Ultrasonographic findings and the clinical results of treatment for lymphedema

Current Diagnostic Measures for Lymphedema: A Comprehensive Review

ABSTRACT

Lymphedema presents diagnostic challenges due to complex symptomatology and multifaceted onset. This literature review synthesizes diagnostic measures ranging from clinical assessments to advanced imaging techniques and emerging technologies. It explores the challenges in early detection and delves into the disparities in access to advanced diagnostic tools, which exacerbate health outcome differences across populations. This review not only provides insights into the effectiveness of current diagnostic modalities but also underscores the necessity for ongoing research and innovation. The goal is to enhance the accuracy, affordability, and accessibility of lymphedema diagnostics. This is crucial for guiding future research directions and for the development of standardized diagnostic protocols that could help mitigate the progression of lymphedema and enhance the quality of life for affected individuals.

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.

Focused liquid ultrasonography in dropsy protocol for quantitative assessment of subcutaneous edema

BACKGROUND

Although subcutaneous edema is a common symptom of critically ill patients, it is still underreported due to the lack of a systematic method for evaluating it. The present study aims to describe the occurrence and distribution of subcutaneous edema, as well as the risk factors associated with it, in critically ill patients using the focused liquid ultrasonography in dropsy (FLUID) protocol, and to assess their impact on ICU mortality.

METHODS

The FLUID protocol and the pitting test were performed on general ICU patients in China. Cohen's Kappa coefficient and Bland-Altman plots were used to evaluate the agreement between the two methods at each measurement site and between the whole-body subcutaneous edema scores, respectively, while a repeated measures ANOVA was performed to compare the differences between the two methods in whole-body and body-part measurements. A generalized linear model was used to evaluate the risk factors for subcutaneous edema development and the relationship between subcutaneous edema severity and ICU mortality.

RESULTS

A total of 145 critically ill patients were evaluated using both approaches, of whom 40 (27.6%) experienced subcutaneous edema. Over 1440 measurements, it was found that ultrasound discovered more subcutaneous edema than the pitting test (ultrasound: 522[36.3%], pitting test: 444[30.8%], χ² = 9.477, p = 0.002). The FLUID protocol scored edema severity significantly higher than the pitting test in the whole body and specific body parts, including the abdominal wall, thighs, chest wall, and hands. Subcutaneous edema exhibited gravity-dependent distribution patterns, particularly in the abdominal wall. The APACHE II, NT-proBNP, serum creatinine, and sepsis were independent risk factors for subcutaneous edema development. The score of ultrasonic subcutaneous edema was related to ICU mortality.

CONCLUSIONS

The FLUID protocol provides a comprehensive strategy for the semi-quantitative assessment of subcutaneous edema in critically ill patients. In detecting the onset and severity of edema, ultrasound was found to outperform the pitting test. Subcutaneous edema showed a gravity-dependent distribution pattern, and its severity was associated with mortality.

From histo-anatomy to sonography in lymphedema: EURO-MUSCULUS/USPRM approach

Lymphedema is a disorder characterized by the accumulation of protein-rich lymphatic fluid in the cutaneous and subcutaneous tissue. Based on the underlying causes, it is classified into primary and secondary forms. The use of ultrasound has recently become widespread in the field of lymphedema - especially for its diagnosis and treatment planning. In this study, we briefly reviewed the anatomy and histology of the skin and subcutaneous tissue - to propose a standardized ultrasound assessment of the superficial tissues in patients with upper-/lower-limb lymphedema. We believe that identification of the sono-histological patterns of the dermo-epidermal complex and subcutaneous tissue has place to serve as a simple and reproducible strategy to evaluate their edema diseases that are often subject to an inaccurate diagnosis in daily clinical practice.

Association of Dermal Hypoechogenicity and Cellulitis History in Patients with Lower Extremity Lymphedema: A Cross-Sectional Observational Study

Background: Recurrent cellulitis has high impact on physical, psychological, and social aspects for lymphedema patients. We speculated that identification of characteristics of skin and subcutaneous adipose tissue with cellulitis history can help considering new approach for prevention of recurrent cellulitis in lymphedema patients. Therefore, in this study, we aimed to noninvasively identify the ultrasonographic features of skin and subcutaneous tissue of lymphedema in patients with a cellulitis history. Method and Results: This was a cross-sectional study, and all data were collected from patients' medical records. We assessed ultrasonographic images of the lower extremity of patients with lymphedema that were obtained in a lymphedema clinic. The ultrasonographic images were analyzed on the basis of the following five features: dermal hypoechogenicity, unclear dermal border, unclear superficial fascia, increased subcutaneous echogenicity, and subcutaneous cobblestone appearance. Fifty-two ultrasonographic images from 19 female patients with lower extremity lymphedema, including 8 with and 11 without a cellulitis history, were analyzed. The proportion of dermal hypoechogenicity on the upper leg was significantly higher in the patients with than in those without a cellulitis history (75.0% vs. 9.1%, p = 0.006). Conclusion: Cellulitis history in lymphedema patients appears to be associated with dermal hypoechogenicity, particularly in the proximal lower extremity. This finding suggests that it may be the initial step to consider new approach for prevention of recurrent cellulitis in lymphedema patients.

