-term side effects that persist over time, such as lymphedema and neuropathy. Similarly, the advent of new therapies such as endocrine therapy revolutionized breast cancer outcomes, but side effects are still present even in years of follow-up after cure. Besides the side effects of medical and surgical therapy, breast cancer is a real disruption in patients' lives considering quality of life-related aspects such as the distortion of body image, the psychological consequences of the diagnosis, and the impact on family dynamics. Therefore, the doctor-patient relationship is central to providing the best support both during treatment and afterwards. The aim of this review is to summarize the consequences of medical and surgical treatment on breast cancer patients and to emphasize the importance of early prevention of side effects to improve patients' quality of life.

Bioelectrical impedance analysis for early screening of upper limb subclinical lymphedema: A case–control study

Breast cancer-related lymphedema is a treatment-related chronic disease that causes great distress and medical burden. Early screening and precautionary measures for lymphedema could improve well-being and decrease medical costs. Herein, we used bioelectrical impedance analysis for early screening of lymphedema. We set up a verifiable standardized subclinical standard to screen subclinical lymphedema in postoperative breast cancer patients using bioelectrical impedance. The first part determined the criteria of subclinical lymphedema. Among the 424 female participants, 127 were healthy women, whereas 297 were postoperative breast cancer survivors. Subclinical standard boundaries were determined by the 95% confidence interval of the healthy women. The screening rate of patients with subclinical lymphedema was inferred by comparing the subclinical standard boundaries and the postoperative patient values. A total of 14.81–20.87% of postoperative breast cancer survivors were identified as patients with subclinical lymphedema. The second part provided the results of the verification test of this subclinical standard. The data of the verification test from 30 healthy women and 30 screened patients met the subclinical standard, and 30 breast cancer survivors with lymphedema verified the utility and feasibility of the subclinical standard. Therefore, this standard could provide a screening tool for early the identification of subclinical breast cancer survivors. Early detection helps implement personal and precise medical precautions for patients with subclinical lymphedema.

Effectiveness of an expert assessment and individualised treatment compared with a minimal home-based exercise program in women with late-term shoulder impairments after primary breast cancer surgery: study protocol for a randomised controlled trial

Background

In breast cancer patients, late-term upper limb sequelae, such as shoulder pain and impaired shoulder function, remain common after primary breast cancer surgery. The aim of this trial is to evaluate whether an expert assessment of shoulder impairments, followed by an individualised treatment plan, is superior to a minimal physiotherapeutic rehabilitation program in reducing shoulder symptoms, among women with late-term shoulder impairments after primary breast cancer.

Methods/design

The study is designed as a stratified, parallel-group, assessor-blinded, randomised, controlled trial conducted in Denmark; 130 participants with late-term shoulder impairments 3–7 years after primary surgery for breast cancer will be recruited. Participants will be randomised (allocation 1:1) to either an expert assessment of shoulder impairments followed by an individualised treatment plan or to follow a minimal physiotherapeutic rehabilitation program delivered in a pamphlet. The primary outcome will be a change in shoulder pain and function from baseline to 12 weeks after initiating the treatment, as measured by the patient-reported outcome Shoulder Pain and Disability Index (SPADI) questionnaire.

Discussion

There has been an insufficient focus in research and clinical practice on late-term shoulder impairment in women following surgery for breast cancer. This trial will focus on interventions towards late-term shoulder impairments and is expected to provide evidence-based knowledge to physiotherapists and women about the management of shoulder pain and impaired shoulder function.

Trial registration

ClinicalTrials.gov NCT05277909. Registered on 11 March 2022.

ICG lymphographic findings following immediate lymphatic reconstruction in breast cancer patients

BACKGROUND

Immediate lymphatic reconstruction (ILR), performed at the time of axillary lymph node dissection (ALND), has demonstrated promising reductions in breast cancer-associated lymphedema. However, questions remain over the effects of adjuvant therapies on the continued patency of the lymphaticovenous anastomosis. Our study aimed to assess lymphographic outcomes, including ICG pattern and LVB patency, in patients at high risk for breast cancer-associated lymphedema following axillary ILR.

