Measurement Properties of Instruments for Measuring of Lymphedema: Systematic Review

Digital Volumetric Measurements Based on 3D Scans of the Lower Limb: A Valid and Reproducible Method for Evaluation in Lymphedema Therapy

BACKGROUND

Exact quantification of volumetric changes of the extremities is difficult and often error-prone. The aim of this study was to establish a standardized method based on 3-dimensional (3D) scans. Furthermore, this study tests the method in terms of reproducibility and evaluates volume changes after surgical therapy in patients suffering from lymphedema on the lower extremity.

METHODS

3D scans of the lower limb were performed with a mobile 3D scanner; "repeatability" and "interobserver reliability" of digital volumetry were tested. Furthermore, the method was applied on 31 patients suffering from chronic lymphedema.

RESULTS

Calculations of repeatability of the volume based on 20 3D scans of the same lower leg showed a mean volume of 2.488 ± 0.011 liters (range: 2.470-2.510). The mean volume of the different examiners did not differ significantly (F(2,18) = 1.579, P = 0.233). The paired t-test showed a significant mean volume decrease of 375 mL (95% confidence interval = 245/505 mL) between pretreatment and post-treatment (t (30) = 5.892, P < 0.001).

CONCLUSIONS

3D volumetry is a noninvasive, easy, and quick method to assess volume changes of the lower leg. Other than the low costs, it is reproducible and precise and therefore ideal for evolution of therapy in lymphedema.

Reliability, concurrent validity, and clinical feasibility of measurement methods determining volume in patients with lower limb lymphedema and healthy controls

PURPOSE

To investigate reliability, concurrent validity, and clinical feasibility of measurements assessing volume in patients with lower limb lymphedema (LLL) and healthy controls.

MATERIALS AND METHODS

To investigate intra- and interrater reliability, 47 patients with LLL and 30 healthy controls were assessed three times by two assessors. To investigate between session reliability, 50 participants were reassessed two weeks later. Each assessment included measurements of the midline region (hip circumference; suprapubic volume), leg volume (perimeter every 4 cm; Perometer®), and foot volume (water displacement; figure-of-eight method). Concurrent validity was assessed with correlation coefficients. Measurements were timed and practical limitations were reviewed. Clinical trial registration number: NCT: 05269264.

RESULTS

Measurements of the total volume of different regions showed weak to very high intraclass correlation coefficients (ICCs) (0.131-998). Absolute and relative volume differences had lower ICC values (0.360-0.976). A strong correlation was found between the total volumes of the same region. The Perometer® and figure-of-eight method were the fastest method for leg and foot volume, respectively.

CONCLUSIONS

The assessed total volumes might be more valuable in assessing the evolution of volume in bilateral LLL than the calculated absolute and relative differences between both limbs. The Perometer® and figure-of-eight method were the most time efficient for leg and foot volume, respectively.Implications for rehabilitationLymphedema is a chronic condition for which a reliable and clinically feasible assessment of volume is essential for the diagnosis, treatment decisions, and the evaluation of the treatment.This study shows that the total leg/foot volumes were more reliable than the calculated absolute and relative differences between both limbs and could therefore more valuable to evaluate bilateral lower limb lymphedema.For the assessment of leg volume, the Perometer® was the most reliable and fastest method.For the evaluation of the foot volume, the figure-of-eight method was overall the best method.

Limited consensus on the diagnosis and treatment of lymphedema after head and neck cancer: results from an International Delphi study

PURPOSE

To explore current practice variation and degree of consensus among international clinical experts regarding the diagnosis, classification, measurement, and treatment of head and neck lymphedema (HNL) after head and neck cancer treatment.

MATERIALS AND METHODS

We conducted an online Delphi study. Eligible participants were clinical researchers who had (co)authored at least one publication on HNL and healthcare professionals who had treated at least five patients with HNL the last two years. The first round was to collect views about current best practices. The second and third rounds delved deeper into these topics using statements with 7-point adjective rating scales.

RESULTS

An expert panel of seventeen participants (7 clinicians, 8 researchers, and 2 others) from 8 countries completed all rounds. Regarding diagnosis, there was limited consensus on most subjects, with palpation being most endorsed. No consensus was reached on the need to use standardized classification systems. As a treatment method, complex decongestive therapy (CDT) was the most commonly used in practice and investigated in the literature. However, no consensus was reached on the importance of aspects of CDT.

CONCLUSIONS

There is substantial intra- and international practice variation in the management of HNL. This calls for more robust evidence and guidelines.

SurLym trial: study protocol for a multicentre pragmatic randomised controlled trial on the added value of reconstructive lymphatic surgery to decongestive lymphatic therapy for the treatment of lymphoedema

INTRODUCTION

Lymphoedema is a chronic condition caused by lymphatic insufficiency. It leads to swelling of the limb/midline region and an increased risk of infection. Lymphoedema is often associated with mental and physical problems limiting quality of life. The first choice of treatment is a conservative treatment, consisting of exercises, skin care, lymph drainage and compression. Reconstructive lymphatic surgery is also often performed, that is, lymphovenous anastomoses, lymph node transfer or a combination. However, robust evidence on the effectiveness of reconstructive lymphatic surgery is missing. Therefore, the objective of this trial is to investigate the added value of reconstructive lymphatic surgery to the conservative treatment in patients with lymphoedema.

METHODS AND ANALYSIS

A multicentre randomised controlled and pragmatic trial was started in March 2022 in three Belgian university hospitals. 90 patients with arm lymphoedema and 90 patients with leg lymphoedema will be included. All patients are randomised between conservative treatment alone (control group) or conservative treatment with reconstructive lymphatic surgery (intervention group). Assessments are performed at baseline and at 1, 3, 6, 12, 18, 24 and 36 months. The primary outcome is lymphoedema-specific quality of life at 18 months. Key secondary outcomes are limb volume and duration of wearing the compression garment at 18 months. The approach of reconstructive lymphatic surgery is based on presurgical investigations including clinical examination, lymphofluoroscopy, lymphoscintigraphy, lymph MRI or CT angiography (if needed). All patients receive conservative treatment during 36 months, which is applied by the patient's own physical therapist and by the patient self. From months 7 to 12, the hours a day of wearing the compression garment are gradually decreased.

ETHICS AND DISSEMINATION

The study has been approved by the ethical committees of University Hospitals Leuven, Ghent University Hospital and CHU UCL Namur. Results will be disseminated via peer-reviewed journals and presentations.

TRIAL REGISTRATION NUMBER

NCT05064176.

Limb Volume Measurements: A Comparison of Circumferential Techniques and Optoelectronic Systems against Water Displacement

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.

Comparison of the effects of different functional exercise sequences on lymphedema in breast cancer: protocol for an exploratory randomised controlled cross-over trial

INTRODUCTION

Breast cancer-related lymphedema (BCRL) is a common postoperative complication of breast cancer. It develops in a chronic and vicious cycle. Once lymphedema occurs, it cannot be cured and bring serious physiological, psychological, social and economic burden to patients. Upper limb functional exercises are an effective and convenient intervention for managing lymphedema. However, the optimal exercise sequence remains unclear. Therefore, we aim to compare the effects of exercise sequences under the guidance of commonly used exercise sequences and lymphatic flow theory.

METHODS

An exploratory randomised controlled cross-over trial will be conducted. 32 patients with BCRL are randomly allocated into two groups (group A and group B). Group A patients will perform functional exercise from wrist joint to shoulder joint, and the exercise direction of group B is opposite to that of group A, that is, from shoulder joint to wrist joint end. Exercise time is once a day, each 20-30 min, for 2 weeks. After 2 weeks of washout period, A and B groups of exchange exercise sequences (exercise frequency and duration unchanged). The primary outcome is upper limb circumference, and secondary outcomes are upper limb function and lymphedema symptoms.

ETHICS AND DISSEMINATION

This study protocol is presented in accordance with the Standard Protocol Items: Recommendations for Interventional Trials guidelines. All participants will sign a written informed consent. The research ethics regional committee of Shanghai Seventh People's Hospital has approved the study. Regardless of the outcome of this study, the results will be published in open-access journals to ensure public access.

TRIAL REGISTRATION NUMBER

ChiCTR2200066463.

