Lymphedema: classification, diagnosis and therapy

Lymphaticovenous and Lymph Node-to-Vein Anastomosis to Improve Milroy Disease-Related Chylothorax and Lymphedema

BACKGROUND

Primary lymphedema is characterized by lymphatic dysplasia in which one variant is Milroy disease. The association with congenital chylothorax is even rarer, with poor outcome. This is the first report to use peripheral lymphovenous anastomosis (LVA) and lymph node-to-vein anastomosis (LNVA) for the management of such condition.

METHODS

A retrospective chart review of patients with Milroy disease with complication of chylothorax between 2019 until 2023 was performed. Clinical assessment and radiologic investigations were reviewed.

RESULTS

Six patients with a mean age of 12 ± 3.9 years and disease duration of 10.5 ± 2.8 years were reviewed. Three had International Society of Lymphology stage 3 disease, and the others had stage 2 (late) disease. All had bilateral lower extremity lymphedema and chylothorax with history of chest tube drainage. After LVA and LNVA, significant reduction in extremity volume ( P = 0.028) along with nearly complete resolution of chylothorax were noted during the long-term follow-up (32 ± 17.9 months).

CONCLUSIONS

Milroy disease complicated with chylothorax remains challenging. This is the first report using peripheral bypass (LVA and LNVA), which resulted in improvement of both lower extremity lymphedema and chylothorax. The utility of this approach represents a promising modality in the management of this devastating condition.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A New Secondary Chronic Lymphedema Rat Model Improved by High-Fat Diet

Purpose: Secondary chronic lymphedema is a complication that seriously affects the quality of life of cancers survivors which is urgent to be studied. However, the current animal models generally have some defects such as short duration that affect the research process. To acquire an animal model which is easier to accomplish as well as higher success rate is the main goal of our experiment. Methods: The hind limb model of rats with secondary chronic lymphedema was established by near infrared fluorescence-guided lymphatic system destruction combined with high-fat diet innovation. The model was evaluated by limb circumference, volume, near-infrared fluorescence imaging of lymphatic vessels, and a series of histopathological staining. Results: The model was successfully established by operation combined with a high-fat diet and kept persistent effective lasting up to 16 weeks. Compared with the normal diet group, the high-fat group received a higher success rate (77.77% vs. 55.55%), a more obvious degree of limb swelling, and a more significant level of subcutaneous inflammatory factor infiltration at the edema site. Based on it, we kept research and found out that there was no significant difference in the process of subcutaneous fibrosis between the two groups. Conclusions: High-fat diet may improve secondary chronic lymphedema rat model success rate as well as effectiveness by changing the level of inflammatory infiltration in the site of lymphedema.

Brazilian Consensus Statement on Lipedema using the Delphi methodology

Lipedema, historically underrecognized, has recently gained attention due to advancements in research and growing public awareness. The Brazilian Consensus Statement on Lipedema, developed by the Brazilian Society of Angiology and Vascular Surgery, aims to establish clear recommendations for the diagnosis, treatment, and management of lipedema. Using the Delphi methodology, experts elaborated 90 statements about lipedema, which were then evaluated by a panel of 113 professionals. The statements were analyzed using SurveyMonkey, with a 75% agreement threshold required for their inclusion in the consensus statement. Most statements achieved significant consensus, with only 9 topics requiring further investigation. This consensus statement highlights the complexity of lipedema, the effectiveness of conservative treatment over surgery, the need for multidisciplinary approaches, and the importance of awareness to reduce underdiagnosis and stigma. It also underscores the ongoing need for research to develop more effective management strategies.

RELEVANT-C study: patient-reported prevalence of lower extremity lymphedema after sentinel lymph node mapping vs lymphadenectomy after surgery for early-stage cervical cancer

OBJECTIVE

To compare the prevalence of patient-reported lower extremity lymphedema and evaluate patient-reported quality of life after sentinel lymph node mapping vs comprehensive lymphadenectomy with or without sentinel lymph node mapping for the surgical management of early-stage cervical cancer.

METHODS

In July 2022, we mailed a survey that included a validated 13-item lower extremity lymphedema screening questionnaire to patients who underwent lymph node evaluation at the time of primary surgery for the 2018 International Federation of Gynecology and Obstetrics stage IA1 to IIB cervical cancer between January 1, 2006, and January 31, 2019. We excluded patients diagnosed with lower extremity lymphedema prior to surgery and those who answered ≤6 survey items, and we carried out 2 group comparisons: sentinel lymph node mapping vs lymphadenectomy with or without sentinel lymph node mapping, and patients with lower extremity lymphedema vs patients without.

RESULTS

Of 459 potential participants, 90 (20%) responded to the survey, all of which were evaluable (37 sentinel lymph nodes; 53 lymphadenectomies ± sentinel lymph nodes). Self-reported lower extremity lymphedema prevalence was 10.8% (4/37) in the sentinel lymph node mapping group and 43.4% (23/53) in the lymphadenectomy with or without sentinel lymph node mapping group (OR 6.32, 95% CI 2.14 to 23.5, p = .002). Histologic subtype and number of lymph nodes removed were associated with increased prevalence of lower extremity lymphedema. After adjusting for the histology subtype, lymphadenectomy retained independent association with an increased prevalence of lower extremity lymphedema over sentinel lymph node mapping (OR 4.96, 95% CI 1.61 to 18.8, p = .009). Patients with self-reported lower extremity lymphedema had significantly worse quality of life compared to those without self-reported lower extremity lymphedema.

CONCLUSIONS

We found sentinel lymph node mapping to be independently associated with a significantly decreased prevalence of patient-reported lower extremity lymphedema and with improved quality of life in patients undergoing surgical management of early-stage cervical cancer.

Multi-Stage Surgical Debulking for Advanced Lower Limb Lymphedema: Achieving Cosmetic and Functional Success

Lymphedema, characterized by impaired lymphatic drainage, presents in primary and secondary forms, causing limb enlargement and other complications. Management involves a multidisciplinary approach, with manual lymphatic drainage and surgery as key interventions. Treatment aims to improve quality of life, with surgical debulking showing positive outcomes, as demonstrated in a case of severe lower limb lymphedema. A 40-year-old male with severe congenital lymphedema praecox presented with left lower extremity swelling and cellulitis. Despite previous unsuccessful surgery, subsequent debulking surgeries over nine months improved function and appearance. Biopsies confirmed lymphedema praecox diagnosis. Lymphedema poses significant challenges, often requiring surgical intervention such as the Charles procedure, which involves surgically removing skin and soft tissue layers down to the deep fascia in the affected limb, with the excised skin repurposed as a graft for coverage, in severe cases. However, milder cases may go unnoticed, leading to delayed treatment. Our patient experienced advanced lymphedema, necessitating a staged surgical approach to minimize risks and enhance outcomes. This strategy successfully managed blood loss and improved cosmetic results, ultimately improving the patient's quality of life. Lymphedema poses complex challenges, with tailored treatments such as staged procedures essential for optimal outcomes. Our case emphasizes the need for careful consideration and patient counseling, highlighting the value of strategic management approaches. By minimizing risks and optimizing outcomes, we aim to enhance the quality of life for individuals with lymphedema, underscoring our commitment to ongoing improvement in patient care.

Comparison of leg volume ratio between inguinal lymphadenectomy and inguino-pelvic lymphadenectomy in patients with skin cancer of the lower extremity

BACKGROUND

The timing of intervention to treat lymphedema differs among facilities. Understanding differences in the prevalence and severity of lymphedema following different surgical procedures for lymphadenectomy could promote early intervention to treat lymphedema. There is currently little evidence to support the notion that inguino-pelvic lymphadenectomy is associated with greater morbidity than inguinal lymphadenectomy, although it is believed that the difference in the extent of surgery results in a difference in the severity of lymphedema. In this study, we compared volume percentage change between inguinal lymphadenectomy and inguino-pelvic lymphadenectomy in patients with skin cancer of the lower extremity.

PATIENTS AND METHODS

A total of 29 patients with skin cancer of a lower extremity who underwent lymphadenectomy were classified into an inguinal lymphadenectomy group and an inguino-pelvic lymphadenectomy group. The increase in the volume of the affected side compared with that of the unaffected side in the whole lower extremity, thigh, and lower leg was calculated on volume-rendered computed tomography images.

RESULTS

The mean volume percentage increase in the inguinal lymphadenectomy group and the inguino-pelvic lymphadenectomy group was, respectively, 6.72% and 11.18% in the whole lower extremity and 7.30% and 2.55% in the lower leg, showing no statistically significant differences. In contrast, the mean volume percentage increase in the respective groups was 7.03% and 19.78% in the thigh, showing a statistically significant difference (p = 0.0275 < 0.05).

CONCLUSIONS

The findings of this study indicate that the leg volume of the whole lower extremity may not have worse outcomes in inguino-pelvic lymphadenectomy compared with inguinal lymphadenectomy.

