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Lilja C, Madsen CB, Damsgaard TE, Sørensen JA, Thomsen JB. Surgical treatment algorithm for breast cancer lymphedema-a systematic review. Gland Surg 2024; 13:722-748. [PMID: 38845835 PMCID: PMC11150198 DOI: 10.21037/gs-23-503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/19/2024] [Indexed: 06/09/2024]
Abstract
Background Various surgical treatments are increasingly adopted and gaining popularity for lymphedema treatment. However, challenges persist in selecting appropriate treatment modalities targeted for individual patients and achieving consensus on choice of treatment as well as outcomes. The systematic review aimed to create a treatment algorithm incorporating the latest scientific knowledge, to provide healthcare professionals and patients with a tool for informed decision-making, when selecting between treatments or combining them in a relevant manner. This systematic review evaluated and synthesized the evidence on the effectiveness of three surgical treatments for breast cancer-related lymphedema (BCRL): lymphovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and liposuction. Methods We conducted a systematic search of electronic databases on 18 June 2023, including Medline, Embase, Cochrane Library, Google Scholar, and ClinicalTrials.org. Eligible studies were randomized controlled trials, non-randomized comparative studies, and observational studies that assessed the outcomes of LVA, VLNT, or liposuction in managing BCRL. The primary results of interest were changes in arm volume, lymphatic flow, and quality of life. Two independent reviewers performed the study selection and data extraction. Following this, we systematically reviewed and conducted a risk of bias assessment. Results were qualitatively presented, and a treatment algorithm was developed based on the available data. Results We identified 16,593 papers, after removal of duplicates. Following assessment of studies, 73 articles met the inclusion criteria, including 2,373 patients. We were not able to conduct a meta-analysis due to considerable heterogeneity in the methodologies and outcome measures across the studies. Liposuction appears effective for patients presenting with non-pitting lymphedema. LVA indicates variable success rate, with some evidence indicating a reduction in limb volume and symptomatic relief amongst early stages of lymphedema. VLNT showed promising results for limb volume reduction and symptom improvement in patients presenting with mild and moderate lymphedema. Conclusions Liposuction, LVA, and VLNT seem to be effective treatments for BCRL, when targeted for the appropriate patient. Well-conducted high evidence clinical studies in the field are still lacking to uncover the efficacy of surgical treatment for BCRL.
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Affiliation(s)
- Caroline Lilja
- Research Unit of Plastic Surgery, Odense University Hospital, Odense, Denmark
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christoffer Bing Madsen
- Research Unit of Plastic Surgery, Odense University Hospital, Odense, Denmark
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark
| | - Tine Engberg Damsgaard
- Research Unit of Plastic Surgery, Odense University Hospital, Odense, Denmark
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Plastic Surgery, University Hospital of Southern Denmark, Lillebaelt Hospital, Vejle, Denmark
| | - Jens Ahm Sørensen
- Research Unit of Plastic Surgery, Odense University Hospital, Odense, Denmark
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jørn Bo Thomsen
- Research Unit of Plastic Surgery, Odense University Hospital, Odense, Denmark
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Choi JE, Chang MC. Management of lymphedema is really a matter in patients with breast cancer. World J Clin Cases 2024; 12:2482-2486. [PMID: 38817238 PMCID: PMC11135456 DOI: 10.12998/wjcc.v12.i15.2482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 04/08/2024] [Accepted: 04/19/2024] [Indexed: 05/14/2024] Open
Abstract
Lymphedema is a prevalent complication affecting patients with breast cancer, greatly impacting their quality of life. This editorial describes diagnostic methods and therapeutic interventions for managing lymphedema in patients with breast cancer. Diagnosis relies on clinical evaluation and objective measures, including arm circumference and volumetric assessments, along with lymphoscintigraphy and ultrasonic measurements. Treatment primarily involves complex decongestive physical therapy, comprising manual lymphatic drainage, compression therapy, exercise, and meticulous skin care. These interventions aim to reduce swelling, alleviate discomfort, and prevent further complications. Additionally, lifestyle modifications such as avoiding extreme temperatures and maintaining proper hygiene are essential. Flavonoids can be used for drug therapy. Despite its prevalence, lymphedema often receives inadequate attention in clinical practice, emphasizing the importance of raising awareness and enhancing medical services for affected individuals. Clinicians play a pivotal role in educating patients about preventive measures and ensuring timely intervention. Overall, a comprehensive approach encompassing early diagnosis, multidisciplinary management, and patient education is essential to mitigate the burden of lymphedema in patients with breast cancer and improve their overall well-being.