METHODS

Baseline ICG lymphography studies performed during ILR of 15 patients were compared to repeat ICG studies obtained during second-stage breast reconstructive procedures to assess for changes in lymphatic flow patterns through the at-risk arm and transit into the axilla.

RESULTS

All 15 patients in this study demonstrated linear lymphatic flow in baseline lymphography. Repeat lymphographic studies showed linear lymphatic transit in 12/15 patients. Of these 12 patients, 10 received chemotherapy, and all 12 received post-mastectomy radiation (PMRT). Dermal backflow patterns were recorded in 3/15 patients. All 3 patients received chemotherapy and 2/3 underwent PMRT. Additionally, repeat ICG studies of 7/12 lymphedema-free patients demonstrated clear visualization of linear ICG flow from the lymphatics of the arm into the axilla.

CONCLUSION

We have demonstrated that ICG lymphography can be implemented as a postoperative tool to assess lymphatic function in patients who have undergone ILR in the axilla. Repeat ICG studies in the majority of patients demonstrated linear ICG flow similar to baseline studies. Additionally, ICG flow patterns through the axilla in repeat lymphography provided visual evidence supporting sustained LVB patency, despite axillary irradiation.

Lymphatic Complications Prevention and Soft Tissue Reconstruction after Soft Tissue Sarcoma Resection in the Limbs

Background and Objectives: The definitive treatment of soft tissue sarcomas (STS) requires a radical surgical removal of the tumor, which often leads to large soft tissue defects. When they are located in the limbs, significant damage to the lymphatic pathways is not uncommon. In the present article, we present different techniques aimed at both reconstructing the defect and restoring sufficient lymph drainage, thus preventing short- and long-term lymphatic complications. Materials and Methods: Between 2018 and 2020, 10 patients presenting a soft tissue defect with lymphatic impairment received a locoregional reconstruction by means of either pedicled or free SCIP flap. Seven patients required a second flap to reach a good dead space obliteration. In six cases, we performed an interpositional flap, namely a soft tissue transfer with lymphatic tissue preservation, and in four cases a lymphatic flow-through flap. In all cases, the cause of the defect was STS surgical excision. The average age was 60.5 years old (ranging 39-84), seven patients were females and six were males. Results: All the patients were successfully treated. In two cases, minor post-operative complications were encountered (infected seroma), which were conservatively managed. No secondary procedures were required. The average follow-up was 8.9 months (ranging 7-12 months). No signs of lymphedema were reported during this time. In all cases, complete range of motion (ROM) and a good cosmetic result were achieved. Conclusions: A reconstructive procedure that aims not only to restore the missing volume, but also the lymphatic drainage might successfully reduce the rate of postoperative complications. Both lymphatic interpositional flaps and lymphatic flow-through flaps could be effective, and the right choice must be done according to each patient's needs.

Shoulder arthroplasty in patients with upper extremity lymphedema may result in transient or permanent lymphedema worsening

INTRODUCTION

Upper extremity lymphedema can complicate mastectomy, lymph node dissection, and radiation. The purpose of this study is to present the outcomes of shoulder arthroplasty in patients with lymphedema.

METHODS

The 19 shoulders with a shoulder arthroplasty and lymphedema on the surgical side (6 anatomic, 12 reverse, 1 hemiarthroplasty) were followed for four years (1-10 years). There were 2 males and 17 females; average age was 67.8 (48-86) years. Breast carcinoma was the most common reason for lymphedema (75%). A dedicated lymphedema questionnaire could be completed for 14 shoulders.

RESULTS

Pain improved from moderate or severe preoperatively to no or mild in 18 shoulders. Motion improved in elevation (55° preoperatively, 107° at last follow-up), external rotation (14°, 43°), and internal rotation (sacrum, L5). Complications included an acromion stress fracture with a deep infection (1), deep infection (1), superficial infection (1), and glenoid loosening (1). Lymphedema worsened in nine cases, but worsening was permanent in only four. Currently, lymphedema treatment is being performed by 93% of survey respondents. No patients reported lymphangitis or lymphangiosarcoma.

