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Bhimani F, McEvoy M, Chen Y, Gupta A, Pastoriza J, Cavalli A, Obaid L, Rachofsky C, Fruchter S, Feldman S. Comprehensive strategies in breast cancer-related lymphedema prevention: insights from a multifaceted program. Front Oncol 2024; 14:1418610. [PMID: 39081716 PMCID: PMC11286467 DOI: 10.3389/fonc.2024.1418610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/24/2024] [Indexed: 08/02/2024] Open
Abstract
Background Breast cancer-related lymphedema (BCRL) profoundly impacts patients' quality of life, causing heightened depression, anxiety, and physical limitations. Surgical removal of the axillary nodes, combined with radiation therapy, is a significant risk factor for BCRL. Smarter axillary surgery, coupled with early detection and fostering lymphedema education, significantly improves BCRL management, promoting timely diagnosis and treatment. A lymphedema prevention program encompassing all these factors can significantly aid in preventing, treating, and reducing the severity of BCRL cases. Therefore, our study aims to share our insights and experiences gained from implementing a lymphedema prevention program at our institution. Methods & Results At our institution, axillary reverse mapping (ARM) is performed on all patients undergoing axillary surgery. We surveil these patients with pre- and postoperative SOZO® measurements using bioimpedance spectroscopy to detect sub-clinical lymphedema. Concerning education, we use a 3-pronged approach with surgeons, nurse practitioners, and video representation for patients. We have had 212 patients undergo the ARM procedure since 2019, with three (1.41%) developing persistent lymphedema. Conclusion Our study underscores the significance of a comprehensive lymphedema prevention program, integrating smarter axillary surgery, early detection, and patient education. The lymphedema rate of 1.41% not only validates the success rate of these interventions but also advocates for their widespread adoption to enhance the holistic care of breast cancer survivors. As we continue to refine and expand our program, further research, and long-term follow-up are crucial to improve prevention strategies continually and enhance the overall well-being of individuals at risk of BCRL.
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Affiliation(s)
- Fardeen Bhimani
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
| | - Maureen McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
| | - Yu Chen
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
| | - Anjuli Gupta
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
| | - Jessica Pastoriza
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
| | - Arianna Cavalli
- Albert Einstein College of Medicine, Bronx, NY, United States
| | - Liane Obaid
- Albert Einstein College of Medicine, Bronx, NY, United States
| | | | - Shani Fruchter
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, United States
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Miaskowski C, Conley YP, Cooper BA, Paul SM, Smoot BJ, Hammer MJ, Fu M, Levine JD. Identification Of A Higher Risk Lymphedema Phenotype And Associations With Cytokine Gene Polymorphisms. J Pain Symptom Manage 2024; 67:375-383.e3. [PMID: 38307372 DOI: 10.1016/j.jpainsymman.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/21/2024] [Accepted: 01/24/2024] [Indexed: 02/04/2024]
Abstract
CONTEXT Breast cancer-related lymphedema (BCRL) is chronic condition that occurs in 5% to 75% of women following treatment for breast cancer. However, little is known about the risk factors and mechanisms associated with a worse BCRL profile. OBJECTIVES Identify distinct BCRL profiles in women with the condition (i.e., lower vs. higher risk phenotype) and evaluate for associations with pro- and anti-inflammatory genes. METHODS Latent class profile analysis (LCPA) was used to identify the BCRL profiles using phenotypic characteristics evaluated prior to surgery. Candidate gene analyses were done to identify cytokine genes associated with the two BCRL profiles. RESULTS Of the 155 patients evaluated, 35.5% (n = 55) were in the Lower and 64.5% (n = 100) were in the Higher Risk classes. Risk factors for membership in the Higher class included: lower functional status, having sentinel lymph node biopsy, axillary lymph node dissection, mastectomy, higher number of positive lymph nodes, and receipt of chemotherapy. Polymorphisms for interleukin (IL)1-beta and IL6 were associated with membership in the Higher Risk class. CONCLUSION The readily available and clinically relevant phenotypic characteristics associated with a worse BCRL profile can be used by clinicians to identify higher risk patients. If confirmed, these characteristics can be tested in predictive risk models. In addition, the candidate gene findings may guide the development of mechanistically-based interventions to decrease the risk of BCRL.
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Affiliation(s)
- Christine Miaskowski
- School of Nursing, University of California, San Francisco, CA, USA; School of Medicine, University of California, San Francisco, CA, USA.
| | | | - Bruce A Cooper
- School of Nursing, University of California, San Francisco, CA, USA
| | - Steven M Paul
- School of Nursing, University of California, San Francisco, CA, USA
| | - Betty J Smoot
- School of Medicine, University of California, San Francisco, CA, USA
| | | | - Mei Fu
- School of Nursing and Health Studies, University of Missouri, Kansas City, MO, USA
| | - Jon D Levine
- School of Medicine, University of California, San Francisco, CA, USA
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Hing JX, Chua YN, Tan PT, Tan MSL, Mok CW, Seet MYL, Lin ZC, Seah CM, Lee WP, Tan SM. Defining breast cancer-related lymphedema (BCRL) prevalence and risk factors: A pragmatic approach to lymphedema surveillance. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2024; 53:80-89. [PMID: 38920232 DOI: 10.47102/annals-acadmedsg.2023264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction We presented the key findings from Singapore's Changi General Hospital Breast Centre's lymphedema surveillance strategy that used patients' reported symptoms, standard arm circumference measurements and clinical assessment in the diagnosis of breast cancer-related lymphedema (BCRL). Our secondary aim was to highlight and discuss important elements of a surveillance strategy that can be implemented to track this outcome measure of breast cancer treatment for future research. Method We conducted a cross-sectional study of 511 breast cancer patients to assess the prevalence of BCRL and its associated risk factors. We defined BCRL prevalence rates based on patients' self-reporting, objective arm circumference measure-ments and clinical diagnosis based on International Society of Lymphology (ISL) staging. Results The median follow-up of patients was 88.8 months. The cumulative prevalence rate in the cohort was 30.9%. The cohort of BCRL patients were older (58.4 versus [vs] 54.9 years), had higher mean Body Mass Index (27.7 vs 25.2), higher proportion of mastectomy (77% vs 64.3%), axillary clearance, less likely breast reconstruction, higher-grade tumour, more lymph nodes excised, more advanced nodal disease, and had undergone adjuvant chemotherapy. However, clinically apparent BCRL was only 6.5% (33 out of 511 patients). The proportion of clinically significant BCRL in patients undergoing sentinel lymph node biopsy (SLNB) or axillary sampling was 1.7% compared to 9.9% in patients who had undergone axillary clearance. Majority of the BCRL were subclinical or mild in severity. Conclusion Our study showed that our rates of BCRL were comparable to international rates and highlighted similar patient profiles who were at risk of developing the disease. Having a comprehensive lymphedema surveillance strategy is paramount in paving the way for future studies.
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Affiliation(s)
- Jun Xian Hing
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
| | - Yen Nee Chua
- Department of Nursing, Changi General Hospital, Singapore
| | - Pei Ting Tan
- Clinical Trials and Research Unit, Changi General Hospital, Singapore
| | | | - Chi Wei Mok
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
| | - Melissa Yert Li Seet
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
| | - Zar Chi Lin
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
| | - Chin Mui Seah
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
| | - Wai Peng Lee
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
| | - Su-Ming Tan
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
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Wong HC, Wallen MP, Chan AW, Dick N, Bonomo P, Bareham M, Wolf JR, van den Hurk C, Fitch M, Chow E, Chan RJ. Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidance for the prevention of breast cancer-related arm lymphoedema (BCRAL): international Delphi consensus-based recommendations. EClinicalMedicine 2024; 68:102441. [PMID: 38333542 PMCID: PMC10850412 DOI: 10.1016/j.eclinm.2024.102441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/18/2023] [Accepted: 01/11/2024] [Indexed: 02/10/2024] Open
Abstract
Background Developing strategies to prevent breast cancer-related arm lymphoedema (BCRAL) is a critical unmet need because there are no effective interventions to eradicate it once it reaches a chronic state. Certain strategies such as prospective surveillance programs and prophylactic lymphatic reconstruction have been reported to be effective in clinical trials. However, a large variation exists in practice based on clinician preference, organizational standards, and local resources. Methods A two-round international Delphi consensus process was performed from February 27, 2023 to May 25, 2023 to compile opinions of 55 experts involved in the care and research of breast cancer and lymphoedema on such interventions. Findings Axillary lymph node dissection, use of post-operative radiotherapy, relative within-arm volume increase one month after surgery, greater number of lymph nodes dissected, and high body mass index were recommended as the most important risk factors to guide selection of patients for interventions to prevent BCRAL. The panel recommended that prospective surveillance programs should be implemented to screen for and reduce risks of BCRAL where feasible and resources allow. Prophylactic compression sleeves, axillary reverse mapping and prophylactic lymphatic reconstruction should be offered for patients who are at risk for developing BCRAL as options where expertise is available and resources allow. Recommendations on axillary management in clinical T1-2, node negative breast cancer patients with 1-2 positive sentinel lymph nodes were also provided by the expert panel. Routine axillary lymph node dissection should not be offered in these patients who receive breast conservation therapy. Axillary radiation instead of axillary lymph node dissection should be considered in the same group of patients undergoing mastectomy. Interpretation An individualised approach based on patients' preferences, risk factors for BCRAL, availability of treatment options and expertise of the healthcare team is paramount to ensure patients at risk receive preventive interventions for BCRAL, regardless of where they are receiving care. Funding This study was not supported by any funding. RJC received investigator grant support from the Australian National Health and Medical Research Council (APP1194051).
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Affiliation(s)
- Henry C.Y. Wong
- Department of Oncology, Princess Margaret Hospital, Hong Kong S.A.R, China
| | - Matthew P. Wallen
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Adrian Wai Chan
- Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong S.A.R, China
| | - Narayanee Dick
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Pierluigi Bonomo
- Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Italy
| | - Monique Bareham
- Flinders Health Medical Research Consumer Advisory Board, Flinders University, South Australia, Australia
- South Australia Lymphoedema Compression Garment Subsidy Advisory Group, South Australia, Australia
| | - Julie Ryan Wolf
- Department of Radiation Oncology, University of Rochester, New York, USA
| | - Corina van den Hurk
- R&D Department, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, Netherlands
| | - Margaret Fitch
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Edward Chow
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Raymond J. Chan
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
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Koelmeyer LA, Gaitatzis K, Thompson B, Ward LC. Effects of Body Positioning When Assessing Lymphedema of the Lower Limb Using Bioimpedance Spectroscopy. Lymphat Res Biol 2024; 22:43-54. [PMID: 37851985 DOI: 10.1089/lrb.2022.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
Background: Bioimpedance spectroscopy (BIS) measurements are conventionally performed in supine position with a lead device attached to gel-backed electrodes, and more recently, with a stand-on device that uses fixed stainless-steel electrodes under the hands and feet. The aim of this study was to assess and compare BIS measurements made in supine, sitting, and standing positions using lead and stand-on impedance devices in participants with and without unilateral leg lymphedema. Materials and Methods: Participants with self-ascribed unilateral leg lymphedema (n = 24) and healthy controls (n = 71) were recruited using a cross-sectional study design. Triplicate BIS measurements were taken for each device in each position. Results: Impedance measurements with either device were reliable with coefficient of variation of 0.6% or lower. The magnitude of mean differences in absolute impedance values between devices were between 1% and 6% dependent on condition. L-Dex scores between the two devices were highly correlated (r = 0.82) and ∼70% of participants in the lymphedema group were classified as having lymphedema using the recommended cut-off with either device. There was no significant interleg difference of controls using the lead device; however, small, but significant differences (p = 0.0001) were found when using the stand-on device. Conclusion: The findings demonstrate that reliable impedance measurements of the legs can be made with either device in lying, sitting, or standing positions. However, data between the devices were not directly interchangeable. Although the risk of misidentification was small, reference ranges appropriate to the device and measurement position should be used when converting data to L-Dex scores.
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Affiliation(s)
- Louise A Koelmeyer
- Australian Lymphoedema Education, Research and Treatment Centre, Department of Health Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Katrina Gaitatzis
- Australian Lymphoedema Education, Research and Treatment Centre, Department of Health Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Belinda Thompson
- Australian Lymphoedema Education, Research and Treatment Centre, Department of Health Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Leigh C Ward
- Australian Lymphoedema Education, Research and Treatment Centre, Department of Health Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- School of Chemistry and Molecular Biosciences, The University of Queensland, St. Lucia, Brisbane, Australia
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Trinh XT, Chien PN, Long NV, Van Anh LT, Giang NN, Nam SY, Myung Y. Development of predictive models for lymphedema by using blood tests and therapy data. Sci Rep 2023; 13:19720. [PMID: 37957217 PMCID: PMC10643602 DOI: 10.1038/s41598-023-46567-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023] Open
Abstract
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.
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Affiliation(s)
- Xuan-Tung Trinh
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea
| | - Pham Ngoc Chien
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea
| | - Nguyen-Van Long
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea
| | - Le Thi Van Anh
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea
| | - Nguyen Ngan Giang
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea
- Department of Medical Device Development, College of Medicine, Seoul National University, Seoul, 03080, Republic of Korea
| | - Sun-Young Nam
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea.
| | - Yujin Myung
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea.
