Lymphedema diagnosis, treatment, and follow-up from the view point of physical medicine and rehabilitation specialists

Addition of prophylactic compression garments to standard care to prevent irreversible lower limb lymphoedema after gynaeco-oncological therapy (Gynolymph): protocol for a randomised controlled trial embedded within an observation cohort study

INTRODUCTION

In female patients diagnosed with gynaecological cancer, the main priority is treating cancer itself. However, a significant number of these patients develop lower limb lymphoedema (LLL), with its incidence strongly influenced by the diagnostic cut-off (a difference in leg circumference between both legs of 5% or 10%). LLL significantly impacts patients' quality of life (QoL) due to functional impairment, the daily time investment required for treatment, financial costs and affected body image. Additionally, it increases the risk of cellulitis, often leading to hospitalisation for intravenous antibiotics. Timely recognition and acknowledgement of symptoms are crucial first steps in improving the QoL for these women. LLL is a common and irreversible complication following treatment for gynaecological cancer. Despite its clinical significance, there are limited prospective studies investigating LLL incidence, risk factors, early detection and clinical course in this patient population. Therefore, the objective of this observational cohort study is to investigate the incidence rate of stage 0-1 or stage 2-3 LLL based on the International Society of Lymphology criteria in the first 2 years after gynaecological cancer treatment. The embedded randomised control study (RCT) examines the added value of prophylactic compression garments (class II) to standard care in preventing irreversible lymphoedema after gynaeco-oncological therapy.

METHODS AND ANALYSIS

In June 2022, two university hospitals in Belgium initiated a multicentre observational cohort study, which also includes an embedded RCT. The study aims to enrol 400 patients before they begin cancer treatment or within 14 days of starting chemotherapy, radiotherapy or surgery. This cohort will be followed for up to 2 years. The embedded RCT will focus on patients who develop clinical lymphoedema stage 0-1 within the first 12 months following their initial cancer treatment. A total of 196 patients will be randomised into two groups: the intervention group (98 patients), receiving usual care plus prophylactic compression garments (compression class 2 (CCL2): 23-32 mm Hg), and the control group (98 patients), receiving only usual care. The RCT aims to assess the impact of adding prophylactic compression garments to standard care on further deterioration. Assessments will be conducted at baseline, and at 3, 12 and 24 months after initial cancer treatment. An additional assessment (T-visit) will be provided if there is a transition to LLL stage 0-1 or from stage 0-1 to stage 2-3 LLL, based on follow-up findings or patient initiative, using the predictive value of a validated self-report lower extremity questionnaire. This questionnaire is part of a lymph diary app provided to all patients. The primary outcome of the observational study is to determine the incidence rate of stage 0-1 or stage 2-3 LLL in the first 2 years after gynaecological cancer treatment. The primary outcome of the RCT is to evaluate the effect of wearing CCL2 preventive garments to avoid progression to higher-stage lymphoedema in patients who develop LLL within 1 year of treatment. Key secondary outcomes of the observational study include the timing of the development of LLL, risk factors for developing LLL and the impact of LLL on QoL and sexuality, as well as the evaluation of screening and diagnostic tools. The secondary outcomes of the RCT include tolerance and compliance with wearing the preventive compressive garments, the impact of the garments on limb volume and the patient's time and financial investment.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the two academic hospitals: the University Hospital of Ghent in September 2021 and the University Hospital of Leuven in December 2021. Approval has been granted for the study protocol, informed consent forms and other related documents by the main Ethics Committee of Ghent (BC-09915) and the local Ethics Committee of Leuven (S65724). All patients will provide written informed consent before participating in the trial. The results will be shared through peer-reviewed journals and presentations.

TRIAL REGISTRATION NUMBER

NCT05469945.

Accuracy of Infrared Thermography in Diagnosing Breast Cancer-Related Lymphedema

Background/Objectives: Infrared thermography (IRT) is an imaging technique used in clinical practice to detect changes in skin temperature caused by several dysfunctions, including breast cancer-related lymphedema (BCRL). Thus, the present study aimed to assess the reproducibility and accuracy of IRT in diagnosing BCRL. Methods: This cross-sectional study included participants who underwent a unilateral mastectomy and used indirect volumetry for lymphedema detection. IRT analysis was recorded in four positions, analyzing maximum, mean, and minimum temperatures, as well as the temperature differences between the upper limbs. The analysis encompassed reliability, agreement, accuracy, and the establishment of cut-off points for sensitivity and specificity. A total of 88 upper limbs were included; 176 thermograms were captured, and 1056 regions of interest were analyzed. Results: IRT presented excellent intra- and inter-rater reproducibility and reliability with excellent intraclass correlation coefficient values (0.99 to 1.00). In addition, this assessment reached a sensitivity of 85% and a specificity of 56%; the cut-off point considered a temperature difference of -0.45 °C. Conclusions: IRT was a reliable and reproducible assessment, and the temperature difference between the upper limbs evidenced moderate accuracy. Thus, IRT is recommended as a complementary technique for detecting BCRL.

Assessing breast cancer-related lymphedema screening and treatment gaps in a safety-net hospital

BACKGROUND AND OBJECTIVES

We evaluated the unmet breast cancer-related lymphedema (BCRL) treatment and education needs at New England's largest safety-net hospital serving a diverse population by assessing prevalence, risk factors, and treatment.