CONCLUSION

Shoulder arthroplasty for an upper extremity with lymphedema provides substantial improvements in pain and motion; however, infection is a concerning complication. Fifty percent of the patients will experience worsening of their lymphedema and in 20% worsening may be permanent.

The effect of limb position on the reliability of leg circumference measurements in patients diagnosed with lower limb lymphoedema

OBJECTIVE

To establish the intrarater reliability of lower limb circumference measures in a sample of individuals who are diagnosed with lower limb lymphoedema and to evaluate if change in limb position has an effect on the reliability of circumferential measures.

METHOD

A sample of forty-one adults diagnosed with a lower limb lymphoedema were recruited. Participants had their affected leg measured three times by a qualified therapist during a standard outpatient appointment: twice in a lying position and once in sitting with knee flexed at 90°. To examine the intrarater reliability, interclass correlation coefficients (ICC) with 95% confident intervals were calculated.

RESULTS

Excellent intrarater reliability was established at each measurement point and for the sum of circumferential measures when the limb remeasured in the same position by the same therapist. Changing the position of the limb resulted in lower intrarater reliability values at 10 and 30 cm from the base of the foot.

CONCLUSIONS

The current study provides evidence for the intrarater reliability of lower limb circumference measures and highlights the need for consistency when remeasuring and monitoring the limb of those diagnosed with lower limb lymphoedema.

IMPLICATIONS FOR CANCER SURVIVORS

Lymphoedema is a significant problem for breast cancer survivors but also provides lifetime risk to all survivors of lymph node surgery for solid tumours. The monitoring and surveillance of leg circumference measures of people diagnosed with lower limb lymphoedema has been a valuable instrument when reviewing progress of this chronic condition.

Managing Lymphedema in Fracture Care: Current Concepts and Treatment Principles

Lymphatic flow plays a notable role in the regulation of bone formation and remodeling. Chronic accumulation of the lymph fluid within tissues may lead to issues with proper bone healing after fractures, emphasizing the importance of proper management of lymphedema after trauma. Many associated risk factors place patients at risk for lymphedema, including previous surgery with nodal dissection, radiation therapy, infection, malignancy, family history of congenital lymphedema, and trauma. The benchmark imaging technique for the diagnosis of lymphedema is lymphoscintigraphy. Other modalities include duplex ultrasonography, CT, and MRI. First-line conservative treatment of lymphedema is compression. Complete decongestive therapy or complex physical therapy, also known as decongestive lymphatic therapy (DLT), has shown positive results in reducing lymphedema. Surgical interventions aim to either reconstruct and restore function of the lymphatic system or debulk and reduce tissues and fluids. Understanding the significance of lymphedema on bone healing and techniques available to recognize it are important factors in preventing delay in diagnosis and ensuring proper management of lymphedema after trauma.

The Development of a Mobile Health App for Breast Cancer Self-Management Support in Taiwan: Design Thinking Approach

Background

Evidence has shown that breast cancer self-management support from mobile health (mHealth) apps can improve the quality of life of survivors. Although many breast cancer self-management support apps exist, few papers have documented the procedure for the development of a user-friendly app from the patient’s perspective.

Objective

This study aimed to investigate the information needs of Taiwanese women with breast cancer to inform the development of a self-management support mHealth app.

Methods

A 5-step design thinking approach, comprising empathy, define, ideate, prototype, and test steps, was used in the focus groups and individual interviews conducted to collect information on the requirements and expectations of Taiwanese women with breast cancer with respect to the app. A thematic analysis was used to identify information needs.

Results

A total of 8 major themes including treatment, physical activity, diet, emotional support, health records, social resources, experience sharing, and expert consultation were identified. Minor themes included the desire to use the app under professional supervision and a trustworthy app manager to ensure the credibility of information.

Conclusions

The strengths of the design thinking approach were user-centered design and cultural sensitivity. The results retrieved from each step contributed to the development of the app and reduction of the gap between end users and developers. An mHealth app that addresses these 8 main themes can facilitate disease self-management for Taiwanese women with breast cancer.

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.