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Affiliation(s)
- Jung Eun Choi
- Department of Surgery, College of Medicine, Yeungnam University, Daegu 705-717, South Korea
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu 705-717, South Korea
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3
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Farina G, Galli M, Borsari L, Aliverti A, Paraskevopoulos IT, LoMauro A. Limb Volume Measurements: A Comparison of Circumferential Techniques and Optoelectronic Systems against Water Displacement. Bioengineering (Basel) 2024; 11:382. [PMID: 38671803 PMCID: PMC11048605 DOI: 10.3390/bioengineering11040382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/02/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Accurate measurements of limb volumes are important for clinical reasons. We aimed to assess the reliability and validity of two centimetric and two optoelectronic techniques for limb volume measurements against water volumetry, defined as the gold standard. METHODS Five different measurement methods were executed on the same day for each participant, namely water displacement, fixed-height (circumferences measured every 5 (10) cm for the upper (lower limb) centimetric technique, segmental centimetric technique (circumferences measured according to proportional height), optoelectronic plethysmography (OEP, based on a motion analysis system), and IGOODI Gate body scanner technology (which creates an accurate 3D avatar). RESULTS A population of 22 (15 lower limbs, 11 upper limbs, 8 unilateral upper limb lymphoedema, and 6 unilateral lower limb lymphoedema) participants was selected. Compared to water displacement, the fixed-height centimetric method, the segmental centimetric method, the OEP, and the IGOODI technique resulted in mean errors of 1.2, 0.86, -16.0, and 0.71%, respectively. The corresponding slopes (and regression coefficients) of the linear regression lines were 1.0002 (0.98), 1.0047 (0.99), 0.874 (0.94) and 0.9966 (0.99). CONCLUSION The centimetric methods and the IGOODI system are accurate in measuring limb volume with an error of <2%. It is important to evaluate new objective and reliable techniques to improve diagnostic and follow-up possibilities.
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Affiliation(s)
- Giovanni Farina
- Istituto Clinico Città Studi di Milano, Via Ampère, 47, 20131 Milan, Italy;
| | - Manuela Galli
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Via Giuseppe Ponzio, 34, 20133 Milan, Italy; (M.G.); (L.B.); (A.A.)
| | - Leonardo Borsari
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Via Giuseppe Ponzio, 34, 20133 Milan, Italy; (M.G.); (L.B.); (A.A.)
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Via Giuseppe Ponzio, 34, 20133 Milan, Italy; (M.G.); (L.B.); (A.A.)
| | | | - Antonella LoMauro
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Via Giuseppe Ponzio, 34, 20133 Milan, Italy; (M.G.); (L.B.); (A.A.)
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Zaleska MT, Krzesniak NE. High Pressure 3 × 30 Minute Compression Methods for Advanced Lower Limb Lymphedema Patients. Lymphat Res Biol 2024; 22:153-162. [PMID: 38593454 DOI: 10.1089/lrb.2023.0064] [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: 04/11/2024] Open
Abstract
Introduction: In advanced lymphedema of lower limbs, stage III bandaging under the routinely applied pressure of 40-60 mmHg remains largely ineffective. This is caused by skin and subcutaneous tissue stiffness due to fibrosis. Edema fluid accumulates deep in the subcutaneous tissue. Evacuating this fluid requires a high external compression force to overcome the resistance of fibrous tissue. We aimed to investigate the effectiveness of the compression method, with high pressure lasting for 3 days. Methods and Results: Twenty-one patients with lower limb lymphedema, stage III, of the postinflammatory type were included. Patients with acute inflammatory symptoms, venous thrombosis, profuse varicose veins, diabetes, and cardiac insufficiency with edema were excluded. A 10-cm-wide rubber bandage was applied to the foot and calf. The interface pressure measured using PicoPress ranged from 58 to 120 mmHg. Skin and deep tissue tonometry, skin water concentration, leg circumference, and drop of interface pressure were measured. Ultrasound examination was done before and after each compression session. The calf circumference decreased by 15.9 ± 5.4%, deep tissue stiffness by 58.9 ± 18.9%, skin stiffness by 69.6 ± 13.5%, and skin water concentration by 43.8 ± 11.5%. Interface pressure dropped to 66.3 mmHg (28-110 mmHg); ultrasonography images showed less fluid in the tissue. Conclusions: High-pressure 30-minute leg compression can remove excess edema fluid within 3 days and enable adjustment of nonstretch compression stockings. This method is more effective in advanced lymphedema at the beginning of therapy than the standard 30-50-mmHg bandaging as it provides an immediate effect.