The past and future of peri-operative interventions to reduce arthrogenic quadriceps muscle inhibition after total knee arthroplasty: A narrative review

Total knee arthroplasty (TKA) improves patient-reported function by alleviating joint pain, however the surgical trauma exacerbates already impaired muscle function, which leads to further muscle weakness and disability after surgery. This early postoperative strength loss indicates a massive neural inhibition and is primarily driven by a deficit in quadriceps muscle activation, a process known as arthrogenic muscle inhibition (AMI). To enhance acute recovery of quadriceps muscle function and long-term rehabilitation of individuals after TKA, AMI must be significantly reduced in the early post-operative period. The aim of this narrative review is to review and discuss previous efforts to mitigate AMI after TKA and to suggest new approaches and interventions for future efficacy evaluation. Several strategies have been explored to reduce the degree of post-operative quadriceps AMI and improve strength recovery after TKA by targeting post-operative swelling and inflammation or changing neural discharge. A challenge of this work is the ability to directly measure AMI and relevant contributing factors. For this review we focused on interventions that aimed to reduce post-operative swelling or improve knee extension strength or quadriceps muscle activation measured by twitch interpolation. For individuals undergoing TKA, the use of anti-inflammatory medications, tranexamic acid, cryotherapy, intra-articular drains, torniquets, and minimally invasive surgical techniques for TKA have limited benefit in attenuating quadriceps AMI early after surgery. However, interventions such as inelastic compression garments, voluntary muscle contractions, and neuro-muscular electrical stimulation show promise in mitigating or circumventing AMI and should continue to be refined and explored.

Association between Bioimpedance Spectroscopy and Magnetic Resonance Lymphangiography in the Diagnosis and Assessment of Lymphedema

BACKGROUND

 This study assesses associations between bioimpedance spectroscopy (BIS) and magnetic resonance lymphangiography (MRL) in the staging and assessment of lymphedema.

METHODS

 Adults who received MRL and BIS between 2020 and 2022 were included. We collected fluid, fat, and lymphedema severity ratings, and measured fluid stripe thickness, subcutaneous fat width, and lymphatic diameter on MRL. BIS lymphedema index (L-Dex) scores were collected from patient charts. We assessed sensitivity and specificity of L-Dex scores to detect MRL-identified lymphedema, and examined associations between L-Dex scores and MRL imaging measures.

RESULTS

 Forty-eight limbs across 40 patients were included. L-Dex scores had 72.5% sensitivity and 87.5% specificity for detecting MRL-defined lymphedema, with a 96.7% estimated positive predictive value and 38.9% negative predictive value. L-Dex scores were associated with MRL fluid and fat content scores (p ≤ 0.05), and lymphedema severity (p = 0.01), with better discrimination between fluid than fat content levels on pairwise analysis, and poor discrimination between adjacent severity levels. L-Dex scores were correlated with distal and proximal limb fluid stripe thickness (distal: rho = 0.57, p < 0.01; proximal: rho = 0.58, p < 0.01), partially correlated with distal subcutaneous fat thickness when accounting for body mass index (rho = 0.34, p = 0.02), and were not correlated with lymphatic diameter (p = 0.25).

CONCLUSION

 L-Dex scores have high sensitivity, specificity, and positive predictive value for the identification of MRL-detected lymphedema. L-Dex has difficulty distinguishing between adjacent severity levels of lymphedema and a high false negative rate, explained in part by reduced discrimination between levels of fat accumulation.

Assessment Modalities for Lower Extremity Edema, Lymphedema, and Lipedema: A Scoping Review

Lower extremity swelling may be broadly characterized as due to edema, lymphedema, or lipedema. Differentiation between these three conditions is important for providing appropriate treatment. This review analyzes and compares different clinical diagnostic modalities for these conditions, with the aim of assisting in the process of choosing the most appropriate diagnostic modality by highlighting the advantages and limitations of each. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for a systematic search of peer-reviewed literature, the following diagnostic methods for lower extremity swelling were investigated: (1) ultrasound (US), (2) lymphoscintigraphy (LSG), (3) computed tomography (CT), (4) bioimpedance spectroscopy (BIS), (5) tissue dielectric constant (TDC), and (6) magnetic resonance imaging (MRI), including magnetic resonance lymphangiography (MRL). The databases used in the search were PubMed, ProQuest, CINAHL Complete, Web of Science, Embase, and Biomedical Reference Collection. After retrieving 115 studies based on predetermined inclusion criteria, a total of 31 studies were critically evaluated. The main results indicate the following: duplex US is the modality of choice to initially identify lower extremity edema such as deep venous thrombosis (DVT) and venous reflux due to its high sensitivity and specificity. CT venography of the lower extremity appears to bethe preferred option for gynecologic cancer patients with lower extremity swelling post-treatment, as it measures subcutaneous tissue volumes to look for DVTs, lymphoceles, and cancer recurrence. TDC is a recommended modality for a variety of conditions, including edema and lymphedema, in part, due to its noninvasive localized assessment capabilities and ease of use. LSG emerges as an effective imaging modality for lymphedema characterization with minimal invasiveness and high sensitivity and specificity. BIS is widely used to identify and monitor lower extremity lymphedema but has been reported to have low sensitivity and lacks the ability to account for changes in tissue composition such as fibrosis. US and MRL are favored for lipedema diagnosis, with MRL providing comprehensive anatomical and functional insights, albeit with cost and accessibility limitations compared to US. While CT, MRI, US, and TDC are all useful for differentiating lymphedema from lipedema, MRI is the preferred modality due to its anatomical and functional diagnostic capabilities. However, US is a pragmatic alternative for use with obese patients or when MRI is not an option.

The VASCERN PPL working group patient pathway for primary and paediatric lymphoedema

Lymphoedema is caused by an imbalance between fluid production and transport by the lymphatic system. This imbalance can be either caused by reduced transport capacity of the lymphatic system or too much fluid production and leads to swelling associated with tissue changes (skin thickening, fat deposition). Its main common complication is the increased risk of developing cellulitis/erysipelas in the affected area, which can worsen the lymphatic function and can be the cause of raised morbidity of the patient if not treated correctly/urgently. The term primary lymphoedema covers a group of rare conditions caused by abnormal functioning and/or development of the lymphatic system. It covers a highly heterogeneous group of conditions. An accurate diagnosis of primary lymphoedema is crucial for the implementation of an optimal treatment plan and management, as well as to reduce the risk of worsening. Patient care is diverse across Europe, and national specialised centres and networks are not available everywhere. The European Reference Network on Rare Multisystemic Vascular Diseases (VASCERN) gathers the best expertise in Europe and provide accessible cross-border healthcare to patients with rare vascular diseases. There are six different working groups in VASCERN, which focus on arterial diseases, hereditary haemorrhagic telangiectasia, neurovascular diseases, lymphoedema and vascular anomalies. The working group Paediatric and Primary Lymphedema (PPL WG) gathers and shares knowledge and expertise in the diagnosis and management of adults and children with primary and paediatric lymphoedema. The members of PPL WG have worked together to produce this opinion statement reflecting strategies on how to approach patients with primary and paediatric lymphoedema. The objective of this patient pathway is to improve patient care by reducing the time to diagnosis, define the best management and follow-up strategies and avoid overuse of resources. Therefore, the patient pathway describes the clinical evaluation and investigations that lead to a clinical diagnosis, the genetic testing, differential diagnosis, the management and treatment options and the patient follow up at expert and local centres. Also, the importance of the patient group participation in the PPL WG is discussed.

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

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

The Utilization of e-Health in Lymphedema Care: A Narrative Review

Background: Electronic health (e-Health), refers to technologies that can be utilized to enhance patient care as well as collect and share health information. e-Health comprises several umbrella terms, including telehealth, mobile health, e-Health, wearables, and artificial intelligence. The types of e-Health technologies being utilized in lymphedema (LE) care are unknown. Method: In this narrative review, a search of published research on the utilization of e-Health technologies in LE-related care was conducted. Results: Five different types of e-Health modalities were found (robotics, artificial intelligence, electronic medical records, smart wearable devices, and instructive online information) spanning 14 use cases and 4 phases of care (preventative, diagnostic, assessment, and treatment phases). Broad e-Health utilization examples were found including robotic-assisted surgery to reduce the likelihood of LE after lymphadenectomy, machine learning to predict patients at risk of filarial-related LE, and a novel wearable device prototype designed to provide lymphatic drainage. Conclusions: e-Health has reported merit in the prevention, diagnoses, assessment, and treatment of LE with utilization demonstrating cutting edge applicability of e-Health for achieving optimal patient care and outcomes. As technology continues to advance, additional research into the utilization of e-Health in LE care is warranted.