Musculoskeletal involvement in neglected tropical diseases: a comprehensive review

Neglected tropical diseases (NTDs) encompass a group of diseases predominantly found in tropical regions, with origins dating back to their inclusion in the United Nations Millennium Development Goals in 2000. This initiative aimed to raise awareness and global funding to combat these diseases, which thrive in areas with limited sanitation, healthcare, and education. NTDs are caused by various pathogens such as bacteria, fungi, parasites, and viruses and affect over two billion individuals in resource-poor communities, leading to preventable deaths and devastating consequences. While the musculoskeletal system is only occasionally affected, the resulting chronic disabilities prevent individuals from working, posing a significant socioeconomic burden in this region of the world. Some NTDs exhibit distinct imaging features, and radiologists need to be aware of these characteristics to facilitate early treatment. In this review, we delve into musculoskeletal NTDs, focusing on clinical features and imaging findings, differential diagnosis, and clinical management.

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.

Effects of Lymphaticovenous Anastomosis on Quality of Life, Body Image, and Spiritual Health in Lymphedema Patients: A Prospective Cohort Study

BACKGROUND

Lymphedema is a debilitating condition that significantly affects quality of life due to its chronic nature and visible symptoms. Lymphaticovenous anastomosis (LVA) has emerged as a promising surgical intervention, yet its effects on body image and spiritual health alongside physical symptoms have not been thoroughly examined. This study evaluates the efficacy of LVA in improving symptoms, quality of life (QOL), body image, and spiritual well-being in lymphedema patients.

METHODS

A prospective cohort study was conducted at Kaohsiung Chang Gung Memorial Hospital, Taiwan, involving 44 patients with lymphedema undergoing LVA surgery. Evaluations were made pre-surgery, one month post-surgery, and six months post-surgery using the 36-Item Short Form Health Survey (SF-36), Multidimensional Body-Self Relations Questionnaire-Appearance Scales (MBSRQ-AS), and a spiritual health scale. Statistical analysis was performed using one-way repeated measures ANOVA.

RESULTS

Significant improvements were observed in lymphedema symptoms and QOL measures at six months post-operation. SF-36 results showed enhanced scores in nearly all domains, particularly in physical functioning and role-physical. The appearance orientation scores from the MBSRQ-AS significantly increased, indicating improved perceptions in some dimensions of body image.

CONCLUSIONS

LVA surgery significantly enhances physical and psychological outcomes in patients with lymphedema, with marked improvements in symptoms, QOL, and body image perceptions. The findings suggest that while LVA is effective in addressing the physical and psychological aspects of lymphedema, it does not impact spiritual dimensions. This underscores the need for holistic approaches in the management of lymphedema to address all facets of patient well-being.

Primary lymphedema of childhood: Treatment results from a tertiary center

BACKGROUND

Primary lymphedema is the most common form of lymphedema presenting in the pediatric age group. Childhood lymphedema is caused by hereditary or congenital malformations in the lymphatic system that can manifest at birth or during childhood or adolescence.

OBJECTIVES

Complex decongestive therapy (CDT) is the cornerstone of conservative management of lymphedema in both adult and pediatric lymphedema patients, although pediatric treatment guidelines are still lacking. In this study we aimed to assess the effects of CDT on pediatric patients.

METHODS

Childhood lymphedema patients who presented to the lymphedema rehabilitation unit of our university hospital before the age of 18 and who were treated for lymphedema with CDT were included in the study. Data on patient demographics, disease characteristics, and treatment duration were recorded. Limb volumes were calculated from patient measurements using a spreadsheet software (Limb Volume Calculator) that utilized the geometric formula for volume of a truncated cone. Measurements were taken before treatment and also weekly after initiation of treatment. Percent excess volume (PEV) was used instead of absolute volume difference to define the severity of lymphedema.

RESULTS

A total of 34 limbs from 24 patients were included in the study. The mean age of the patients was 10.1 ± 4.9 years and 14 (58.3 %) were female. Most patients had one affected limb but 16 had bilateral lower-extremity lymphedema. The mean duration of treatment with CDT was 153.6 ± 155.8 days. Excess volume percentage change between pre-treatment PEV (602.8 ± 713.8) and post-treatment PEV (514.6 ± 699.1) was found to be statistically significant (p < 0.05).

CONCLUSION

Pediatric lymphedema management is a difficult and less well studied area in lymphedema rehabilitation. Our data support the use of CDT, which is a safe and effective treatment method, for pediatric lymphedema patients.

Venous thromboembolic outcomes in patients with lymphedema and lipedema: An analysis from the National Inpatient Sample

BACKGROUND

Patients with lymphedema and lipedema share physical exam findings that may lead to misdiagnosis. Poor mobility is common in patients with obesity and patients with lymphedema and lipedema. This may constitute a risk factor for venous thromboembolism (VTE). Our objective was to evaluate the association of VTE in obese patients with lymphedema and lipedema.

METHODS

The National Inpatient Sample (NIS) was searched from 2016 to 2020 to identify hospital admissions of obese female patients with lymphedema and lipedema. Patients were analyzed in the context of presence or absence of VTE while adjusting for complex cluster sampling techniques. Predictors of VTE were accessed by multivariable regression.

RESULTS

Lymphedema was identified in 189,985 patients and lipedema in 50,645 patients. VTE was observed in 3.12% (n = 374,210) of patients with obesity. In patients with obesity, VTE was more common in patients with lymphedema than without (2.6% vs 1.6%; p < 0.01). Similarly, VTE was more common in patients with lipedema than without (0.6% vs 0.4%; p < 0.01). After multivariable logistic regression, VTE events in obese patients with lymphedema were higher versus without (OR 1.6; CI 1.08-2.43; p = 0.02). Similarly, VTE events were more common in obese patients with lipedema versus obese patients without lipedema (OR 1.20; CI 1.03-1.41; p = 0.02).

CONCLUSIONS

In this hypothesis-generating study, lymphedema and lipedema show a positive association with VTE after adjusting for baseline patient characteristics such as obesity, which is a known independent risk factor for VTE. Mechanisms whereby lymphedema and lipedema are associated with VTE should be investigated.

Treatment of Rat Lymphedema by Propeller Lymphatic Tissue Flap Combined with Nanofibrillar Collagen Scaffolds

BACKGROUND

 The aim of our study was to evaluate a new propeller vascularized lymphatic tissue flap (pVLNT) combined with aligned nanofibrillar collagen scaffolds (CS) (BioBridge) in reducing lymphedema in the rat lymphedema model.

METHODS

 Unilateral left hindlimb lymphedema was created in 15 female Sprague-Dawley rats following inguinal and popliteal lymph nodes (LN) resection and radiation. An inguinal pVLNT was elevated from the contralateral groin and transferred through a skin tunnel to the affected groin. Four collagen threads were attached to the flap and inserted in the hindlimb at the subcutaneous level in a fan shape. The three study groups consisted of group A (control), group B (pVLNT), and group C (pVLNT + CS). Volumetric analysis of both hindlimbs was performed using micro-computed tomography imaging before the surgery (at initial time point) and then at 1 and 4 months, postoperatively, and the relative volume difference (excess volume) was measured for each animal. Lymphatic drainage was assessed by indocyanine green (ICG) fluoroscopy for number and morphology of new collectors and the time required for ICG to move from injection point to the midline.

RESULTS

 Four months after the induction of lymphedema, an increased relative volume difference remained in group A (5.32 ± 4.74%), while there was a significant relative volume reduction in group B (-13.39 ± 8.55%) and an even greater reduction in group C (-14.56 ± 5.04%). ICG fluoroscopy proved the functional restoration of lymphatic vessels and viability of pVLNT in both B and C groups. Notably, only group C demonstrated statistically significant improvements in lymphatic pattern/morphology and in the number of lymphatic collectors as compared with the control group A.

CONCLUSION

 The pedicle lymphatic tissue flap combined with SC is an effective procedure for the treatment of lymphedema in rats. It can be easily translated into treatment of humans' lower and upper limb lymphedema and further clinical studies are warranted.

Lymphangiogenesis after nonvascularized lymph node transplantation: Lymphangiographic findings in mice and minipigs

The establishment of new connections after NVLNT (non-vascularized lymph node transplantation) is still poorly understood. The purpose of this study was to investigate lymphatic connections after NVLNT using lymphangiography. In a mice model, 40 mice were allocated to undergo NVLNT or sham surgery. On day 21 after NVLNT, the lymphatic vessels were observed on near-infrared fluorescence imaging with indocyanine green. In a minipig model, 12 minipigs underwent NVLNT. On day 14 after NVLNT, the transplanted lymph node and donor site were checked by ultrasound, and minipigs with viable transplanted LNs were allocated to lipiodol lymphangiography or MR lymphangiography groups. Transplanted LN engraftment was examined with immunohistochemical staining. After NVLNT in mice, the signal intensities in the popliteal region at 3 minutes and 5 minutes were higher in the transplanted side than the control side (21.3 ± 8.1 vs. 11.0 ± 4.6 at 3 minutes, 26.7 ± 6.8 vs. 19.7 ± 5.9 at 5 minutes), while in the sham group, there were no significant differences between sides. In minipigs, lipiodol lymphangiography (n = 5) showed Lipiodol accumulation in transplanted LNs with innumerable newly formed lymphatic vessels and lymphovenous shunts. MR lymphangiography (n = 5) showed higher enhancement on the transplanted side compared to the control side. Histology showed successful engraftment of transplanted LNs in 16 out of 20 (80%) mice and 9 out of 12 (75%) minipigs. Omnidirectional lymphangiogenesis forming a dense lymphatic network and spontaneous formation of lymphovenous shunts were shown after NVLNT.