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Affiliation(s)
- Marzanna T Zaleska
- Clinical and Research Department of Applied Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Warsaw, Poland
- Department of Vascular Surgery, Central Clinical Hospital of the Ministry of Internal Affairs, Warsaw, Poland
| | - Natalia E Krzesniak
- Department of Plastic and Reconstructive Surgery, Medical Centre of Postgraduate Education, Warsaw, Poland
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Schiltz D, Eibl D, Mueller K, Biermann N, Prantl L, Taeger CD. Therapist versus Machine-Immediate Effects of Manual versus Mechanical Lymphatic Drainage in Patients with Secondary Lymphedema. J Clin Med 2024; 13:1277. [PMID: 38592094 PMCID: PMC10931544 DOI: 10.3390/jcm13051277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/10/2024] [Accepted: 02/20/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Complex decongestive therapy (CDT) is the standard and basic therapy for lymphedema. The central component of CDT is manual lymphatic drainage (MLD). In addition to CDT, other measures such as intermittent pneumatic compression therapy (IPCT) (active compression machine therapy) are available. In this prospective research study, the objective and subjective effects of MLD and IPCT on lymphedema of the lower extremity were investigated and both therapies were directly compared. Furthermore, the patients' body mass index (BMI) and stage of lymphedema were tested for their effect on the respective therapy. Methods: Patients participating in the study received both therapies (MLD and IPCT) on the same lymphedema-affected limb at an interval of two days. The objective volumetric therapy effect was measured by the digital volume measurement of the affected limb. The subjective effects of the therapies were measured using two specially designed questionnaires. Results: A total of 40 patients were included in the study. There was no significant difference in the volume differences between the interventions, BMI categories, lymphedema, or treatment order regarding the immediate and two-day effect. Conclusions: No significant difference was found in the subjective or objective therapy efficacy of the two methods. Intermittent pneumatic compression therapy is considered a comparable therapeutic procedure when properly indicated.
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Affiliation(s)
- Daniel Schiltz
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany (N.B.); (L.P.)
- Department of Plastic and Aesthetic Surgery, Hand Surgery, Helios Hospital Emil von Behring, 14165 Berlin, Germany
| | - Dominik Eibl
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany (N.B.); (L.P.)
| | - Karolina Mueller
- Center for Clinical Studies, University Hospital Regensburg, 93053 Regensburg, Germany;
| | - Niklas Biermann
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany (N.B.); (L.P.)
| | - Lukas Prantl
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany (N.B.); (L.P.)
| | - Christian Dirk Taeger
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany (N.B.); (L.P.)