The Comparative Efficacy of Conventional Short-Stretch Multilayer Bandages and Velcro Adjustable Compression Wraps in Active Treatment Phase of Patients with Lower Limb Lymphedema

Background: Compression is the most important component of complete decongestive therapy (CDT), but there is no standard best method for applying compression. The aim of this study was to evaluate the comparative efficacy of conventional multilayer short-stretch bandaging, and a velcro adjustable compression wrap with regard to volume reduction, ultrasonographic measurements, functional-status, and quality of life (QoL) in the active CDT period of patients with lower limb lymphedema. Methods and Results: The demographic and clinical variables of lower limb lymphedema patients were recorded. All patients received skin care education, manual lymphatic drainage, and supervised lyphedema exercises, and were randomly allocated to Group1 (multilayer short-stretch bandaging-Rosidal-K^®) or to Group 2 (adjustable-compression-velcro-wrap-Circaid Reduction-kit^®) for a duration of 3 weeks with 15 sessions. Limb volumes were assessed by perometer. Ultrasonographic measurements included subcutaneous soft tissue thickness. The functional disability and QoL were evaluated by the Lower Extremity Functional Scale and LYMQOL-Leg (Lymphedema Quality of Life Questionnaire-Leg), respectively, at baseline, after CDT, and at first-month follow-up. Thirty-six patients (10 male and 26 female) with mean age of 51.6 ± 11.7 years were included. Fourteen patients had primary and 22 patients had secondary lymphedema. The median duration of lymphedema was 68 months. Significant improvements in volumes and ultrasonographic measurments were observed in both groups at the end of therapies, and improvements sustained up to a month. Appearance, symptoms, and overall QoL-subscores were improved only in Group 2. Conclusion: In conclusion, adjustable compression velcro-wrap performed as a part of CDT can greatly reduce the volume similiar to conventional multilayer bandages, as well as improve the QoL. It can be a comfortable alternative to the conventional multilayer bandages in the active treatment phase of the CDT.

The role of ultrasonography in follow-up of effectiveness of Complex Decongestive Therapy (CDT) in different subgroups of patients with breast cancer-related lymphoedema

OBJECTIVE

To determine the role of ultrasonography in the follow-up of effectiveness of complex decongestive therapy (CDT) in different subgroups of patients with breast cancer-related lymphoedema (BCRL).

METHODS

Forty-seven patients with unilateral upper BCRL were enrolled in the study. The patient group was divided into two subgroups according to body mass index (BMI) as obese and non-obese and three subgroups according to International Society of Lymphology staging. All patients underwent CDT, the circumference measurements and ultrasonographic soft tissue thicknesses evaluations were performed at two anatomic sites, and upper extremity limb volumes were calculated using the truncated cone formula before and after CDT.

RESULTS

There were significant decreases in both circumferential measurements and ultrasonographic soft tissue thicknesses in non-obese patients and stage 2 lymphoedema patients after 15 sessions of CDT. The ultrasonographic soft tissue thickness values were correlated with the upper arm and forearm circumference values before (r = 0.491, p < .001, r = 0.841, p < .001, respectively) and after (r = 0.535, p < .001, r = 0.714, p < .001, respectively) CDT.

CONCLUSIONS

Ultrasonography presents as a reliable method to measure the soft tissue thickness and treatment efficacy after CDT in only non-obese and stage 2 patients with BCRL.

Evaluation Methods for the Measurement of Lower Leg Edema in Healthy Young Adults

BACKGROUND

In recent years, objective quantitative evaluations have become particularly important. Both qualitative and quantitative evaluations are also available for edema. It is thought that the technical problem of quantitative evaluation can be solved by using a simple and reproducible method. Several studies have evaluated various methods for measuring edema. Limitations, such as weaknesses, measurement complexity, and errors, have been identified. Therefore, this study aimed to consider a simple and effective measurement method for the quantitative evaluation of edema.

METHODS

This study was a prospective, observational study. The subjects were 15 healthy adults (2 male and 13 female). Measurements were performed on the subjects' right lower leg once in the morning and once in the afternoon, with a minimum interval of 4 hours.