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Lauritzen E, Bredgaard R, Laustsen-Kiel CM, Hansen L, Tvedskov T, Damsgaard TE. Indocyanine green angiography in oncoplastic breast surgery, a prospective study. J Plast Reconstr Aesthet Surg 2023; 85:276-286. [PMID: 37541044 DOI: 10.1016/j.bjps.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/30/2023] [Accepted: 07/08/2023] [Indexed: 08/06/2023]
Abstract
INTRODUCTION The use of Indocyanine green angiography (ICG-A) in oncoplastic breast-conserving surgery (OBCS) has not yet been investigated. This prospective trial applied ICG-A in volume displacement and replacement OBCS to localize perforators and determine tissue supplied by the perforator. Furthermore, to investigate and correlate the intraoperative ICG-A to postoperative surgical site infection, skin necrosis, epidermolysis, and timely onset of adjuvant therapy. METHODS ICG-A was performed at three pre-set timepoints during surgery; after lumpectomy, upon dissection of possible perforators, and after wound closure. All patients were followed with clinical evaluations before surgery, 4 weeks, 4-6 months, and 12 months postoperatively. RESULTS Eleven patients were included: seven volume displacement and four volume replacement OBCS. ICG-A located the tissue supplied by the perforator and demonstrated sufficient perfusion in all cases. The ICG-A corresponded to the surgeons' clinical assessment. One patient developed a postoperative infection and seroma and was treated conservatively. No patients had postoperative necrosis, loss of reconstruction, or lymphedema of the arm. Edema of the breast occurred in four patients (36.4%). Scar assessments were significantly worse at 4-weeks and 4-6 months. The quality of life improved significantly during follow-up. Adjuvant treatment was administered timely in all cases. CONCLUSION ICG-A was feasible for OBCS in assessing intraoperative perfusion. Perfusion was sufficient in all patients and corresponded to the surgeon's clinical evaluation. No patients developed postoperative necrosis. Though edema of the breast occurred in 36.4%, a larger sample size is needed to investigate a possible correlation with ICG-A. Further studies, which includes patients requiring extensive tissue replacement challenging the borders of perfusion, are needed.
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Affiliation(s)
- Elisabeth Lauritzen
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Rikke Bredgaard
- Department of Plastic Surgery, Herlev Gentofte Hospital, Denmark
| | | | - Laura Hansen
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tove Tvedskov
- Department of Breast Surgery, Herlev Gentofte Hospital, Denmark
| | - Tine Engberg Damsgaard
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Copenhagen, Denmark
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Jeffers EJ, Wagner JL, Kilgore LJ. ASO Author Reflections: Breast Cancer-Related Lymphedema (BCRL) Surveillance Recommendations with Bioimpedance Spectroscopy. Ann Surg Oncol 2023; 30:6266-6267. [PMID: 37612546 DOI: 10.1245/s10434-023-14099-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 07/24/2023] [Indexed: 08/25/2023]
Affiliation(s)
- Elizabeth J Jeffers
- Division of Breast Surgical Oncology, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Jamie L Wagner
- Division of Breast Surgical Oncology, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Lyndsey J Kilgore
- Division of Breast Surgical Oncology, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA.
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Syed Ibrahim SA, Ibrahim F, Taib NAM, Cho J. A Low-Cost, Portable, and Mobile-Based Bioimpedance Lymphedema Diagnosis and Monitoring System (Mobilymph): A Validation Study. Lymphat Res Biol 2023; 21:463-468. [PMID: 37093011 DOI: 10.1089/lrb.2022.0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
Background: Breast cancer-related lymphedema (BCRL) is a debilitating chronic illness. Early management and prevention of disease progression rely on lymphedema monitoring and assessment. At present, lymphedema monitoring systems are costly and do not promote remote monitoring. Thus, a low-cost, portable, mobile-based bioimpedance lymphedema monitoring system (Mobilymph) was developed to ensure continuous lymphedema surveillance. Method and Results: Forty-five healthy and 100 BCRL participants were recruited in this study. Mobilymph bioimpedance measurement was validated with a Quadscan 4000 on healthy participants' arms. The interarm bioimpedance ratio was determined to evaluate the discriminatory capability of Mobilymph to detect BCRL. Mobilymph's bioimpedance results show no significant difference compared to Quadscan 4000. The interarm bioimpedance ratios were significantly different (p < 0.001), between participants in healthy and Stage 1, Stage 0 and Stage 1, and Stage 1 and Stage 2. Healthy and Stage 0 participants had similar interarm impedance ratios (p = 0.63). Conclusion: The bioimpedance results show that Mobilymph bioimpedance measurement is comparable to Quadscan 4000 and can detect BCRL arms. Thus, Mobilymph lymphedema monitoring system offers a feasible solution for early lymphedema diagnosis and treatment monitoring. Clinical trial registration number: MREC ID No.: 2020316-8181.
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Affiliation(s)
- Syarifah Aisyah Syed Ibrahim
- Department of Biomedical Engineering, Faculty of Engineering, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Fatimah Ibrahim
- Department of Centre for Innovation in Medical Engineering, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Nur Aishah Mohd Taib
- Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Jongman Cho
- Department of Biomedical Engineering, Inje University, Gimhae, Korea
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10
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Jeffers EJ, Wagner JL, Korentager SS, Larson KE, Balanoff CR, Baker J, Chollet-Hinton L, Kilgore LJ. Breast Cancer-Related Lymphedema (BCRL) and Bioimpedance Spectroscopy: Long-Term Follow-Up, Surveillance Recommendations, and Multidisciplinary Risk Factors. Ann Surg Oncol 2023; 30:6258-6265. [PMID: 37535267 DOI: 10.1245/s10434-023-13956-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/06/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Early detection and intervention for breast cancer-related lymphedema (BCRL) significantly decreases progression to persistent BCRL (pBCRL). We aimed to provide long-term follow-up on our early detection with bioimpedance spectroscopy (BIS) and early home intervention demonstrating reduced pBCRL to guide surveillance recommendations. PATIENTS AND METHODS In total, 148 female patients with breast cancer who had axillary lymph node dissection (ALND) from November 2014 to December 2017 were analyzed. Baseline BIS measurements and postoperative follow-up occurred every 3 months for 1 year, biannual for 1 year, and then annually. An elevated BIS triggered evaluation and initiation of at-home interventions with reassessment for resolution versus persistent BCRL (pBCRL). High-risk factors and timing were analyzed. RESULTS Mean follow-up was 55 months, and 65 (44%) patients had an abnormal BIS. Of these, 54 (82%) resolved with home intervention. The overall pBCRL rate was 8%. Average time to first abnormal BIS was 11.7 months. None of the stage 0 patients (0/34) and only 5/25 (20%) of stage 1 patients had pBCRL. All of stage 2 and stage 3 patients (7/7) had pBCRL. pBCRL correlated with number of positive nodes, percentage of positive nodes, stage of lymphedema at diagnosis, and recurring abnormal BIS measurements (p < 0.05). CONCLUSIONS We have shown that patients undergoing ALND with early BCRL identified by BIS who performed home interventions had an 8% pBCRL rate. Patients at high risk for pBCRL should have routine surveillance starting at 9 months postoperatively to identify an opportunity for early intervention.
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Affiliation(s)
- Elizabeth J Jeffers
- Division of Breast Surgical Oncology, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Jamie L Wagner
- Division of Breast Surgical Oncology, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Sabrina S Korentager
- Division of Breast Surgical Oncology, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Kelsey E Larson
- Division of Breast Surgical Oncology, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Christa R Balanoff
- Division of Breast Surgical Oncology, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Jordan Baker
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Lynn Chollet-Hinton
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Lyndsey J Kilgore
- Division of Breast Surgical Oncology, Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA.
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Johansson K, Blom K, Nilsson-Wikmar L, Brogårdh C. Early Intervention with a Compression Sleeve in Mild Breast Cancer-Related Arm Lymphedema: A 12-Month Prospective Observational Study. Cancers (Basel) 2023; 15:2674. [PMID: 37345010 DOI: 10.3390/cancers15102674] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/03/2023] [Accepted: 05/05/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND In our previous randomized controlled trial (RCT), the progression/no progression of mild breast cancer-related arm lymphedema (BCRL) was examined among women randomized to a compression group (CG) with a compression sleeve (compression class (ccl) 1) or not (NCG) for 6 months. In the present prospective study, BCRL in the CG and NCG was followed for 12 months. METHODS At the end of the RCT, 33 women with mild BCRL were eligible in the CG and 37 in the NCG. The proportional differences in no progression/progression of BCRL were defined as a >2% increase from start of RCT or exceeding 10% in the lymphedema relative volume as measured by the water displacement method. In addition, changes in the lymphedema relative volume and tissue dielectric constant ratio, which measures local tissue water, were examined. At the end of the RCT (i.e., after 6 months), a one-month break of the compression treatment was made in the CG. If the lymphedema relative volume progressed by definition, the compression treatment was resumed and continued, with follow-up of all women at 9 and 12 months. RESULTS A larger proportion of women in the NCG showed progression (57%, 61%, 67%) compared to the CG (16%, 22%, 31%) at 6, 9, and 12 months (p < 0.001, 0.005, 0.012), respectively. Twelve (33%) women in the NCG did not progress at all. No changes of the lymphedema relative volume and local tissue water were found over time at any follow-ups, but were stable on a low level. CONCLUSIONS To avoid the progression of mild BCRL into a chronic issue in the long-term, compression sleeve ccl 1 may be applied immediately after early diagnosis of mild BCRL.
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Affiliation(s)
- Karin Johansson
- Department of Health Sciences, Lund University, 221 00 Lund, Sweden
| | - Katarina Blom
- Department of Health Sciences, Lund University, 221 00 Lund, Sweden
- Physiotherapy Cancer, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Lena Nilsson-Wikmar
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, 141 52 Huddinge, Sweden
| | - Christina Brogårdh
- Department of Health Sciences, Lund University, 221 00 Lund, Sweden
- Department of Neurology, Rehabilitation Medicine, Memory Disorders and Geriatrics, Skåne University Hospital, 221 85 Lund, Sweden
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12
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Donahue PMC, MacKenzie A, Filipovic A, Koelmeyer L. Advances in the prevention and treatment of breast cancer-related lymphedema. Breast Cancer Res Treat 2023; 200:1-14. [PMID: 37103598 DOI: 10.1007/s10549-023-06947-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/06/2023] [Indexed: 04/28/2023]
Abstract
PURPOSE Breast cancer-related lymphedema (BCRL) represents a lifelong risk for breast cancer survivors and once acquired becomes a lifelong burden. This review summarizes current BCRL prevention and treatment strategies. FINDINGS Risk factors for BCRL have been extensively studied and their identification has affected breast cancer treatment practice, with sentinel lymph node removal now standard of care for patients with early stage breast cancer without sentinel lymph node metastases. Early surveillance and timely management aim to reduce BCRL incidence and progression, and are further facilitated by patient education, which many breast cancer survivors report not having adequately received. Surgical approaches to BCRL prevention include axillary reverse mapping, lymphatic microsurgical preventative healing (LYMPHA) and Simplified LYMPHA (SLYMPHA). Complete decongestive therapy (CDT) remains the standard of care for patients with BCRL. Among CDT components, facilitating manual lymphatic drainage (MLD) using indocyanine green fluorescence lymphography has been proposed. Intermittent pneumatic compression, nonpneumatic active compression devices, and low-level laser therapy appear promising in lymphedema management. Reconstructive microsurgical techniques such as lymphovenous anastomosis and vascular lymph node transfer are growing surgical considerations for patients as well as liposuction-based procedures for addressing fatty fibrosis formation from chronic lymphedema. Long-term self-management adherence remains problematic, and lack of diagnosis and measurement consensus precludes a comparison of outcomes. Currently, no pharmacological approaches have proven successful. CONCLUSION Progress in prevention and treatment of BCRL continues, requiring advances in early diagnosis, patient education, expert consensus and novel treatments designed for lymphatic rehabilitation following insults.
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Affiliation(s)
- Paula M C Donahue
- Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, 2201 21St Children's Way, Suite 1218, Nashville, TN, 37212, USA.
- Dayani Center for Health and Wellness, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Adrien MacKenzie
- Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Louise Koelmeyer
- Faculty of Medicine, Health, and Human Sciences, Australian Lymphoedema Education, Research, and Treatment (ALERT), Macquarie University, Sydney, Australia
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13
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Naumann L, Reul-Hirche H, Comans T, Burns CL, Paratz J, Cottrell M. Evaluating telehealth for the education and monitoring of lymphoedema and shoulder dysfunction after breast cancer surgery. Support Care Cancer 2023; 31:239. [PMID: 36973519 PMCID: PMC10042668 DOI: 10.1007/s00520-023-07693-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 03/16/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE The primary aim of this study was to compare the attendance rates at a group lymphoedema education and same-day individual surveillance appointment between telehealth (TH) and in-person (IP) care for participants following breast cancer (BC) surgery. Secondary aims included evaluating participant satisfaction and costs between the two service models, while also determining the extent of technical issues and clinician satisfaction towards TH. METHODS Participants following axillary lymph node dissection surgery attended a group lymphoedema education and same-day 1:1 monitoring session via their preferred mode (TH or IP). Attendance rates, satisfaction and costs were recorded for both cohorts, and technical disruption and clinician satisfaction for the TH cohort. RESULTS Fifty-five individuals participated. All 28 participants who nominated the IP intervention attended, while 22/27 who nominated the TH intervention attended an appointment. Overall reported participant experience was positive with no significant differences between cohorts. All TH appointments were successfully completed. Clinicians reported high satisfaction for delivery of education (median = 4[IQR 4-5]) and individual assessment (median = 4[IQR 3-4]) via TH. Median attendance costs per participant were Australian $39.68 (Q1-Q3 $28.52-$68.64) for TH and Australian $154.26 (Q1-Q3 $81.89-$251.48) for the IP cohort. CONCLUSION Telehealth-delivered lymphoedema education and assessment for individuals following BC surgery was associated with favourable satisfaction, cost savings and minimal technical issues despite lower attendance than IP care. This study contributes to the growing evidence for TH and its potential applicability to other populations where risk for cancer-related lymphoedema exists.