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Gülören G, Doğan Y, Özgül S, Gürşen C, Çinar GN, İpekten F, Akbayrak T. Acute Effects of Remedial Exercises with and without Compression on Breast-Cancer-Related Lymphedema. Healthcare (Basel) 2023; 11:2949. [PMID: 37998441 PMCID: PMC10671079 DOI: 10.3390/healthcare11222949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/25/2023] Open
Abstract
Remedial exercises are an important part of the treatment for lymphedema, but there is little evidence to support the acute effects of remedial exercises with or without compression. The aim of this study was to investigate whether and how daily (performed within 24 h) remedial exercises with and without compression bandaging acutely affect the severity of lymphedema and its symptoms in breast-cancer-related lymphedema (BCRL). In total, 34 patients with BCRL completed three sets of remedial exercises (within 24 h) with and without compression bandaging in a randomized order separated by a 3-day wash-out period. The severity of lymphedema and extracellular water ratio were assessed before and 24 h post exercise by using bilateral circumferential measurements and bioimpedance spectroscopy (in L-dex score), respectively, and the severity of self-reported symptoms (swelling, heaviness, and tightness) was assessed using a visual analogue scale. While there was no difference in all outcomes at 24 h post exercise without compression (p > 0.05), all outcomes decreased significantly compared to baseline at 24 h after the exercise with compression (p < 0.001). The remedial exercises performed in the absence of compression within 24 h do not acutely increase the lymphedema and symptoms in BCRL. These are important preliminary findings, which can be used to inform future prospective evaluation of the long-term effects of remedial exercise performed without compression.
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Affiliation(s)
- Gülbala Gülören
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara 06100, Turkey; (Y.D.); (S.Ö.); (C.G.); (G.N.Ç.); (T.A.)
| | - Yahya Doğan
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara 06100, Turkey; (Y.D.); (S.Ö.); (C.G.); (G.N.Ç.); (T.A.)
| | - Serap Özgül
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara 06100, Turkey; (Y.D.); (S.Ö.); (C.G.); (G.N.Ç.); (T.A.)
| | - Ceren Gürşen
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara 06100, Turkey; (Y.D.); (S.Ö.); (C.G.); (G.N.Ç.); (T.A.)
| | - Gamze Nalan Çinar
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara 06100, Turkey; (Y.D.); (S.Ö.); (C.G.); (G.N.Ç.); (T.A.)
| | - Funda İpekten
- Department of Biostatistics, Faculty of Medicine, Erciyes University, Kayseri 38039, Turkey;
| | - Türkan Akbayrak
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara 06100, Turkey; (Y.D.); (S.Ö.); (C.G.); (G.N.Ç.); (T.A.)
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Duffield A. Assessment and management of upper limb lymphoedema in advanced disease: a case study. Br J Community Nurs 2023; 28:S22-S28. [PMID: 37757820 DOI: 10.12968/bjcn.2023.28.sup10.s22] [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: 09/29/2023]
Abstract
Lymphoedema is thought to affect around 200 000 people in the UK (NHS England, 2023). Secondary lymphoedema is a relatively common complication of cancer and cancer treatment, and in advanced disease it may present a challenging issue for community nursing staff caring for patients approaching the end of their lives. In this article, a case study considers the assessment and treatment of upper limb lymphoedema in a patient with advanced metastatic breast cancer. Management of this complex and distressing condition requires holistic assessment and collaborative care planning with the patient and their wider care team, including onward referral to specialist lymphoedema and palliative care services. The case study considers the typical presentation of lymphoedema in an upper limb, exclusion of reversible causes for oedema, awareness of palliative care emergencies such as superior vena cava obstruction, and the provision of supportive therapeutic interventions in context of the patient's expressed wishes for her ongoing care.
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Affiliation(s)
- Amy Duffield
- Lymphoedema Nurse Practitioner, Sussex Community NHS Foundation Trust, West Sussex
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8
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Muñoz-Alcaraz MN, Jiménez-Vílchez AJ, Pérula-de Torres LÁ, Serrano-Merino J, García-Bustillo Á, Pardo-Hernández R, González-Bernal JJ, González-Santos J. Effect of Conservative Rehabilitation Interventions on Health-Related Quality of Life in Women with Upper Limb Lymphedema Secondary to Breast Cancer: A Systematic Review. Healthcare (Basel) 2023; 11:2568. [PMID: 37761765 PMCID: PMC10531370 DOI: 10.3390/healthcare11182568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/10/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
Breast cancer-related lymphedema (BCRL) of the upper limb is a very common condition in women undergoing breast cancer treatment; it can cause considerable alterations in the daily life of patients and a decrease in their health-related quality of life (HRQoL). Currently, there are many conservative therapies that try to palliate the symptoms, but the results are still controversial and there are still no globally accepted treatments. The purpose of this article is to determine the effect, according to the current available evidence, on HRQoL of different conservative interventions in the rehabilitation of BCRL in the upper limb in women. Eighteen articles that compared the effects of standard treatments, such as manual lymphatic drainage-based decongestive therapy or compression measures, and other newer treatments, including new technologies and other types of treatment programs, were reviewed. According to the results of this review, the most recommended modality for the improvement of HRQoL would be a complex decongestive technique without manual lymphatic drainage. Although there are clinical trials that have demonstrated the effectiveness of various treatments, the results of the positive effects on HRQoL remain highly controversial. There is a need to continue to develop studies to help guide therapeutic decisions that can promote HRQoL in women affected by upper limb BCRL.
