Who Will Continuously Depend on Compression to Control Persistent or Progressive Breast Cancer-Related Lymphedema Despite 2 Years of Conservative Care?

Financial burden of lymphedema among breast cancer survivors in Iran: A qualitative study

BACKGROUND

Breast cancer-related lymphedema (BCRL) is a chronic complication of breast cancer that requires long-term management. This condition imposes significant disturbance on breast cancer survivors (BCSs) physically, emotionally, and, financially. The purpose of this study was to approach the financial burden of BCRL in Iran.

METHODS

This qualitative study was performed based on the standards for reporting qualitative research (SRQR) guidelines. Semi-structured and in-depth interviews were conducted using a voice recorder. Data analysis was performed based on the content analysis method of Graneheim and Lundman. Nine women with BCRL participated in the study.

RESULTS

Three major themes were generated based on the captured data: (1) direct costs related to BCRL management, (2) indirect costs imposed by BCRL at work or home, and, (3) benefits of costs which was a great concern of BCSs that how much these costs eventually make their condition better. High costs of garments, lack of insurance coverage, and, difficulties in accessing lymphedema care were among the frequently mentioned problems by BCSs with BCRL.

CONCLUSION

The financial burden of BCRL is significant on BCSs in Iran. The establishment of insurance coverage policies, easier access to health services, and, implanting patient-centered measures in evidence-based lymphedema guidelines, could be proper interventions to lower the financial burden of BCRL.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Decompression of Axillary Vein: An Essential Adjunct for Advanced Lymphedema

BACKGROUND

In advanced lymphedema, lymphovenous anastomosis (LVA) can be a solution based on using the pressure gradient between the high-pressure lymphatics and the low-pressure veins. If the vein pressure is high, the effect of surgery will be less optimal. This study evaluated the effect of axillary vein perivascular scar release on LVA.

METHODS

This is a retrospective study of 40 upper limb stage 2 and 3 lymphedema patients divided into 2 groups with an average follow-up of 33 months (minimum of at least 12 months): the scar release group ( n = 25) and the control group ( n = 15). All patients underwent LVA with or without lymph node transfer. Demographic data, outcome (volumetric change and bioimpedence analysis [BIA]), and major vein (axillary, basilic, and cephalic) diameter changes were evaluated.

RESULTS

Both groups showed significant reduction in volume and BIA parameters after LVA. The scar release group (24 of 25 with lymph node transfer and 1 without) showed statistically higher reduction of BIA analysis compared with the control group at 1, 6, and 12 months after LVA. The changes in the major veins after axilla scar release showed significant changes in all 3 veins. There was a significant correlation between cephalic vein diameter reduction and BIA measurement.

CONCLUSIONS

The release of perivascular scar in the axillary vein may result in better outcome after LVA. This is based on the finding that scar release shows correlation between cephalic vein diameter reduction and BIA measurement suggesting reduction of venous pressure in the peripheral vein increasing the pressure gradient between the lymphatic and venous system allowing better outflow after LVA.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Ultrasonographic features of the skin and subcutis: correlations with the severity of breast cancer-related lymphedema

PURPOSE

Assessing the severity of breast cancer-related lymphedema (BCRL) requires various clinical tools, yet no standardized methodology is available. Ultrasonography shows promise for diagnosing lymphedema and evaluating its severity. This study explored the clinical utility of ultrasonography in patients with BCRL.

METHODS

In this retrospective cross-sectional study, patients with unilateral BCRL were examined. The analyzed data included demographics, lymphedema location, International Society of Lymphology (ISL) stage, surgical history, treatment regimens, and arm circumference. Skin, subcutis, and muscle thicknesses were assessed ultrasonographically at predetermined sites, and the percentage of excess thickness was calculated. Multivariate logistic regression analysis was employed to identify associations between ultrasonographic measurements and advanced lymphedema (ISL 2 or 3). The Lymphedema Quality of Life arm questionnaire was used to evaluate patient-reported outcomes regarding lymphedema and their correlations with ultrasonographic findings.

RESULTS

Among 118 patients, 71 were classified as ISL 0-1 and 47 as ISL 2-3. Patients with advanced lymphedema were older, had higher nodal stages, underwent more axillary lymph node dissections, and had higher rates of dominant-arm lymphedema. Multivariate logistic regression revealed significant associations of greater skin thickness (adjusted odds ratio [OR], 4.634; 95% confidence interval [CI], 1.233 to 17.419), subcutis thickness (adjusted OR, 7.741; 95% CI, 1.649 to 36.347), and subcutis echogenicity (adjusted OR, 4.860; 95% CI, 1.517 to 15.566) with advanced lymphedema. Furthermore, greater skin thickness (P=0.016) and subcutis echogenicity (P=0.023) were correlated with appearance-related discomfort.

CONCLUSION

Ultrasonographic measurements were significantly associated with advanced lymphedema in BCRL. Ultrasonography represents a valuable diagnostic and severity assessment tool for lymphedema.