METHODS

This was a retrospective cohort study examining breast cancer surgery patients from September 2016 to September 2021. The primary outcome was BCRL diagnosis. Secondary outcomes included BCRL risk factors, and physical and occupational therapy (PT/OT) referral frequency and completion.

RESULTS

Of 639 patients, 17% of patients had documented BCRL, which was significantly associated with axillary lymph node dissection (ALND). There were no racial, insurance, breast radiation, or BMI category differences between patients with and without a BCRL diagnosis. Of those with BCRL, 58% received a PT/OT referral, and 56% completed their referral. There were no racial, insurance, or BMI category differences between those who received a PT/OT referral and those who did not.

CONCLUSION

In our high-risk population, rates of documented BCRL were higher than expected, approaching rates of ALND, despite the majority undergoing sentinel lymph node biopsy (SLNB). PT/OT referral and completion rates were low, concerning for an unmet BCRL treatment and education need. No disparities in care delivery were seen, but a program that addresses treatment gaps and ensures accessible and patient-centered BCRL care is urgently needed.

A comparative evaluation of the efficacy of complete decongestive therapy in the treatment of unilateral breast cancer-related lymphedema with and without metabolic syndrome

AIM

This study aimed to investigate the effect of the presence of metabolic syndrome (MetS) on the limb volume and quality of life (QoL) of patients who underwent complex decongestive therapy (CDT) due to unilateral breast cancer-related lymphedema (BCRL).

METHODS

Forty female patients with unilateral BCRL, of whom 20 had MetS (MetS group) and 20 did not have MetS (control group), were included in the study. The participants received CDT 5 days a week for 3 weeks. The participants' limb volume (percentage of excess volume (PEV) and percentage reduction of excess volume (PREV) was determined using a tape measure, and their QoL was assessed using the Lymphedema Quality of Life questionnaire (LYMQoL) before and after treatment.

RESULTS

After the treatment, the PEV and PREV values and LYMQoL-symptoms scores of the patients improved (p < 0.05); however, the LYMQoL-function, appearance/body image, mood/emotions, and overall QoL scores did not change in the MetS group (p > 0.05). In the control group, the PEV and PREV values and the LYMQoL-appearance/body image, mood/emotions, and overall QoL scores improved (p < 0.05), but the LYMQoL-symptoms and LYMQoL-function scores did not change (p > 0.05). There was a greater increase in the post-treatment PEV and PREV values of the control group compared to the MetS group (p < 0.001).

CONCLUSION

The study yielded that CDT was an effective treatment in BCRL with and without MetS; however, the improvement was greater in BCRL cases without MetS than in those with MetS. Therefore, the presence of MetS should be taken into account in the treatment of lymphedema in patients who develop BCRL.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT05426993. Registered 2022-06-16. https://clinicaltrials.gov/search?cond=NCT05426993.

Lower limb lymphedema disrupts both static and dynamic balance

BACKGROUND

The impact of lower-limb-lymphedema on quality of life of patients regarding balance is unclear due to the scarcity of literature. The aim of this study was to determine the static and dynamic balance of patients with lower-limb-lymphedema in comparison with healthy subjects.

METHODS

This case-control designed study included 30 lymphedema patients and 30 healthy individuals, of whom were 52 female and 8 male with a mean age of 50.63 ± 9.72 years. Static balance stability and anterior-posterior with lateral sway parameters on four conditions (eyes-opened-stable-ground, eyes-closed-stable-ground, eyes-opened-unstable-ground, eyes-closed-unstable-ground) and dynamic stability of all participants were evaluated.

FINDINGS

The demographic variables were similar between the groups. Majority of the patients had lymphedema due to cancer surgery with a stage of 2. Dynamic stability was significantly disrupted in lymphedema group in comparison with controls (P = 0.049). Static balance parameters were impaired on all conditions except the eyes opened-stable ground in lymphedema patients (P = 0.048,P = 0.043,P = 0.017). The dynamic with static balance and lateral sway parameters were correlated with the duration of lymphedema(P = 0.046,P = 0.002,P = 0.005). Anterior-posterior sway on eyes-closed-unstable-ground condition was correlated with functional status (P = 0.02). Static balance on eyes-opened-unstable-ground condition and anterior-posterior sway parameters were correlated with physical activity level (P = 0.015,P = 0.016,P < 0.05).

INTERPRETATION

Closing eyes and the deterioration of ground caused significant alteration of the static and dynamic balance both separately and together in patients with lower-limb-lymphedema compared to healthy subjects. Regarding the static and dynamic imbalance, we suggest the evaluation of balance and inclusion of balance exercises in routine lymphedema rehabilitation program, especially in the early period of disease.

Elephantiasis Nostras Verrucosa in a Patient With Lymphedema Tarda

This case report presents a rare and complex clinical scenario of a 42-year-old male diagnosed with elephantiasis nostras verrucosa in the context of lymphedema tarda. The patient's seven-year history of insidious and progressively worsening swelling over the left lower limb, inguino-scrotal region, and left upper limb posed diagnostic challenges, leading to a multidisciplinary evaluation. Clinical examination, imaging studies, and laboratory investigations were integral in confirming the diagnosis. The manifestation of elephantiasis nostras verrucosa, characterized by extensive hyperkeratosis, added a unique dimension to the clinical presentation. A comprehensive treatment approach involving nutritional supplementation and pharmacological interventions was initiated to address the multifaceted aspects of lymphatic dysfunction. This case underscores the importance of a collaborative and holistic approach to managing complex lymphatic disorders, contributing valuable insights to the medical literature.