Complete Reduction of Leg Lymphedema after Liposuction: A 5-Year Prospective Study in 67 Patients without Recurrence

BACKGROUND

Lymphedema leads to adipose tissue deposition that cannot be removed using conservative methods. Previous studies have shown a complete reduction in excess volume in limbs with lymphedema when treated with liposuction and controlled compression therapy (CCT). We present the long-term outcomes of all patients treated with liposuction and CCT for lower extremity lymphedema (LEL) who were followed up for 5 years.

METHODS

Sixty-seven LEL patients underwent liposuction and CCT. Thirty-six patients had primary lymphedema and 31 patients had secondary lymphedema. The outcomes included excess leg volume over a follow-up period of 5 years. Any association between patient characteristics and treatment outcomes was analyzed.

RESULTS

The preoperative excess volume prior was 3515 mL [interquartile range (IQR): 2225-5455 mL], and the volume ratio to the unaffected leg was 1.35 (IQR: 1.25-1.53). One year after treatment, the excess volume decreased by 101% (IQR: 84-116). The decrease in excess volume continued during the 5-year follow-up, and at the end of the study, the excess volume had decreased by 115% (IQR: 98-124). No major complications were noted.

CONCLUSIONS

Liposuction and CCT are safe and effective procedures for removing excess adipose tissue and normalizing the leg volume in patients with late-stage LEL. When no satisfactory results are obtained with conservative methods, such as complex decongestive therapy, and there is no or minimal pitting on limb examination, excess adipose tissue is present, and liposuction can be considered.

Imaging Modalities for Evaluating Lymphedema

Lymphedema is a progressive condition. Its therapy aims to reduce edema, prevent its progression, and provide psychosocial aid. Nonsurgical treatment in advanced stages is mostly insufficient. Therefore-in many cases-surgical procedures, such as to restore lymph flow or excise lymphedema tissues, are the only ways to improve patients' quality of life. Imaging modalities: Lymphoscintigraphy (LS), near-infrared fluorescent (NIRF) imaging-also termed indocyanine green (ICG) lymphography (ICG-L)-ultrasonography (US), magnetic resonance lymphangiography (MRL), computed tomography (CT), photoacoustic imaging (PAI), and optical coherence tomography (OCT) are standardized techniques, which can be utilized in lymphedema diagnosis, staging, treatment, and follow-up. Conclusions: The combined use of these imaging modalities and self-assessment questionnaires deliver objective parameters for choosing the most suitable surgical therapy and achieving the best possible postoperative outcome.

Development of predictive models for lymphedema by using blood tests and therapy data

Lymphedema is a disease that refers to tissue swelling caused by an accumulation of protein-rich fluid that is usually drained through the lymphatic system. Detection of lymphedema is often based on expensive diagnoses such as bioimpedance spectroscopy, shear wave elastography, computed tomography, etc. In current machine learning models for lymphedema prediction, reliance on observable symptoms reported by patients introduces the possibility of errors in patient-input data. Moreover, these symptoms are often absent during the initial stages of lymphedema, creating challenges in its early detection. Identifying lymphedema before these observable symptoms manifest would greatly benefit patients by potentially minimizing the discomfort caused by these symptoms. In this study, we propose to use new data, such as complete blood count, serum, and therapy data, to develop predictive models for lymphedema. This approach aims to compensate for the limitations of using only observable symptoms data. We collected data from 2137 patients, including 356 patients with lymphedema and 1781 patients without lymphedema, with the lymphedema status of each patient confirmed by clinicians. The data for each patient included: (1) a complete blood count (CBC) test, (2) a serum test, and (3) therapy information. We used various machine learning algorithms (i.e. random forest, gradient boosting, decision tree, logistic regression, and artificial neural network) to develop predictive models on the training dataset (i.e. 80% of the data) and evaluated the models on the external validation dataset (i.e. 20% of the data). After selecting the best predictive models, we created a web application to aid medical doctors and clinicians in the rapid screening of lymphedema patients. A dataset of 2137 patients was assembled from Seoul National University Bundang Hospital. Predictive models based on the random forest algorithm exhibited satisfactory performance (balanced accuracy = 87.0 ± 0.7%, sensitivity = 84.3 ± 0.6%, specificity = 89.1 ± 1.5%, precision = 97.4 ± 0.7%, F1 score = 90.4 ± 0.4%, and AUC = 0.931 ± 0.007). We developed a web application to facilitate the swift screening of lymphedema among medical practitioners: https://snubhtxt.shinyapps.io/SNUBH_Lymphedema . Our study introduces a novel tool for the early detection of lymphedema and establishes the foundation for future investigations into predicting different stages of the condition.

Acute Effects of Remedial Exercises with and without Compression on Breast-Cancer-Related Lymphedema

Remedial exercises are an important part of the treatment for lymphedema, but there is little evidence to support the acute effects of remedial exercises with or without compression. The aim of this study was to investigate whether and how daily (performed within 24 h) remedial exercises with and without compression bandaging acutely affect the severity of lymphedema and its symptoms in breast-cancer-related lymphedema (BCRL). In total, 34 patients with BCRL completed three sets of remedial exercises (within 24 h) with and without compression bandaging in a randomized order separated by a 3-day wash-out period. The severity of lymphedema and extracellular water ratio were assessed before and 24 h post exercise by using bilateral circumferential measurements and bioimpedance spectroscopy (in L-dex score), respectively, and the severity of self-reported symptoms (swelling, heaviness, and tightness) was assessed using a visual analogue scale. While there was no difference in all outcomes at 24 h post exercise without compression (p > 0.05), all outcomes decreased significantly compared to baseline at 24 h after the exercise with compression (p < 0.001). The remedial exercises performed in the absence of compression within 24 h do not acutely increase the lymphedema and symptoms in BCRL. These are important preliminary findings, which can be used to inform future prospective evaluation of the long-term effects of remedial exercise performed without compression.

Rasch validation and refinement of the Lymphedema Life Impact Scale version 2 in an Italian cohort with secondary lymphedema

PURPOSE

To produce and validate an Italian version of the Lymphedema Life Impact Scale version 2 (LLISv2-It), a tool measuring the impact of lymphedema on health-related quality of life, and investigate its main psychometric characteristics.

METHODS

After translation and cross-cultural adaptation of the LLISv2, we administered it to 156 subjects with secondary lymphedema (upper or lower limb), together with (depending on the limb involved) either the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) or the Lower Extremity Functional Scale (LEFS). We analyzed the performance of LLISv2-It using Classical Test Theory and Rasch methods.

RESULTS

Cronbach alpha was 0.89. Item fit statistics indicated that item #12 was underfitting (Infit MnSQ = 1.56; Outfit MnSq = 1.75). Test-retest reliability of the 17-item version (without item #18, not scored, according to the original authors) and of a 16-item version (without #12 and #18-a unidimensional item set) were both excellent (ICC2.1 = 0.93; 95%). The minimum detectable change was 8.9 points. The correlation of LLISv2-It with DASH and LEFS was r = 0.81 and -0.57, respectively.

CONCLUSIONS

The Italian version of the LLISv2 is reliable and valid. To make the tool more psychometrically sound, we recommend to not calculate items #12 and #18 in the total score.

IMPLICATIONS FOR REHABILITATIONThe Lymphedema Life Impact Scale (LLISv2) is particularly useful as a validated condition-specific health-related quality of life measure for patients with chronic edema/lymphedema. We have validated its Italian version (LLISv2-It).We also examined the psychometric properties of the LLISv2 in individuals with secondary lymphedema of either upper or lower limb, using both classical test theory and Rasch techniques, to provide insights for further refinement of the questionnaire.Based on our results, we recommend not to count item #12 in the total score (besides #18, as already suggested by the original authors). Moreover, we determined that the minimum detectable change of the LLISv2 was 9 points. This information is helpful in clinical practice to understand if the change in score is not due to chance (measurement error).Although further research is warranted, the present validation study of the LLISv2 increases the confidence in the metric quality and clinical utility of the scale to assess lymphedema-specific health-related quality of life in individuals with secondary lymphedema of either upper or lower limb.

In Vivo Dynamic and Static Analysis of Lymphatic Dysfunction in Lymphedema Using Near-Infrared Fluorescence Indocyanine Green Lymphangiography

BACKGROUND

Near-infrared fluorescence indocyanine green lymphangiography, a primary modality for detecting lymphedema, which is a disease due to lymphatic obstruction, enables real-time observations of lymphatics and reveals not only the spatial distribution of drainage (static analysis) but also information on the lymphatic contraction (dynamic analysis).

METHODS

We have produced total lymphatic obstruction in the upper limbs of 18 Sprague-Dawley rats through the dissection of proximal (brachial and axillary) lymph nodes and 20-Gy radiation (dissection limbs). After the model formation for 1 week, 9 animal models were observed for 6 weeks using near-infrared fluorescence indocyanine green lymphangiography by injecting 6-μL ICG-BSA (indocyanine green-bovine serum albumin) solution of 20-μg/mL concentration. The drainage pattern and leakage of lymph fluid were evaluated and time-domain signals of lymphatic contraction were observed in the distal lymphatic vessels. The obtained signals were converted to frequency-domain spectrums using signal processing.