Test-Retest Reliability of a Protocol for Assessment of Local Tissue Water in the Head and Neck Area

Background: Lymphedema measurement is vital to select appropriate treatment and monitor its progress. Quantifying lymphedema in the head and neck area is challenging. The use of tissue dielectric constant (TDC) measurements has shown promising results in other body areas. This study aims to determine the test-retest reliability of a TDC measurement protocol developed for the head and neck area. Methods and Results: A detailed measurement protocol, including eight measurement points per side, was developed. Subsequently, the reliability of the protocol was tested in a sample of healthy participants (n = 50, 28 males). Using the LymphScanner (Delfin, Finland), participants were subjected to two measurement sessions. Each measurement point was measured three times per session. Test-retest reliability for each point was evaluated using intraclass correlation coefficients (ICCs) and standard errors of measurement (SEMs). Using the average of three measurements, reliability was good to excellent for all points (ICCs 0.81-0.95), with small measurement errors (SEMs 1.51-2.86). The reliability of a single measurement was moderate to excellent for all measurement points (ICCs 0.58-0.87), with larger, but still small, measurement errors (SEMs 1.65-3.39). When using single measurements, the lowest ICCs were found for the temporal (left 0.73 and right 0.67) and submandibular (left 0.58 and right 0.77) locations. Conclusion: Measurements with the LymphScanner, taken according to the developed protocol, are reliable in healthy participants. We recommend using the average of three measurements to optimize reliability. The protocol is fit for further testing in patient populations and for determining normal values in a larger scale study with healthy subjects.

Culturally adapted translation of LYMPH-Q upper extremity module from English to Mandarin Chinese

BACKGROUND

Breast cancer-related lymphedema (BCRL) is one of the debilitating complications after breast cancer treatment. Several forms of patient-reported outcome measures (PROMs) were developed to evaluate the severity of BCRL based on the patients' perspective. LYMPH-Q Upper Extremity Module is a newly developed questionnaire for BCRL. This study aimed to demonstrate the process of translation and cultural adaption from English to Mandarin Chinese.

METHODS AND RESULTS

The translation process followed the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) best-practice guidelines for the translation and cultural adaption of PROM. The process included four steps: forward translation, back translation, back translation review, and patient interviews. In total, five patients with BCRL were recruited for patient interviews. The forward translation step involved two professional translators whose native language was Mandarin Chinese. A reconciled translated version was produced. In the back translation step, the reconciled translated version in Mandarin Chinese was sent to another professional translator whose native language was English. The back-translated version in English was sent back to the developer of LYMPH-Q for review. In this step, 22 items were revised. In the final step of patient interviews, 15 items were revised based on the patients' feedback.

CONCLUSION

The development of Mandarin Chinese version of LYMPH-Q Upper Extremity Module and its utilization in conjunction with the existing objective measures could provide a more well-rounded picture of the status of patients with BCRL worldwide.

Evaluation of upper limb lymphoedema and diagnostic accuracy of bioimpedance spectroscopy. A comprehensive validation in a Brazilian population

Lymphoedema is a complication of breast cancer treatment. Its early diagnosis is related to a good prognosis for lymphoedema treatment. The bioimpedance spectroscopy (BIS) evaluates changes in extracellular fluid. The objective of our study was to evaluate the validity, agreement and accuracy of BIS in the diagnosis of breast cancer-related lymphoedema in a Brazilian population.

Methods

This is a prospective, cross-sectional study of a convenience sample of 462 women who underwent surgical treatment for breast cancer (mastectomy or breast-conserving treatment). The validity, agreement and accuracy were performed comparing BIS (lymphoedema index (L-DEX) ≥ 6.5 or 10) with volumetry by water displacement, which is the gold standard for evaluating lymphoedema. Receiver operating characteristic curve was performed. Additionally, other methods like perimetry and indirect volumetry of the upper limbs were compared with water displacement volumetry (direct volumetry), and the BIS were compared with subjective evaluation.

Results

Considering L-DEX ≥ 10 the sensitivity of the BIS was 44.1%, specificity 95.4%, positive predictive value (PPV) was 70.7%, negative predictive value (NPV) was 87% and kappa was 0.459. The BIS with L-DEX ≥ 6.5, the sensitivity, specificity, PPV, NPV and kappa were 57%, 88.5%, 55.8%, 89% and 0.452, respectively. Area under curve was 0.724 and a possible cut-off point of L-DEX ≥ 7.35 with sensitivity of 57%, specificity of 90.7% and kappa value = 0.489.

Conclusion

Although BIS was significantly associated with the subjective evaluation of lymphoedema, it showed low sensitivity and agreement and moderate correlation when used as a method for diagnosing the condition. Thus, it is not the most valid method for evaluating lymphoedema. In addition, it was not the most accurate method when compared with other objective evaluation tools. Public health resources are scarce and must be used consciously. The knowledge that BIS is not a more accurate method than other, lower-cost instruments allows for better targeting of these resources.

Quantification of breast lymphoedema following conservative breast cancer treatment: a systematic review

PURPOSE

Breast lymphoedema is a possible side effect of breast conserving surgery, but it is poorly understood. This is due, in part, to difficulty assessing the breast. This systematic review described outcome measures that quantify breast lymphoedema signs and symptoms and evaluated the measurement properties for these outcome measures.

METHOD

Seven databases were searched using terms in four categories: breast cancer, lymphoedema and oedema, clinician reported (ClinROM) and patient reported outcome measures (PROM) and psychometric and measurement properties. Two reviewers independently reviewed studies and completed quality assessments. The Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology was used for studies including measurement property evidence.

RESULTS

Fifty-six papers were included with thirteen questionnaires, eight patient-reported rating scales, seven physical measures, seven clinician-rating scales and four imaging techniques used to quantify breast lymphoedema. Based on COSMIN methodology, one ClinROM had sufficient reliability, ultrasound measuring dermal thickness. Tissue dielectric constant (TDC) measuring local tissue water had promising reliability. Four questionnaires had sufficient content validity (BLYSS, BLSQ, BrEQ and LYMQOL-Breast).

CONCLUSIONS

Ultrasound is recommended to reliably assess breast lymphoedema signs. No PROM can be recommended with confidence, but BLYSS, BLSQ, BrEQ and LYMQOL-Breast are promising. Further research is recommended to improve evidence of measurement properties for outcome measures.

IMPLICATIONS FOR CANCER SURVIVORS

There are many approaches to assess breast lymphoedema, but currently, only ultrasound can be recommended for use, with others, such as TDC and questionnaires, showing promise. Further research is required for all approaches to improve evidence of measurement properties.

The Use of Wearable Activity Monitors to Measure Upper Limb Physical Activity After Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy

BACKGROUND

We suspect that morbidity from both sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) has been inadequately evaluated to date. Current methodologies are subjective and susceptible to bias. Objective assessment using wearable activity monitors (WAMs) would allow quantitative analysis of recovery by measuring physical activity (PA) and could provide evidence for axillary de-escalation.

PATIENTS AND METHODS

A prospective, single center, observational study was conducted from February 2020 to May 2022. Consecutive patients undergoing breast and/or reconstructive surgery and axillary surgeries were identified from the operating schedules. Patients wore WAMs for an average of 3 days prior to surgery and up to 2 weeks following surgery. In total, 56 patients with breast cancer were recruited, of whom 35 underwent SLNB and 21 ALND.

RESULTS

Patients who underwent ALND experienced significantly worse PA compared with those who underwent SLNB in week 2 (median 66.4% versus 72.7%, p = 0.015). Subgroup analysis revealed significantly lower PA in simple mastectomy (Mx)-ALND versus Mx-SLNB (median 90.3% versus 70.5%, p = 0.015) in week 2. The PA for SLNB did not return to baseline at 2 weeks after surgery.

CONCLUSIONS

Compared with SLNB, ALND results in a lower PA level in week 2. The findings also indicate that SLNB has a protracted effect on PA levels, which extend to 2 weeks postoperatively. Monitoring recovery objectively following breast cancer surgery provides patients and surgeons with more information regarding the predicted outcomes of their surgery, which can drive the development of a personalized rehabilitation program.