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.

Lymphedema is associated with CELSR1 in Phelan-McDermid syndrome

Lymphedema is a troubling condition present in many disorders including the rare genetic disorder known as Phelan-McDermid syndrome (PMS). The neurobehavioral features of PMS, also known as 22q13.3 deletion syndrome, have been investigated, but little research exists on lymphedema in PMS. In this investigation, clinical and genetic data from 404 people with PMS were reviewed from the PMS-International Registry revealing a prevalence of 5% with lymphedema. Lymphedema was reported in 1 out of 47 people (2.1%) with PMS due to a SHANK3 variant and 19 out of 357 people (5.3%) with PMS due to 22q13.3 deletions. Lymphedema was more common among those in their teens or adulthood (p = 0.0011) and those with deletions >4 Mb. People with lymphedema had significantly larger deletions (mean 5.375 Mb) than those without lymphedema (mean 3.464 Mb, p = 0.00496). Association analysis identified a deletion of the CELSR1 gene to be the biggest risk factor (OR = 12.9 95% CI [2.9-56.2]). Detailed assessment of 5 subjects identified all had deletions of CELSR1, developed symptoms of lymphedema starting at age 8 or older, and typically responded well to standard therapy. In conclusion, this is the largest assessment of lymphedema in PMS to date and our results suggest that individuals with deletions >4 Mb or those with CELSR1 deletions should be assessed for lymphedema.

Effectiveness of Digital Health on the Quality of Life of Long-Term Breast Cancer Survivors: A Systematic Review

OBJECTIVES

To identify, critically appraise, and synthesize the available evidence on the effectiveness of digital health interventions to improve the quality of life or any of its four dimensions (physical, psychological, social, and spiritual) in women survivors of breast cancer who are in the extended or permanent survival stage.

DATA SOURCES

Systematic review-Four databases were searched: PubMed, CINAHL, PsycINFO, and Web of Science.

CONCLUSION

The clinical evidence shows a positive relationship or association between eHealth use and improved quality of life in breast cancer survivors at extended or permanent survival stage. However, the findings point to a deficit in the assessment of the social and spiritual domains that play a fundamental role in the quality of life of survivors.

IMPLICATION FOR NURSING PRACTICE

The findings found reflect implications of great value for nursing practice because these professionals are the main users of digital health tools to provide them to patients. Using these digital tools contributes to improving evidence-based practice and providing greater efficiency and effectiveness in the care of long-term cancer survivors.

Investigation of physical activity, fear of falling, and functionality in individuals with lower extremity lymphedema

PURPOSE

To investigate the fear of falling, physical activity, and functionality in patients with lymphedema in the lower extremities.

METHODS

Sixty-two patients who developed stage 2-3 lymphedema in the lower extremities due to primary or secondary causes (age: 56.03 ± 7.83 years) and 59 healthy controls (age: 54.61 ± 5.43 years) were included in the study. The sociodemographic and clinical characteristics of all individuals included in the study were recorded. In both groups, fear of falling was evaluated with the Tinetti Falls Efficacy Scale (TFES), lower extremity functionality with the Lower Extremity Functional Scale (LEFS), and physical activity with the International Physical Activity Questionnaire-Short Form (IPAQ-SF).

RESULTS

There was no statistically significant difference between the demographic characteristics of the groups (p > 0.05). The primary and secondary lymphedema groups had similar LEFS (p = 0.207, d = 0.16), IPAQ (p = 0.782, d = 0.04), and TFES (p = 0.318, d = 0.92) scores. However, the TFES score of the lymphedema group was significantly higher than that of the control group (p < 0.01, d = 0.52), while the LEFS (p < 0.01, d = 0.77) and IPAQ scores (p = 0.001, d = 0.30) were significantly higher in the latter. There was a negative correlation between LEFS and TFES (r = -0.714, p < 0.001) and between TFES and IPAQ (r = -0.492, p < 0.001). LEFS and IPAQ were positively correlated (r = 0.619, p < 0.001).

CONCLUSION

It was determined that individuals with lymphedema developed a fear of falling, and their functionality was negatively affected. This negative effect on functionality can be attributed to reduced physical activity and an increased fear of falling.

Review of diagnosis, differential diagnosis, and management of retroperitoneal lymphangioma

Lymphatic malformation (LM) is the currently preferred term for what was previously known as lymphangioma. Retroperitoneal LMs are extremely rare, benign, cystic masses that arise from lymphatic vessels. They can be challenging to diagnose because they resemble other retroperitoneal cystic tumors. The development of treatment strategies for rare diseases, including retroperitoneal LM, requires the acquisition of new knowledge to enhance our understanding of the disease progression. Therefore, we present an update regarding fundamental and advanced issues associated with retroperitoneal LM. This review describes the epidemiology, histopathology, biomedicine, clinical manifestations, radiological features, differential diagnosis, and management of this lesion.

Can Tissue Stiffness Measured Using Shear-Wave Elastography Represent Lymphedema in Breast Cancer?