RESULTS

The results of both static and dynamic analyses proved to be effective in accurately identifying the extent of lymphatic disruption in the dissection limbs. The static analysis showed abnormal drainage patterns and increased leakage of lymph fluid to the periphery of the vessels compared with the control (normal) limbs. Meanwhile, the waveforms were changed and the contractile signal frequency increased by 58% in the dynamic analysis. Specifically, our findings revealed that regular lymphatic contractions, observed at a frequency range of 0.08 to 0.13 Hz in the control limbs, were absent in the dissection limbs. The contractile regularity was not fully restored for the follow-up period, indicating a persistent lymphatic obstruction.

CONCLUSIONS

The dynamic analysis could detect the abnormalities of lymphatic circulation by observing the characteristics of signals, and it provided additional evaluation indicators that cannot be provided by the static analysis. Our findings may be useful for the early detection of the circulation problem as a functional evaluation indicator of the lymphatic system.

The utility of computed tomography venography in the routine evaluation of patients who present to a lymphedema center with lower extremity edema

OBJECTIVE

Computed tomography venography (CTV) is not routinely used to screen patients presenting with a presumed lower extremity lymphedema diagnosis for left iliac vein obstruction (IVO) or May-Thurner syndrome (MTS). The objective of this study is to determine the utility of routine CTV screening for these patients by evaluating the proportion presenting with clinically significant CTV-identified left IVO.

METHODS

We retrospectively reviewed 121 patients who had presented to our lymphedema center with lower extremity edema between November 2020 and May 2022. Information regarding demographics, comorbidities, lymphedema characteristics, and imaging reports was collected. Cases of IVO present on CTV were reviewed by a multidisciplinary team to determine the clinical significance of the CTV findings.

RESULTS

Of the patients with complete imaging studies, 49% (n = 25) had abnormal lymphoscintigraphy findings, 45% (n = 46) had reflux on ultrasound, and 11.4% (n = 9) had IVO on CTV. Seven patients (6%) had CTV findings of IVO and edema of either the isolated left (n = 4) or bilateral (n = 3) lower extremities. Cases of IVO on CTV were determined by the multidisciplinary team to be the predominant cause of lower extremity edema for three of these seven cases (43%; or 2.5% of all 121 patients).

CONCLUSIONS

Six percent of patients presenting to a lymphedema center with lower extremity edema had left-sided IVO on CTV suggestive of MTS. However, the cases of IVO were determined to be clinically significant <50% of the time or for 2.5% of all patients. CTV should be reserved for patients with isolated left-sided or bilateral lower extremity edema with a greater left-sided component and a history of findings that raise clinical suspicion for MTS.

The effect of complex decongestive physiotherapy applied with different compression pressures on skin and subcutaneous tissue thickness in individuals with breast cancer-related lymphedema: a double-blinded randomized comparison trial

PURPOSE

The aim of this study was to evaluate the effect of compression bandage applied with different pressures on the skin and subcutaneous thickness in individuals with breast cancer-related lymphedema (BCRL).

METHODS

21 individuals with stage 2 unilateral BCRL participated in the study. Individuals were randomly allocated into two groups as low-pressure bandage (20-30 mmHg) (n: 11) and high-pressure bandage (45-55 mmHg) (n: 10). Skin and subcutaneous tissue thickness, extremity volume, sleep quality, treatment benefit, and comfort were evaluated by ultrasound from 6 reference points (as hand dorsum, wrist volar, forearm volar, arm volar, forearm dorsum, and arm dorsum), volumetric measurement, Pittsburgh Sleep Quality Index, Patient Benefit Index-Lymphedema, and visual analog scale, respectively. Complex decongestive physiotherapy was applied to both groups. Compression bandage was applied according to their group. Individuals were evaluated at the baseline, 1st session, 10th session, 20th session, and at 3-month follow-up.

RESULTS

Skin thickness decreased significantly in the volar reference points of the extremity in the high-pressure bandage group (p = 0.004, p = 0.031, and p = 0.003). Subcutaneous tissue thickness significantly decreased at all reference points in the high-pressure bandage group (p < 0.05). In the low-pressure bandage group, skin thickness only decreased in the forearm dorsum and the arm dorsum (p = 0.002, p = 0.035) and subcutaneous tissue thickness changed for all points (p < 0.05) except for hand and arm dorsum (p = 0.064, p = 0.236). Edema decreased in a shorter time in the high-pressure bandage group (p < 0.001). No significant differences were found in sleep quality, treatment benefit, and comfort for both groups (p = 0.316, p = 0.300, and p = 0.557, respectively).

CONCLUSION

High pressure was more effective in reducing subcutaneous tissue thickness in the dorsum of hand and arm. The usage of high-pressure can be recommended especially in cases which have edema in the dorsum of hand and arm which is difficult to resolve. Also, high-pressure bandage can provide faster edema resolution and can be used in rapid volume reduction as desired. Treatment outcomes may improve with high-pressure bandage without any impairment in comfort, sleep quality, and treatment benefit.

TRIAL REGISTRATION NUMBER AND DATE

NCT05660590, 12/26/2022 retrospectively registered.

Therapeutic Lymphangiogenesis Is a Promising Strategy for Secondary Lymphedema

Secondary lymphedema is caused by lymphatic insufficiency (lymphatic drainage failure) following lymph node dissection during the surgical treatment or radiation therapy of breast or pelvic cancer. The clinical problems associated with lymphedema are reduced quality of life in terms of appearance and function, as well as the development of skin ulcers, recurrent pain, and infection. Currently, countermeasures against lymphedema are mainly physical therapy such as lymphatic massage, elastic stockings, and skin care, and there is no effective and fundamental treatment with a highly recommended grade. Therefore, there is a need for the development of a fundamental novel treatment for intractable lymphedema. Therapeutic lymphangiogenesis, which has been attracting attention in recent years, is a treatment concept that reconstructs the fragmented lymphatic network to recover lymphatic vessel function and is revolutionary to be a fundamental cure. This review focuses on the translational research of therapeutic lymphangiogenesis for lymphedema and outlines the current status and prospects in the development of therapeutic applications.

A Novel Dressing Composed of Adipose Stem Cells and Decellularized Wharton's Jelly Facilitated Wound Healing and Relieved Lymphedema by Enhancing Angiogenesis and Lymphangiogenesis in a Rat Model

Lymphedema causes tissue swelling due to the accumulation of lymphatic fluid in the tissue, which delays the process of wound-healing. Developing effective treatment options of lymphedema is still an urgent issue. In this study, we aim to fabricate tissue-engineered moist wound dressings with adipose stem cells (ASCs) and decellularized Wharton's jelly (dWJ) from the human umbilical cord in order to ameliorate lymphedema. Rat ASCs were proliferated and an apparent layer was observed on dWJ at day 7 and 14. A rat tail lymphedema model was developed to evaluate the efficacy of the treatment. Approximately 1 cm of skin near the base of the rat tail was circularly excised. The wounds were treated by secondary healing (control) (n = 5), decellularized Wharton's jelly (n = 5) and ASC-seeded dWJ (n = 5). The wound-healing rate and the tail volume were recorded once a week from week one to week five. Angiogenesis and lymphangiogenesis were assessed by immunochemistry staining with anti-CD31 and anti-LYVE1. The results showed that the wound-healing rate was faster and the tail volume was lesser in the ASC-seeded dWJ group than in the control group. More CD31+ and LYVE-1+ cells were observed at the wound-healing area in the ASC-seeded dWJ group than in the control group. This proves that tissue-engineered moist wound dressings can accelerate wound-healing and reduce lymphedema by promoting angiogenesis and lymphangiogenesis.

Validation of a Lymphedema Index Score Based on Noncontrast Magnetic Resonance Lymphangiography: Correlation with Clinical Staging and Indocyanine Green Lymphangiography

Background: A standardized lymphedema grading system is a prerequisite for accurately and objectively evaluating its severity, both preoperatively and postoperatively. The purpose of this study was to establish a clinically feasible noncontrast magnetic resonance lymphangiography (NMRL) protocol and a standardized scoring system for the evaluation of lymphedema. Methods and Results: From January 2020 to February 2021, 39 patients who had been clinically diagnosed with lymphedema and had undergone NMRL were included. The severity and circumferential extent of lymphedema were assessed using magnetic resonance imaging, and a combined index was devised as the sum of the product of the severity and extent scores determined at four different levels. A magnetic resonance imaging (MRI) stage was allocated based on the combined index score, its correlation with clinical indices was analyzed. The MR and clinical staging showed a percentage agreement of 85.9% and a kappa coefficient of 0.641, indicating moderate agreement (p < 0.001). Both the interlimb volume and interlimb impedance ratios differed significantly between groups (p < 0.001 for both). The correlation analysis revealed a significant correlation between the combined index score and the inter-limb volume ratio (r = 0.70, p < 0.001) and inter-limb impedance ratio at both 1 kHz (r = 0.71, p < 0.001) and 5 kHz (r = 0.71, p < 0.001). The interobserver agreement was moderate for the severity score, extent score, and combined score. Conclusion: The proposed standardized scoring system for evaluating lymphedema based on NMRL can reproducibly determine the severity and extent of lymphedema in both the upper and lower extremities, and correlates strongly with established clinical measures.