Lymphatic remapping by long-term lymphoscintigraphy follow-up in secondary lymphedema after breast cancer surgery

The purpose of the study is to investigate long-term changes on lymphoscintigraphy and their association with clinical factors in breast cancer-related lymphedema (BCRL) patients. This single-center cohort study included BCRL patients who underwent baseline and follow-up lymphoscintigraphy. The percentage of excessive circumference (PEC) of the affected upper limb compared with the unaffected side was used as an indicator of the clinical severity of BCRL. Each 99mTc-phytate lymphoscintigraphy image was categorized according to the Taiwan lymphoscintigraphy staging system. Clinical parameters and the lymphoscintigraphy stage at baseline and follow-up were compared and analyzed. Eighty-seven patients were included. Baseline and follow-up lymphoscintigraphies were performed at median 7 (interquartile range [IQR]: 2‒14) and 78 (IQR: 49‒116) months after surgery, respectively. Both lymphoscintigraphy stage and PEC showed variable change with overall increases in their severity. Stepwise multivariable analysis revealed follow-up lymphoscintigraphy stage (P = 0.001) to be independent variables for PEC at follow-up, however, baseline lymphoscintigraphy stage was not. The clinical courses of BCRL and patients' lymphoscintigraphy patterns showed diverse changes over long-term follow-up. In addition to initial lymphoscintigraphy for diagnosis, lymphatic remapping by follow-up lymphoscintigraphy can be useful to visualize functional changes in the lymphatic system that may guide the optimal management in BCRL.

The Dynamic Lymphaticovenular Anastomosis for Breast Cancer-related Lymphedema without Compression: Salvaging Lymphedema Patients Who Lost Conservative Treatment Opportunity

In conservative treatment for breast cancer-related lymphedema (BCRL), compression therapy has a crucial role. However, some BCRL patients are unable to use compression, and then their lymphedema continues to worsen as they miss treatment opportunity. Although lymphaticovenular anastomosis (LVA) is an effective and minimally invasive surgical treatment for BCRL, compression therapy is still important to enhance lymphatic fluid flow in LVA. The authors previously reported the dynamic LVA method for BCRL, in which patient's natural hand movements theoretically propel lymph to the anastomosed vein. This study is conducted to clarify whether dynamic LVA can salvage BCRL patients without pre- and postoperative compression therapy.

Methods

The study involved 17 BCRL patients, 18 limbs. All patients had International Society of Lymphology stage-2 lymphedema, but they had no compression: six patients had difficulty by other diseases to undergo compression, and other 11 patients refused any compression usage because of the burden of the treatment itself. Three dynamic LVAs were performed in each patient.

Results

Patients' mean age was 60.4 ± 10.1, and mean body mass index was 24.0 ± 3.3. The mean follow-up period was 25.5 ± 9.2 months. The volume of the lymphedematous limb, according to the upper extremity lymphedema (UEL) index, was reduced in all 18 limbs postoperatively (postoperative UEL index 101.8 ± 9.4 versus preoperative UEL index 116.0 ± 20.1; P < 0.01). Twelve of the 18 limbs were cured without edema.

Conclusion

Even without compression therapy, International Society of Lymphology stage-2 BCRL patients can be treated by the dynamic LVA method.

Risk of Lymphedema and Death after Lymph Node Dissection with Neoadjuvant and Adjuvant Treatments in Patients with Breast Cancer: An Eight-Year Nationwide Cohort Study

Knowledge on the impact of neoadjuvant and adjuvant treatments on post-surgery lymphedema (LE) in patients with breast cancer is limited due to methodological limitations and an insufficient sample size. We investigated the risk of LE in patients going through long-term anticancer treatment regimens using a national cohort from the Korean National Health Insurance Service database from 2011-2013. Incidence rate ratio, Kaplan-Meier analysis, and Cox proportional regression analysis were performed. A total of 39,791 patients were included. While minimal lymph node dissection (SLNB) reduced the risk of LE (hazard ratio [HR] 0.51) as expected, neoadjuvant chemotherapy (NAC) followed by SLNB did not reduce the risk. Adjusting for adjuvant chemotherapy (AC) as time-varying exposure decreased the risk of LE in the SLNB group (HR 0.51), but not the mortality risk (HR 0.861). A longer duration of NAC, especially taxane-based, combined with SLNB reversed the effect and increased risk of LE. The findings highlight the importance of not only early surveillance before and after surgery, but also long-term surveillance during adjuvant treatment by surgeons and oncologists in order to reduce the risk of LE.

Comparison of machine learning models for predicting the risk of breast cancer-related lymphedema in Chinese women

Objective

Predictive models for the occurrence of cancer symptoms by using machine learning (ML) algorithms could be used to aid clinical decision-making in order to enhance the quality of cancer care. This study aimed to develop and validate a selection of classification models that used ML algorithms to predict the occurrence of breast cancer-related lymphedema (BCRL) among Chinese women.