Background: Lymphedema causes skin and subcutaneous fibrosis. However, quantitative methods for estimating the severity of fibrosis due to lymphedema have not been established. We evaluated skin stiffness using shear-wave elastography (SWE) and aimed to identify stiffness-associated factors in patients with breast cancer-related lymphedema (BCRL). Methods and Results: Thirty-six women (mean age, 57.5 ± 1.78 years; range, 39-77 years) were retrospectively recruited for this study. The mid-arm and mid-forearm circumferences were measured. The percentage differences in arm and forearm circumferences were used as an indicator of the severity of lymphedema at the time of SWE measurement and the measurement taken when the symptoms were most severe. Not subcutaneous tissues but cutaneous tissues of the affected arm and forearm showed a significant increase in shear-wave velocity (SWV) compared with those of the unaffected side. However, SWV was not correlated with the severity of lymphedema as a percentage difference when symptoms were most severe. Body mass index and lymphedema duration showed no significant correlation with the SWV of cutaneous tissues on the affected upper extremities. Conclusions: SWE can adequately estimate cutaneous fibrosis between the affected and unaffected limbs in patients with BCRL. However, evaluation of subcutaneous fibrosis is limited. Therefore, SWE can be an effective tool for evaluating cutaneous fibrosis in patients with BCRL.

Burden of lymphedema in long-term breast cancer survivors by race and age

BACKGROUND

Risk assessment for breast cancer-related lymphedema has emphasized upper-limb symptoms and treatment-related risk factors. This article examined breast cancer-related lymphedema after surgery, overall and in association with broader demographic and clinical features.

METHODS

The Carolina Breast Cancer Study phase 3 followed participants for breast cancer-related lymphedema from baseline (on average, 5 months after breast cancer diagnosis) to 7 years after diagnosis. Among 2645 participants, 552 self-reported lymphedema cases were identified. Time-to-lymphedema curves and inverse probability weighted conditional Cox proportional hazards model were used to evaluate whether demographics and clinical features were associated with breast cancer-related lymphedema.

RESULTS

Point prevalence of breast cancer-related lymphedema was 6.8% at baseline, and 19.9% and 23.8% at 2 and 7 years after diagnosis, respectively. Most cases had lymphedema in the arm (88%-93%), whereas 14% to 27% presented in the trunk and/or breast. Beginning approximately 10 months after diagnosis, younger Black women had the highest risk of breast cancer-related lymphedema and older non-Black women had the lowest risk. Positive lymph node status, larger tumor size (>5 cm), and estrogen receptor-negative breast cancer, as well as established risk factors such as higher body mass index, removal of more than five lymph nodes, mastectomy, chemotherapy, and radiation therapy, were significantly associated with increased hazard (1.5- to 3.5-fold) of lymphedema.

CONCLUSIONS

Findings highlight that hazard of breast cancer-related lymphedema differs by demographic characteristics and clinical features. These factors could be used to identify those at greatest need of lymphedema prevention and early intervention.

LAY SUMMARY

In this study, the aim was to investigate breast cancer-related lymphedema (BCRL) burden. This study found that risk of BCRL differs by race, age, and other characteristics.

Prediction of breast cancer-related lymphedema risk after postoperative radiotherapy via multivariable logistic regression analysis

PURPOSE

We identified novel clinical and dosimetric prognostic factors affecting breast cancer-related lymphedema after postoperative radiotherapy (RT) and developed a multivariable logistic regression model to predict lymphedema in these patients.

METHODS AND MATERIALS

In total, 580 patients with unilateral breast cancer were retrospectively reviewed. All patients underwent breast surgery and postoperative RT with or without systemic treatment in 2015. Among the 580 patients, 532 with available RT plan data were randomly divided into training (n=372) and test (n=160) cohorts at a 7:3 ratio to generate and validate the lymphedema prediction models, respectively. An area under the curve (AUC) value was estimated to compare models.

RESULTS

The median follow-up duration was 5.4 years. In total, 104 (17.9%) patients experienced lymphedema with a cumulative incidence as follows: 1 year, 10.5%; 3 years, 16.4%; and 5 years, 17.6%. Multivariate analysis showed that body mass index ≥25 kg/m2 (hazard ratio [HR] 1.845), dissected lymph nodes ≥7 (HR 1.789), and taxane-base chemotherapy (HR 4.200) were significantly associated with increased lymphedema risk. Conversely, receipt of RT at least 1 month after surgery reduced the risk of lymphedema (HR 0.638). A multivariable logistic regression model using the above factors, as well as the minimum dose of axillary level I and supraclavicular lymph node, was created with an AUC of 0.761 and 0.794 in the training and test cohorts, respectively.

CONCLUSIONS

Our study demonstrated that a shorter interval from surgery to RT and other established clinical factors were associated with increased lymphedema risk. By combining these factors with two dosimetric parameters, we propose a multivariable logistic regression model for breast cancer-related lymphedema prediction after RT.