Lymphatic flow through (LyFT) ALT flap: an original solution to reconstruct soft tissue loss with lymphatic leakage or lower limb lymphedema

INTRODUCTION

The lympho-venous shunt using the distal vein of ALT flap pedicle allowed at the same time the coverage of the inguinal defects and to perform lymphovenous shunt into a run-in vein of the descending branch of the lateral circumflex femoral pedicle, draining the lymph through the flap pedicle. Surgical technique, complications and final outcomes (both clinical and lymphoscintigraphic) are reported.

METHODS

Five patients (45.8 y.o.[22-70]) with groin soft tissue loss with lymphatic leakage or lower limb lymphedema, benefited of the described technique. The ALT flap was used to cover the defect and, at the same time, we could perform a lymphovenous shunt between afferent lymphatics to the thigh and the descending branch of the lateral circumflex femoral pedicle, distal to the perforator nourishing the flap. Clinical and lymphoscintigraphic assessment of the limbs, cease of lymphorrhea or cellulitis/lymphangitis episodes, eventual downstaging of physiologic/physical therapy were recorded. LYMphatic Quality Of Life in leg (LYMQoLLeg) and patient satisfaction were evaluated.

RESULTS

Average flap size was 88.8cm² (range 84-126). The mean number of multi-lymphovenous anastomosis (MLVA) performed was 1.8 (range 1-3) per patient with 1-3 lymphatics shunted into each vein. Only one hemato-seroma requiring surgical revision. Mean improvement of perometer values was 48.2% (range 27.7-67.7) with an average follow-up of 13.6 months (range 12-17). Lymphoscintigraphy showed disappearing of the lymphatic leak and lymphedema with a high satisfaction of LYMQoL score.

DISCUSSION

The combination of pedicle flap with lympho-venous bypass as lymphatic derivation concept, improving the chronic morbidity scenarios of lymphatic complications.

Radiation therapy attenuates lymphatic vessel repair by reducing VEGFR-3 signalling

Introduction: Surgery and radiotherapy are key cancer treatments and the leading causes of damage to the lymphatics, a vascular network critical to fluid homeostasis and immunity. The clinical manifestation of this damage constitutes a devastating side-effect of cancer treatment, known as lymphoedema. Lymphoedema is a chronic condition evolving from the accumulation of interstitial fluid due to impaired drainage via the lymphatics and is recognised to contribute significant morbidity to patients who survive their cancer. Nevertheless, the molecular mechanisms underlying the damage inflicted on lymphatic vessels, and particularly the lymphatic endothelial cells (LEC) that constitute them, by these treatment modalities, remain poorly understood. Methods: We used a combination of cell based assays, biochemistry and animal models of lymphatic injury to examine the molecular mechanisms behind LEC injury and the subsequent effects on lymphatic vessels, particularly the role of the VEGF-C/VEGF-D/VEGFR-3 lymphangiogenic signalling pathway, in lymphatic injury underpinning the development of lymphoedema. Results: We demonstrate that radiotherapy selectively impairs key LEC functions needed for new lymphatic vessel growth (lymphangiogenesis). This effect is mediated by attenuation of VEGFR-3 signalling and downstream signalling cascades. VEGFR-3 protein levels were downregulated in LEC that were exposed to radiation, and LEC were therefore selectively less responsive to VEGF-C and VEGF-D. These findings were validated in our animal models of radiation and surgical injury. Discussion: Our data provide mechanistic insight into injury sustained by LEC and lymphatics during surgical and radiotherapy cancer treatments and underscore the need for alternative non-VEGF-C/VEGFR-3-based therapies to treat lymphoedema.

Lymphoscintigraphic alterations in lower limbs in women with lipedema in comparison to women with overweight/obesity

Introduction: Lipedema is a bilateral enlargement of the legs due to abnormal depositions of subcutaneous fat. Recent studies using lymphoscintigraphy documented that lipedema associates with lymphatic alterations. It is still not known, whether non-lipedema obesity also leads to similar lymphoscintigraphic changes within lower legs. Clinically, both, lipedema and obesity may progress to secondary lymphedema. The aim of the study was to evaluate lymphoscintigraphy of lower limbs in women with lipedema in comparison to overweight/obese women. Methods: 51 women (in the mean age of 43.3 ± 13.56) with the diagnosis of lipedema and 31 women (in the mean age of 44.7 ± 13.48) with overweight/obesity were enrolled into the study. Women in both study groups had no clinical signs of lymphedema. The groups were matched by mean volume of their legs, calculated using the formula for a truncated cone. Lymphoscintigraphy was evaluated in every women qualitatively. Body composition parameters were assessed using bioelectric impedance analysis (BIA). Results: Lymphoscintigraphic alterations within lower extremities were similar in both, lipedema and overweight/obese groups and were present in majority of women in both study groups. The most common lymphoscintigraphic alteration in both groups were additional lymphatic vessels (in the lipedema group observed in 76.5% of patients and in the overweight/obesity group - in 93.5%). Visualization of popliteal lymph nodes and dermal backflow were observed respectively in 33% and in 5.9% in the group with lipedema and in 45.2% and in 9.7% in the overweight/obesity group. There were significant relationships between severity of lymphoscintigraphic alterations and weight, lean body mass (LBM), total body water (TBW), volume of both legs and thigh circumference in the lipedema group. Such relationships were absent in the overweight/obesity group. Discussion: Our study indicates that lymphatic alterations are present before development to clinically visible secondary lymphedema in both conditions, lipedema and overweight/obesity. In majority of women from both study groups they indicate rather an overload of the lymphatic system than insufficiency. Lymphoscintigraphic alterations are similar in both groups, therefore, lymphoscintigraphy is not a diagnostic tool that might distinguish lipedema from overweight/obesity.

Edema of limbs as the primary symptom of gastric signet-ring cell carcinoma: A case report and literature review

BACKGROUND

Metastatic skin cancers are relatively rare dermatological malignancies. They usually present as nodules, erythematous lesions, scar-like lesions or other lesion types. Signet-ring cell carcinoma (SRCC) is an uncommon histological type of gastric cancer that usually behaves aggressively and has a poor prognosis. Skin metastasis may be the first sign of clinically silent visceral cancer or recurrence of an internal malignancy.

CASE SUMMARY

Herein we report on the case of a 55-year-old man with edema of a lower extremity as the primary symptom which progressed from local to generalized pitting edema in the year following skin involvement. Pathological evidence from gastroscopic specimens and subcutaneous tissue biopsy showed typical signet-ring cells and gland-like structures. Consistently, immunohistochemical analysis revealed positive pan-cytokeratin expression in tumor cells. A diagnosis of gastric SRCC with skin metastasis was established. Moreover, lymphoscintigraphy showed an obvious accumulation of radiotracer on the anterior and posterior sides of the right leg which indicated lymphedema. We reviewed the relevant literature on subcutaneous metastases of gastric SRCC.

CONCLUSION

This rare case emphasizes the importance of physical examination as it may help elucidate the etiology of edema.

Effectiveness of three exercise programs and intensive follow-up in improving quality of life, pain, and lymphedema among breast cancer survivors: a randomized, controlled 6-month trial

PURPOSE

Postoperative complications of breast cancer (BC) seriously affect the quality of life (QOL) of survivors. Physical activity is related to prevention of complications and improvement of QOL. Follow-up can keep patients motivated to exercise. This study aimed to (1) compare the effect of three exercise programs on lymphedema, pain, and QOL in BC patients and (2) explore the effect of intensive follow-up on the outcomes of exercise programs.

METHODS

A single-blind randomized parallel controlled trial with a 6-month intervention was carried out in China in 2021. The study sample included 200 women with BC. The patients were randomly divided into 4 groups. G₀ (control group) was joint mobility exercise (JME) group; G₁ was joint mobility exercise + intensive follow-up (IF) group; G₂ was JME + aerobic exercise (AE) + IF group; and G₃ was JME + progressive resistance exercise (PRE) + IF group. Outcome measures were evaluated at baseline (T₁), 3 months post-intervention (T₂), and 6 months post-intervention (T₃). The following instruments and measurements were administered before and after the intervention: the Functional Assessment of Cancer Therapy-Breast (FACT-B) instrument, the numerical rating scale (NRS), and the relative volume change (RVC). Verificating aim 1 is by comparing the results of G₁, G₂, and G₃, and verificating aim 2 is achieved by comparing G₀ and G₁. Differences before and after the intervention were determined by analysis of variance of repeated measures and Kruskal-Wallis nonparametric analysis of variance.

RESULTS

Among the exercise programs, JME + PRE + IF resulted in the best improvement in QOL (T2: ΔG₃-G₀ = 13.032, P = 0.008; T2: ΔG₃-G₁ = 13.066, P < 0.001; ΔG₃-G₀ = 17.379, P < 0.001). For pain relief, JME + AE + IF had the best improvement (T3: ΔG₂-G₁ =  - 0.931, P = 0.010; ΔG₂-G₀ =  - 1.577, P < 0.001). For the prevention of lymphedema, JME + AE + IF (Z = 2.651, P = 0.048) and JME + PRE + IF (Z = 3.277, P = 0.006) had the similar effect, but JME + PRE + IF is better than JME + AE + IF.