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Affiliation(s)
- María Nieves Muñoz-Alcaraz
- Interlevel Clinical Management Unit of Physical Medicine and Rehabilitation, Reina Sofía University Hospital, 14004 Córdoba, Spain;
- Córdoba and Guadalquivir Health District, Andalusia Health Service, 14011 Córdoba, Spain;
- Maimonoides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Córdoba, 14004 Córdoba, Spain;
| | | | - Luis Ángel Pérula-de Torres
- Maimonoides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Córdoba, 14004 Córdoba, Spain;
| | - Jesús Serrano-Merino
- Córdoba and Guadalquivir Health District, Andalusia Health Service, 14011 Córdoba, Spain;
- Maimonoides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Córdoba, 14004 Córdoba, Spain;
| | - Álvaro García-Bustillo
- Faculty of Health Sciences, University of Burgos, 09001 Burgos, Spain; (R.P.-H.); (J.J.G.-B.); (J.G.-S.)
| | - Rocío Pardo-Hernández
- Faculty of Health Sciences, University of Burgos, 09001 Burgos, Spain; (R.P.-H.); (J.J.G.-B.); (J.G.-S.)
| | | | - Josefa González-Santos
- Faculty of Health Sciences, University of Burgos, 09001 Burgos, Spain; (R.P.-H.); (J.J.G.-B.); (J.G.-S.)
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Doubblestein D, Campione E, Hunley J, Schaverien M. Pre- and Post-Microsurgical Rehabilitation Interventions and Outcomes on Breast Cancer-Related Lymphedema: a Systematic Review. Curr Oncol Rep 2023; 25:1031-1046. [PMID: 37402044 PMCID: PMC10474983 DOI: 10.1007/s11912-023-01439-9] [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] [Accepted: 06/19/2023] [Indexed: 07/05/2023]
Abstract
PURPOSE OF REVIEW Breast cancer-related lymphedema (BCRL) is a debilitating progressive disease resulting in various impairments and dysfunctions. Complete decongestive therapy embodies conservative rehabilitation treatments for BCRL. Surgical procedures performed by plastic and reconstructive microsurgeons are available when conservative treatment fails. The purpose of this systematic review was to investigate which rehabilitation interventions contribute to the highest level of pre- and post-microsurgical outcomes. RECENT FINDINGS Studies published between 2002 and 2022 were grouped for analysis. This review was registered with PROSPERO (CRD42022341650) and followed the PRISMA guidelines. Levels of evidence were based upon study design and quality. The initial literature search yielded 296 results, of which, 13 studies met all inclusion criteria. Lymphovenous bypass anastomoses (LVB/A) and vascularized lymph node transplant (VLNT) emerged as dominant surgical procedures. Peri-operative outcome measures varied greatly and were used inconsistently. There is a dearth of high quality literature leading to a gap in knowledge as to how BCRL microsurgical and conservative interventions complement each other. Peri-operative guidelines are needed to bridge the knowledge and care gap between lymphedema surgeons and therapists. A core set of outcome measures for BCRL is vital to unify terminological differences in the multidisciplinary care of BCRL. Complete decongestive therapy embodies conservative rehabilitation treatments for breast cancer-related lymphedema (BCRL). Surgical procedures performed by microsurgeons are available when conservative treatment fails. This systematic review investigated which rehabilitation interventions contribute to the highest level of pre- and post-microsurgical outcomes. Thirteen studies met all inclusion criteria and revealed that there is a dearth of high quality literature leading to a gap in knowledge as to how BCRL microsurgical and conservative interventions complement each other. Furthermore, peri-operative outcome measures were inconsistent. Peri-operative guidelines are needed to bridge the knowledge and care gap between lymphedema surgeons and therapists.