Acquired lymphedema: Molecular contributors and future directions for developing intervention strategies

Lymphedema is a debilitating chronic disease that mostly develops as an adverse reaction to cancer treatment modalities such as chemotherapy, surgery, and radiotherapy. Lymphedema also appears to be a deteriorating consequence of roundworm infections, as best represented by filariasis. According to its origin, lymphedema is classified as primary lymphedema and acquired lymphedema. The latter is an acquired condition that, hitherto, received a considerably low attention owing to the less number of fatal cases been reported. Notably, despite the low mortality rate in lymphedema, it has been widely reported to reduce the disease-free survival and thus the quality of life of affected patients. Hence, in this review, we focused on acquired lymphedema and orchestration of molecular interplays associated with either stimulation or inhibition of lymphedema development that were, in vast majority, clearly depicted in animal models with their specific and distinct technical approaches. We also discussed some recent progress made in phytochemical-based anti-lymphedema intervention strategies and the specific mechanisms underlying their anti-lymphedema properties. This review is crucial to understand not only the comprehensive aspects of the disease but also the future directions of the intervention strategies that can address the quality of life of affected patients rather than alleviating apparent symptoms only.

Single and combined impacts of irradiation and surgery on lymphatic vasculature and fibrosis associated to secondary lymphedema

Lymphedema (LD) refers to a condition of lymphatic dysfunction associated with excessive fluid accumulation, fibroadipose tissue deposition and swelling. In industrialized countries, LD development mainly results from a local disruption of the lymphatic network by an infection or cancer-related surgery (secondary LD). In the absence of efficient therapy, animal models are needed to decipher the cellular and molecular mechanisms underlying LD and test putative drugs. In this study, we optimized and characterized a murine model of LD that combines an irradiation of the mice hind limb and a radical surgery (lymph node resection associated to lymphatic vessel ligation). We investigated the respective roles of irradiation and surgery in LD formation by comparing their impacts, alone or in combination (with different intervention sequences), on eight different features of the pathology: swelling (paw thickness), indocyanine green (ICG) clearance, lymphatic vasculature remodeling, epidermal and dermal thickening, adipocyte accumulation, inflammatory cell infiltration and collagen deposition. This study supports the importance of radiation prior to surgery to experimentally induce a rapid, severe and sustained tissue remodeling harboring the different hallmarks of LD. We provide the first experimental evidence for an excessive deposition of periostin (POSTN) and tenascin-C (TNC) in LD. Through a computerized method of digital image quantification, we established the spatial map of lymphatic expansion, as well as collagen, POSTN and TNC deposition in papillary and reticular dermis of lymphedematous skins. This mouse model is available to study the patho-physiology of LD and test potential therapeutic targets.

Health-related quality of life and assessment in patients with lower limb lymphoedema: a systematic review

OBJECTIVE

To determine the impact of lower limb lymphoedema (LLL) on health-related quality of life (HRQoL), and to identify the methodologies used to assess HRQoL and their adherence to the World Health Organization (WHO)-recommended HRQoL dimensions.

METHOD

A systematic review was used following the PRISMA guidance. Studies were eligible if they assessed HRQoL in adult patients with LLL. The search was conducted between September 2019 and February 2020 using CINAHL, PubMed, Scopus, EMBASE and the Cochrane Library database. Data were placed onto a pre-developed data extraction table and analysed using a narrative synthesis. Evidence-based Librarianship (EBL) was used for quality appraisal.

RESULTS

A total of 18 studies were identified, among which 10 were cross-sectional and eight were longitudinal studies. Twelve HRQoL questionnaires were identified and the Lymphoedema Quality of Life tool (LYMQoL) was the most commonly used. All of the studies except one had an EBL validity score of ≥75%. Although LLL causes a considerable impairment in HRQoL, the findings varied across the studies. All the studies considered at least four of the six WHO recommended dimensions, with none considering the spirituality dimension. Furthermore, physical functioning and wellbeing were discovered to be the worst affected HRQoL dimensions.

CONCLUSION

LLL adversely affects physical function, wellbeing and thus the HRQoL. The LYMQoL is the most commonly used questionnaire; despite this, all elements of the WHO recommendations were not captured in the included studies. However, accurate information on HRQoL indicating the impact of the disease on survivors' lives and complete wellbeing is needed to inform evidence-based decision-making. Furthermore, having a universally accepted, disease-specific methodology will facilitate comparison and contrasting of HRQoL in patients with LLL.

DECLARATION OF INTEREST

The authors have no conflicts of interest.

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.

Surgical treatment of lower extremity lymphedema with subcutaneous implantation of silicone tubing

A 65-year-male patient was admitted to our clinic with swollen, painful, and wound discharge of lower extremity. There was widespread edema, skin infection, and lymphangitis secondary Stage 3 lymphedema below the knee. In addition to conventional treatment methods, lymphatic artificial pathway creation was used with subcutaneous implantation of silicone tubing. In conclusion, subcutaneous implantation of silicone tubing is a new technique that can be applied in advanced stage lymphedema patients, which increases the effectiveness of compression therapy.

May-Thurner Syndrome and Lymphedema Reconstruction

May-Thurner syndrome (MTS) is an anatomical variant that results in compression of the left common iliac vein by the right common iliac artery. Although often asymptomatic, lower extremity swelling/edema, deep venous thrombosis, post-thrombotic syndrome, and eventual lymphedema (due to long-standing venous obstruction) can develop. The clinical management of patients presenting for lymphedema surgery with concomitant or undiagnosed MTS is not well described.

Methods

This review investigates two patients who were evaluated for unilateral lower extremity lymphedema, both of whom were subsequently diagnosed with MTS. Standard imaging (including lymphoscintigraphy, indocyanine green lymphangiography, and magnetic resonance venography) were performed to identify proximal venous obstruction. Treatment was accomplished using vascular surgical management, including stenting of the iliac vein before lymphedema reconstruction with vascularized lymph node transfer and multiple lymphovenous bypass.