CONCLUSION

JME + PRE have the best effect in improving the QOL and preventing lymphedema after surgery. In improving pain, the effect of JME + AE appears earlier, and the overall effect of JME + PRE is better. In addition, long-term and planned monitoring and follow-up are also important.

Rest/Stress Intradermal Lymphoscintigraphy for the Functional Imaging of the Lymphatic System

PURPOSE

Lymphoscintigraphy is the criterion-standard method for diagnosing lymphedema, and there is no universally standardized imaging modality. In our center, we use a new approach: rest/stress intradermal lymphoscintigraphy.

METHODS

We tested 231 consecutive patients with suspected lymphedema. All patients were studied after a complex physical therapy program to reduce edema. Two doses of 99m Tc-nanocolloid were injected intradermally. Two static planar scans were taken at rest following tracer injection. Next, patients performed an isotonic muscular exercise for 2 minutes followed by postexercise scans. Subsequently, a prolonged exercise was performed for 30 to 40 minutes, after which delayed scans were taken. Abnormal patterns were distinguished into minor or major findings, according to severity.

RESULTS

We identified superficial lymphatic vessels and regional lymph nodes in approximately 80% of limbs. Deep vessels were visualized in 26% of limbs. Minor findings were reported in 22.7% of limbs examined, whereas major findings were reported in 53.2% of limbs.

CONCLUSION

We observed major findings including lymph stagnation, extravasation, or dermal backflow in a significantly higher percentage of limbs with secondary lymphedema than in primary. We also observed the deep lymphatic pathways in a significantly higher percentage of limbs with primary lymphedema. Intradermal radiotracer injection, combined with isotonic muscular exercise, may offer a better and faster imaging of lymphatic pathways, evaluating the effects of muscular exercise on lymphatic drainage. Based on the in-depth information of the lymphatic pathways provided by rest/stress intradermal lymphoscintigraphy, microsurgeons can obtain important functional information to perform supermicrosurgical lymphatic-venous anastomosis or vascularized lymph node transfer.

KATP channels in lymphatic function

KATP channels function as negative regulators of active lymphatic pumping and lymph transport. This review summarizes and critiques the evidence for the expression of specific KATP channel subunits in lymphatic smooth muscle and endothelium, the roles that they play in normal lymphatic function, and their possible involvement in multiple diseases, including metabolic syndrome, lymphedema, and Cantú syndrome. For each of these topics, suggestions are made for directions for future research.

The effect of upper limb lymphedema in posture of patients after breast cancer surgery

BACKGROUND

Upper limb lymphedema is one of the complications following breast cancer-related surgery. It is a fact that there are alterations in posture of the trunk following surgery, however, there is not much data on whether upper limb lymphedema has any effect on body posture.

OBJECTIVES

The main purpose of the study was to investigate the effect of upper limb lymphedema in the trunk posture and spine mobility of patients following breast cancer surgery.

METHODS

Twenty-seven women with lymphedema and 29 women without lymphedema with mastectomy or breast-conserving surgery participated in the study. Posture was evaluated by the New York Posture Rating Chart and spinal stability and thoracic mobility were evaluated by the Spinal Mouse device.

RESULTS

Posture and spine posture scores were significantly higher in the without lymphedema group (p= 0.004; 0.041; respectively). There was a significant difference between the groups in terms of lateral (p< 0.001) and posterior (p< 0.001) view of shoulders, spine (p= 0.027), upper (p< 0.001) and lower back (p= 0.009), and trunk postures (p= 0.001).

CONCLUSIONS

Body posture and spine are more affected due to upper limb lymphedema following breast cancer surgery. Alterations of posture mainly occur on shoulders, spine, upper and lower back, and trunk, but not on head and neck postures.

Liposuction and Controlled Compression Therapy Reduce the Erysipelas Incidence in Primary and Secondary Lymphedema

BACKGROUND

Skin infections are a recurring problem for people with lymphedema, and lymphedema has been proven to be the single most important risk factor for developing erysipelas in the leg. This study aimed to determine whether liposuction for late-stage lymphedema reduces the rate of erysipelas in lower extremity lymphedema.

METHODS

One-hundred twenty-four patients with a median age of 49 years who had liposuction and controlled compression therapy for lower extremity lymphedema were included. Excess volumes were calculated before and after surgery. Median preoperative and postoperative patient years at risk were 11 and 5 years, respectively.

RESULTS

With a total of 1680 preoperative person years at risk and 335 bouts of erysipelas experienced in 64 patients, the preoperative incidence rate was 0.20 bouts per person per year, and the period prevalence was 52%. Postoperatively, the patients were followed over a total of 763 person years at risk, and 28 patients experienced a total of 53 bouts of erysipelas, resulting in a postoperative incidence rate of 0.07 bouts per person per year, and a period prevalence of 23%. This represents a 65% decrease in the erysipelas incidence rate (P < 0.001). The preoperative median excess volume of 3158 ml was reduced with a median of 100% (P < 0.0001).

CONCLUSIONS

Liposuction and controlled compression therapy significantly reduce the risk for erysipelas in lower extremity lymphedema and completely reduces the excess volume. This finding is similar to our previous research including patients with upper extremity lymphedema.

Evaluation of the External Jugular Vein Overlying the Sternocleidomastoid Muscle as Venous Lymph-Node Flap

Background: Until recently, vascularized lymph-node flaps were based on arterial and venous donor vessels. Now, venous lymph-node flaps form a novel promising concept in the treatment of advanced-stage lymphedema. In preliminary studies, the external jugular vein has shown promising results as a venous lymph-node flap. However, nothing is known about the number of lymph nodes adjacent to the external jugular vein. Methods: Standardized specimens of the external jugular vein and surrounding fatty tissue directly overlying the sternocleidomastoid muscle were obtained during routine neck dissection. Histologic evaluation was performed in order to evaluate for the presence of lymph nodes within the tissue. Results: A total of 20 specimens were evaluated. There was no vein in 4 of the samples. We found lymph nodes in 9 of the remaining 16 samples. In 7 samples, lymph nodes were absent. Conclusion: Our results suggest that the vein directly overlying the sternocleidomastoid muscle may not be the ideal candidate for a venous lymph-node flap.

Lymphocintilographic evaluation of lymphatic circulation in victims of circuferential degloving injuries of the lower limbs

INTRODUCTION

secondary forms of lymphedema may occur as consequence of tumors, surgeries, radiotherapy, trauma and infections. Degloving injuries are severe and infrequent forms of trauma, with avulsion at the level of muscular fascia, and consequent injury of the lymphatic system.

OBJECTIVE

to evaluate the alterations in lymphatic circulation in patients being victims of circumferential degloving injuries in the lower limbs, using lymphoscintigraphic.

PATIENTS AND METHODS

retrospective analysis of the cases treated in the period from 2010 to 2016. Segmental, circumferential and unilateral injuries with involvement of the lower limbs were included. Lymphoscintigraphy was performed after a minimum interval of 12 months after the end of treatment. The non-injured lower limb was used as control. The Kleinhans Semiquantitative Index (KSI) was used for the semiquantitative evaluation of the lymphoscintigraphic findings.

RESULTS

eighteen patients were evaluated, six of whom were female and 12 were male. The mean age was 28.11 years. The average vertical extension of the circumferential traumatized segment was 29.33cm. The injured area presented variations of 5 to 15% of the body surface, with an average of 8.95%. Lymphoscintigraphy was performed after an average interval of 22.55 months. Alterations were observed on the traumatized limb (TL) in 13 patients. All control limbs (CL) were normal. The mean KSI observed in TL was 8.32, while in CL, the average value was 0.58 (p<0.001).

CONCLUSION

patients with circumferential degloving injuries in the lower limbs present compromised lymphatic circulation and high probability to develop lymphedema.

Psychometric Properties of Quality of Life Questionnaires for Patients with Breast Cancer-Related Lymphedema: A Systematic Review

Backgrounds: Assessing quality of life (QoL) using a well-developed and validated questionnaire is an essential part of a breast cancer-related lymphedema (BCRL) treatment. However, a QoL questionnaire with the best psychometric properties is so far unknown. The aim of this systematic review is to evaluate the psychometric properties of the questionnaires measuring the QoL of patients with BCRL. Methods: A thorough search was performed to identify published studies in electronic databases such as Medline (via Ovid), EBSCOhost, PubMed, Scopus, and Web of Science, on 8 February 2022, by using search terms as follows: ‘quality of life’; ‘breast cancer’; ‘upper limb’; ‘lymphedema’; ‘questionnaire’; and ‘measurement properties.’ Two reviewers conducted article selection, data extraction, and quality assessment independently. The third reviewer helped solve any possible disagreements between the two reviewers. The COSMIN checklist and manual were used to assess the quality of included studies. Results: A total of nineteen articles with nine questionnaires were included and assessed using the COSMIN Risk of Bias checklist. Most studies only assessed content validity, structural validity, internal consistency, reliability, and construct validity. Lymph-ICF-UL showed the most ‘sufficient’ and ‘high’ quality of evidence ratings for its measurement properties. Conclusion: The most appropriate questionnaire for use based on our assessment is Lymph-ICF-UL.