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Affiliation(s)
| | | | - Julie Hunley
- Department of Occupational Therapy, Mount Mary University, Milwaukee, WI, USA
| | - Mark Schaverien
- Department of Plastic Surgery, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Liu M, Li B, Hao K, Zhang Y, Hao Q, Li X, Wang R. Quantitative evaluation of primary lower extremity lymphedema staging using MRI: a preliminary study. Quant Imaging Med Surg 2023; 13:4839-4851. [PMID: 37581039 PMCID: PMC10423363 DOI: 10.21037/qims-22-795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 05/11/2023] [Indexed: 08/16/2023]
Abstract
Background The staging of primary lower extremity lymphedema (LEL) is difficult yet vital in clinical work, and magnetic resonance imaging (MRI) can be used for quantitative assessment of primary LEL due to its high resolution for soft tissues. In this study, we evaluated the value of MRI-based soft tissue area measurements for staging primary LEL. Methods A total of 90 consecutive patients with clinically diagnosed primary lower limb lymphoedema from January 2017 to December 2019 in Beijing Shijitan Hospital were enrolled retrospectively. Short time inversion recovery (STIR) sequence was applied to measure the total, muscle, bone, and subcutaneous areas in the upper 1/3 level of the bilateral lower calf. The difference between the affected and unaffected calf regarding the subcutaneous area was obtained, and (subcutaneous area)/(bone area) and (subcutaneous area)/(muscle area) were calculated. According to the International Society of Lymphology (ISL) clinical staging standard established in 2020, all patients were divided into stages I, II, and III, accordingly. Statistical analysis was performed to determine the validity of MRI measurements in staging LEL. Results There were 33 patients classified as stage I clinically, 44 patients as stage II, and 13 patients as stage III. There were significant differences in total, subcutaneous, the difference in subcutaneous area of limbs, subcutaneous/bone (S/B), and subcutaneous/muscle (S/M) between stage I and II as well as between stage I and III (P<0.001), but not between stage II and III (P=0.706, 0.329, and 0.229, respectively). A positive correlation was detected between the clinical stage and difference in subcutaneous area of limbs (rho =0.752, P<0.001), S/B (rho =0.747, P<0.001), S/M (rho =0.709, P<0.001), and subcutaneous (rho =0.723, P<0.001). For staging primary LEL, receiver operating characteristic (ROC) curves indicated that the difference in subcutaneous area of limbs had the best discrimination ability among parameters [area under the ROC curve (AUC) =0.950; 95% confidence interval (CI): 0.875-0.987; sensitivity: 95.45%; specificity: 84.85%], followed by S/B (AUC =0.930; 95% CI: 0.848-0.975; sensitivity: 77.27%; specificity: 93.94%) and S/M (AUC =0.895; 95% CI: 0.804-0.953; sensitivity: 77.27%; specificity: 90.91%). The ROC curves indicated that subcutaneous area (AUC =0.927; 95% CI: 0.844-0.974; sensitivity: 84.09%, specificity: 90.91%) and total (AUC =0.852; 95% CI: 0.753-0.923; sensitivity: 70.45%; specificity: 90.91%) also had discrimination ability between stage I and II. Conclusions The measurement of the soft tissue area of the calf may be used as an auxiliary method for staging primary LEL. For patients with unilateral primary LEL, the difference in subcutaneous area of limbs could be a specific indicator to distinguish clinical stage I from II.