Methods

This was a retrospective cohort study of consecutive cases that had been diagnosed with breast cancer, stages I-IV. Forty-eight variables were grouped into five feature sets. Five classification models with ML algorithms were developed, and the models' performance and the variables’ relative importance were assessed accordingly.

Results

Of 370 eligible female participants, 91 had BCRL (24.6%). The mean age of this study sample was 49.89 (SD ​= ​7.45). All participants had had breast cancer surgery, and more than half of them had had a modified radical mastectomy (n ​= ​206, 55.5%). The mean follow-up time after breast cancer surgery was 28.73 months (SD ​= ​11.71). Most of the tumors were either stage I (n ​= ​49, 31.2%) or stage II (n ​= ​252, 68.1%). More than half of the sample had had postoperative chemotherapy (n ​= ​227, 61.4%). Overall, the logistic regression model achieved the best performance in terms of accuracy (91.6%), precision (82.1%), and recall (91.4%) for BCRL. Although this study included 48 predicting variables, we found that the five models required only 22 variables to achieve predictive performance. The most important variable was the number of positive lymph nodes, followed in descending order by the BCRL occurring on the same side as the surgery, a history of sentinel lymph node biopsy, a dietary preference for meat and fried food, and an exercise frequency of less than three times per week. These factors were the most influential predictors for enhancing the ML models’ performance.

Conclusions

This study found that in the ML training dataset, the multilayer perceptron model and the logistic regression model were the best discrimination models for predicting the outcome of BCRL, and the k-nearest neighbors and support vector machine models demonstrated good calibration performance in the ML validation dataset. Future research will need to use large-sample datasets to establish a more robust ML model for predicting BCRL deeply and reliably.

Crosstalk Between microRNAs and the Pathological Features of Secondary Lymphedema

Secondary lymphedema is characterized by lymphatic fluid retention and subsequent tissue swelling in one or both limbs that can lead to decreased quality of life. It often arises after loss, obstruction, or blockage of lymphatic vessels due to multifactorial modalities, such as lymphatic insults after surgery, immune system dysfunction, deposition of fat that compresses the lymphatic capillaries, fibrosis, and inflammation. Although secondary lymphedema is often associated with breast cancer, the condition can occur in patients with any type of cancer that requires lymphadenectomy such as gynecological, genitourinary, or head and neck cancers. MicroRNAs demonstrate pivotal roles in regulating gene expression in biological processes such as lymphangiogenesis, angiogenesis, modulation of the immune system, and oxidative stress. MicroRNA profiling has led to the discovery of the molecular mechanisms involved in the pathophysiology of auto-immune, inflammation-related, and metabolic diseases. Although the role of microRNAs in regulating secondary lymphedema is yet to be elucidated, the crosstalk between microRNAs and molecular factors involved in the pathological features of lymphedema, such as skin fibrosis, inflammation, immune dysregulation, and aberrant lipid metabolism have been demonstrated in several studies. MicroRNAs have the potential to serve as biomarkers for diseases and elucidation of their roles in lymphedema can provide a better understanding or new insights of the mechanisms underlying this debilitating condition.

Cellulitis Is Associated with Severe Breast Cancer-Related Lymphedema: An Observational Study of Tissue Composition

Simple Summary

Cellulitis is a common complication in Breast Cancer-Related Lymphedema (BCRL); however, it is not known whether cellulitis is associated with the severity and biocompositon of BCRL. This study showed that cellulitis was associated with more excess volume, fat, and lean arm mass. Treatments should aim to prevent cellulitis in BCRL to possibly avoid the condition exacerbating.

Abstract

Cellulitis is a common complication in Breast Cancer-Related Lymphedema (BCRL). The excess amount of fat and lean mass in BCRL is a vital factor in patient stratification, prognosis, and treatments. However, it is not known whether cellulitis is associated with the excess fat and lean mass in BCRL. Therefore, this prospective observational study was designed to fundamentally understand the heterogonous biocomposition of BCRL. For this study, we consecutively enrolled 206 patients with unilateral BCRL between January 2019 and February 2020. All patients underwent Dual-Energy X-Ray Absorptiometry scans, bioimpedance spectroscopy, indocyanine green lymphangiography comprehensive history of potential risk factors, and a clinical exam. Multivariate linear and beta regression models were used to determine the strength of association and margins effect. Sixty-nine patients (33%) had at least one previous episode of cellulitis. Notably, a previous episode of cellulitis was associated with 20 percentage points more excess fat and 10 percentage points more excess lean mass compared to patients without cellulitis (p < 0.05). Moreover, each 1 increase in the patients BMI was associated with a 0.03 unit increase in the fat mass proportion of the lymphedema arm. Cellulitis was associated with more excess fat and lean arm mass in BCRL. In addition, patients BMI affect the proportion of fat mass in the arm.