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Affiliation(s)
- Leonie Naumann
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Hildegard Reul-Hirche
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
- School of Health Sciences and Social Work, Griffith University, Brisbane, Australia
| | - Tracy Comans
- Centre for Health Services Research, University of Queensland, Brisbane, Australia
- Allied Health Professions, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Clare L Burns
- Speech Pathology Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jenny Paratz
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Health Sciences and Social Work, Griffith University, Brisbane, Australia
| | - Michelle Cottrell
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
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14
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Brunelle CL, Taghian AG. Breast Cancer–Related Lymphedema: the Prospective Surveillance Model, Early Intervention Strategies, and Role of Complete Decongestive Therapy. CURRENT BREAST CANCER REPORTS 2023. [DOI: 10.1007/s12609-023-00471-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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15
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Shah C, Whitworth P, Valente S, Schwarz GS, Kruse M, Kohli M, Brownson K, Lawson L, Dupree B, Vicini FA. Bioimpedance spectroscopy for breast cancer-related lymphedema assessment: clinical practice guidelines. Breast Cancer Res Treat 2023; 198:1-9. [PMID: 36566297 PMCID: PMC9883343 DOI: 10.1007/s10549-022-06850-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 11/30/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE Breast cancer-related lymphedema (BCRL) represents a significant concern for patients following breast cancer treatment, and assessment for BCRL represents a key component of survivorship efforts. Growing data has demonstrated the benefits of early detection and treatment of BCRL. Traditional diagnostic modalities are less able to detect reversible subclinical BCRL while newer techniques such as bioimpedance spectroscopy (BIS) have shown the ability to detect subclinical BCRL, allowing for early intervention and low rates of chronic BCRL with level I evidence. We present updated clinical practice guidelines for BIS utilization to assess for BCRL. METHODS AND RESULTS Review of the literature identified a randomized controlled trial and other published data which form the basis for the recommendations made. The final results of the PREVENT trial, with 3-year follow-up, demonstrated an absolute reduction of 11.3% and relative reduction of 59% in chronic BCRL (through utilization of compression garment therapy) with BIS as compared to tape measurement. This is in keeping with real-world data demonstrating the effectiveness of BIS in a prospective surveillance model. For optimal outcomes patients should receive an initial pre-treatment measurement and subsequently be followed at a minimum quarterly for first 3 years then biannually for years 4-5, then annually as appropriate, consistent with previous guidelines; the target for intervention has been changed from a change in L-Dex of 10 to 6.5. The lack of pre-operative measure does not preclude inclusion in the prospective surveillance model of care. CONCLUSION The updated clinical practice guidelines present a standardized approach for a prospective model of care using BIS for BCRL assessment and supported by evidence from a randomized controlled trial as well as real-world data.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH USA
| | | | - Stephanie Valente
- Department of Breast Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH USA
| | - Graham S. Schwarz
- Deparment of Plastic Surgery, Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, OH USA
| | - Megan Kruse
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH USA
| | - Manpreet Kohli
- Department of General Surgery, RWJ Barnabas Health, West Long Beach, NJ USA
| | - Kirstyn Brownson
- Department of General Surgery, University of Utah, Salt Lake City, UT USA
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16
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Effect of Telerehabilitation Versus In-Clinic Rehabilitation Delivery on Self-Efficacy in Breast Cancer–Related Lymphedema. REHABILITATION ONCOLOGY 2022. [DOI: 10.1097/01.reo.0000000000000326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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17
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Hendrickx AA, Küthe SW, van der Schans CP, Krijnen WP, Mouës-Vink CM, Damstra RJ. Early Referral for Breast-Cancer-Related Lymphedema: Do We Follow the Evidence? A Two-Year Prospective Multicenter Cohort Study. Cancers (Basel) 2022; 14:cancers14236016. [PMID: 36497495 PMCID: PMC9738967 DOI: 10.3390/cancers14236016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
The early detection of breast-cancer-related lymphedema and referral for therapy has the potential to reduce lymphedema-related morbidity. Although research shows the benefits, a gap is observed between evidence and daily practice. We aimed to determine whether the early detection of lymphedema and referral for treatment is adequate following the current guidelines. Women with primary breast cancer treated with breast-conserving therapy or ablative treatment were included. Demographic-, general health-, tumor-, and treatment-related data were recorded. Bilateral arm volume measurements were performed preoperatively and 3, 6, 12, and 24 months post-surgery. A 5% or greater Relative Volume Change was considered the cutoff point for lymphedema and as an indication for therapy referral. After 24 months post-surgery, the main outcomes show that among the patients with early signs of lymphedema, based on a Relative Volume Change ≥5%, a nonreferral for therapy was noted in 83%. Additionally, we observed a significant improvement of the mean Relative Volume Change at 24 months within this group, which might implicate that nonreferral was an adequate choice and that watchful waiting is appropriate when lymphedema is detected within the first year post-surgery.
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Affiliation(s)
- Ad A. Hendrickx
- Center of Expertise for Lymphovascular Medicine, Nij Smellinghe Hospital, Compagnonsplein 1, 9202 NN Drachten, The Netherlands
- Research Group Healthy Ageing Allied Health Care and Nursing, Hanze University of Applied Sciences, 9747 AS Groningen, The Netherlands
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
- Correspondence:
| | - Saskia W. Küthe
- Research Group Healthy Ageing Allied Health Care and Nursing, Hanze University of Applied Sciences, 9747 AS Groningen, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Medical Center Leeuwarden, 8934 AD Leeuwarden, The Netherlands
| | - Cees P. van der Schans
- Research Group Healthy Ageing Allied Health Care and Nursing, Hanze University of Applied Sciences, 9747 AS Groningen, The Netherlands
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
| | - Wim P. Krijnen
- Research Group Healthy Ageing Allied Health Care and Nursing, Hanze University of Applied Sciences, 9747 AS Groningen, The Netherlands
| | - Chantal M. Mouës-Vink
- Department of Plastic, Reconstructive and Hand Surgery, Medical Center Leeuwarden, 8934 AD Leeuwarden, The Netherlands
| | - Robert J. Damstra
- Center of Expertise for Lymphovascular Medicine, Nij Smellinghe Hospital, Compagnonsplein 1, 9202 NN Drachten, The Netherlands
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18
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Ridner SH, Dietrich MS, Boyages J, Koelmeyer L, Elder E, Hughes TM, French J, Ngui N, Hsu J, Abramson VG, Moore A, Shah C. A Comparison of Bioimpedance Spectroscopy or Tape Measure Triggered Compression Intervention in Chronic Breast Cancer Lymphedema Prevention. Lymphat Res Biol 2022; 20:618-628. [PMID: 35099283 PMCID: PMC9810346 DOI: 10.1089/lrb.2021.0084] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background: This study compared rates of progression to chronic breast cancer-related lymphedema (defined as ≥ 10% arm volume change from baseline requiring complex decongestive physiotherapy [CDP]) following an intervention for subclinical lymphedema (S-BCRL) triggered by bioimpedance spectroscopy (BIS) or by tape measurement (TM). Methods and Results: This stratified, randomized, international trial enrolled new breast cancer patients undergoing: mastectomy/partial mastectomy, axillary treatment (dissection, sentinel lymph node biopsy [SLNB] >6 nodes or radiation), radiation therapy (chest wall/breast, supraclavicular fossa), or taxane-based chemotherapy. Following postsurgery eligibility reassessment, centralized, 1:1 randomization to prospective surveillance by BIS or TM occurred. S-BCRL detection triggered a 4-week, 12-hour per day, compression sleeve, and gauntlet intervention. The primary outcome (n = 209), rates of postintervention progression to CDP, was assessed over 3 years. Between June 24, 2014 and September 11, 2018, 1200 patients were enrolled, 963 randomized (BIS n = 482; TM n = 481) and 879 analyzed (BIS n = 442; TM n = 437). Median follow-up was 32.9 months (interquartile range = 22, 35). BIS patients triggered an intervention at a lower rate than TM patients (20.1%, n = 89 vs. 27.5%, n = 120, p = 0.011). Median months to trigger were longer with BIS than TM (9.7; 95% confidence interval [CI], 8.2-12.6 vs. 3.9; 95% CI, 2.8-4.5, p = 0.001). Overall, 14.4% (n = 30) progressed post-intervention, with reduced likelihood for BIS patients than TM patients (7.9%, n = 7 vs. 19.2%, n = 23; relative risk = 0.41; 95% CI, 0.13-0.81; absolute reduction 11.3%; 95% CI, 2.3-20.3; p = 0.016). Conclusions: Compared to TM, BIS provides a more precise identification of patients likely to benefit from an early compression intervention. Clinical Trial Registration number: NCT02167659.
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Affiliation(s)
- Sheila H. Ridner
- Vanderbilt University School of Nursing, Nashville, Tennessee, USA.,Address correspondence to: Sheila H. Ridner, PhD, RN, FAAN, Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, USA
| | - Mary S. Dietrich
- Vanderbilt University School of Nursing, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - John Boyages
- Australian Lymphoedema Education, Research, and Treatment Program, Macquarie University, Macquarie Park, Australia.,Department of Clinical Medicine, Macquarie University, Macquarie Park, Australia.,Medicine, Health & Human Sciences, ICON Cancer Center, Wahroonga, Australia
| | - Louise Koelmeyer
- Australian Lymphoedema Education, Research, and Treatment Program, Macquarie University, Macquarie Park, Australia.,Department of Clinical Medicine, Macquarie University, Macquarie Park, Australia
| | - Elisabeth Elder
- Westmead Breast Cancer Institute, Westmead Hospital, Westmead, Australia.,The University of Sydney, Sydney, Australia.,Lakeside Specialist Breast Clinic, Lakeview Private Hospital, Norwest, Australia
| | - T. Michael Hughes
- Northern Surgical Oncology, Sydney Adventist Hospital, Wahroonga, Australia.,Sydney Adventist Hospital Clinical School, College of Health and Medicine, Australian National University, Acton, Australia
| | - James French
- Westmead Breast Cancer Institute, Westmead Hospital, Westmead, Australia.,The University of Sydney, Sydney, Australia.,Lakeside Specialist Breast Clinic, Lakeview Private Hospital, Norwest, Australia
| | - Nicholas Ngui
- Northern Surgical Oncology, Sydney Adventist Hospital, Wahroonga, Australia
| | - Jeremy Hsu
- Department of Clinical Medicine, Macquarie University, Macquarie Park, Australia.,Westmead Breast Cancer Institute, Westmead Hospital, Westmead, Australia.,The University of Sydney, Sydney, Australia
| | - Vandana G. Abramson
- Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Andrew Moore
- Southeast Cancer Center, Cape Girardeau, Missouri, USA
| | - Chirag Shah
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
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19
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Blom KY, Johansson KI, Nilsson-Wikmar LB, Brogårdh CB. Early intervention with compression garments prevents progression in mild breast cancer-related arm lymphedema: a randomized controlled trial. Acta Oncol 2022; 61:897-905. [PMID: 35657063 DOI: 10.1080/0284186x.2022.2081932] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Early diagnosis and compression treatment are important to prevent progression in breast cancer-related arm lymphedema (BCRAL). However, some mild BCRAL can be reversible, and therefore, compression treatment may not be needed. The aim of this study was to investigate the proportion of women with mild BCRAL showing progression/no progression of lymphedema after treatment with or without compression garments, differences in changes of lymphedema relative volume (LRV), local tissue water and subjective symptoms during 6 months. Also, adherence to self-care was examined. MATERIAL AND METHODS Seventy-five women diagnosed with mild BCRAL were randomized to a compression group (CG) or noncompression group (NCG). Both groups received self-care instructions, and the CG were treated with a standard compression garment (ccl 1). Women in the NCG who progressed in LRV ≥2%, or exceeded 10% dropped out, and received appropriate treatment. The proportion showing progression/no progression of LRV, and changes in LRV was measured by Water Displacement Method. Changes in local tissue water were measured by Tissue Dielectric Constant (TDC), subjective symptoms by Visual Analogue Scale, and self-care by a questionnaire. RESULTS A smaller proportion of LRV progression was found in the CG compared to the NCG at 1, 2 and 6 months follow-up (p ≤ 0.013). At 6 months, 16% had progression of LRV in the CG, compared to 57% in the NCG, (p = 0.001). Thus, 43% in the NCG showed no progression and could manage without compression. Also, CG had a larger reduction in LRV, at all time-points (p ≤ 0.005), and in the highest TDC ratio, when same site followed, at 6 months (p = 0.025). Subjective symptoms did not differ between the groups, except at 1 month, where the CG experienced more reduced tension (p = 0.008). There were no differences in adherence to self-care. CONCLUSION Early treatment with compression garment can prevent progression in mild BCRAL. Trial registration: ISRCT nr ISRCTN51918431.