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Affiliation(s)
- Mengke Liu
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Bin Li
- Department of MRI, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Kun Hao
- Department of Lymph Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yan Zhang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Qi Hao
- Department of Radiology, Beijing Shijitan Hospital, Peking University Ninth School of Clinical Medicine, Beijing, China
| | - Xingpeng Li
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Rengui Wang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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May-Thurner Syndrome and Lymphedema Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4377. [PMID: 35702363 PMCID: PMC9187167 DOI: 10.1097/gox.0000000000004377] [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: 02/23/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022]
Abstract
May-Thurner syndrome (MTS) is an anatomical variant that results in compression of the left common iliac vein by the right common iliac artery. Although often asymptomatic, lower extremity swelling/edema, deep venous thrombosis, post-thrombotic syndrome, and eventual lymphedema (due to long-standing venous obstruction) can develop. The clinical management of patients presenting for lymphedema surgery with concomitant or undiagnosed MTS is not well described. Methods This review investigates two patients who were evaluated for unilateral lower extremity lymphedema, both of whom were subsequently diagnosed with MTS. Standard imaging (including lymphoscintigraphy, indocyanine green lymphangiography, and magnetic resonance venography) were performed to identify proximal venous obstruction. Treatment was accomplished using vascular surgical management, including stenting of the iliac vein before lymphedema reconstruction with vascularized lymph node transfer and multiple lymphovenous bypass. Results Both patients we examined in this review had improvement of lymphedema with vascular surgical management. Literature review reveals that MTS has an incidence as high as 20% in the population, although commonly unidentified due to lack of symptomatology. Conclusions There are no studies documenting the incidence of MTS in patients referred for lymphedema surgical management. Routine studies should be obtained to screen for proximal venous obstruction in patients presenting for surgical management of lower extremity lymphedema. Additional research is needed regarding the approach to managing patients with both MTS and lymphedema. Careful observational and prospective studies may elucidate the appropriate time interval between venous stenting and lymphedema microsurgical reconstruction.
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Muñoz-Alcaraz MN, Pérula-de Torres LA, Jiménez-Vílchez AJ, Rodríguez-Fernández P, Olmo-Carmona MV, Muñoz-García MT, Jorge-Gutiérrez P, Serrano-Merino J, Romero-Rodríguez E, Rodríguez-Elena L, Refusta-Ainaga R, Lahoz-Sánchez MP, Miró-Palacios B, Medrano-Cid M, Magallón-Botaya R, Santamaría-Peláez M, Mínguez-Mínguez LA, González-Bernal JJ. Impact of Activity-Oriented Propioceptive Antiedema Therapy on the Health-Related Quality of Life of Women with Upper-Limb Lymphedema Secondary to Breast Cancer-A Randomized Clinical Trial. J Clin Med 2022; 11:1884. [PMID: 35407490 PMCID: PMC9000148 DOI: 10.3390/jcm11071884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/18/2022] [Accepted: 03/25/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Alterations derived from lymphedema in the upper-limb secondary to breast cancer-related lymphedema (BCRL) decrease the health-related quality of life (HRQoL), but there is limited evidence of the impact of the different interventions on it. The aim of this research was to compare the effect of conventional treatment with another treatment based on Activity-Oriented Antiedema Proprioceptive Therapy (TAPA) on HRQoL in women diagnosed with BCRL. METHODS A prospective clinical study was designed with two parallel arms. The study population consisted of women diagnosed with BCRL in stage I and II, belonging to different institutions in Córdoba and Aragon, Spain. Sociodemographic and HRQoL-related variables, pain, tightness, heaviness and functionality were obtained before and after treatments. RESULTS 51 women participated in the study, 25 received the conventional treatment and 26 the TAPA, with a mean age of 59.24 ± 9.55 years. HRQoL was significantly related to upper-limb function and pain on the participants' affected side. In addition, covariance analysis (ANCOVA) showed that the TAPA treatment interfered less in the performance of activities of daily life and produced significant improvements in the social dimension of HRQoL. CONCLUSIONS the non-use of compressive elements in the rehabilitative treatment of the BCRL that is proposed with TAPA improves aspects such as self-image and participation in social and recreational activities.