Segmentation of Arm Ultrasound Images in Breast Cancer-Related Lymphedema: A Database and Deep Learning Algorithm

OBJECTIVE

Breast cancer treatment often causes the removal of or damage to lymph nodes of the patient's lymphatic drainage system. This side effect is the origin of Breast Cancer-Related Lymphedema (BCRL), referring to a noticeable increase in excess arm volume. Ultrasound imaging is a preferred modality for the diagnosis and progression monitoring of BCRL because of its low cost, safety, and portability. As the affected and unaffected arms look similar in B-mode ultrasound images, the thickness of the skin, subcutaneous fat, and muscle have been shown to be important biomarkers for this task. The segmentation masks are also helpful in monitoring the longitudinal changes in morphology and mechanical properties of tissue layers.

METHODS

For the first time, a publicly available ultrasound dataset containing the Radio-Frequency (RF) data of 39 subjects and manual segmentation masks by two experts, are provided. Inter- and intra-observer reproducibility studies performed on the segmentation maps show a high Dice Score Coefficient (DSC) of 0.94±0.08 and 0.92±0.06, respectively. Gated Shape Convolutional Neural Network (GSCNN) is modified for precise automatic segmentation of tissue layers, and its generalization performance is improved by the CutMix augmentation strategy.

RESULTS

We got an average DSC of 0.87±0.11 on the test set, which confirms the high performance of the method.

CONCLUSION

Automatic segmentation can pave the way for convenient and accessible staging of BCRL, and our dataset can facilitate development and validation of those methods.

SIGNIFICANCE

Timely diagnosis and treatment of BCRL have crucial importance in preventing irreversible damage.

The Usefulness of a Three-Microneedle Device for Indocyanine Green Fluorescence Lymphography

Background: Indocyanine green (ICG) fluorescence lymphography is widely used to diagnose lymphedema. There is little consensus on the appropriate injection method for ICG fluorescence lymphangiography. We used a three-microneedle device (TMD) for skin injection of ICG solution and investigated its usefulness. Methods and Results: Thirty healthy volunteers were injected with ICG solution using a 27-gauge (27G) needle in one foot and a TMD in the other foot. Injection-related pain was evaluated using the Numerical Rating Scale (NRS) and Face Rating Scale (FRS). The skin depth of the injected ICG solution was evaluated by injecting the solution into the skin of amputated lower limbs using a 27G needle or TMD using ICG fluorescence microscopy. The median and interquartile range of the NRS scores was 3 (3-4) and 2 (2-4) in the 27G needle and TMD groups, respectively; that of the FRS scores was 2 (2-3) and 2 (1-2) in the 27G needle and TMD groups, respectively. Injection-related pain was significantly lower with the TMD than with the 27G needle. The lymphatic vessels were similarly visible using both needles. The depth of the ICG solution varied for each injection with a 27G needle (400-1200 μm) and was consistent at ∼300-700 μm below the skin surface using the TMD. Injection depth was significantly different between the 27G needle and the TMD. Conclusions: Injection-related pain decreased using the TMD, and ICG solution depth was consistent on fluorescence lymphography. A TMD may be useful for ICG fluorescence lymphography. Clinical Trials Registry (UMIN-CTR; ID: UMIN000033425).

Early Intervention with a Compression Sleeve in Mild Breast Cancer-Related Arm Lymphedema: A 12-Month Prospective Observational Study

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.

Retrospective study on the trajectories of lower limb volume after outpatient-based complex decongestive therapy in post-operative gynecological cancer patients with lymphedema

PURPOSE

To determine the effect of outpatient-based complex decongestive therapy in patients with secondary lower limb lymphedema (LLL) after gynecologic cancer surgery using group-based trajectory modeling (GBTM), and to examine factors predictive of the treatment course.

METHODS

This retrospective study included participants who underwent surgery for gynecological cancer with pelvic lymph node dissection and subsequently visited the outpatient clinic for the treatment of stage II LLL according to the International Society of Lymphology. The improvement rate of edema at the initial visit and 3, 6, and 12 months later was assessed by calculating the volume of the lower extremity using the circumferential method. For evaluation of the patterns of treatment course, logistic regression analysis was performed after group estimation by the trend of the treatment course using GBTM.

RESULTS

A total of 148 women (mean age 60.6 years (standard deviation: 13.4 years)) were analyzed. Three improvement trajectories were identified: (1) no response group, with worsening rather than improvement (n = 26); (2) moderate response group, with a slow improvement rate (n = 89); and (3) high response group, with a high improvement rate (n = 33). In addition, adherence to compression therapy at 3 months post-intervention was found to be a predictor in the no response group.

CONCLUSIONS

GBTM estimated that there are three patterns of the treatment course in patients with LLL after gynecologic cancer surgery. Adherence to compression therapy at 3 months post-intervention is a predictor of the treatment effectiveness.

Variation in Leg Tissue Dielectric Constant Values of Healthy Young Adult Females With and Without Compression Bandaging

Background The clinical efficacy of a compression application has been often limited to the assessment of the change in limb volume, change in clinical symptoms (i.e., wound size, pain, range of motion, incidence of cellulitis), or vascular hemodynamics of the whole limb. Assessing compression-related biophysical changes of a localized area, such as around a wound, or in an area outside of an extremity cannot be objectively assessed by these measurements. Tissue dielectric constant (TDC) values, which provide a measure of the local tissue water (LTW) content, offer an alternative method to document variation in the LTW content of the skin in a specific location. The goals of the present research were (1) to characterize TDC values, expressed as percentage tissue water, from multiple areas along the medial aspect of the lower leg of healthy volunteers and (2) to explore the potential utilization of the TDC values to assess change in tissue water content in a localized area following compression applications. Methods TDC was measured at 10, 20, 30, and 40 cm proximal to the medial malleolus on the medial aspect of the right leg of 18 young adult healthy women with an age range of 18-23 years and a body mass index of 18.7 to 30.7kg/m^2.. TDC was measured at baseline and after 10 minutes of exercise with compression in place on three separate days during which three different compression applications were assessed: a longitudinal elastic stockinette, a two-layer cohesive compression kit, and a combination of the two. Leg circumferences and compression-related interface pressures were also measured. Results Test-Retest Reliability of circumferential measurements and TDC values evaluated using Intraclass correlation coefficient (ICC _3,1) revealed excellent and moderate-to-good reliability, respectively. Analysis of TDC values along the length of the limb using Friedman's test, revealed a small but statistically significant overall difference among baseline TDC values attributable to a smaller value at 40 cm. The largest difference in cumulative average was 7.7% which occurred between 20 and 40 cm, with all other differences between locations less than 1%. No significant differences between the compression applications were observed. Conclusion  The present findings demonstrate the utility of TDC measurements as a modality to assess compression-related changes in the legs of healthy women as a foundation for their potential use in assessing outcomes of compression treatments for persons with lower extremity edema or lymphedema. The absence of a significant change in TDC values in these healthy non-edematous conditions and the demonstrated reliability of the TDC measurements on three different days provides further support for the utility of such applications of TDC measurements. The extension to patients with lower extremity edema or lymphedema needs to be evaluated.

Effect of Flat-Knitted Medical Compression Stockings on Venous Malformations

Venous malformations are one of the most common vascular anomalies. Our study aimed to investigate the effect of medical compression stockings of class I and II on the volume of venous malformations. Patients with venous malformations on upper or lower extremities were enrolled. They wore flat-knitted medical compression stockings of class I and II in a randomized order for four weeks each. Magnetic resonance imaging (MRI) and perometry were performed with and without wearing compression stockings. The 12-Item Short Form Survey (SF-12) questionnaire was performed before and after wearing compression stockings for four weeks each. A total of 18 patients completed the evaluations. Both compression classes showed a significant reduction of the volume of the venous malformations in the lesion itself based on MRI in comparison with baseline (both p < 0.001). Measurements taken with perometry did not reveal a significant difference in comparison to baseline (p = 0.09 and p = 0.22). The results of the SF-12 questionnaire demonstrated no significant differences before and after wearing the compression stockings of class I or class II for four weeks or between the two classes of compression therapy. Our results indicate that wearing medical compression stockings of both class I and class II significantly reduces the volume of venous malformation, without compromising the quality of life, while the effect of class II compression stockings on volume reduction was significantly better than that of class I.