RESULTS

The actual volume of the lower leg was correlated with all indices except the ultrasonic echo findings for subcutaneous tissue. The intra-subject and inter-subject reliabilities for the indices using digital images were very high. The lower leg volume was greater significantly in the afternoon from the morning.

CONCLUSION

The leg circumference was measured by utilizing a tape, while the width and volume were measured by utilizing digital imaging suitable for quantitatively evaluating edema. Furthermore, swelling of the lower leg with time can occur in the absence of daily exercise.

Validity of a New Quantitative Evaluation Method that Uses the Depth of the Surface Imprint as an Indicator for Pitting Edema

This study examined the validity of a practical evaluation method for pitting edema by comparing it to other methods, including circumference measurements and ultrasound image measurements. Fifty-one patients (102 legs) from a convalescent ward in Maruyama Hospital were recruited for study 1, and 47 patients (94 legs) from a convalescent ward in Morinaga Hospital were recruited for study 2. The relationship between the depth of the surface imprint and circumferential measurements, as well as the relationship between the depth of the surface imprint and the thickness of the subcutaneous soft tissue on an ultrasonogram, were analyzed using a Spearman correlation coefficient by rank. There was no significant relationship between the surface imprint depth and circumferential measurements. However, there was a significant relationship between the depth of the surface imprint and the thickness of the subcutaneous soft tissue as measured on an ultrasonogram (correlation coefficient 0.736). Our findings suggest that our novel evaluation method for pitting edema, based on a measurement of the surface imprint depth, is both valid and useful.

Dermal Structure in Lymphedema Patients with History of Acute Dermatolymphangioadenitis Evaluated by Histogram Analysis of Ultrasonography Findings: A Case-Control Study

BACKGROUND

Acute dermatolymphangioadenitis (ADLA) is a risk factor for increasing of edema and worsening severity. Reducing ADLA frequency is an important objective of lymphedema management because ADLA episodes are strongly associated with poor quality of life. Lymphedema changes dermal and subcutaneous structure, favoring ADLA; ADLA recurrence may be caused by structural change of the dermis. However, the structure of the skin following ADLA episodes has not been studied in depth. The aim of this study was to examine changes in the skin after episodes of ADLA in breast cancer-related lymphedema (BCRL) using histogram analysis of ultrasonography findings.

METHODS AND RESULTS

This was a case-control study with matching for the duration of lymphedema. We compared 10 limbs (5 BCRL patients, Cases) with a history of ADLA and 14 limbs (7 BCRL patients, Controls) without. Ultrasonography was performed using a 20-MHz probe, and measurements were made at a site 10 cm proximal to the ulnar styloid process. We compared "skewness" of the images in the dermis from the histogram analysis. This study was approved by the Ethics Committee of Kanazawa University. Skewness was significantly different between the affected and unaffected limbs (p = 0.02). Cases showed a positive value (median 0.74, range -0.18 to 1.26), whereas Controls showed a negative value (median -0.21, range -0.45 to 0.31).

CONCLUSIONS

Episodes of ADLA changed the distribution of echogenicity on imaging, which indicates a change in the collagen fibers in the dermis. These findings might contribute to improving the management of lymphedema and prevention of recurrent ADLA.

Computed tomography-based quantitative assessment of lower extremity lymphedema following treatment for gynecologic cancer

Objective

To develop an algorithmic quantitative skin and subcutaneous tissue volume measurement protocol for lower extremity lymphedema (LEL) patients using computed tomography (CT), to verify the usefulness of the measurement techniques in LEL patients, and to observe the structural characteristics of subcutaneous tissue according to the progression of LEL in gynecologic cancer.

Methods

A program for algorithmic quantitative analysis of lower extremity CT scans has been developed to measure the skin and subcutaneous volume, muscle compartment volume, and the extent of the peculiar trabecular area with a honeycombed pattern. The CT venographies of 50 lower extremities from 25 subjects were reviewed in two groups (acute and chronic lymphedema).

Results

A significant increase in the total volume, subcutaneous volume, and extent of peculiar trabecular area with a honeycombed pattern except quantitative muscle volume was identified in the more-affected limb. The correlation of CT-based total volume and subcutaneous volume measurements with volumetry measurement was strong (correlation coefficient: 0.747 and 0.749, respectively). The larger extent of peculiar trabecular area with a honeycombed pattern in the subcutaneous tissue was identified in the more-affected limb of chronic lymphedema group.

Conclusion

CT-based quantitative assessments could provide objective volume measurements and information about the structural characteristics of subcutaneous tissue in women with LEL following treatment for gynecologic cancer.