Multimodality Approach to Lymphedema Surgery Achieves and Maintains Normal Limb Volumes: A Treatment Algorithm to Optimize Outcomes

Surgical treatment of advanced lymphedema is challenging and outcomes are suboptimal. Physiologic procedures including lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) improve lymphatic flow but cannot reverse fibrofatty tissue deposition, whereas liposuction removes fibrofatty tissue but cannot prevent disease progression. The adjunctive use of nanofibrillar collagen scaffolds (BioBridge^TM) can promote lymphangiogenesis. We report a treatment algorithm utilizing a multimodality approach to achieve sustained normal limb volumes in patients with stage II-III lymphedema. A retrospective review of late stage II-III lymphedema patients treated with liposuction, physiologic procedures, and BioBridge^TM from 2016 through 2019 was conducted. Treatment outcome in the form of excess volume reduction is reported. Total of 14 patients underwent surgical treatment of late stage II and III lymphedema according to our triple therapy algorithm. Patients had a baseline median volume excess of 29% (19.8, 43.3%). The median volume excess was improved to 0.5% (−4.3, 3.8%) at 14.4 months from the first stage surgery (p < 0.05) and further improved to −1.0% (−3.3, 1.3%) after triple therapy with BB placement at 24.6 months. A triple therapy surgical treatment algorithm can optimize outcomes and achieve sustained normalization of limb volume in late stage II-III lymphedema. The incorporation of nanofibrillar collagen scaffold technology allows for improved and sustained volume reduction.

Evidence Mapping of the Treatments for Breast Cancer-related Lymphedema

Women treated for breast cancer are facing a lifetime risk of developing lymphedema, which occurs in up to 40% of this population. There is a lack of evidence and limited knowledge regarding the treatment of breast cancer-related lymphedema (BCRL). The aim of this study was to identify, describe, and organize the currently available evidence in the treatment of BCRL.

METHODS

We conducted an evidence mapping review study according to the methodology proposed by Global Evidence Mapping. We performed a systematic search in Medline, Embase, Central (Cochrane), and Epistemonikos, from 2000-2020. We included studies about all treatment types for BCRL, including surgical and nonsurgical treatment. Results were summarized in narrative and tabular forms.

RESULTS

A total of 240 studies were included in this mapping review, distributed as follows: 147 experimental studies [102 randomized clinical trials (RCTs) and 45 quasi-experimental clinical trials], 48 observational studies (34 prospective and 14 retrospective studies), and 45 systematic reviews (17 of them with metanalysis). Most of the RCTs were on nonsurgical interventions. Only two RCTs addressed surgical intervention.

CONCLUSIONS

In the last 20 years, there were an average of 12 publications per year on the treatment of BCRL. Recently this lack of attention has been partially corrected, as the majority were published in the past 5 years. However, most of them were on nonsurgical interventions. Well-designed RCTs on surgery are needed to measure the effectiveness of the applied interventions.

Long-Term Outcomes of Lymph Node Transfer in Secondary Lymphedema and Its Correlation with Flap Characteristics

BACKGROUND

This retrospective study aimed to assess the impact of certain flap characteristics on long-term outcomes following microsurgical treatment in Breast Cancer-Related Lymphedema (BCRL) patients.

METHODS

Sixty-four out of 65 BCRL patients, guided by the "Selected Lymph Node" ("SeLyN") technique, underwent Vascularized Lymph Node Transfer (VLNT) between 2012 and 2018. According to their surface size, flaps were divided into small (<25 cm², n = 32) and large (>25 cm², n = 32). Twelve large and six small flaps were combined with free abdominally based breast reconstruction procedures. Lymphedema stage, flap size, vascular pedicle and number of lymph nodes (LNs) were analyzed in correlation with long-term Volume Differential Reduction (VDR).

RESULTS

At 36-month follow-up, no major complication was recorded in 64 cases; one flap failure was excluded from the study. Mean flap size was 27.4 cm², mean LNs/flap 3.3 and mean VDR 55.7%. Small and large flaps had 2.8 vs. 3.8 LNs/flap (p = 0.001), resulting in 49.6% vs. 61.8% VDR (p = 0.032), respectively. Lymphedema stage and vascular pedicle (SIEA or SCIA/SCIP) had no significant impact on VDR.

CONCLUSION

In our series, larger flaps included a higher number of functional LNs, directly associated with better outcomes as quantified by improved VDR.

Predictive role of lymphoscintigraphy undergoing lymphovenous anastomosis in patients with lower extremity lymphedema: a preliminary study

BACKGROUND

We investigated whether preoperative lymphoscintigraphy could predict the treatment response of unilateral lymphovenous anastomosis (LVA) in patients with lower extremity lymphedema.

MATERIALS AND METHODS

A total of 17 patients undergoing lymphoscintigraphy subsequent to LVA was included. As qualitative lymphoscintigraphic indicators, ilioinguinal lymph node uptake, main lymphatic vessel, collateral vessel, and four types of dermal backflow patterns (absent; distal only; proximal only; whole lower limb) were evaluated. Lymph node uptake ratio, extremity uptake ratio, and injection site clearance ratio were obtained as quantitative lymphoscintigraphic indicators at 1 and 2-h after injection. To evaluate therapy response, the volume difference ratio of the whole lower limb at 3 months (early response) and 1 year (late response) was measured. Volume difference ratios (continuous variable and binary variable with a cut-off value of zero) were compared according to the lymphoscintigraphic variables.

RESULTS

The group with whole lower limb dermal backflow had a greater volume change than the other groups (p = 0.047). The group with dermal backflow in the whole lower limb OR only in the distal part had a higher rate of volume reduction than the group with dermal backflow only in the proximal part OR absent (p = 0.050). The 2-h extremity uptake ratio was the only indicator that positively correlated with early and late volume difference ratio (p = 0.016, p = 0.001). The rate of volume decrease at 1 year was high in patients with high 2-h extremity uptake ratio (p = 0.027). As the amount of dermal backflow increases, the postoperative therapeutic effect increases (p = 0.040).

CONCLUSIONS

Preoperative lymphoscintigraphy is useful to predict both early and late therapy response in patients with lower extremity lymphedema undergoing LVA. Both dermal backflow pattern and extremity uptake ratio may be predictive lymphoscintigraphic indicators.

Adding Pneumatic Compression Therapy in Lower Extremity Lymphedema Increases Compliance of Treatment, While Decreasing the Infection Rate

Background: Lymphedema (LE) is a chronic condition that requires lifelong treatment. Although pneumatic compression therapy (PCT) is one treatment option, current algorithms consider it as an adjunct to standard LE. The purpose of this study is to evaluate the importance of adapting PCT for lower extremity LE (LEL) in relation to patient compliance and rate of infection. Materials and Methods: Patients diagnosed with LEL were followed prospectively. Patient demographics, comorbidities, treatment modality, compliance, infection due to LE, and hospitalization were recorded. LEL patients with no-PCT were also recorded in the same time period to evaluate the treatment compliance and the need for physical therapy visits. The no-PCT group received the standard LE care, whereas the PCT group received the standard LE care plus a new-generation pneumatic compression device. Results: A total of 69 patients were enrolled in this study. The PCT group had 50 patients and no-PCT group had 19 patients. The PCT group had median 58.5 months of LE symptoms, while non-PCT patients had median 23 months of LE symptoms (p = 0.11). Infection rates decreased by 32% and hospitalizations due to infection decreased by 14% after PCT treatment had been initiated. Physical therapy needs decreased by 24% after PCT use. At median 18 months, follow-up compliance for PCT was 84%, but compliance for manual lymphatic drainage was almost half (53%) in no-PCT group. Conclusions: PCT leads to a decrease in infection rate, hospital admissions, and physical therapy (PT) visits in clinically significant LEL. Although there is no cost calculation in this study, it can be correlated to significant cost savings due to a reduction of infection and hospitalization and the need for PT visits. Adoption of PCT offers a superior value proposition to not only patients but also the health care system. Cost analysis should be followed.

Volumetric assessment of lower limb oedema using 3D laser scanning technique: a systematic review

Clinically, oedema is described as an abnormal build-up of interstitial fluid in the body that is enough to produce palpable swelling. Its assessment offers valuable information to clinicians as this can inform management interventions; and help monitor adherence to home therapy programmes and activity levels. The aim of this systematic review is to establish the utility of 3D scanning technologies in the assessment of lower limb oedema. A computer-based search was completed in October 2020. Four studies were identified which utilised a 3D scanner to measure lower limb oedema. A review of the studies found very little evidence to support the efficacy of 3D laser scanning technology, although they show that the use of the technology is feasible. Current methods of lower leg oedema measurement have issues with reliability, practicability and time taken. There is a need for future studies to validate new methods of oedema assessment using technologies such as 3D laser scanning.

Use of non-contrast MR in diagnosing secondary lymphedema of the upper extremities

PURPOSE

The purpose of the study is to determine if a combination of dermal thickening and subcutaneous fluid honeycombing on non-contrast MRI, termed the dermal rim sign (DRS), can be diagnostically analogous to dermal backflow seen on lymphoscintigraphy in patients with secondary upper extremity lymphedema.