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Affiliation(s)
- Katarina Y. Blom
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Physiotherapy Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Karin I. Johansson
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Lena B. Nilsson-Wikmar
- Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, Sweden
| | - Christina B. Brogårdh
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Neurology, Rehabilitation Medicine, Memory Disorders and Geriatrics, Skåne University Hospital, Lund, Sweden
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20
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Turgay T, Denkçeken T, Maralcan G. The role of bioimpedance spectroscopy method in severity and stages of breast cancer-related lymphedema. Turk J Surg 2022; 38:11-17. [DOI: 10.47717/turkjsurg.2022.5550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 02/21/2022] [Indexed: 11/23/2022]
Abstract
Objective: The correlation between lymphedema severity and stages determined by standard diagnostic methods and Bioimpedance Spectroscopy (BIS) technique was examined in breast cancer-related lymphedema (BCRL) patients.
Material and Methods: The bioimpedance analyzer device was connected to the 1.0 cm disc electrodes which were connected to the affected and unaffected (healthy) arm of the patients. We evaluated the performance of the impedance (Z) at multiple frequencies (5-50-100-200 kHz) and phase angle (PA), resistance (R), and reactance (XC) at 50 kHz on the lymphedema severity and stages. Bioimpedance measurements were applied to all volunteers in cooperation with the Physical Therapy and Rehabilitation Department. In this study, the correlation between BCRL severity and stages and bioimpedance values was examined.
Results: A total of 31 female patients were recruited to compare the BIS technique with standard diagnostic techniques. The severity of lymphedema was found among the patients as follows; mild 14 (45.2%), moderate 10 (32.3%), and severe 7 (22.6%). The stage distribution of volunteers was; 15 (48.4%) patients in Stage 0, 10 (32.3%) patients in Stage 1, 5 (16.1%) patients in Stage 2, and 1 (3.2%) patient in Stage 3. The ratio of affected and unaffected arm bioimpedance mean values were calculated. Although, this ratio at 50-100-200 kHz Z and 50kHz R were significantly correlated with the lymphedema stages (p< 0.05), there was no correlation and significant difference between the ratio of the bioimpedance values and lymphedema severity (p> 0.05).
Conclusion: The BIS technique is timesaving and can determine lymphedema stages. We found a significant correlation between BCRL stages and BIS, and it appears that BIS is an appropriate, inexpensive, simple, and noninvasive technique for detecting the stages of BCRL.
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21
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Naczk A, Huzarski T, Doś J, Górska-Doś M, Gramza P, Gajewska E, Naczk M. Impact of Inertial Training on Muscle Strength and Quality of Life in Breast Cancer Survivors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:3278. [PMID: 35328964 PMCID: PMC8951502 DOI: 10.3390/ijerph19063278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 12/10/2022]
Abstract
The aim of the study was to evaluate the impact of inertial training on the muscle strength, on breast-cancer-related lymphedema, and on quality of life in breast cancer survivors. After a mastectomy, 24 women (age, 66.2 ± 10.6 years) were randomized to a training (n = 12) or control group (n = 12). The training group performed inertial training twice per week for 6 weeks with a training load of about 70% of the maximal force. Before and after training, we tested the maximum force of shoulder flexors, extensors, abductors, and adductors; body composition; breast-cancer-related lymphedema; and disabilities of the arm, shoulder, and hand. Inertial training significantly improved the strength in all tested muscles (from 32 to 68%; effect size (ES) from 0.89 to 1.85 in the impaired limb and from 31 to 64%; ES from 0.86 to 1.57 in the unimpaired limb). However, changes in the control group were not significant. Quality of life improved following treatment; the disabilities of the arm, shoulder, and hand score decreased significantly by 24.5% (ES from—0.29 to 1.38), p ≤ 0.05 in the training group and by 3.99% (ES from −0.49 to 1.14) in the control group p > 0.05. Breast-cancer-related lymphedema and body composition did not change significantly after the intervention in either group. We recommend inertial training for increasing muscle strength and improving quality of life in breast cancer survivors.
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Affiliation(s)
- Alicja Naczk
- Faculty of Physical Culture in Gorzow Wielkopolski, University School of Physical Education in Poznan, 66-400 Gorzow Wielkopolski, Poland; (A.N.); (J.D.); (M.G.-D.)
| | - Tomasz Huzarski
- Institute of Medical Sciences, Collegium Medicum, University of Zielona Gora, 65-417 Zielona Gora, Poland;
| | - Janusz Doś
- Faculty of Physical Culture in Gorzow Wielkopolski, University School of Physical Education in Poznan, 66-400 Gorzow Wielkopolski, Poland; (A.N.); (J.D.); (M.G.-D.)
- Department of Oncological Physiotherapy, Greater Poland Cancer Centre, 61-866 Poznan, Poland
| | - Magdalena Górska-Doś
- Faculty of Physical Culture in Gorzow Wielkopolski, University School of Physical Education in Poznan, 66-400 Gorzow Wielkopolski, Poland; (A.N.); (J.D.); (M.G.-D.)
| | - Piotr Gramza
- Association of Lubusz Innovation Network, 66-400 Gorzow Wielkopolski, Poland;
| | - Ewa Gajewska
- Department of Developmental Neurology, Poznan University of Medical Sciences, 60-355 Poznan, Poland;
| | - Mariusz Naczk
- Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, 65-417 Zielona Gora, Poland
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22
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Naczk A, Doś J, Górska-Doś M, Sibilski R, Gramza P, Gajewska E, Naczk M. Relationship between Viscoelastic Properties of Tissues and Bioimpedance Spectroscopy in Breast-Cancer-Related Lymphedema. J Clin Med 2022; 11:jcm11051294. [PMID: 35268385 PMCID: PMC8911425 DOI: 10.3390/jcm11051294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/17/2022] [Accepted: 02/24/2022] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to assess the relationship between the viscoelastic properties of tissues and breast-cancer-related lymphedema (BCRL). After a mastectomy, 46 females were allocated into a lymphedema group (L; n = 15, lymphedema occurred) and a control group (C; n = 31, lack of lymphedema). Bioimpedance spectroscopy was used to test BCRL. The mechanical properties of the tissues in both upper limbs were tested using myotonometry. In group L, tone, stiffness, relaxation time, and creep measured on the biceps brachii of the impaired limb significantly differed from the results on the unimpaired limb. In group C, the differences were not significant. Moreover, both tone and stiffness were inversely correlated with the level of lymphedema (r = −0.72 and r = −0.88, respectively), and both relaxation and creep were significantly related to the level of lymphedema (r = 0.71 and r = 0.59, respectively), when myotonometry was completed on the biceps brachii of the impaired limb in group L. The relationships were not significant in group C. Measurements of viscoelastic properties can provide useful information concerning lymphedema. Our findings suggest that significant correlations between selected mechanical properties of the tissues and BCRL can be used in BCRL detection and treatment.
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Affiliation(s)
- Alicja Naczk
- Faculty of Physical Culture in Gorzow Wielkopolski, University School of Physical Education in Poznan, Estkowskiego Street 13, 66-400 Gorzow Wielkopolski, Poland; (A.N.); (J.D.); (M.G.-D.)
| | - Janusz Doś
- Faculty of Physical Culture in Gorzow Wielkopolski, University School of Physical Education in Poznan, Estkowskiego Street 13, 66-400 Gorzow Wielkopolski, Poland; (A.N.); (J.D.); (M.G.-D.)
- Department of Oncological Physiotherapy, Greater Poland Cancer Centre, Garbary Street 15, 61-866 Poznan, Poland
| | - Magdalena Górska-Doś
- Faculty of Physical Culture in Gorzow Wielkopolski, University School of Physical Education in Poznan, Estkowskiego Street 13, 66-400 Gorzow Wielkopolski, Poland; (A.N.); (J.D.); (M.G.-D.)
| | - Robert Sibilski
- Institute of Medical Sciences, Collegium Medicum, University of Zielona Gora, Licealna Street 9, 65-417 Zielona Gora, Poland;
| | - Piotr Gramza
- Association of Lubusz Innovation Network, Teatralna Street 49, 66-400 Gorzow Wielkopolski, Poland;
| | - Ewa Gajewska
- Department of Developmental Neurology, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355 Poznan, Poland;
| | - Mariusz Naczk
- Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, Licealna Street 9, 65-417 Zielona Gora, Poland
- Correspondence:
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Rafn BS, Christensen J, Larsen A, Bloomquist K. Prospective Surveillance for Breast Cancer-Related Arm Lymphedema: A Systematic Review and Meta-Analysis. J Clin Oncol 2022; 40:1009-1026. [PMID: 35077194 DOI: 10.1200/jco.21.01681] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The call to integrate prospective surveillance for lymphedema into cancer care pathways is building momentum to enable early intervention and prevent the progression of the condition. We offer a critical evaluation of the literature on prospective surveillance and early management for cancer-related lymphedema and evaluate the effect of such programs in preventing chronic lymphedema (CRD42019137965). METHODS Five databases and two registries were searched for randomized controlled trials or observational studies that assessed the incidence or prevalence of lymphedema associated with participation in a prospective surveillance program, published until February 26, 2021. Numbers triggered for early lymphedema management, resolved, and chronic lymphedema were extracted. Pooled relative risk (trials) and pooled rate (cumulative incidence; observational studies) of chronic lymphedema was calculated. Subgroup analyses assessed the effect of study design, length of follow-up, and extent of axillary surgery. RESULTS Twenty-three studies were included, of which 21 studies evaluated breast cancer-related arm lymphedema (BCRaL). Participation in prospective surveillance with early management reduced the risk of chronic BCRaL versus usual care (relative risk 0.31; 95% CI, 0.10 to 0.95; two randomized controlled trials; N = 106). The pooled rate of chronic BCRaL was 4% (95% CI, 3 to 6; 15 observational studies; N = 3,545), and 6% (95% CI, 4 to 9) when restricted to participants with axillary lymph node dissection (12 studies; N = 1,527). CONCLUSION The findings suggest that participation in prospective surveillance with early management reduces the risk of chronic BCRaL. Only a minority of patients at high risk of lymphedema because of axillary surgery developed chronic lymphedema. More robust research is needed to determine whether prospective surveillance with early management can reduce the risk of chronic lymphedema, particularly among cancer survivors other than breast cancer.
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Affiliation(s)
- Bolette S Rafn
- Cancer Survivorship and Treatment Late Effects Research Unit (CASTLE), Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jan Christensen
- Department of Occupational Therapy and Physiotherapy, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Anders Larsen
- University Hospitals Centre for Health Research (UCSF), Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Kira Bloomquist
- University Hospitals Centre for Health Research (UCSF), Copenhagen University Hospital, Rigshospitalet, Denmark
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Chang CC, Jan WL, Juan CH, Meng NH, Lin BS, Chen HC. Novel Wireless Bioimpedance Device for Segmental Lymphedema Analysis Post Dual-Site Free Vascularized Lymph Node Transfer: A Prospective Cohort Study. SENSORS 2021; 21:s21248187. [PMID: 34960279 PMCID: PMC8707995 DOI: 10.3390/s21248187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 01/02/2023]
Abstract
An innovative wireless device for bioimpedance analysis was developed for post-dual-site free vascularized lymph node transfer (VLNT) evaluation. Seven patients received dual-site free VLNT for unilateral upper or lower limb lymphedema. A total of 10 healthy college students were enrolled in the healthy control group. The device was applied to the affected and unaffected limbs to assess segmental alterations in bioimpedance. The affected proximal limb showed a significant increase in bioimpedance at postoperative sixth month (3.3 [2.8, 3.6], p = 0.001) with 10 kHz currents for better penetration, although the difference was not significant (3.3 [3.3, 3.8]) at 1 kHz. The bioimpedance of the affected distal limb significantly increased after dual-site free VLNT surgery, whether passing with the 1 kHz (1.6 [0.7, 3.4], p = 0.030, postoperative first month; 2.8 [1.0, 4.2], p = 0.027, postoperative third month; and 1.3 [1.3, 3.4], p = 0.009, postoperative sixth month) or 10 kHz current ((1.4 [0.5, 2.7], p = 0.049, postoperative first month; 3.2 [0.9, 6.3], p = 0.003, postoperative third month; and 3.6 [2.5, 4.1], p < 0.001, postoperative sixth month). Bioimpedance alterations on the affected distal limb were significantly correlated with follow-up time (rho = 0.456, p = 0.029 detected at 10 kHz). This bioimpedance wireless device could quantitatively monitor the interstitial fluid alterations, which is suitable for postoperative real-time surveillance.
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Affiliation(s)
- Chang-Cheng Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung 404332, Taiwan; (C.-C.C.); (W.-L.J.)