Bioelectrical impedance analysis in patients with breast cancer-related lymphedema before and after lymphaticovenular anastomosis

OBJECTIVE

Bioelectrical impedance analysis (BIA) as a measure of lymphedema has been gaining popularity because of its measurement simplicity and noninvasiveness. This study was performed to investigate the effectiveness of BIA for assessment of the outcomes of lymphaticovenular anastomosis (LVA) in patients with breast cancer-related lymphedema.

METHODS

This study involved 25 patients with unilateral breast cancer-related lymphedema who underwent LVA. Segmental multifrequency BIA and conventional circumferential volume measurement were performed preoperatively and 6 months postoperatively from June 2018 to June 2021 at Hiroshima University Hospital International Center for Lymphedema. The patients' clinicopathological data, operative details, and preoperative and postoperative BIA results were investigated.

RESULTS

Segmental multifrequency BIA and circumferential volume measurement were strongly correlated in the lymphedema-affected upper limb both before and after LVA. The interlimb volume, interlimb extracellular water ratio (r = 0.784; P < .001), and interlimb extracellular water/total body water ratio were positively correlated (r = 0.612; P < .01), whereas the phase angle was negatively associated (r = -0.556; P < .01).

CONCLUSIONS

Segmental multifrequency BIA can be a useful tool for assessing the severity of lymphedema and monitoring the outcomes of LVA.

Indirect partial volumetry in breast cancer-related lymphoedema: Distribution of oedema and clinical-diagnostic implications

INTRODUCTION AND OBJECTIVES

Currently, the assessment of lymphoedema related to breast cancer (BCRL) is performed through the global perimeter volumetry. We implemented an additional system with partial measures (hand, forearm, and upper arm) that allows us to approximate the segmental distribution of oedema. We used this measurement tool to determine the oedema distribution and its evolution, as well as its possible impact on clinical assessment.

METHODS

We carried out a retrospective observational study of the patients referred to our service with suspected BCRL.

INCLUSION CRITERIA

Unilateral breast cancer, availability of global and partial digital medical record, and follow-up for a minimum of 24 months. Of the 210 selected patients, 190 were considered affected (≥10% excess volume). We analysed at three time points (initial, final, and peak involvement) the oedema distribution and segmental predominance and its relationship with the evolutionary course and the severity of the process. We subsequently examined, at the initial timepoint, the concordance of the global assessment with the partial assessment for the clinical classification of the 210 patients in the initial sample.

RESULTS

The BCRL oedema was characteristically irregular, with the forearm being the most affected segment and the hand the least affected (RM ANOVA: p<0.001). The irregularity was related to its severity (χ²: p<0.001) and the evolutionary course (Student t-test: p<0.005 for the hand). Overall, disagreement of 46.67% was observed between the clinical classification of the global and partial assessment.

CONCLUSIONS

This work supports the need to add partial volumetry to the commonly used global assessment.

New Device to Measure Cross-Sectional Areas and Segmental Volumes of Objects and Limbs

Purpose

High accuracy volume measurements have important implications in different medical and non-medical situations. All methods used to date have challenges to achieve a usable clinical accuracy. Moreover, current methods have limitations to measure segmental volumes. We developed a new device that is able to measure a continuous profile of the cross-sectional areas along an object. Herewith the total volume of an object or any part of it are correspondingly determined.

Methods

The Peracutus Aqua Meth (PAM) generates continuous profiles of cross-sectional areas. Water is pumped in or out of a measuring unit at a nearly fixed flow rate and the speed of the water level (dh/dt) is measured continuously using a pressure sensor at the bottom. The change of the water level is a measure for the cross-sectional area of an object at any height. Signal processing is required to obtain valuable measurements. Three static objects and an arm of a test object were measured to demonstrate the accuracy and repeatability of the new device.

Results

Cross-sectional areas of a PVC pipe obtained with the PAM and with a caliper were compared. The differences between the two methods were less than 1.3%. Volume measurements of two mannequin arms show standard deviations of 0.37% and 0.34%, respectively, whereas the standard deviation of the volume measurement of a genuine arm was only 1.07%. These figures surpass reported clinical accuracy.

Conclusion

The new device demonstrates that determining the cross-section and its volumes of objects is possible in an accurate, reliable, and objective way. The results show that segmental volume measurements of human limbs are possible. Application in clinical and non-clinical situations seems meaningful.

Whole-body phase angle correlates with pre-operative markers in total joint arthroplasty

Background

Bioimpedance derived whole body phase angle (ϕ), a measure of cellular integrity, has been identified as an independent marker of morbidity and mortality in many medical and surgical specialties. While similar measures of water homeostasis like extracellular edema (EE) have been associated with pre-operative risk, ϕ has not been studied in orthopaedics, despite potential to serve as a pre-operative marker. This study aims to identify relationships between ϕ, EE, and body composition metrics, laboratory values, patient reported outcomes, and comorbidities.

Methods

Multi-frequency bioimpedance analysis (BIA) records, laboratory values, and patient reported outcomes of adult patients presenting to an academic arthroplasty clinic were retrospectively reviewed. Correlation coefficients between ϕ, EE, and reviewed information were conducted.

Results

ϕ was significantly correlated (p<0.001) most positively with measures of lean tissue such as skeletal muscle mass (r=0.48), appendicular skeletal muscle index (r=0.39), lean body mass (r=0.43), and dry lean mass (r=0.47), while it held negative correlations (p<0.001) with age (r= -0.55), and body fat mass (r= -0.11). ϕ was not correlated with body mass index (BMI, p = 0.204). In contrast, EE demonstrated its strongest positive correlations (p<0.001) with body fat mass (r=0.32), age (r=0.50), and BMI (r=0.26), and its strongest negative correlations (p<0.001) with serum albumin (r= -0.37) and total protein (r= -0.23).

Conclusions

Based on their associations with markers of health and fitness, BIA determined ϕ and EE demonstrate relationships to markers currently implemented in orthopaedic practice. This likely indicates that ϕ has potential as a comprehensive surrogate for several commonly used markers to quantify pre-operative risk. In the future, ϕ may aid in developing risk-stratifications for intervention and prevention of complications.

Volumetry of Hand and Forearm: A 3D Volumetric Approach

BACKGROUND

Swelling and edema of the hand and forearm may occur in various traumatic and degenerative diseases. So far, no precise measurement protocol exists. The objective of this study was to evaluate an examination protocol with relevant regions of interest (ROIs) measured by a 3-dimensional (3D) scanner to achieve precise, reproducible, and objective measurements for an optimized detection of volumes of the hand and forearm.

METHODS

A 3D scan protocol was developed using an Artec, 3D scanner EVA to measure discrete hand volumes of healthy volunteers. Five areas were defined as ROIs, representing volumes of the finger, metacarpus, wrist, hand, and distal forearm. Contralateral limbs were used for volume comparisons and calculation of volume differences.

RESULTS

For this study, 12 individuals (58.3% women, 24 hands and forearms) with a mean age of 27.1 ± 3 years were included. Mean volume values for left and right ROIs correlated with each other, with slightly higher volumes for the right upper extremity. Volume differences showed statistically significant results for the finger region (ROI I; P = .009), the metacarpal region (ROI II; P < .001), hand region (ROI IV; P = .001), and forearm region (ROI V; P = .006), with the exception of the wrist region (ROI III; P = .722).

CONCLUSIONS

Our results demonstrate that this 3D volumetric approach is a reliable and objective tool for measuring volumes and circumferences in hand and forearm. Based on our determined ROIs, further studies are needed to explore the significance for clinical applications.

Does Manual Lymphatic Drainage Add Value in Reducing Suprafascial Fluid Accumulation and Skin Elasticity in Patients With Breast Cancer-Related Lymphedema?

OBJECTIVE

The purpose of this study was to investigate the effectiveness of fluoroscopy-guided manual lymph drainage (MLD) versus that of traditional and placebo MLD, when added to decongestive lymphatic therapy (DLT) for the treatment of breast cancer-related lymphedema (BCRL) (EFforT-BCRL trial), on the suprafascial accumulation of lymphatic fluid and skin elasticity.