Results

Both patients we examined in this review had improvement of lymphedema with vascular surgical management. Literature review reveals that MTS has an incidence as high as 20% in the population, although commonly unidentified due to lack of symptomatology.

Conclusions

There are no studies documenting the incidence of MTS in patients referred for lymphedema surgical management. Routine studies should be obtained to screen for proximal venous obstruction in patients presenting for surgical management of lower extremity lymphedema. Additional research is needed regarding the approach to managing patients with both MTS and lymphedema. Careful observational and prospective studies may elucidate the appropriate time interval between venous stenting and lymphedema microsurgical reconstruction.

The efficacy of Kinesio taping on lymphedema following head and neck cancer therapy: a randomized, double blind, sham-controlled trial

OBJECTIVE

The aim was to investigate the effectiveness of Kinesio taping for lymphedema following head and neck cancer therapy and its effect on patient compliance and quality of life.

METHODS

A total of 66 patients with lymphedema following head and neck cancer therapy were randomly allocated to the therapeutic Kinesio taping group (n = 33) and the sham Kinesio taping group (n = 33). All participants received manual lymphatic drainage, Kinesio taping, and home exercises for the first four weeks, and only home exercises for the second four weeks. The tape measurements, a scale of external lymphedema, a scale of the internal lymphedema, and quality of life were evaluated in both groups. The perceived discomfort consisting of limitation of daily living activities, pain, tightness, stiffness, and heaviness were also recorded.

RESULTS

When the group x time effect was evaluated, it was observed that external lymphedema was significantly reduced in both groups according to neck and face composite measurements (p < .001). However, in these measurements, a significant difference was found between the groups in favor of the KT group (p = .001, p = .032, respectively). At the end of the study, there was no significant difference in terms of internal lymphedema in both groups (p = .860). The quality of life parameters such as global health status and swallowing were significantly better in the Kinesio taping group (p < .001). There was no significant difference in the parameters of perceived discomfort between the two groups (p = .282, p = .225, p = .090, p = .155, p = .183, respectively).

CONCLUSION

Kinesio taping is effective in tape measurements and positively affects the quality of life in lymphedema following head and neck cancer therapy.

Drug-Related Lymphedema: Mysteries, Mechanisms, and Potential Therapies

The lymphatic circulation is an important component of the circulatory system in humans, playing a critical role in the transport of lymph fluid containing proteins, white blood cells, and lipids from the interstitial space to the central venous circulation. The efficient transport of lymph fluid critically relies on the rhythmic contractions of collecting lymph vessels, which function to "pump" fluid in the distal to proximal direction through the lymphatic circulation with backflow prevented by the presence of valves. When rhythmic contractions are disrupted or valves are incompetent, the loss of lymph flow results in fluid accumulation in the interstitial space and the development of lymphedema. There is growing recognition that many pharmacological agents modify the activity of ion channels and other protein structures in lymph muscle cells to disrupt the cyclic contraction and relaxation of lymph vessels, thereby compromising lymph flow and predisposing to the development of lymphedema. The effects of different medications on lymph flow can be understood by appreciating the intricate intracellular calcium signaling that underlies the contraction and relaxation cycle of collecting lymph vessels. For example, voltage-sensitive calcium influx through long-lasting ("L-type") calcium channels mediates the rise in cytosolic calcium concentration that triggers lymph vessel contraction. Accordingly, calcium channel antagonists that are mainstay cardiovascular medications, attenuate the cyclic influx of calcium through L-type calcium channels in lymph muscle cells, thereby disrupting rhythmic contractions and compromising lymph flow. Many other classes of medications also may contribute to the formation of lymphedema by impairing lymph flow as an off-target effect. The purpose of this review is to evaluate the evidence regarding potential mechanisms of drug-related lymphedema with an emphasis on common medications administered to treat cardiovascular diseases, metabolic disorders, and cancer. Additionally, although current pharmacological approaches used to alleviate lymphedema are largely ineffective, efforts are mounting to arrive at a deeper understanding of mechanisms that regulate lymph flow as a strategy to identify novel anti-lymphedema medications. Accordingly, this review also will provide information on studies that have explored possible anti-lymphedema therapeutics.

The Impact of COVID-19 Lockdown on Patients with Lymphedema

Background: The coronavirus disease 2019 (COVID-19) pandemic poses a challenge to management of lymphedema. The aim of this study was to assess general health conditions and evaluate the problems and concerns of lymphedema patients with regard to access to care and provision of management and control follow-ups during the lockdown period between March and June 2020. Methods: A web-based online survey, which included questions about demographic and clinical properties, compliance with restrictions and self-management, complications, needs, and difficulties in accessing health care, as well as the presence of psychological symptoms, was applied. Results: Two hundred three patients (190 female and 13 male) replied. Majority of them (73.4%) were between 30 and 60 years old and had high school/university education (67%). The duration of lymphedema was more than 3 years and sites were commonly extremities with mild to moderate intensity in 70.5% patients. Majority of them adhered to stay home warnings (88.7%). Weight gain was a common problem and self-care methods were generally skipped (81.8%). Seventeen percent of them had wounds and/or cellulitis. Forty percent of patients needed to apply to health centers to renew the pressure garment, but could not reach it. More than 70% of patients had sleep disorders and anxiety/stress. Majority of patients used television and social media to get information related to COVID-19 and the exposure time was commonly 2 to 6 hours. Conclusions: The COVID-19 lockdown had a great impact on lymphedema patients' health care not only from medical but also from psychosocial aspects. All these implications have to be identified and dealt with properly to avoid concerns and consequences of future pandemic lockdowns. Lymphedema services should be well prepared to be delivered virtually, enable effective care, and share knowledge to meet the needs of patients suffering from lymphedema.