Lymphaticovenular anastomosis for breast cancer-related upper extremity lymphedema: a literature review

Breast cancer-related lymphedema is a long-term condition that affects almost half of breast cancer survivors. Clinical studies have looked at the benefits of lymphaticovenular anastomosis (LVA) for the treatment of upper extremities lymphedema after breast cancer, however, there is still controversy if it improves lymphedema. This study aimed to analyze the studies and outcomes related to LVA for breast cancer-related lymphedema. A PubMed/Medline search was performed using "lymphovenous bypass", "upper extremity lymphedema", "arm lymphedema after breast cancer treatment", and "lymphaticovenular anastomosis" as key words. Only English articles reporting outcomes after LVA were included. We found 22 articles that met the inclusion criteria. Positive outcomes were found in 21 studies with an objective volume reduction and subjective symptoms relief after LVA. This literature review concluded that LVA has demonstrated a significant decrease in upper extremity volumes and an improvement in subjectively reporting symptoms in breast cancer-related lymphedema patients.

Treatment for lymphedema following head and neck cancer therapy: A systematic review

OBJECTIVE

To perform the first systematic review evaluating all established treatment modalities of head and neck lymphedema resulting from head and neck cancer therapy. Since craniofacial lymphedema treatment represents unique challenges not addressed by extremity lymphedema therapies, a systematic review and evaluation of treatment modalities specific to this area is needed to guide clinical management and further research.

DATA SOURCES

Four electronic databases were searches from inception to September 2018. These included Scopus (Embase), PubMed (Medline), Clinicaltrials.gov, and Cochrane Databases.

REVIEW METHODS

A search string was developed, and all databases queried for keywords on three subjects: head and neck cancer, lymphedema, and therapy. Results were uploaded to an EndNote database where relevant items were identified by hand-searching all titles and abstracts. Subsequently results were combined, duplicates removed, and full papers screened according to eligibility criteria.

RESULTS

Of a total 492 search results, twenty-six items met eligibility criteria for this review. These included fourteen cohort studies, seven case reports, two randomized controlled trials, two systematic reviews, and one narrative review totaling 1018 study subjects. The manual lymph drainage group had the largest number of studies and participants, with fewer studies investigating selenium, liposuction, and lymphaticovenular anastomosis.

CONCLUSION

Evidence for the efficacy of all types of lymphedema therapy is limited by paucity of large randomized controlled trials. While manual lymph drainage is best studied, liposuction and surgical treatments have also been effective in a small number of patients.

Vascularized gastroepiploic lymph node transfer significantly improves breast cancer-related lymphedema

BACKGROUND

Vascularized lymph node transfer (VLNT) is a surgical treatment for lymphedema. Multiple methods have been described and each has significant disadvantages.

STUDY DESIGN

We performed VLNT in patients with upper extremity lymphedema resulting from breast cancer surgery. We used lymph nodes of the greater curvature of the stomach (VLNTg). We describe outcomes of the patients suffering from postmastectomy lymphedema who received VLNTg for treatment of lymphedema. Harvest from the periphery of the left gastroepiploic vessel was conducted.

RESULTS

We retrospectively reviewed data of 24 female patients suffering from lymphedema following breast cancer treatment who underwent lymph node transplantation from 2012 to 2017. Axillary lymphadenectomy had been performed in all cases. In 18 patients, upper limb lymphedema was present for at least 1 year (mean = 5.6 years; range, 1-15 years). In 6 patients, it was present for only a few months (mean = 5 months; range, 3-8 months).

CONCLUSIONS

The greater curvature of the stomach nodes (VLNTg) is an excellent option for the treatment of upper extremity lymphedema because there is no risk of complications and the scar is easily concealed. Improvement from lymphedema can be expected in a majority of patients.

Dorsal Wrist Placement for Vascularized Submental Lymph Node Transfer Significantly Improves Breast Cancer-Related Lymphedema

Background

Vascularized submental lymph node flap transfer to the wrist is an effective treatment for breast cancer-related lymphedema. Dorsal placement was hypothesized to offer superior outcomes due to favorable venous drainage; however, the flap is more visible in this position compared with the volar side and was a cosmetic concern for patients. This study compared the treatment response of breast cancer-related lymphedema with the placement of vascularized submental lymph node flaps at the wrist, between dorsal and volar recipient sites.