MATERIALS AND METHODS

Upper extremity MRI and lymphoscintigraphy were performed on patients referred to a multidisciplinary lymphedema clinic for suspicion of secondary lymphedema. Sensitivity, specificity, and positive and negative predictive values of DRS on MRI in detecting dermal backflow on lymphoscintigraphy and the correlation between DRS, Indocyanine Green (ICG) lymphography, bioimpedence L-Dex® ratio and MRI Lymphedema Staging were calculated. Weighted interobserver agreements on the presence and location of DRS on MRI were calculated.

RESULTS

Of the 45 patients in the study, 91.1% (41/45) of patients had history of breast cancer. The average age was 58.4 ± 10.5 years, with a mean symptom duration of 4.7 ± 4.4 years. The mean BMI was 30.5 ± 7.0 kg/m². Interobserver agreement on the presence and the extent of DRS on MRI was 0.93 [95% confidence-interval: 0.80-1]. DRS was present in 97% (32/33) of patients who demonstrated dermal backflow on lymphoscintigraphy. Sensitivity, specificity, PPV, and NPV of DRS were 96.6% [81.7%-99.9%], and 75.0% [47.6%-92.7%], 87.5% [74.9%-94.3%], and 92.3% [63.1%-98.8%]. DRS was associated with severity on ICG lymphography and bioimpedance (both p < 0.001).

CONCLUSIONS

DRS on non-contrast MRI is highly predictive of dermal backflow and correlates with clinical measures of lymphedema severity. DRS may be used as an independent diagnostic biomarker to identify patients who would benefit from dedicated exams.

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

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

Outcomes of Lymphovenous Anastomosis for Upper Extremity Lymphedema: A Systematic Review

BACKGROUND

Lymphovenous anastomosis (LVA) is an accepted microsurgical treatment for lymphedema of the upper extremity (UE). This study summarizes and analyzes recent data on the outcomes associated with LVA for UE lymphedema at varying degrees of severity.

METHODS

A literature search was conducted in the PubMed database to extract articles published through June 19, 2020. Studies reporting data on postoperative improvement in limb circumference/volume or subjective improvement in quality of life for patients with primary or secondary lymphedema of the UE were included. Extracted data consisted of demographic data, number of patients and upper limbs, duration of symptoms before LVA, surgical technique, follow-up, and objective and subjective outcomes.

RESULTS

A total of 92 articles were identified, of which 16 studies were eligible for final inclusion comprising a total of 349 patients and 244 upper limbs. The average age of patients ranged from 38.4 to 64 years. The duration of lymphedema before LVA ranged from 9 months to 7 years. The mean length of follow-up ranged from 6 months to 8 years. Fourteen studies reported an objective improvement in limb circumference or volume measurements following LVA, ranging from 0% to 100%. Patients included had varying severity of lymphedema, ranging from Campisi stage I to IV. The maximal improvement in objective measurements was found in patients with lower stage lymphedema.

CONCLUSION

LVA is a safe, effective technique for the treatment of UE lymphedema refractory to decompressive treatment. Results of LVA indicate greater efficacy in earlier stages of lymphedema before advanced lymphatic sclerosis.

Foxo1 deletion promotes the growth of new lymphatic valves

Patients with congenital lymphedema suffer from tissue swelling in part due to mutations in genes regulating lymphatic valve development. Lymphatic valve leaflets grow and are maintained throughout life in response to oscillatory shear stress (OSS), which regulates gene transcription in lymphatic endothelial cells (LECs). Here, we identified the first transcription factor, Foxo1, that repressed lymphatic valve formation by inhibiting the expression of valve-forming genes. We showed that both embryonic and postnatal ablation of Foxo1 in LECs induced additional valve formation in postnatal and adult mice in multiple tissues. Our quantitative analyses revealed that after deletion, the total number of valves in the mesentery was significantly (P < 0.01) increased in the Foxo1LEC-KO mice compared with Foxo1fl/fl controls. In addition, our quantitative real-time PCR (RT-PCR) data from cultured LECs showed that many valve-forming genes were significantly (P < 0.01) upregulated upon knockdown of FOXO1. To confirm our findings in vivo, rescue experiments showed that Foxc2+/- mice, a model of lymphedema-distichiasis, had 50% fewer lymphatic valves and that the remaining valves exhibited backleak. Both valve number and function were completely restored to control levels upon Foxo1 deletion. These findings established FOXO1 as a clinically relevant target to stimulate de novo lymphatic valve formation and rescue defective valves in congenital lymphedema.

Sex Hormones in Lymphedema

Simple Summary

Lymphedema is a life-long disease that affects a large number of patients treated for breast-, gynecological-, and urologic cancers in Western countries. Given that hormone levels are strongly modified in these conditions, and that patients widely undergo through hormone therapy, it is tempting to speculate that hormones might be key regulators in the maintenance of lymphedema. Despite an obvious prevalence for women, the role of sex hormones and gender has been poorly investigated in this pathology. This review aims to decipher how sex hormones interact with lymphatic vessels and whether hormone therapy could participate in lymphedema development.

Abstract

Lymphedema is a disorder of the lymphatic vascular system characterized by impaired lymphatic return resulting in swelling of the extremities and accumulation of undrained interstitial fluid/lymph that results in fibrosis and adipose tissue deposition in the limb. Whereas it is clearly established that primary lymphedema is sex-linked with an average ratio of one male for three females, the role of female hormones, in particular estrogens, has been poorly explored. In addition, secondary lymphedema in Western countries affects mainly women who developed the pathology after breast cancer and undergo through hormone therapy up to five years after cancer surgery. Although lymphadenectomy is identified as a trigger factor, the effect of co-morbidities associated to lymphedema remains elusive, in particular, estrogen receptor antagonists or aromatase inhibitors. In addition, the role of sex hormones and gender has been poorly investigated in the etiology of the pathology. Therefore, this review aims to recapitulate the effect of sex hormones on the physiology of the lymphatic system and to investigate whetherhormone therapy could promote a lymphatic dysfunction leading to lymphedema.

Reduced lymphedema after sentinel lymph node biopsy versus lymphadenectomy for endometrial cancer

Objective

Endometrial cancer surgical staging includes lymph node assessment which can lead to lower extremity lymphedema. The aim of this study was to estimate prevalence after sentinel lymph node biopsy versus lymphadenectomy.

Methods

Consecutive patients who underwent minimally invasive surgery at the Mayo Clinic, Rochester, Minnesota, USA, between January 2009 and June 2016 for newly diagnosed endometrial cancer were mailed our validated 13 item lower extremity lymphedema screening questionnaire. We also ascertained via questionnaire whether the patient was ever diagnosed with lower extremity lymphedema.

Results

Among 378 patients included in the analysis, 127 (33.5%) had sentinel lymph node biopsy with or without side specific lymphadenectomy (sentinel lymph node cohort) and 251 (66.4%) underwent bilateral lymphadenectomy prior to sentinel lymph node biopsy implementation at our institution or as 'backup' after sentinel lymph node mapping (lymphadenectomy cohort). The prevalence of lower extremity lymphedema was 41.5% (157/378), with 69 patients (18.3%) self-reporting a lower extremity lymphedema diagnosis after their endometrial cancer surgery at a median of 54.3 months (interquartile range 31.2–70.1 months), and an additional 88 patients (23.3%) identified by the screening questionnaire. The prevalence of lower extremity lymphedema was significantly higher in the lymphadenectomy cohort compared with the sentinel lymph node group (49.4% (124/251) vs 26.0% (33/127); p<0.001). When the cohorts were restricted to patients surgically managed after the introduction of sentinel lymph node, the prevalence of lower extremity lymphedema was still significantly higher in the lymphadenectomy cohort compared with the sentinel lymph node cohort (39.0% (41/105) vs 26.0% (33/127); p=0.03). In a multivariable analysis adjusted for body mass index, receipt of adjuvant external beam radiation, diabetes, congestive heart failure, and International Federation of Gynecology and Obstetrics grade, the adjusted odds ratio for the association between type of nodal sampling (lymphadenectomy cohort vs sentinel lymph node cohort) and lower extremity lymphedema was 2.75 (95% confidence interval 1.69 to 4.47, p<0.001).

Conclusions

Sentinel lymph node biopsy was associated with a decreased risk of post-treatment lymphedema compared with lymphadenectomy in patients who underwent surgical staging for endometrial carcinoma.

Synthesis and evaluation of butein derivatives for in vitro and in vivo inflammatory response suppression in lymphedema

Herein, we demonstrate that butein (1) can prevent swelling in a murine lymphedema model by suppressing tumor necrosis factor α (TNF-α) production. Butein derivatives were synthesized and evaluated to identify compounds with in vitro anti-inflammatory activity. Among them, 20 μM of compounds 7j, 7m, and 14a showed 50% suppression of TNF-α production in mouse peritoneal macrophages after lipopolysaccharide stimulation. Compound 14a, exhibited the strongest potency with an in vitro IC₅₀ of 14.6 μM and suppressed limb volume by 70% in a murine lymphedema model. The prodrug strategy enabled a six-fold increase in kinetic solubility of compound 1 and five-fold higher levels of active metabolite in the blood for compound 14a via oral administration in the pharmacokinetics study. We suggest that the compound 14a could be developed as a potential therapeutic agent targeting anti-inflammatory activity to alleviate lymphedema progression.