Staging Breast Cancer-Related Lymphedema with Bioimpedance Spectroscopy

Background: A number of different classification schemes, with generally similar but not identical criteria, exist to describe the different stages of lymphedema. Criteria may include both subjective and objective assessments. The present study investigated whether bioelectrical impedance parameters had utility in staging breast cancer-related lymphedema. Methods and Results: Hierarchical agglomerative cluster analysis was used to assign women (n = 221) at risk of or with clinically ascribed lymphedema to clusters sharing similar impedance characteristics. Five clusters could be identified with each cluster containing proportions of participants that closely aligned with staging allocation, according to International Society of Lymphology criteria, at initial presentation. The use of cluster analysis for tracking of lymphedema progression or response to treatment is demonstrated. Conclusions: No single assessment provides definitive assignment of a patient to lymphedema stage. Staging is usually achieved by identifying and allocating a patient to a lymphedema stage shared by a group of patients with similar clinical signs. Cluster analysis of impedance data provides similar groupings of patients and could provide a useful adjunct objective assessment for staging lymphedema.

Natural Coumarins: Exploring the Pharmacological Complexity and Underlying Molecular Mechanisms

Coumarins belong to the benzopyrone family commonly found in many medicinal plants. Natural coumarins demonstrated a wide spectrum of pharmacological activities, including anti-inflammatory, anticoagulant, anticancer, antibacterial, antimalarial, casein kinase-2 (CK2) inhibitory, antifungal, antiviral, Alzheimer's disease inhibition, neuroprotective, anticonvulsant, phytoalexins, ulcerogenic, and antihypertensive. There are very few studies on the bioavailability of coumarins; therefore, further investigations are necessitated to study the bioavailability of different coumarins which already showed good biological activities in previous studies. On the evidence of varied pharmacological properties, the present work presents an overall review of the derivation, availability, and biological capacities of coumarins with further consideration of the essential mode of their therapeutic actions. In conclusion, a wide variety of coumarins are available, and their pharmacological activities are of current interest thanks to their synthetic accessibility and riches in medicinal plants. Coumarins perform the valuable function as therapeutic agents in a range of medical fields.

Correlation of older age with severity of lymphedema in breast cancer survivors: A systematic review

BACKGROUND

Breast cancer is the most frequent cause of secondary lymphedema. Besides being progressive and chronic, lymphedema is usually hard to treat. That is why the clinicians are more focused on the prevention of its development and progression.

OBJECTIVE

The aim of this study is to evaluate the possible relationship between the age of patients and the severity of breast cancer-related lymphedema (BCRL).

METHODS

PubMed, Scopus, and Ovid MEDLINE databases were searched for articles, which described the relationship between aging and BCRL development. Two authors searched for and selected articles independently.

RESULTS

Out of 562 studies selected, 8 studies met the inclusion criteria. However, 2 papers had the same study population, so only 7 were included in the final analysis. The total number of patients in those 7 studies was 3,904. Five out of 7 studies included in our review depicted the association of more severe forms of BCRL with older age.

CONCLUSION

The final analysis showed that aging is related to the severity of BCRL. However, due to heterogeneity in study outcome reporting, the cause and effect relationship could not be determined.

Stewart-Treves syndrome and other cutaneous malignancies in the context of chronic lymphedema: a systematic review

INTRODUCTION

Angiosarcoma developing in chronically lymphedematous tissue, or Stewart-Treves syndrome (STS), is a rare and lethal complication of lymphedema. This systematic review summarizes characteristics and outcomes of STS and other cutaneous malignancies arising in chronic lymphedema.

METHODS

MEDLINE and EMBASE databases were searched on February 19th, 2021, to identify 200 articles included in the analysis.

RESULTS

Of 369 included patients, 89.7% (n = 331/369) had STS and 10.3% (n = 38/369) had other associated malignancies. Mean age of onset was 61.2 years, and 85.9% (n = 317/369) of cases were female. Common risk factors were previous cancer history (69.8%, n = 258/369) and radiation history (53.7%, n = 198/369). Lymphedema was most commonly attributed to surgical causes (68.3%, n = 252/369). STS begins on average 14.9 years after lymphedema with mortality of 53.9% (n = 178/331) and remission rate of 16.1% (n = 53/331). Other malignancies begin on average 23.7 years after lymphedema, with mortality of 10.5% (n = 4/38) and remission rate of 31.6% (n = 12/38). STS and other malignancies had 5-year survivals of 22.4% and 65.2%, respectively (P = 0.00145). For all patients, patients initially treated with excision had the best survival (median: 48 months, 5-year survival: 43.3%) and radiotherapy had the worst survival (median: 10 months, 5-year survival: 6.5%) (P = 0.0141).