METHODS

In this multicenter, 3-arm, double-blind, randomized controlled trial (EFforT-BCRL trial), 194 participants (mean age = 61 [SD = 10] years) with unilateral BCRL were recruited. All participants received standardized DLT (education, skin care, compression therapy, exercises) and were randomized to fluoroscopy-guided, traditional, or placebo MLD. Participants received 60 min/d of treatment during the 3-week intensive phase and 18 sessions of 30 minutes during the 6-month maintenance phase. During this phase, participants were instructed to wear a compression garment, to perform exercises, and to perform a self-MLD procedure once daily. This study comprises secondary analyses of the EFforT-BCRL trial. Outcomes were the amount of fluid accumulation in the suprafascial tissues (local tissue water, extracellular fluid, and thickness of the skin and subcutaneous tissue) and skin elasticity at the level of the arm and trunk. Measurements were performed at baseline; after intensive treatment; after 1, 3, and 6 months of maintenance treatment; and after 6 months of follow-up.

RESULTS

At the level of the arm, there was a significant improvement over time in the 3 groups for most of the outcomes. At the level of the trunk, no remarkable improvement was noted within the individual groups. No significant interaction effects (between-group differences) were present. Only skin elasticity at the level of the arm, evaluated through palpation, showed a significant interaction effect.

CONCLUSION

All 3 groups showed similar improvements in response to DLT regardless of the type of MLD that was added. The effect of the addition of MLD to other components of DLT for reducing local tissue water and extracellular fluid or skin thickness and for improving skin elasticity and fibrosis in participants with chronic BCRL was limited.

IMPACT

Although MLD has been applied all over the world for many years, evidence regarding its added value in reducing arm volume in patients with BCRL is lacking. These results show that adding MLD to other components of DLT has limited value in reducing local tissue water and extracellular fluid or skin thickness and in improving skin elasticity and fibrosis in patients with chronic BCRL. To date, there is no clinical indication to continue including time-consuming MLD in physical therapist sessions for patients with chronic BCRL.

Early Referral for Breast-Cancer-Related Lymphedema: Do We Follow the Evidence? A Two-Year Prospective Multicenter Cohort Study

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.

Higher Rate of Lymphedema with Inguinal versus Axillary Complete Lymph Node Dissection for Melanoma: A Potential Target for Immediate Lymphatic Reconstruction?

Background: The present study was conducted to define the lymphedema rate at our institution in patients undergoing axillary (ALND) or inguinal (ILND) lymph node dissection (LND) for melanoma. It aimed to examine risk factors predisposing patients to a higher rate of lymphedema, highlighting which patients could be targeted for immediate lymphatic reconstruction (ILR). Methods: A retrospective chart review was conducted between October 2015 and July 2020 to identify patients who had undergone ALND or ILND for melanoma. The main outcome measures were rates of transient and permanent lymphedema. Univariate and multivariate analyses were performed to assess the relationship between lymphedema rate and factors related to patient characteristics, surgical procedure, pathology findings, and adjuvant treatment. Results: Between October 2015 and July 2020, 66 patients underwent LND for melanoma: 34 patients underwent ALND and 32 patients underwent ILND. At a median follow-up of 29 months, 85.3% (n = 29) of patients having had an ALND did not experience lymphedema, versus 50.0% (n = 16) of ILND (p = 0.0019). The rates of permanent lymphedema for patients having undergone ALND and ILND were 11.8% (n = 4) and 37.5% (n = 12) respectively (p = 0.016, NS). The rate of transient lymphedema was 2.9% (n = 1) for ALND and 12.5% (n = 4) for ILND (p = 0.13, NS). On univariate analysis, the location of LND and wound infection were found to be significant factors for lymphedema. On multivariate analysis, only the location of LND remained a significant predictor, with the inguinal location predisposing to lymphedema. Conclusion: This study highlights the high rate of lymphedema following ILND for melanoma and is a potential target for future patients to be considered for ILR.

Prediction of lymphedema occurrence in patients with breast cancer using the optimized combination of ensemble learning algorithm and feature selection

Background

Breast cancer-related lymphedema is one of the most important complications that adversely affect patients' quality of life. Lymphedema can be managed if its risk factors are known and can be modified. This study aimed to select an appropriate model to predict the risk of lymphedema and determine the factors affecting lymphedema.

Method

This study was conducted on data of 970 breast cancer patients with lymphedema referred to a lymphedema clinic. This study was designed in two phases: developing an appropriate model to predict the risk of lymphedema and identifying the risk factors. The first phase included data preprocessing, optimizing feature selection for each base learner by the Genetic algorithm, optimizing the combined ensemble learning method, and estimating fitness function for evaluating an appropriate model. In the second phase, the influential variables were assessed and introduced based on the average number of variables in the output of the proposed algorithm.

Result

Once the sensitivity and accuracy of the algorithms were evaluated and compared, the Support Vector Machine algorithm showed the highest sensitivity and was found to be the superior model for predicting lymphedema. Meanwhile, the combined method had an accuracy coefficient of 91%. The extracted significant features in the proposed model were the number of lymph nodes to the number of removed lymph nodes ratio (68%), feeling of heaviness (67%), limited range of motion in the affected limb (65%), the number of the removed lymph nodes ( 64%), receiving radiotherapy (63%), misalignment of the dominant and the involved limb (62%), presence of fibrotic tissue (62%), type of surgery (62%), tingling sensation (62%), the number of the involved lymph nodes (61%), body mass index (61%), the number of chemotherapy sessions (60%), age (58%), limb injury (53%), chemotherapy regimen (53%), and occupation (50%).

Conclusion

Applying a combination of ensemble learning approach with the selected classification algorithms, feature selection, and optimization by Genetic algorithm, Lymphedema can be predicted with appropriate accuracy. Developing applications by effective variables to determine the risk of lymphedema can help lymphedema clinics choose the proper preventive and therapeutic method.

Defining the region of interest of the knee for perioperative volumetric assessment with a portable 3D scanner in orthopedic and trauma surgery

Background

The aim of this study was to characterize three regions of interest (ROI) around the knee with a portable 3D scanner (Artec 3D scanner EVA). Soft tissue topography assessment with an optimized, precise, and reproducible method may assist surgeons when managing soft tissue swelling in the post traumatic setting.

Methods

12 healthy volunteers (24 legs, 7 women, 5 man) were included in this study. The patient cohort showed a mean age of 27.1 years (SD±3), a mean weight of 70 kg (SD±13) and a mean height of 171 cm (SD±8.8). All scans were recorded by the same examiner in the same room and with the same scanner (Artec, 3 D scanner EVA). Three volume regions of interest (ROI) were defined: the distal femur (circumference measured between the of superior extent of the patella to 10 cm proximal), the knee joint (measured from the top of the patella to the tibial tuberosity) and the proximal tibia (tibial tuberosity to 10 cm distal).

Results

The mean volume of the right leg was 3.901 l (I. distal femur: 1.63 l, knee joint: 1.33 l, proximal tibia: 1.10 l) and mean volume of the left leg was 3.910 l (I. distal femur: 1.66 l, knee joint: 1.34 l, proximal tibia: 1.12 l). The volume difference between the right and left leg was 0.094 l (SD ± 0.083 l) The Wilcoxon-Mann-Whitney test showed no significant differences of the volumes between the right and left leg.

Conclusions

This study demonstrates that portable 3D scanning could be an accurate and reliable tool for orthopedics and trauma surgeons. Based on the ROIs of this pilot study, further studies are needed to test the significance for clinical applications for patients with an injured knee.

Early intervention with compression garments prevents progression in mild breast cancer-related arm lymphedema: a randomized controlled trial

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.

Evaluating the accuracy of three-dimensional surface-imaging for circumference analysis of the thigh

BACKGROUND

Three-dimensional (3D) surface-imaging is an increasingly popular and useful tool in surgical planning and evaluation. These systems are used for anthropometric measurements of the face, breast and upper extremity. Its accuracy has, however, not yet been evaluated for the thigh. This could prove useful in the evaluation of autologous breast reconstructions using fasciocutaneous tissue of the thigh, such as the profunda artery perforator (PAP) flap.

METHODS

Thirty-five patients who underwent PAP flap surgery and 35 healthy controls were included. Thigh circumferences were measured using a flexible measuring tape at pre-defined levels. 3D images of the thigh were taken with the Canfield Vectra XT and fused to create 3D reconstructions. 3D circumferences were measured using the Vectra Analysis Module. Measuring tape and 3D circumferences were compared for mutual agreement.