- School of Medicine, College of Medicine, China Medical University, Taichung 404333, Taiwan
- Institute of Imaging and Biomedical Photonics, National Yang Ming Chiao Tung University, Tainan 711010, Taiwan
| | - Wei-Ling Jan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung 404332, Taiwan; (C.-C.C.); (W.-L.J.)
| | - Cheng-Huei Juan
- Institute of Biomedical Science, China Medical University, Taichung 404333, Taiwan;
| | - Nai-Hsin Meng
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung 404332, Taiwan;
| | - Bor-Shyh Lin
- Institute of Imaging and Biomedical Photonics, National Yang Ming Chiao Tung University, Tainan 711010, Taiwan
- Correspondence: (B.-S.L.); (H.-C.C.); Tel.: +886-6-3032121-57835 (B.S.-L.); +886-4-22052121-1538 (H.-C.C.)
| | - Hung-Chi Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung 404332, Taiwan; (C.-C.C.); (W.-L.J.)
- International Medical Service Center, China Medical University Hospital, Taichung 404332, Taiwan
- Correspondence: (B.-S.L.); (H.-C.C.); Tel.: +886-6-3032121-57835 (B.S.-L.); +886-4-22052121-1538 (H.-C.C.)
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Ward LC, Koelmeyer LA, Moloney E. Staging Breast Cancer-Related Lymphedema with Bioimpedance Spectroscopy. Lymphat Res Biol 2021; 20:398-408. [PMID: 34756114 DOI: 10.1089/lrb.2021.0013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background: A number of different classification schemes, with generally similar but not identical criteria, exist to describe the different stages of lymphedema. Criteria may include both subjective and objective assessments. The present study investigated whether bioelectrical impedance parameters had utility in staging breast cancer-related lymphedema. Methods and Results: Hierarchical agglomerative cluster analysis was used to assign women (n = 221) at risk of or with clinically ascribed lymphedema to clusters sharing similar impedance characteristics. Five clusters could be identified with each cluster containing proportions of participants that closely aligned with staging allocation, according to International Society of Lymphology criteria, at initial presentation. The use of cluster analysis for tracking of lymphedema progression or response to treatment is demonstrated. Conclusions: No single assessment provides definitive assignment of a patient to lymphedema stage. Staging is usually achieved by identifying and allocating a patient to a lymphedema stage shared by a group of patients with similar clinical signs. Cluster analysis of impedance data provides similar groupings of patients and could provide a useful adjunct objective assessment for staging lymphedema.
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Affiliation(s)
- Leigh C Ward
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Australia
| | - Louise A Koelmeyer
- Australian Lymphoedema Education, Research & Treatment Program, Department of Clinical Medicine, Macquarie University, Sydney, Australia
| | - Emma Moloney
- Australian Lymphoedema Education, Research & Treatment Program, Department of Clinical Medicine, Macquarie University, Sydney, Australia
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Onoda S, Satake T, Kinoshita M. Relationship Between Lymphaticovenular Anastomosis Outcomes and The Number and Types of Anastomoses. J Surg Res 2021; 269:103-109. [PMID: 34547586 DOI: 10.1016/j.jss.2021.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 07/25/2021] [Accepted: 08/01/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Lymphaticovenular anastomosis (LVA) is the first-line treatment for lymphedema in many hospitals. However, many aspects of its effects remain unclear. This study aimed to analyze problems with regard to the relationship between lymphaticovenular anastomosis and outcomes of surgery for lymphedema in the upper and lower extremities. METHODS Eighteen articles were selected for review. The following information was extracted from these articles as factors associated with LVA for lymphedema in the upper and lower extremities: number of cases, average patient age, mean number of bypasses, lymphedema stage, duration and type of lymphedema, anastomotic technique, follow-up period, type of scale, and treatment outcomes. RESULTS Upper extremity lymphedema: The average age of patients was 54.2 (range: 41.3-60.1) years. The mean number of anastomoses was 3.91 (range: 1.0-7.2). Six of nine articles provided data for volume change, and the mean volume change was 29% (-5%-50%). Lower extremity lymphedema: The average age of patients was 50.3 (range: 34-64 years). The mean number of anastomoses was 4.6 (range: 2.1-9.3). Comparison was difficult as different methods were used for postoperative evaluation (lower extremity lymphedema index in three patients, limb circumference in one, volume change in two, and restaging in three). CONCLUSIONS We obtained useful information with regard to the effects of LVA in this review. An increased number of anastomoses between the lymphatic ducts and veins did not seem to improve the effectiveness of LVA. With regard to the stage of lymphedema, LVA may be useful for both early and advanced stages.
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Affiliation(s)
- Satoshi Onoda
- Department of Plastic and Reconstructive Surgery, Kagawa Rosai Hospital, Kagawa, Japan.
| | - Toshihiko Satake
- Department of Plastic and Reconstructive Surgery, Toyama University Hospital, Toyama, Japan
| | - Masahito Kinoshita
- Department of Plastic and Reconstructive Surgery, Kagawa Rosai Hospital, Kagawa, Japan
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Wei X, Lu Q, Jin S, Li F, Zhao Q, Cui Y, Jin S, Cao Y, Fu MR. Developing and validating a prediction model for lymphedema detection in breast cancer survivors. Eur J Oncol Nurs 2021; 54:102023. [PMID: 34500318 DOI: 10.1016/j.ejon.2021.102023] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/30/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Early detection and intervention of lymphedema is essential for improving the quality of life of breast cancer survivors. Previous studies have shown that patients have symptoms such as arm tightness and arm heaviness before experiencing obvious limb swelling. Thus, this study aimed to develop a symptom-warning model for the early detection of breast cancer-related lymphedema. METHODS A cross-sectional study was conducted at a tertiary hospital in Beijing between April 2017 and December 2018. A total of 24 lymphedema-associated symptoms were identified as candidate predictors. Circumferential measurements were used to diagnose lymphedema. The data were randomly split into training and validation sets with a 7:3 ratio to derive and evaluate six machine learning models. Both the discrimination and calibration of each model were assessed on the validation set. RESULTS A total of 533 patients were included in the study. The logistic regression model showed the best performance for early detection of lymphedema, with AUC = 0.889 (0.840-0.938), sensitivity = 0.771, specificity = 0.883, accuracy = 0.825, and Brier scores = 0.141. Calibration was also acceptable. It has been deployed as an open-access web application, allowing users to estimate the probability of lymphedema individually in real time. The application can be found at https://apredictiontoolforlymphedema.shinyapps.io/dynnomapp/. CONCLUSION The symptom-warning model developed by logistic regression performed well in the early detection of lymphedema. Integrating this model into an open-access web application is beneficial to patients and healthcare providers to monitor lymphedema status in real-time.
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Affiliation(s)
- Xiaoxia Wei
- Division of Medical & Surgical Nursing, School of Nursing, Peking University, 100191, Beijing, China
| | - Qian Lu
- Division of Medical & Surgical Nursing, School of Nursing, Peking University, 100191, Beijing, China.
| | - Sanli Jin
- Division of Medical & Surgical Nursing, School of Nursing, Peking University, 100191, Beijing, China
| | - Fenglian Li
- Division of Medical & Surgical Nursing, School of Nursing, Peking University, 100191, Beijing, China
| | - Quanping Zhao
- Department of Breast Surgery, People's Hospital, Peking University, 100044, Beijing, China
| | - Ying Cui
- Department of Breast Surgery, People's Hospital, Peking University, 100044, Beijing, China
| | - Shuai Jin
- Division of Medical & Surgical Nursing, School of Nursing, Peking University, 100191, Beijing, China
| | - Yiwei Cao
- Division of Medical & Surgical Nursing, School of Nursing, Peking University, 100191, Beijing, China
| | - Mei R Fu
- Rutgers, The State University of New Jersey School of Nursing, Camden, USA
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Evaluating the Impact of Immediate Lymphatic Reconstruction for the Surgical Prevention of Lymphedema. Plast Reconstr Surg 2021; 147:373e-381e. [PMID: 33620920 DOI: 10.1097/prs.0000000000007636] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Breast cancer-related lymphedema affects one in five patients. Its risk is increased by axillary lymph node dissection and regional lymph node radiotherapy. The purpose of this study was to evaluate the impact of immediate lymphatic reconstruction or the lymphatic microsurgical preventative healing approach on postoperative lymphedema incidence. METHODS The authors performed a retrospective review of all patients referred for immediate lymphatic reconstruction at the authors' institution from September of 2016 through February of 2019. Patients with preoperative measurements and a minimum of 6 months' follow-up data were identified. Medical records were reviewed for demographics, cancer treatment data, intraoperative management, and lymphedema incidence. RESULTS A total of 97 women with unilateral node-positive breast cancer underwent axillary nodal surgery and attempt at immediate lymphatic reconstruction over the study period. Thirty-two patients underwent successful immediate lymphatic reconstruction with a mean patient age of 54 years and body mass index of 28 ± 6 kg/m2. The median number of lymph nodes removed was 14 and the median follow-up time was 11.4 months (range, 6.2 to 26.9 months). Eighty-eight percent of patients underwent adjuvant radiotherapy of which 93 percent received regional lymph node radiotherapy. Mean L-Dex change was 2.9 units and mean change in volumetry by circumferential measurements and perometry was -1.7 percent and 1.3 percent, respectively. At the end of the study period, we found an overall 3.1 percent rate of lymphedema. CONCLUSION Using multiple measurement modalities and strict follow-up guidelines, the authors' findings support that immediate lymphatic reconstruction at the time of axillary surgery is a promising, safe approach for lymphedema prevention in a high-risk patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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29
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Gasteratos K, Morsi-Yeroyannis A, Vlachopoulos NC, Spyropoulou GA, Del Corral G, Chaiyasate K. Microsurgical techniques in the treatment of breast cancer-related lymphedema: a systematic review of efficacy and patient outcomes. Breast Cancer 2021; 28:1002-1015. [PMID: 34254232 PMCID: PMC8354929 DOI: 10.1007/s12282-021-01274-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 06/17/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Secondary lymphedema is the abnormal collection of lymphatic fluid within subcutaneous structures. Patients with lymphedema suffer a low quality of life. In our study, we aim to provide a systematic review of the current data on patient outcomes regarding breast cancer-related lymphedema (BCRL), and the most prevalent reconstructive techniques. METHODS A PubMed (MEDLINE) and Scopus literature search was performed in September 2020. Studies were screened based on inclusion/exclusion criteria. The protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO), and it was reported in line with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). RESULTS The search yielded 254 papers from 2010 to 2020. 67 were included in our study. Lymphaticovenous anastomosis (LVA)-a minimally invasive procedure diverting the lymph into the dermal venous drainage system-combined with postoperative bandaging and compression garments yields superior results with minimal donor site lymphedema morbidity. Vascularized lymph node transfer (VLNT)-another microsurgical technique, often combined with autologous free flap breast reconstruction-improves lymphedema and brachial plexus neuropathies, and reduces the risk of cellulitis. The combination of LVA and VLNT or with other methods maximizes their effectiveness. Vascularized lymph vessel transfer (VLVT) consists of harvesting certain lymph vessels, sparing the donor site's lymph nodes. CONCLUSION Together with integrated lymphedema therapy, proper staging, and appropriate selection of procedure, safe and efficient surgical techniques can be beneficial to many patients with BCRL.
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Affiliation(s)
- Konstantinos Gasteratos
- Department of Plastic and Reconstructive Surgery, Papageorgiou General Hospital, Thessaloniki, Greece
| | | | | | | | - Gabriel Del Corral
- Department of Plastic and Reconstructive Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Kongkrit Chaiyasate
- Division of Plastic and Reconstructive Surgery, Oakland University William Beaumont School of Medicine, William Beaumont and Beaumont Children's Hospital, 3555 W 13 Mile Rd, Suite N120, Royal Oak, MI, 48073, USA.
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30
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Forte AJ, Huayllani MT, Boczar D, Avila FR, Kassis S, Ciudad P, Lu X, Moore PA, McLaughlin SA. Use of bioimpedance spectroscopy for prospective surveillance and early diagnosis of breast cancer-related lymphedema. Breast Dis 2021; 40:85-93. [PMID: 33646139 DOI: 10.3233/bd-201008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Bioimpedance spectroscopy has been suggested as a useful tool for early diagnosis of breast cancer-related lymphedema (BCRL). We aimed to describe the outcomes of published studies that evaluated bioimpedance analysis as a method for prospective surveillance and early diagnosis of BCRL. METHODS We queried the PubMed, Ovid Medline, and EMBASE databases to identify studies that evaluated use of bioimpedance spectroscopy as a diagnostic tool. We used the keywords "bioimpedance" AND ("lymphedema" OR "lymphoedema") in the search. Only English-language studies that reported quantitative outcomes for patients with BCRL were included. RESULTS Of 152, 235 and 116 identified articles in PubMed, Ovid Medline and EMBASE databases, only 22 were included. Use of bioimpedance analysis for prospective surveillance has been shown to prevent chronic BCRL. All the cross-sectional and retrospective studies that evaluated bioimpedance for diagnosis of BCRL reported significantly different L-Dex scores between lymphedema patients and healthy participants; in addition, bioimpedance scores were positively correlated with volume of lymphedema. CONCLUSION Bioimpedance analysis is a potential tool with demonstrated benefits for prevention of chronic BCRL and may be an economic and great alternative for early diagnosis of BCRL.