Methods

A retrospective longitudinal study examined 15 patients receiving vascularized submental lymph node flaps at the wrist performed by a single surgeon with a mean follow-up of 17 months. Clinical and biometric analyses, including quality of life questionnaires, circumference measurements, and number of infections were conducted.

Results

All patients showed improvements in quality of life, reduced episodes of cellulitis, and reduced limb circumference measurements compared with preoperative data. Dorsal placement (n = 7) delivered significant reductions in limb circumference at all levels after 1 year (P = 0.04) and in overall function domains in the Lymphedema Specific Quality of Life Questionnaires (P = 0.04) compared with volar placement (n = 8). Venous outflow was greater in the dorsal recipient veins (P < 0.0001).

Conclusions

Patients electing to undergo vascularized lymph node transfer to the wrist should be aware that when both options are effective, dorsal placement offers improvement in outcomes despite reduced cosmesis. These results have been incorporated into an evidence-based treatment algorithm that can inform the patient and physician on the decision-making in the breast and plastic surgical spheres.

Lymphoedema After Breast Cancer Treatment is Associated With Higher Body Mass Index: A Systematic Review and Meta-Analysis

Background:

Excess body weight has been identified as an important risk factor for lymphoedema following breast cancer treatment, however it remains unclear how much risk increases as weight increases. We conducted a meta-analysis to assess the relationship between body mass index (BMI) and risk of lymphoedema in breast cancer patients, and to estimate the level of risk by BMI category.

Methods:

We conducted a systematic search of all articles published through May 2018 in PubMed and the Cochrane library. Studies that included data on BMI and lymphoedema in breast cancer patients were included in the meta-analysis. We compared risk of lymphoedema in BMI groups as: BMI<25 versus BMI≥25, BMI<25 versus BMI≥30, BMI≥25 to <30 versus BMI≥30, BMI<30 versus BMI≥30, BMI<25 versus BMI≥25 to BMI<30.

Results:

After exclusion of ineligible studies, 57 studies were included in the meta-analysis. The mean difference in BMI between patients with lymphoedema compared to those without lymphoedema was 1.7 (95% CI, 1.3–2.2). Compared to patients with a BMI<25, risk of lymphoedema was higher in those with a BMI >25 to <30 (odds ratio [OR] 1.3; 95% CI, 1.2 to 1.5), a BMI≥25 (OR 1.7; 95% CI, 1.5 to 1.9), or a BMI≥30 (OR 1.9; 95% CI, 1.6 to 2.4). Compared to patients with a BMI of >25 to <30, risk of lymphoedema was higher in patients with a BMI>30 (OR 1.5; 95% CI,1.4 to 1.8).

Conclusion:

Excess body weight is a risk factor for lymphoedema following treatment of breast cancer, with the magnitude of risk increasing across higher categories of BMI.

Impact of an educational program on the quality of life of patients with lymphedema: A preliminary evaluation

OBJECTIVE

We report on the preliminary evaluation of a well-designed program, Living with Lymphedema. This longitudinal cohort study assessed patients' quality of life using questionnaires. Our main objective was to evaluate the satisfaction of the patients and their adherence to the program. This was done using a specific questionnaire of satisfaction as well as by noting patients' adherence to the program (number of patients attending all three consultations). The secondary objective was to assess the effect of the program on the patient's quality of life. The assessment criteria were the evolution of the Medical Outcomes Study 36-Item Short Form Health Survey and EuroQol questionnaire scores between the first (C1) and third (C3) consultations.

METHODS

The Living with Lymphedema program targeted all patients with lymphedema in the Grenoble (France) conurbation and within the GRANTED health care network that includes vascular medicine specialists, primary care physicians, physical therapists, and dietitians in the Alpine region of France. All studied patients were ambulatory patients. The GRANTED network took care only of the educational aspect of the disease. All patients with primary or secondary lymphedema were offered the Living with Lymphedema program, whatever their age and the location of the lymphedema (upper or lower limbs). The collection of patient data conformed to the ethical and administrative regulations of the regional health authority. Grenoble Institutional Review Board (CPP Sud-Est V; No. 5891) approval for the study was specifically obtained for this evaluation on December 24, 2012. The program was built around one-to-one consultations, group workshops, and more specialized appointments. It was complementary to the routine medical care received by the patient (not evaluated in this study). It proposed three individual "educational" consultations, seven group workshops, and two specialized consultations with a dietitian. All the consultations or workshops were led by certified professionals trained in therapeutic education.