RESULTS

Thigh circumference measurements by measuring tape correlated excellently with 3D measurements (r = 0.999). Bland-Altman plots demonstrated good agreement with a mean difference of -1.2 mm between the measuring tape and 3D measurements. The mean relative difference of both methods was -0.24%. Paired t-tests showed no significant statistical differences between the measuring tape and 3D circumference measurements in legs that underwent PAP flap surgery and without.

CONCLUSIONS

Flexible measuring tape and 3D circumference measurements of the thigh show excellent correlation. Three-dimensional surface imaging can thus be used to measure thigh circumferences in both patients with and without prior surgery of the thigh.

Relationship between lymphedema after breast cancer treatment and biophysical characteristics of the affected tissue

The treatment of breast cancer is often complicated by lymphedema of the upper limbs. Standard lymphedema evaluation methodologies are not able to measure tissue fibrosis. The ultrasound aspects related to tissue microstructures of lymphedema are neglected in clinical evaluations. The objective of this study was to identify and measure the degree of impairment, topography, and biophysical alterations of subcutaneous lymphedema tissue secondary to the treatment of breast cancer by ultrasonography. Forty-two women at a mean age of 58 (±9.7) years, with unilateral lymphedema due to breast cancer treatment, were evaluated. The upper limbs were divided into affected (affected by lymphedema) and control (contralateral limb). Each limb was subdivided into seven areas, defined by perimetry, evaluated in pairs. The biophysical characteristics thickness, entropy, and echogenicity were evaluated by ultrasonography. The results showed a significant difference in the echogenicity and thickness variables between the affected and unaffected upper limb, in all the extent of the upper limb, while entropy showed no significant difference. The findings indicate that the data presented were consistent both in identifying and measuring the degree of impairment and biophysical changes in the subcutaneous tissue of lymphedema secondary to the treatment of breast cancer.

Manual lymphatic drainage with or without fluoroscopy guidance did not substantially improve the effect of decongestive lymphatic therapy in people with breast cancer-related lymphoedema (EFforT-BCRL trial): a multicentre randomised trial

QUESTIONS

When added to decongestive lymphatic therapy (DLT), what is the effect of fluoroscopy-guided manual lymphatic drainage (MLD) versus traditional MLD or placebo MLD for the treatment of breast cancer-related lymphoedema (BCRL)?

DESIGN

Multicentre, three-arm, randomised controlled trial with concealed allocation, intention-to-treat analysis and blinding of assessors and participants.

PARTICIPANTS

At five hospitals in Belgium, 194 participants with unilateral chronic BCRL were recruited.

INTERVENTION

All participants received standard DLT (education, skin care, compression therapy and exercises). Participants were randomised to also receive fluoroscopy-guided MLD (n = 65), traditional MLD (n = 64) or placebo MLD (n = 65). Participants received 14 sessions of physiotherapy during the 3-week intensive phase and 17 sessions during the 6-month maintenance phase. Participants performed self-management on the other days.

OUTCOME MEASURES

All outcomes were measured: at baseline; after the intensive phase; after 1, 3 and 6 months of maintenance phase; and after 6 months of follow-up. The primary outcomes were reduction in excess volume of the arm/hand and accumulation of excess volume at the shoulder/trunk, with the end of the intensive phase as the primary endpoint. Secondary outcomes included daily functioning, quality of life, erysipelas and satisfaction.

RESULTS

Excess lymphoedema volume decreased after 3 weeks of intensive treatment in each group: 5.3 percentage points of percent excessive volume (representing a relative reduction of 23.3%) in the fluoroscopy-guided MLD group, 5.2% (relative reduction 20.9%) in the traditional MLD group and 5.4% (relative reduction 24.8%) in the placebo MLD group. The effect of fluoroscopy-guided MLD was very similar to traditional MLD (between-group difference 0.0 percentage points, 95% CI -2.0 to 2.1) and placebo MLD (-0.2 percentage points, 95% CI -2.1 to 1.8). Fluid accumulated at the shoulder/trunk in all groups. The average accumulation with fluoroscopy-guided MLD was negligibly less than with traditional MLD (-3.6 percentage points, 95% CI -6.4 to -0.8) and placebo MLD (-2.4 percentage points, 95% CI -5.2 to 0.4). The secondary outcomes also showed no clinically important between-group differences.

CONCLUSION

In patients with chronic BCRL, MLD did not provide clinically important additional benefit when added to other components of DLT.

REGISTRATION

NCT02609724.

Impedance of Extracellular Fluid, Volume, and Local Tissue Water Can Be Reliably Measured in People With Lower Limb Lymphedema

OBJECTIVE

Lower limb lymphedema (LLL) is a chronic condition. To be able to evaluate changes of LLL over time and effects of interventions, reliable measurement methods are important. Currently, there is limited knowledge of the reliability of commonly used measurement methods in LLL. The study objective was to evaluate the test-retest (intrarater) reliability of impedance of extracellular fluid, volume, and local tissue water measurements in people with unilateral or bilateral LLL and measurement errors both for a group of people and for a single individual.

METHODS

Forty-two people with mild to moderate unilateral or bilateral, primary or secondary LLL were measured twice, 2 weeks apart. Impedance of extracellular fluid was measured by bioimpedance spectroscopy and calculated as arm-to-leg ratio, volume with circumference measurements every 4 cm, and local tissue water with tissue dielectric constant at 14 points. Test-retest reliability was evaluated using the intraclass correlation coefficient [ICC(2,1)], changes in the mean, SE of measurement in relative terms (SEM%), and the smallest real difference in relative terms (SRD%).

RESULTS

For the impedance ratio, the reliability was high [ICC(2,1) = 0.79-0.90] and the measurement errors were acceptable (SEM% = 5.0%-5.2%; SRD% = 14.0%-14.4%). For volume, the reliability was high (ICC = 0.99) and the measurement errors were low (SEM% = 1.1%-1.7%; SRD% = 3.1%-4.6%). For the tissue dielectric constant, the reliability was fair to excellent [ICC(2,1) = 0.68-0.96] and the measurement errors were acceptable (SEM% = 4.2%-9.7%; SRD% = 11.7%-26.8%).

CONCLUSIONS

Measurements of impedance of extracellular fluid, volume, and local tissue water are reliable in people with mild to moderate LLL. The measurement errors were acceptable in all 3 methods indicating that real, clinical changes in lymphedema can be measured both for a group of people and a single individual.

IMPACT

The results from this test-retest reliability study can help clinicians and researchers to interpret if real clinical changes in lymphedema occur over time or after an intervention in people with mild to moderate LLL.

Distally Prophylactic Lymphaticovenular Anastomoses after Axillary or Inguinal Complete Lymph Node Dissection Followed by Radiotherapy: A Case Series

Background and Objectives: Lymphedema is an important and underestimated condition, and this progressive chronic disease has serious implications on patients’ quality of life. The main goal of research would be to prevent lymphedema, instead of curing it. Patients receiving radiotherapy after lymph node dissection have a significantly higher risk of developing lymphedema. Through the prophylactic use of microsurgical lymphaticovenular anastomoses in selected patients, we could prevent the development of lymphedema. Materials and Methods: Six patients who underwent prophylactic lymphaticovenular anastomoses in a distal site to the axillary or groin region after axillary or inguinal complete lymph node dissection followed by radiotherapy were analyzed. Patients characteristics, comorbidities, operative details, postoperative complications and follow-up assessments were recorded. Results: Neither early nor late generic surgical complications were reported. We observed no lymphedema development throughout the post-surgical follow-up. In particular, we observed no increase in limb diameter measured at 1, 3, 6 and 12 months postoperatively. Conclusion: In our experience, performing LVA after axillary or groin lymphadenectomy and after adjuvant radiotherapy, and distally to the irradiated area, allows us to ensure the long-term patency of anastomoses in order to obtain the best results in terms of reducing the risk of iatrogenic lymphedema. This preliminary report is encouraging, and the adoption of our approach should be considered in selected patients.

Invention and Clinical Application of an Oversleeve for Measuring Limb Volume in Postoperative Breast Cancer Patients

Background

Lymphedema is a common complication of breast cancer treatment, affecting 1/5 of breast cancer survivors, but there is no reliable way to detect subclinical lymphedema.

Objective

The purpose of this study was to determine the feasibility and reliability of using an oversleeve as a postoperative limb volume measurement tool in breast cancer patients.