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Affiliation(s)
- Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Daniel Boczar
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Salam Kassis
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Xiaona Lu
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Pamela A Moore
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
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Bucci LK, Brunelle CL, Bernstein MC, Shui AM, Gillespie TC, Roberts SA, Naoum GE, Taghian AG. Subclinical Lymphedema After Treatment for Breast Cancer: Risk of Progression and Considerations for Early Intervention. Ann Surg Oncol 2021; 28:8624-8633. [PMID: 34117574 DOI: 10.1245/s10434-021-10173-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/29/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Breast cancer-related lymphedema (BCRL) is a devastating complication of breast cancer (BC) treatment. The authors hypothesized that identifying subclinical lymphedema (SCL) presents an opportunity to prevent BCRL development. They aimed to assess rates of SCL progression (relative volume change [RVC], 5-10%) to BCRL (RVC, ≥10%) in women undergoing axillary surgery for BC via axillary lymph node dissection (ALND) or sentinel lymph node biopsy (SLNB). METHODS Patients treated for BC were prospectively screened at preoperative baseline and throughout the follow-up period using the perometer. The cohort was stratified according to nodal surgery (ALND or SLNB) to analyze rates of progression to BCRL. RESULTS The study cohort included 1790 patients. Of the 1359 patients who underwent SLNB, 331 (24.4%) experienced SCL, with 38 (11.5%) of these patients progressing to BCRL. Of the 431 patients who underwent ALND, 171 (39.7%) experienced SCL, with 67 (39.2%) of these patients progressing to BCRL. Relative to the patients without SCL, those more likely to experience BCRL were the ALND patients with early SCL (< 3 months postoperatively; hazard ratio [HR], 2.60; 95% confidence interval [CI], 1.58-4.27; p = 0.0002) or late SCL (≥3 months postoperatively; HR, 3.14; 95% CI, 1.95-5.05; p < 0.0001) and the SLNB patients with early SCL (HR, 6.75; 95% CI, 3.8-11.98; p < 0.0001 or late SCL (HR, 3.02; 95% CI, 1.65-5.50; p = 0.0003). CONCLUSION The study suggests that patients with SCL after axillary nodal surgery for BC are more likely to progress to BCRL than those who do not experience SCL. This presents a tremendous opportunity for early intervention to prevent BCRL and improve the quality of life for women treated for BC.
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Affiliation(s)
- Loryn K Bucci
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cheryl L Brunelle
- Department of Physical and Occupational Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - Madison C Bernstein
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy M Shui
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Tessa C Gillespie
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sacha A Roberts
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George E Naoum
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Secondary lymphedema from cancer therapy. Clin Exp Metastasis 2021; 39:239-247. [PMID: 33950413 DOI: 10.1007/s10585-021-10096-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 04/03/2021] [Indexed: 10/21/2022]
Abstract
This manuscript is a summary of findings focusing on various aspects of secondary lymphedema specifically as a sequelae of treatment for cancer. The topic was addressed at a session held during the 8th International Congress on Cancer Metastasis that was unique a for the inclusion of patients with lymphedema and therapists joining physicians, healthcare professionals, and researchers in an effort to give an overview of secondary lymphedema following cancer therapy as well as highlighting the unknowns in the field. Lymphedema is defined and both diagnosis and incidence of cancer-related lymphedema are explored. Further, exploration of imaging options for lymphedema and information on the genetic research for patients with cancer-related secondary lymphedema are presented. Patient education and early detection methods are then explored followed by conservative treatment. Finally, an examination of surgical treatment methods available for patients with lymphedema is covered. Overall, this manuscript presents valuable information and updates for those not familiar with incidence, diagnosis, early detection, and rehabilitation of patients with cancer-related secondary lymphedema.
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Brix B, Sery O, Onorato A, Ure C, Roessler A, Goswami N. Biology of Lymphedema. BIOLOGY 2021; 10:biology10040261. [PMID: 33806183 PMCID: PMC8065876 DOI: 10.3390/biology10040261] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/15/2021] [Accepted: 03/23/2021] [Indexed: 12/17/2022]
Abstract
Simple Summary Lymphedema is a chronic, debilitating disease of the lymphatic vasculature. Although several reviews focus on the anatomy and physiology of the lymphatic system, this review provides an overview of the lymphatic vasculature and, moreover, of lymphatic system dysfunction and lymphedema. Further, we aim at advancing the knowledge in the area of lymphatic system function and how dysfunction of the lymphatic system—as seen in lymphedema—affects physiological systems, such as the cardiovascular system, and how those might be modulated by lymphedema therapy. Abstract This narrative review portrays the lymphatic system, a poorly understood but important physiological system. While several reviews have been published that are related to the biology of the lymphatic system and lymphedema, the physiological alternations, which arise due to disturbances of this system, and during lymphedema therapy, are poorly understood and, consequently, not widely reported. We present an inclusive collection of evidence from the scientific literature reflecting important developments in lymphedema research over the last few decades. This review aims at advancing the knowledge on the area of lymphatic system function as well as how system dysfunction, as seen in lymphedema, affects physiological systems and how lymphedema therapy modulates these mechanisms. We propose that future studies should aim at investigating, in-detail, aspects that are related to fluid regulation, hemodynamic responses, and endothelial and/or vascular changes due to lymphedema and lymphedema therapy.
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Affiliation(s)
- Bianca Brix
- Gravitational Physiology and Medicine Research Unit, Division of Physiology, Otto Loewi Research Center, Medical University of Graz, 3810 Graz, Austria; (B.B.); (A.R.)
| | - Omar Sery
- Faculty of Science, Masaryk University, Kotlářská 2, 61137 Brno, Czech Republic;
| | | | - Christian Ure
- Wolfsberg Clinical Center for Lymphatic Disorders, Wolfsberg State Hospital, KABEG, 9400 Wolfsberg, Austria;
| | - Andreas Roessler
- Gravitational Physiology and Medicine Research Unit, Division of Physiology, Otto Loewi Research Center, Medical University of Graz, 3810 Graz, Austria; (B.B.); (A.R.)
| | - Nandu Goswami
- Gravitational Physiology and Medicine Research Unit, Division of Physiology, Otto Loewi Research Center, Medical University of Graz, 3810 Graz, Austria; (B.B.); (A.R.)
- Correspondence: ; Tel.: +43-316-385-73852
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Boyages J, Vicini FA, Shah C, Koelmeyer LA, Nelms JA, Ridner SH. The Risk of Subclinical Breast Cancer-Related Lymphedema by the Extent of Axillary Surgery and Regional Node Irradiation: A Randomized Controlled Trial. Int J Radiat Oncol Biol Phys 2021; 109:987-997. [PMID: 33127493 DOI: 10.1016/j.ijrobp.2020.10.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/09/2020] [Accepted: 10/17/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE To compare the risk of subclinical breast cancer-related lymphedema (sBCRL) using bioimpedance spectroscopy (BIS) or tape measure (TM) by the extent of axillary surgery and regional nodal irradiation (RNI). METHODS AND MATERIALS Patients were randomized to surveillance with TM or BIS. A BIS ≥6.5 L-Dex units or TM volume change ≥5 and <10% above presurgical baselines "triggered" sBCRL. The incidence of sBCRL by sentinel node biopsy or axillary lymph node dissection (ALND) with or without RNI was examined for 484 patients. Radiation was categorized as "limited RNI" (axilla level I/II only) or "extensive RNI" (axilla level III or supraclavicular fossa with or without level I/II). RESULTS At a median follow-up of 20.5 months, 109 of 498 patients (21.9%) triggered sBCRL (BIS 13.5% vs TM 25.6%; P <.001). In patients not receiving RNI, BIS triggered 12.9% of patients undergoing SNB and 25.0% undergoing ALND (P = .18). Extensive RNI significantly increased triggering with BIS versus no RNI after sentinel node biopsy (SNB; 33.3% vs 12.9%; P = .03) but not ALND (30.8% vs 25.0%; P = .69). Triggering by TM was greater than 25% for most subgroups and was inferior to BIS in discriminating the risk of sBCRL by utilization of RNI or axillary surgery. CONCLUSIONS The lower triggering rates with BIS and its better discrimination of the risk of sBCRL by receipt and type of RNI compared with TM support its use for posttreatment surveillance to detect sBCRL and to initiate early intervention. The risk of sBCRL increased with more extensive axillary treatment. Patients having ALND or extensive RNI require close surveillance for BCRL. Longer follow-up is required to determine rates of progression to clinical lymphedema.
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Affiliation(s)
- John Boyages
- Australian Lymphedema Education, Research and Treatment program, Macquarie University, Sydney, Australia; Icon Cancer Centre, Wahroonga, New South Wales, Australia.
| | - Frank A Vicini
- Michigan Healthcare Professionals, 21St Century Oncology, Farmington Hills, Michigan
| | - Chirag Shah
- Cleveland Clinic, Taussig Cancer Institute, Department of Radiation Oncology, Cleveland, Ohio
| | - Louise A Koelmeyer
- Australian Lymphedema Education, Research and Treatment program, Macquarie University, Sydney, Australia
| | - Jerrod A Nelms
- TTi Health Research and Economics, Westminster, Maryland
| | - Sheila H Ridner
- School of Nursing, Vanderbilt University, Nashville, Tennessee
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Kim N, Kim H, Hwang JH, Park W, Cho WK, Yeo SM, Lee H, Lee SK. Longitudinal impact of postmastectomy radiotherapy on arm lymphedema in patients with breast cancer: An analysis of serial changes in arm volume measured by infrared optoelectronic volumetry. Radiother Oncol 2021; 158:167-174. [PMID: 33667586 DOI: 10.1016/j.radonc.2021.02.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/16/2021] [Accepted: 02/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE This study was conducted to evaluate the longitudinal impact of postmastectomy radiation therapy (PMRT) on persistent severe lymphedema (PSL) using arm volume measurements by an infrared optoelectronic volumetry. MATERIALS AND METHODS Of the patients who underwent mastectomy between 2008 and 2016, we included 330 patients with secondary arm lymphedema. Percentage of excessive volume (PEV) of the arm were serially assessed using an optoelectronic volumetry 1, 3, 6, 12, 18, 24, 36, and 48 months after the lymphedema diagnosis (Tlymh_Dx). We defined PSL as 2 or more episodes of PEV ≥ 20%. Risk factors for PSL were evaluated using stepwise regression analyses. RESULTS Patients who received PMRT (n = 202, 61.2%) were more likely to have larger extent of axillary node dissection (AND), and frequent stage II/III lymphedema at Tlymh_Dx than those who did not receive PMRT (p < 0.001). With a median follow-up of 72.5 months, PSL occurred in 71 (21.5%) patients. Patients with PSL were more frequently treated with AND of ≥ 20 nodes without reconstruction, had advanced lymphedema stage and higher PEV at Tlymh_Dx, and more frequent events of cellulitis compared to those without PSL. The risk of developing PSL was significantly associated with PMRT with regional node irradiation (RNI), AND of ≥20 nodes, lymphedema stage, and PEV at Tlymh_Dx, cellulitis, and compliance with physical therapy. CONCLUSION PMRT, especially RNI, was associated with a consistent increase in PEV in patients with arm lymphedema. Therefore, timely physical therapy is necessary for this patient population.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Ji Hye Hwang
- Department of Physical & Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung Mi Yeo
- Department of Physical & Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyebin Lee
- Department of Radiation Oncology, Kangbook Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sei Kyung Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Koelmeyer L, Gaitatzis K, Ridner SH, Boyages J, Nelms J, Hughes TM, Elder E, French J, Ngui N, Hsu J, Stolldorf D. Implementing a prospective surveillance and early intervention model of care for breast cancer-related lymphedema into clinical practice: application of the RE-AIM framework. Support Care Cancer 2021; 29:1081-1089. [PMID: 32613370 PMCID: PMC10979505 DOI: 10.1007/s00520-020-05597-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/23/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Chronic lymphedema following breast cancer (BC) affects individuals physically, functionally, psychologically, and financially. Despite national guidelines and evidence-based research supporting a prospective surveillance and early intervention model of care (PSM), bridging the gap between research and clinical practice has been difficult. METHOD As part of an international randomized controlled trial (RCT), Australian women with BC from four hospitals were recruited, monitored for lymphedema at regular intervals over a 3-year period, and were provided a compression garment if intervention was triggered. The reach, effectiveness, adoption, implementation and maintenance (RE-AIM) evaluation framework was used retrospectively to assess a PSM at the individual and organizational level for those who had completed at least 2-year follow-up (N = 219) in the RCT. RESULTS The application of the RE-AIM framework retrospectively demonstrated an extensive reach to patients across public and private settings; the effectiveness of prospective surveillance and early intervention was achieved through low progression rates to clinical lymphedema (1.8%), and all hospital sites initially approached adopted the research study. Key implementation strategies necessary for effectiveness of this model of care included education to health professionals and patients, staff acceptability, and development of a referral and care pathway. Maintenance dimensions were evaluated both at the individual level with 92-100% adherence rates for all nonoptional study appointments over the 2-year period, and at the organizational-level, PSM was sustained after recruitment ceased for the research study. CONCLUSION The PSM for lymphedema in BC can be successfully implemented using the RE-AIM framework applied retrospectively. The implementation of the PSM used in the RCT has assisted in changing clinical practices and improving the quality and effectiveness of the health care system.