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Affiliation(s)
- María Nieves Muñoz-Alcaraz
- Inter-Level Clinical Management Unit of Physical Medicine and Rehabilitation, Reina Sofía University Hospital—Córdoba and Guadalquivir Health District, Andalusia Health Service, 14004 Córdoba, Spain; (M.N.M.-A.); (M.V.O.-C.); (M.T.M.-G.); (P.J.-G.)
- Maimonides Institute for Biomedical Research of Córdoba, Reina Sofía University Hospital, University of Córdoba, 14011 Córdoba, Spain; (L.A.P.-d.T.); (J.S.-M.); (E.R.-R.)
| | - Luis A. Pérula-de Torres
- Maimonides Institute for Biomedical Research of Córdoba, Reina Sofía University Hospital, University of Córdoba, 14011 Córdoba, Spain; (L.A.P.-d.T.); (J.S.-M.); (E.R.-R.)
- Multiprofessional Teaching Unit for Family and Community Care of the Córdoba and Guadalquivir Health District, 14011 Córdoba, Spain
| | | | | | - María Victoria Olmo-Carmona
- Inter-Level Clinical Management Unit of Physical Medicine and Rehabilitation, Reina Sofía University Hospital—Córdoba and Guadalquivir Health District, Andalusia Health Service, 14004 Córdoba, Spain; (M.N.M.-A.); (M.V.O.-C.); (M.T.M.-G.); (P.J.-G.)
| | - María Teresa Muñoz-García
- Inter-Level Clinical Management Unit of Physical Medicine and Rehabilitation, Reina Sofía University Hospital—Córdoba and Guadalquivir Health District, Andalusia Health Service, 14004 Córdoba, Spain; (M.N.M.-A.); (M.V.O.-C.); (M.T.M.-G.); (P.J.-G.)
| | - Presentación Jorge-Gutiérrez
- Inter-Level Clinical Management Unit of Physical Medicine and Rehabilitation, Reina Sofía University Hospital—Córdoba and Guadalquivir Health District, Andalusia Health Service, 14004 Córdoba, Spain; (M.N.M.-A.); (M.V.O.-C.); (M.T.M.-G.); (P.J.-G.)
| | - Jesús Serrano-Merino
- Maimonides Institute for Biomedical Research of Córdoba, Reina Sofía University Hospital, University of Córdoba, 14011 Córdoba, Spain; (L.A.P.-d.T.); (J.S.-M.); (E.R.-R.)
- Multiprofessional Teaching Unit for Family and Community Care of the Córdoba and Guadalquivir Health District, 14011 Córdoba, Spain
| | - Esperanza Romero-Rodríguez
- Maimonides Institute for Biomedical Research of Córdoba, Reina Sofía University Hospital, University of Córdoba, 14011 Córdoba, Spain; (L.A.P.-d.T.); (J.S.-M.); (E.R.-R.)
- Multiprofessional Teaching Unit for Family and Community Care of the Córdoba and Guadalquivir Health District, 14011 Córdoba, Spain
| | - Lorena Rodríguez-Elena
- San Jose Health Center, Aragonese Health Service, 50013 Zaragoza, Spain; (L.R.-E.); (R.R.-A.); (M.P.L.-S.)
| | - Raquel Refusta-Ainaga
- San Jose Health Center, Aragonese Health Service, 50013 Zaragoza, Spain; (L.R.-E.); (R.R.-A.); (M.P.L.-S.)
| | - María Pilar Lahoz-Sánchez
- San Jose Health Center, Aragonese Health Service, 50013 Zaragoza, Spain; (L.R.-E.); (R.R.-A.); (M.P.L.-S.)
| | - Belén Miró-Palacios
- Association of People with Lymphedema in Aragon (ADPLA), 50007 Zaragoza, Spain;
| | - Mayra Medrano-Cid
- Lozano Blesa University Clinical Hospital, Aragonese Health Service, 50009 Zaragoza, Spain;
| | - Rosa Magallón-Botaya
- Institute for Health Research Aragon (IIS Aragon), University of Zaragoza, 50009 Zaragoza, Spain;
| | - Mirian Santamaría-Peláez
- Department of Health Sciences, University of Burgos, 09001 Burgos, Spain; (M.S.-P.); (J.J.G.-B.)
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