Methods

Fifty patients were analyzed based on inclusion criteria. A body volume measurement kit was designed based on the drainage volume method and the circumference measurement method. Twenty-two normal healthy people were measured by the drainage volume (LV) and oversleeve measuring limb volume (OMLV) methods, so as to verify the accuracy of OMLV. Twenty-eight patients with lymphedema diagnosed by the circumdiameter measurement (CDM) method were measured with OMLV for comparison. The difference in measurements between OMLV and CDM was compared in 50 patients with early lymphedema diagnosed by the LV method.

Results

There was no significant difference between the sleeve method and the drainage volume method in the normal population (P = 0.74). All patients with lymphedema diagnosed by CDM met the diagnostic criteria by the OMLV method. In patients with early lymphedema diagnosed by LV, the diagnostic rate with OMLV was significantly higher than that with CDM (P = 0.008).

Conclusion

Similar to LV in the diagnosis of lymphedema, OMLV can effectively improve the diagnostic rate of early lymphedema, providing a new option for the diagnosis and treatment of lymphedema.

Prevention of Secondary Lymphedema after Complete Lymph Node Dissection in Melanoma Patients: The Role of Preventive Multiple Lymphatic-Venous Anastomosis in Observational Era

Background and Objectives: Current guidelines have limited the performance of complete lymph node dissection (CLND) for patients with clinically detectable lymphatic metastases. Despite the limitations of this surgical procedure, secondary lymphedema (SL) is an unsolved problem that affects approximately 20% of patients undergoing CLND. Preventive lymphatic–venous micro-anastomoses (PMLVA) has already demonstrated its efficacy in the prevention of SL in melanoma patients with a positive sentinel lymph node biopsy (SLNB), but the efficacy of this procedure is not demonstrated in patients with clinically detectable lymphatic metastases. Materials and Methods: This retrospective cohort study, was performed in two observation periods. Until March 2018, CLND was proposed to all subjects with positive-SLNB andPMLVA was performed in a subgroup of patients with risk factors for SL (Group 1). From April 2018, according to the modification of melanoma guidelines, all patients with detectable metastatic lymph nodes underwent PMLVA during CLND (Group 2). The frequency of lymphedema in subjects undergoing PMLVA was compared with the control group. Results: Database evaluation revealed 172 patients with melanoma of the trunk with follow-up information for at least 6 mounts. Twenty-three patients underwent PMLVA during CLND until March 2018, 29 from April 2018, and 120 subjects underwent CLND without any preventive surgery (control Group). The frequency of SL was significantly lower in both Group 1 (4.3% vs. 24.2%, p = 0.03) and Group 2 (3.5%, p = 0.01). Patients undergoing PMLVA showed a similar recurrence-free periods and overall survival when compared to the control group. Conclusions: PMLVA significantly reduces the frequency of SL both in immediate and delayed CLND. This procedure is safe and does not lead to an increase in length of hospitalization.

Computed Tomography-Based Quantitative Analysis of Fibrotic Changes in Skin and Subcutaneous Tissue in Lower Extremity Lymphedema Following Gynecologic Cancer Surgery

Background: Lymphedema produces protein-rich fluids that aggravate inflammation in the skin and subcutaneous tissue. Inflammation then induces fibroadipose tissue deposition and fibrosis. However, few methods have been developed to evaluate the severity of fibrosis. Therefore, we aimed to evaluate the subcutaneous fibrotic changes in lower extremity lymphedema following gynecologic cancer surgery using an image analysis tool, the FIJI software. Methods and Results: Seventy-four patients with lymphedema following gynecologic surgery were enrolled in this study. We quantitatively analyzed the cross-sectional area (CSA) of soft tissue compartments, including subcutaneous tissue with the skin, muscle volume, fibrotic changes in subcutaneous tissue, and the perimeter of skin boundaries. The limb circumference and the CSA of the subcutaneous tissue and skin on the affected side were significantly larger than those on the unaffected side. Fibrotic changes showed the same trend. However, muscle volume patterns were different from those of the other compartments. Some patients showed lower muscle volume on the unaffected side than on the affected side. Circumference and cellulitis significantly affected the extent of fibrotic changes in the skin and subcutaneous tissues. Age and duration of lymphedema did not affect fibrosis. Conclusion: Fibrosis of subcutaneous regions with the skin can be quantitatively calculated using an image analysis tool in lower extremity lymphedema following gynecologic cancer surgery. Edema and cellulitis increase fibrotic changes in the subcutaneous tissue with the skin.

Water Distribution Changes in Complex Decongestive Treatment for Leg Lymphedema: Quantitative Evaluation by Direct Segmental Multi-Frequency Bioimpedance Analysis

Background: There is a need for a simple method for the quantitative evaluation of lymphedema swelling. In this study, we performed a direct segmental multi-frequency impedance analysis in patients with leg lymphedema.

Methods: The subjects were 36 patients (6 men and 30 women) with 46 lymphedema legs. The average age was 61 years. All patients had International Society of Lymphology stage II lymphedema. Swelling ratio and ultrasound subcutaneous tissue echo-free space (FS) were examined. InBody 770 was used to measure the extracellular water (ECW), intracellular water (ICW), and total body water (TBW) volumes. Changes before and after complex decongestive treatment (CDT) were examined.

Results: In 26 unilateral cases, the ECW, ICW, and TBW volumes of the affected legs were higher than those of the contralateral unaffected legs, and the ECW/TBW ratio was significantly higher in the affected legs (0.41) than in the contralateral unaffected legs (0.391). There was a significant correlation between the leg swelling ratio and the ECW/TBW ratio between the affected and contralateral unaffected legs (correlation coefficient=0.882). Ultrasound findings of the 46 affected legs were classified into no FS (group 0), minimal or only horizontal FS (group 1), and cobblestone-like FS (group 2). The ECW/TBW ratio of the affected legs in each group was 0.393 (14 legs), 0.407 (10 legs), and 0.426 (22 legs) respectively, demonstrating significant differences among the 3 groups. After CDT, the amount of water decreased in the affected legs and increased in the trunks and both upper limbs. The ECW/TBW ratio decreased significantly, from 0.432 to 0.414 in the affected legs, from 0.401 to 0.392 in the unaffected legs, and from 0.413 to 0.402 in the trunks. The ECW/TBW ratio had not changed and remained below 0.4 in the upper limbs.

Conclusion: The segmental water contents measured by direct segmental multi-frequency impedance analysis correlates well with the degree of lymphedema swelling, and subcutaneous echo findings and can demonstrate water distribution change before and after CDT, which is considered to be a useful quantitative evaluation method for lymphedema. (This is secondary publication from Jpn J Phlebol 2020; 31(1): 1–7.)

The prevalence of undiagnosed postoperative lower limb lymphedema among gynecological oncology patients

OBJECTIVE

Lower limb lymphedema (LLL) is a common postoperative complication among gynecological oncology patients following lymph node resection. In the absence of a screening strategy, LLL is frequently diagnosed only through patient's self-reported symptoms. This study investigated the prevalence of undiagnosed postoperative LLL among gynecological oncology patients and identified the associated risk factors.

MATERIALS AND METHODS

This was a cross-sectional postal questionnaire survey at a tertiary gynecological oncology center. Women with gynecological malignancies who underwent lymph node (inguinal/pelvic/para-aortic) resection between 2010 and 2017 were eligible. The Gynecological Cancer Lymphedema Questionnaire (GCLQ) was used and those with a score of ≥4 were referred to a lymphedema specialist for clinical confirmation.

RESULTS

Among 376 eligible women, postoperative LLL was already diagnosed in 45/376 (12%) women. In the remaining women, 117/331 (35.3%) completed the GCLQ, of which 67/117 (57.3%) scored ≥4. Fifty-five women (55/67, 82.1%) were assessed by a lymphedema specialist and eight cases of postoperative LLL were confirmed. In the 12/67 who declined a clinical assessment, they reported no evidence of LLL. The prevalence of undiagnosed postoperative LLL in our study was 8/117 (6.8%, 95% C.I. 2.3-11.4). On univariate analysis, older women were more likely to have undiagnosed postoperative LLL.

CONCLUSIONS

Undiagnosed postoperative LLL is not uncommon among gynecological oncology patients, especially in older patients. No vulvar cancer patient had undiagnosed LLL. Increased awareness and improved strategies for lymphedema screening are required after lymph node surgery in gynecological oncology.