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Affiliation(s)
- Louise Koelmeyer
- Australian Lymphoedema Education, Research and Treatment (ALERT) Program, Department of Clinical Medicine, Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, Australia.
| | - Katrina Gaitatzis
- Australian Lymphoedema Education, Research and Treatment (ALERT) Program, Department of Clinical Medicine, Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, Australia
| | | | - John Boyages
- Australian Lymphoedema Education, Research and Treatment (ALERT) Program, Department of Clinical Medicine, Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, Australia
- Icon Cancer Centre, Sydney, NSW, Australia
| | - Jerrod Nelms
- TTi Health Research and Economics, Westminster, MD, USA
| | - T Michael Hughes
- Northern Surgical Oncology, Sydney Adventist Hospital, Sydney, NSW, Australia
- Sydney Adventist Hospital Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Elisabeth Elder
- Westmead Breast Cancer Institute and University of Sydney, Sydney, NSW, Australia
| | - James French
- Westmead Breast Cancer Institute and University of Sydney, Sydney, NSW, Australia
| | - Nicholas Ngui
- Northern Surgical Oncology, Sydney Adventist Hospital, Sydney, NSW, Australia
- Sydney Adventist Hospital Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Jeremy Hsu
- Westmead Breast Cancer Institute and University of Sydney, Sydney, NSW, Australia
- Macquarie University Hospital, Macquarie University, Sydney, Australia
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Stout NL, Brunelle C, Scheiman N, Thawer H. Surveillance Protocols for Survivors at Risk for Lymphedema. CURRENT BREAST CANCER REPORTS 2021. [DOI: 10.1007/s12609-020-00402-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Sutherland A, Wagner JL, Korentager S, Butterworth J, Amin AL, Balanoff CR, Hangge A, Larson KE. Is bioimpedance spectroscopy a useful tool for objectively assessing lymphovenous bypass surgical outcomes in breast cancer-related lymphedema? Breast Cancer Res Treat 2021; 186:1-6. [PMID: 33392840 DOI: 10.1007/s10549-020-06059-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/15/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE We sought to determine if bioimpedance spectroscopy (BIS) measurements can accurately assess changes in breast cancer-related lymphedema (BCRL) in patients undergoing lymphovenous bypass (LVB). METHODS Patients undergoing LVB for BCRL refractory to conservative treatment from 1/2015 to 12/2018 were identified from an IRB-approved prospectively maintained database at a single institution. All breast cancer patients were assessed with baseline BIS measurements prior to any oncologic surgery and serial BIS during follow-up office visits including before and after LVB. Clinicopathologic information, LVB operative details, and pre- and post-LVB operative BIS measurements were collected. Analysis focused on clinically significant BIS change, defined as two standard deviations (SD), and comparing LVB anastomosis to BIS changes. RESULTS During the study timeframe, nine patients underwent LVB for treatment of BCRL. The majority (78%) received radiation, taxane chemotherapy, and underwent axillary dissection. An average of 5.6 LVB anastomoses were performed per patient. The average change in BIS following LVB was a 3SD reduction, indicating a clinically significant change. This improvement was stable over time, with persistent 2SD reduction at 22 months postoperatively. The number of LVB anastomoses performed did not significantly correlate with the degree of BIS change. CONCLUSIONS This is the first study to utilize BIS measurements to assess response to LVB surgical intervention for BCRL. BIS measurements demonstrated clinically significant improvement after LVB, providing objective evidence in support of this surgical treatment for BCRL. BIS changes should be reported as key objective data in future studies assessing BCRL interventions, including response to LVB.
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Affiliation(s)
- Amanda Sutherland
- Division of Breast Surgery, Department of Surgery, University of Kansas Medical Center, 4000 Cambridge Street, Kansas City, KS, 66160, USA
| | - Jamie L Wagner
- Division of Breast Surgery, Department of Surgery, University of Kansas Medical Center, 4000 Cambridge Street, Kansas City, KS, 66160, USA
| | - Sabrina Korentager
- Division of Breast Surgery, Department of Surgery, University of Kansas Medical Center, 4000 Cambridge Street, Kansas City, KS, 66160, USA
| | - James Butterworth
- Department of Plastic Surgery, Medical Center, University of Kansas, Kansas City, KS, USA
| | - Amanda L Amin
- Division of Breast Surgery, Department of Surgery, University of Kansas Medical Center, 4000 Cambridge Street, Kansas City, KS, 66160, USA
| | - Christa R Balanoff
- Division of Breast Surgery, Department of Surgery, University of Kansas Medical Center, 4000 Cambridge Street, Kansas City, KS, 66160, USA
| | - Amanda Hangge
- Division of Breast Surgery, Department of Surgery, University of Kansas Medical Center, 4000 Cambridge Street, Kansas City, KS, 66160, USA
| | - Kelsey E Larson
- Division of Breast Surgery, Department of Surgery, University of Kansas Medical Center, 4000 Cambridge Street, Kansas City, KS, 66160, USA.
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McLaughlin SA, Stout NL, Schaverien MV. Avoiding the Swell: Advances in Lymphedema Prevention, Detection, and Management. Am Soc Clin Oncol Educ Book 2020; 40:1-10. [PMID: 32315238 DOI: 10.1200/edbk_280471] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Lymphedema is a feared complication of cancer treatments that negatively affects survivors' quality of life. The true incidence of lymphedema is difficult to determine given its long latency period. As the number of survivors of cancer is increasing in the United States, lymphedema is poised to be a major health concern. The most noteworthy risk factor for lymphedema is comprehensive lymph node dissection. The last 2 decades have witnessed a dramatic shift in cancer treatment in an attempt to systematically de-escalate therapeutic interventions, specifically seeking to shift treatment away from routine lymph node dissection in favor of sentinel node biopsy or radiation strategies, thereby reducing the risk for lymphedema while maintaining survival outcomes. A growing body of robust evidence supports prospective screening and thereby a prospective surveillance model (PSM) for early diagnosis and intervention for the prevention and treatment of lymphedema. Finally, investigators are actively evaluating the effectiveness of contemporary surgical procedures in ameliorating the symptoms and disability of patients with lymphedema and reducing the risk of future episodes of cellulitis, with outcomes of surgery significantly better than with conservative therapy alone. In this article, we review the current data surrounding these initiatives.
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Affiliation(s)
| | - Nicole L Stout
- Department of Hematology Oncology, West Virginia University Cancer Institute, Morgantown, WV
| | - Mark V Schaverien
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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Shah C, Zambelli-Weiner A, Delgado N, Sier A, Bauserman R, Nelms J. The impact of monitoring techniques on progression to chronic breast cancer-related lymphedema: a meta-analysis comparing bioimpedance spectroscopy versus circumferential measurements. Breast Cancer Res Treat 2020; 185:709-740. [PMID: 33245458 PMCID: PMC7921068 DOI: 10.1007/s10549-020-05988-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/20/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Chronic breast cancer-related lymphedema (BCRL) is a potentially serious complication following treatment. Monitoring for progression to BCRL may allow for earlier detection and intervention, reducing the rate of progression to chronic BCRL. Therefore, the purpose of this meta-analysis is to evaluate the impact of monitoring techniques on the incidence of chronic BCRL among patients monitored by bioimpedance spectroscopy (BIS) and circumference as compared to background rates. METHODS Eligible peer-reviewed studies from PubMed, CINHAL, or Google Scholar that were published in English from 2013 onward and conducted in North America, Europe, or Oceania. Incidence rates abstracted from studies were classified by BCRL monitoring method: background (no standardized BIS or circumference assessments), BIS or circumference. A random-effects model was used to calculate a pooled annualized estimate of BCRL incidence while accounting for clinical and methodological heterogeneity. Subgroup analyses examined differences in duration of follow-up as well as breast and axillary surgery. RESULTS 50 studies were included, representing over 67,000 women. The annualized incidence of BCRL was 4.9% (95% CI: 4.3-5.5) for background studies (n = 35), 1.5% (95% CI: 0.6-2.4) for BIS-monitored studies (n = 7), and 7.7% (95% CI: 5.6-9.8) for circumference-monitored studies (n = 11). The cumulative BCRL incidence rate in BIS-monitored patients was 3.1% as compared to 12.9% with background monitoring (69% reduction) and 17.0% with circumference-monitored patients (81% reduction). CONCLUSIONS Evidence suggests that monitoring with BIS allowing for early intervention significantly reduces the relative risk of chronic BCRL with a 69% and 81% reduction compared to background and circumference, respectively. Circumference monitoring did not appear to provide a benefit with respect to chronic BCRL incidence. Based on these results, BIS should be considered for BCRL screening in order to detect subclinical BCRL and reduce rates of chronic BCRL, particularly in high-risk patients.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
| | | | | | - Ashley Sier
- TTi Health Research and Economics, Westminster, MD, USA
| | | | - Jerrod Nelms
- TTi Health Research and Economics, Westminster, MD, USA
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Dylke ES, Ward LC. Three Decades of Bioelectrical Impedance Spectroscopy in Lymphedema Assessment: An Historical Perspective. Lymphat Res Biol 2020; 19:206-214. [PMID: 33232645 DOI: 10.1089/lrb.2020.0085] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Bioelectrical impedance spectroscopy (BIS) is a technology that is widely used for the assessment of body composition. The method is based on the measurement of the electrical resistance of the body or a body region that can be quantitatively related to the amount of water in the tissues. Lymphedema is characterized, at least in its early stages, as an accumulation of lymph, an extracellular fluid. In the late 1980s, it was recognized that it might be possible to adapt BIS protocols to measure this increase in lymph volume. Subsequently, the use of BIS for the early detection of breast cancer-related lymphedema was demonstrated in the early 1990s, with BIS reference values indicative of lymphedema published in 2001. The subsequent two decades have seen BIS become a widely accepted method for lymphedema assessment. This review traces the evolution of the BIS technique since its inception and presents the current state of the art, with particular emphasis on utility in clinical practice.
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Affiliation(s)
- Elizabeth S Dylke
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Leigh C Ward
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Australia
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Prospective surveillance model in the home for breast cancer-related lymphoedema: a feasibility study. Breast Cancer Res Treat 2020; 185:401-412. [PMID: 33006001 PMCID: PMC7529356 DOI: 10.1007/s10549-020-05953-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/23/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE The aim of this study was to assess the feasibility of delivering a prospective surveillance model in the home over 6 months for women at high risk of developing lymphoedema. METHODS A single-group, intervention study recruited 20 women who had surgical and medical treatment for confirmed node-positive invasive breast cancer and therefore at high risk of developing arm lymphoedema. Participants received a package including Bioimpedance Spectroscopy (BIS) monitoring, lymphoedema education and support to promote self-management and physical activity. RESULTS Participants adhered to BIS monitoring 74% of the time, and felt extremely confident in using the device. By 6 months, mean BIS L-Dex scores had increased from 3.5 (SD 5.6) to 8.4 (SD 11.1); five women (25%) who experienced > + 6.5 increase in L-Dex score were fitted with a compression garment. Self-reported symptoms and distress decreased by 0.4 out of 10 (95% CI 0.1 to 0.7); number of self-management strategies used increased by 0.6 (95% CI 0.1 to 1.2); and planned exercise increased by 2.8 h/week (95% CI 0.4 to 5.2). CONCLUSIONS These findings indicate a prospective surveillance model of care in the home with BIS is feasible and associated with increased self-management. A Phase II randomised trial is warranted as well as research exploring the costs associated with implementing this model of care for high-risk individuals.
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Paramanandam VS, Daptardar AA, Kamat MV, Lee MJ, Ward LC, Kilbreath SL, Dylke ES. Interchangeability of Two Electrode Placement Protocols Used by Bioimpedance Spectroscopy Devices in the Detection of Breast Cancer-Related Lymphedema. Lymphat Res Biol 2020; 19:181-188. [PMID: 32986508 DOI: 10.1089/lrb.2020.0072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Bioimpedance spectroscopy (BIS) devices are routinely used in the assessment of breast cancer-related lymphedema (BCRL). The equipotential electrode placement is a commonly used protocol for the assessment of BCRL. However, the sternal notch electrode placement protocol is also in use. Whether these two protocols are interchangeable is not known. Methods and Results: Ethical approval was received from the institutional ethics committee at Tata Memorial Hospital, India. BIS measurements (whole-body right side and affected and unaffected arms) of 100 women with or at risk of BCRL were measured using equipotential and sternal notch protocols. Resistance at zero frequency (R0) was determined, and agreement of the absolute R0 values and the R0 ratio (unaffected/affected) between protocols was evaluated (Bland-Altman analysis and Passing-Bablok regression analysis). Mean absolute differences between protocols were very small for whole-body right side, affected arm, unaffected arm, and the interarm ratio at 0.23 ohms (95% confidence interval [CI]: -3.8 to 4.3), -5.7 ohms (95% CI: -7.5 to -3.9), -9.09 ohms (95% CI: -11.4 to -6.8), and -0.008 ohms (95% CI: -0.02 to 0.001), respectively. Limits of agreement (two standard deviation) between protocols were narrow for whole-body right side, affected arm, unaffected arm, and interarm ratio without any systematic or proportional differences for whole-body right side and the interarm ratio (5.8% to -5.6%, 3.7% to -7.4%, 3.5% to -8.2%, and 5.8% to -5.6%, respectively). Conclusion: The equipotential and sternal notch protocols could be used interchangeably in BCRL assessment. The Clinical Trial Registration number: CTRI/2017/12/010762.