RESULTS

The cohort was the 34 patients included in the program. We found a significant improvement in the physical dimension of the Medical Outcomes Study 36-Item Short Form Health Survey score (P = .01) between C1 and C3 but not for the psychic dimension. Visual analog scale scores of the ability to cope with the lymphedema showed a statistically significant improvement between C1 and C3 (P = .05). No difference was observed in adherence to compression therapy.

CONCLUSIONS

This therapeutic educational program showed a significant improvement in several criteria of quality of life and in the autonomy of patients with lymphedema.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Peculiarities of the obese patient with cancer: a national consensus statement by the Spanish Society for the Study of Obesity and the Spanish Society of Medical Oncology

The relationship between obesity and cancer is clear and is present at all times during course of the disease. The importance of obesity in increasing the risk of developing cancer is well known, and some of the most prevalent tumours (breast, colorectal, and prostate) are directly related to this risk increase. However, there is less information available on the role that obesity plays when the patient has already been diagnosed with cancer. Certain data demonstrate that in some types of cancer, obese patients tolerate the treatments more poorly. Obesity is also known to have an impact on the prognosis, favouring lower survival rates or the appearance of secondary tumours. In this consensus statement, we will analyse the scientific evidence on the role that obesity plays in patients already diagnosed with cancer, and the available data on how obesity control can improve the quality of daily life for the cancer patient.

Multidisciplinary management of breast cancer

Breast cancer, with an increasing incidence, is the most frequently diagnosed cancer in women worldwide. The treatments proposed, generally a combination of surgery, radiotherapy, chemotherapy, endocrine therapy and/or targeted therapy, are constantly improving, allowing a reduction in the mortality rate, but they are still causing many side effects, not only early but also late, which leads us to consider the post-cancer period as a chronic condition. Side effects, reviewed in this commentary, may affect physical functions, psychological status, social situation, body composition, well-being and quality of life of the patient. In view of the extent of these areas in which side effects of breast cancer and of its treatments can be found, the supportive care offered at the end of treatment need to be multidisciplinary. Different supportive care interventions may be proposed to the patients such as psychological and behavioral interventions, complementary therapies, diet interventions, physical activity/rehabilitation or also physiotherapy interventions for example, all having shown some beneficial effects in the literature. The benefits of these supportive care interventions are thereby already established and they are described in this article, but others studies will be needed to clearly define indications and most optimal modalities of application to reduce side effects and improve quality of life of patients.

Race or Resource? BMI, Race, and Other Social Factors as Risk Factors for Interlimb Differences among Overweight Breast Cancer Survivors with Lymphedema

Introduction. High BMI is a risk factor for upper body breast cancer-related lymphedema (BCRL) onset. Black cancer survivors are more likely to have high BMI than White cancer survivors. While observational analyses suggest up to 2.2 times increased risk of BCRL onset for Black breast cancer survivors, no studies have explored race or other social factors that may affect BCRL severity, operationalized by interlimb volume difference (ILD). Materials and Methods. ILD was measured by perometry for 296 overweight (25 > BMI < 50) Black (n = 102) or White (n = 194) breast cancer survivors (>6 months from treatment) in the WISER Survivor trial. Multivariable linear regression examined associations between social and physical factors and ILD. Results. Neither Black race (-0.26, p = 0.89) nor BMI (0.22, p = 0.10) was associated with ILD. Attending college (-4.89, p = 0.03) was the strongest factor associated with ILD, followed by having more lymph nodes removed (4.75, p = 0.01), >25% BCRL care adherence (4.10, p = 0.01), and years since treatment (0.55, p < 0.001). Discussion. Neither race nor BMI was associated with ILD among overweight cancer survivors. Education, a proxy for resource level, was the strongest factor associated with greater ILD. Tailoring physical activity and weight loss interventions designed to address BCRL severity by resource rather than race should be considered.