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Affiliation(s)
- Vincent S Paramanandam
- Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, Australia.,Physiotherapy Department, Tata Memorial Hospital, Mumbai, India
| | | | - Manali V Kamat
- Physiotherapy Department, Tata Memorial Hospital, Mumbai, India
| | - Mi-Joung Lee
- Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
| | - Leigh C Ward
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Australia
| | - Sharon L Kilbreath
- Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
| | - Elizabeth S Dylke
- Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
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Features, Predictors, and Treatment of Breast Cancer-related Lymphedema. CURRENT BREAST CANCER REPORTS 2020; 12:244-254. [PMID: 34012502 DOI: 10.1007/s12609-020-00381-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Purpose of review Breast cancer-related lymphedema (BCRL) is a common sequelae among breast cancer survivors. This review provides updated information on recent studies to prevent, diagnose, and actively treat women with BCRL. Recent findings In total, 63 articles were identified from 2015 and 2020 that assessed incidence, risk factors, surveillance, measurement and definition, treatment, and awareness of BCRL. Depending on the approach and timing of assessment, BCRL incidence rates ranged from 9.1% to 39%. Modified radical mastectomy, number of positive lymph nodes, and postoperative complications were linked to BCRL risk, in addition to chemotherapy, radiation, axillary lymph node dissection, advanced cancer stage, and higher body mass index. Early detection showed favorable BCRL outcomes (e.g., severity, symptoms). Exercise, self-management, complete decongestive therapy, bandaging, and surgery had positive effects on BCRL outcomes. Summary Numerous gaps exist within BCRL literature, such as the value of self-reported surveillance options to identify BCRL early, measurement strategies, and definitions of BCRL. In terms of policies, efforts are needed to educate providers, patients, payers, and legislators about the need for consensus to reduce the burden of BCRL in women being treated for breast cancer.
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Cavezzi A, Urso SU, Paccasassi S, Mosti G, Campana F, Colucci R. Bioimpedance spectroscopy and volumetry in the immediate/short-term monitoring of intensive complex decongestive treatment of lymphedema. Phlebology 2020; 35:715-723. [PMID: 32631170 DOI: 10.1177/0268355520938578] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS To assess (a) immediate/short-term outcomes of intensive complex decongestive treatment of lower limb lymphedema, by means of bioimpedance spectroscopy and tape measurement-based volumetry, and (b) correlation between these two methods. PATIENTS AND METHODS Cohort study on patients affected by unilateral primary or secondary lymphedema, stage II or III. Patients underwent complex decongestive treatment (manual and electro-sound lymphatic drainage, compression bandage, exercises, low-carb nutrition, and dietary supplements) for six days. Before (D0), three and six days after complex decongestive treatment (D3 and D6), volumetry and bioimpedance spectroscopy data of the total limb and lower leg were collected. Statistical analysis was applied to pre-post treatment outcomes and to the volumetry/bioimpedance spectroscopy correlation. RESULTS Forty-one patients (15 males and 26 females, mean age: 50.7 years) were included. A progressive improvement of volumetry and bioimpedance spectroscopy figures was recorded. Total limb and leg volumetry (mean value in cc) was, respectively, 11,072.9 and 3150.8 at D0, 10,493 (-5.2%, p = 0.001) and 2980.2 (-5.4%, p < 0.001) at D6. Total limb lymphatic index at D0 and D6 was 18.9 and 14.8 (-21.5%, p < 0.001). Total limb resistance at D0, D3, and D6 was 200.4, 225.7, and 237.5 (+18.5%, p < 0.001), respectively; leg resistance at D0 and D6 was 117.5 and 150 (+27.7%, p < 0.001), respectively. Total limb reactance at D0, D3, and D6 was 12.2, 15, and 16.6 (+35.5%, p < 0.001), respectively. Leg reactance at D0 and D6 was 7.7 and 11.5 (+ 49.6%, p < 0001), respectively. Correlation volumetry/bioimpedance spectroscopy data were (a) total limb volumetry/resistance rho = -0.449, p < 0.01; volumetry/reactance rho=-0.466, p < 0.01; volumetry/lymphatic index rho = 0.581, p < 0.01; (b) leg volumetry/resistance rho=-0.579, p < 0.01; volumetry/reactance rho=-0.469, p < 0.01; volumetry/lymphatic index rho = 0.466, p < 0.05. CONCLUSIONS Complex decongestive treatment on lymphedematous limbs was effective at short term; both volumetry and bioimpedance spectroscopy showed a statistically significant improvement. Resistance and reactance increase, with lymphatic index decrease, correlated with volumetry decrease. Bioimpedance spectroscopy proved to help to assess fluid decrease and the tissue-related parameters variations.
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Donahue PMC, Crescenzi R, Lee C, Garza M, Patel NJ, Petersen KJ, Donahue MJ. Magnetic resonance imaging and bioimpedance evaluation of lymphatic abnormalities in patients with breast cancer treatment-related lymphedema. Breast Cancer Res Treat 2020; 183:83-94. [PMID: 32601969 DOI: 10.1007/s10549-020-05765-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/20/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Breast cancer treatment-related lymphedema (BCRL) evaluation is frequently performed using portable measures of limb volume and bioimpedance asymmetry. Here quantitative magnetic resonance imaging (MRI) is applied to evaluate deep and superficial tissue impairment, in both surgical and contralateral quadrants, to test the hypothesis that BCRL impairment is frequently bilateral and extends beyond regions commonly evaluated with portable external devices. METHODS 3-T MRI was applied to investigate BCRL topographical impairment. Female BCRL (n = 33; age = 54.1 ± 11.2 years; stage = 1.5 ± 0.8) and healthy (n = 33; age = 49.4 ± 11.0 years) participants underwent quantitative upper limb MRI relaxometry (T2), bioimpedance asymmetry, arm volume asymmetry, and physical evaluation. Parametric tests were applied to evaluate study measurements (i) between BCRL and healthy participants, (ii) between surgical and contralateral limbs, and (iii) in relation to clinical indicators of disease severity. Two-sided p-value < 0.05 was required for significance. RESULTS Bioimpedance asymmetry was significantly correlated with MRI-measured water relaxation (T2) in superficial tissue. Deep muscle (T2 = 37.6 ± 3.5 ms) and superficial tissue (T2 = 49.8 ± 13.2 ms) relaxation times were symmetric in healthy participants. In the surgical limbs of BCRL participants, deep muscle (T2 = 40.5 ± 4.9 ms) and superficial tissue (T2 = 56.0 ± 14.8 ms) relaxation times were elevated compared to healthy participants, consistent with an edematous micro-environment. This elevation was also observed in contralateral limbs of BCRL participants (deep muscle T2 = 40.3 ± 5.7 ms; superficial T2 = 56.6 ± 13.8 ms). CONCLUSIONS Regional MRI measures substantiate a growing literature speculating that superficial and deep tissue, in surgical and contralateral quadrants, is affected in BCRL. The implications of these findings in the context of titrating treatment regimens and understanding malignancy recurrence are discussed.
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Affiliation(s)
- Paula M C Donahue
- Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Dayani Center for Health and Wellness, Nashville, TN, USA
| | - Rachelle Crescenzi
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chelsea Lee
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Maria Garza
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Niral J Patel
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kalen J Petersen
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manus J Donahue
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.
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An Executive Summary of the APTA Academy for Oncologic Physical Therapy Clinical Practice Guideline: Interventions for Breast Cancer–Related Lymphedema. REHABILITATION ONCOLOGY 2020. [DOI: 10.1097/01.reo.0000000000000223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Davies C, Levenhagen K, Ryans K, Perdomo M, Gilchrist L. Interventions for Breast Cancer-Related Lymphedema: Clinical Practice Guideline From the Academy of Oncologic Physical Therapy of APTA. Phys Ther 2020; 100:1163-1179. [PMID: 32589208 PMCID: PMC7412854 DOI: 10.1093/ptj/pzaa087] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 12/22/2019] [Accepted: 03/01/2020] [Indexed: 12/22/2022]
Abstract
A work group from the American Physical Therapy Association (APTA) Academy of Oncologic Physical Therapy developed a clinical practice guideline to aid clinicians in identifying interventions for people with breast cancer-related lymphedema, targeting volume reduction, beginning at breast cancer diagnosis and continuing through cancer treatments and survivorship. Following a systematic review of published studies and a structured appraisal process, recommendations were developed to guide physical therapists and other health care clinicians in their intervention selection. Overall, clinical practice recommendations were formulated based on the evidence for each intervention and were assigned a grade based on the strength of the evidence. The evidence for each specific intervention was synthesized and appraised by lymphedema stage, when the information was available. In an effort to make recommendations clinically applicable, they were presented by modality throughout the care trajectory. Methodology and research populations varied significantly across studies, and it will be important for future research to use standardized definitions for participant characteristics, diagnostic criteria, and interventions.
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Affiliation(s)
| | - Kimberly Levenhagen
- K. Levenhagen, PT, DPT, Department of Physical Therapy & Athletic Training, Saint Louis University, St Louis, Missouri. Dr Levenhagen is a certified lymphedema therapist
| | - Kathryn Ryans
- K. Ryans, PT, DPT, Doctor of Physical Therapy Program, Mercy College, Dobbs Ferry, New York. Dr Ryans is a board-certified clinical specialist in oncologic physical therapy and a certified lymphedema therapist-Lymphology Association of North America
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Onoda S, Nishimon K. The utility of surgical and conservative combination therapy for advanced stage lymphedema. J Vasc Surg Venous Lymphat Disord 2020; 9:234-241. [PMID: 32470619 DOI: 10.1016/j.jvsv.2020.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND In the treatment of lymphedema, a plastic surgeon carries out only surgical treatment, whereas a therapist performs only complex physical therapy. Therefore, a combination treatment strategy is not performed in most cases. Our institution combines a lymphaticovenular anastomosis (LVA) operation with complex physical therapy during the same hospitalization. METHODS From advanced cases of lymphedema of stage II or higher, we included patients who were hospitalized for 2 weeks or more for combined LVA and complex physical therapy. Of the 28 cases studied, 26 were secondary lymphedema and two were primary lymphedema. There were seven upper limb cases and 21 lower limb cases. The mean length of hospital stay was 12 days (7-14 days). We performed a multisite LVA in all 28 patients. The mean number of anastomoses in each case (the side with the most edema for bilateral cases) was 3.96 (2-6). During hospitalization, lymphatic therapists who were familiar with complex physical therapy for lymphedema were trained to provide total care for lymphedema. The content of the education was applied according to the individual patient's status, and an emphasis was placed on development of a treatment regimen that patients could perform continuously by themselves after discharge. RESULTS The average volume reduction in seven patients with upper limb lymphedema was 15.1%; the average in 18 patients with lymphedema of the lower limbs was 13.1%. The average volume reduction in eight patients at stage II was 14.1%; stage II late was 13.0%, and stage III was 14.7%. The other three cases had suffered an exacerbation, and the mean exacerbation was 3.2%. Among the 12 patients who had cellulitis preoperatively, an episode of cellulitis was detected in only two patients during follow-up postoperatively. These two patients were those at late stage II and stage III. The frequency of onset decreased in these two cases. CONCLUSIONS In this study, combination therapy was administrated for lymphedema. We obtained good results in the diseased limbs, including volume reduction and prevention of cellulitis. Therefore, combination therapy might be useful for lymphedema cases at advanced stages.
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Affiliation(s)
- Satoshi Onoda
- Department of Plastic and Reconstructive Surgery, Kagawa Rosai Hospital, Kagawa, Japan; Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Science, University of Okayama, Okayama, Japan.
| | - Kana Nishimon
- Department of Lymphedema Therapy Team, Lymphedema Therapist, Kagawa Rosai Hospital, Kagawa, Japan
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Stout NL, Brown JC, Schwartz AL, Marshall TF, Campbell AM, Nekhlyudov L, Zucker DS, Basen-Engquist KM, Campbell G, Meyerhardt J, Cheville AL, Covington KR, Ligibel JA, Sokolof JM, Schmitz KH, Alfano CM. An exercise oncology clinical pathway: Screening and referral for personalized interventions. Cancer 2020; 126:2750-2758. [PMID: 32212338 DOI: 10.1002/cncr.32860] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Nicole L Stout
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland.,Hematology Oncology Department, Division of Cancer Prevention and Control, West Virginia University Cancer Institute, Morgantown, West Virginia
| | - Justin C Brown
- Cancer Metabolism Research Program, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, Louisiana
| | - Anna L Schwartz
- School of Nursing, Northern Arizona University, Flagstaff, Arizona
| | | | - Anna M Campbell
- Sighthill Campus, Edinburgh Napier University, Edinburgh, Scotland
| | - Larissa Nekhlyudov
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David S Zucker
- Swedish Cancer Rehabilitation Medicine Services, Swedish Cancer Institute, Swedish Health Services, Seattle, Washington
| | - Karen M Basen-Engquist
- Department of Behavioral Science, Division of Cancer Prevention and Population Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Grace Campbell
- University of Pittsburgh School of Nursing and Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania
| | | | - Andrea L Cheville
- Department of Rehabilitation Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kelley R Covington
- Cancer Rehabilitation Program, Select Medical, Mechanicsburg, Pennsylvania
| | | | - Jonas M Sokolof
- Department of Physical Medicine and Rehabilitation, New York University Langone Health, New York, New York
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