CONCLUSION

Malignancy can appear in lymphedematous tissue many years after lymphedema onset. STS has poorer prognosis compared to other malignancies. Further research should be conducted to better understand the causes, risk factors, and management of this phenomenon.

Lymphedema rehabilitation: Provision and practice patterns among service providers: National survey

Information on the current practices and quantification of lymphedema service may be beneficial to promote and improve the current health care system. Therefore, this study aimed to describe the characteristics of lymphedema practitioners, and lymphedema patients' profiles, and provide a comprehensive picture of lymphedema service provision in Saudi Arabia. A cross‐sectional study design used an online survey to gather data. The survey included information about demographic and professional characteristics of lymphedema practitioners, lymphedema profiles, questions on the services provided, and perceived barriers in providing services. Eighteen lymphedema practitioners (38%) responded to the survey. Most of the respondents were physical therapists (94%), who had completed 135 hours of basic training course, and were certified as lymphedema therapists (89%). Most of these practitioners were in Riyadh (58%), Jeddah (25%), and Dammam (17%). About 75% of patients seen by practitioners had secondary lymphedema, predominately breast cancer‐related lymphedema (47%). The average number of lymphedema practitioners per service is three. The perceived barriers reported included an inadequate number of certified therapists (100%), difficulties with transportation and lack of financial support (each; 72%), and limited space for lymphedema practice/management (89%). The results suggest lymphedema practitioners provide reasonable services for lymphedema patients; however, services are still limited and needs are unmet. Therefore, more staffing is required to promote awareness of the condition and related services, to develop and implement appropriate educational strategies, and improve geographical and multidisciplinary coordination of the services in Saudi Arabia.

Biology of Lymphedema

Simple Summary

Lymphedema is a chronic, debilitating disease of the lymphatic vasculature. Although several reviews focus on the anatomy and physiology of the lymphatic system, this review provides an overview of the lymphatic vasculature and, moreover, of lymphatic system dysfunction and lymphedema. Further, we aim at advancing the knowledge in the area of lymphatic system function and how dysfunction of the lymphatic system—as seen in lymphedema—affects physiological systems, such as the cardiovascular system, and how those might be modulated by lymphedema therapy.

Abstract

This narrative review portrays the lymphatic system, a poorly understood but important physiological system. While several reviews have been published that are related to the biology of the lymphatic system and lymphedema, the physiological alternations, which arise due to disturbances of this system, and during lymphedema therapy, are poorly understood and, consequently, not widely reported. We present an inclusive collection of evidence from the scientific literature reflecting important developments in lymphedema research over the last few decades. This review aims at advancing the knowledge on the area of lymphatic system function as well as how system dysfunction, as seen in lymphedema, affects physiological systems and how lymphedema therapy modulates these mechanisms. We propose that future studies should aim at investigating, in-detail, aspects that are related to fluid regulation, hemodynamic responses, and endothelial and/or vascular changes due to lymphedema and lymphedema therapy.

Physical activity levels among ovarian cancer survivors: a prospective longitudinal cohort study

OBJECTIVE

Physical activity following cancer diagnosis is associated with improved outcomes, including potential survival benefits, yet physical activity levels among common cancer types tend to decrease following diagnosis and remain low. Physical activity levels following diagnosis of less common cancers, such as ovarian cancer, are less known. The objectives of this study were to describe physical activity levels and to explore characteristics associated with physical activity levels in women with ovarian cancer from pre-diagnosis to 2 years post-diagnosis.

METHODS

As part of a prospective longitudinal study, physical activity levels of women with ovarian cancer were assessed at multiple time points between pre-diagnosis and 2 years post-diagnosis. Physical activity levels and change in physical activity were described using metabolic equivalent task hours and minutes per week, and categorically (sedentary, insufficiently, or sufficiently active). Generalized Estimating Equations were used to explore whether participant characteristics were related to physical activity levels.

RESULTS

A total of 110 women with ovarian cancer with a median age of 62 years (range 33-88) at diagnosis were included. 53-57% of the women were sufficiently active post-diagnosis, although average physical activity levels for the cohort were below recommended levels throughout the 2-year follow-up period (120-142.5min/week). A decrease or no change in post-diagnosis physical activity was reported by 44-60% of women compared with pre-diagnosis physical activity levels. Women diagnosed with stage IV disease, those earning a lower income, those receiving chemotherapy, and those currently smoking or working were more likely to report lower physical activity levels and had increased odds of being insufficiently active or sedentary.

CONCLUSIONS

Interventions providing patients with appropriate physical activity advice and support for behavior change could potentially improve physical activity levels and health outcomes.

Factors influencing efficacy of complete decongestive treatment in patients with breast cancer-linked arm lymphoedema

Background/Aim: The most recommended form of lymphoedema therapy is complete decongestive treatment (CDT). Efficacy of CDT in patients with arm lymphoedema related to malignant breast tumour has reported in many studies, but the predictive factors of outcome of this therapy have not been yet sufficiently investigated. The purpose of this research was to identify predictive factors of efficacy of CDT in patients with breast cancer-linked arm lymphoedema throughout the intensive phase of therapy. Methods: The prospective study included 51 patients with breast cancer-linked arm lymphoedema who were subjected to a 3-week program of CDT. Patients' clinical and demographic features, breast cancer treatment characteristics, lymphoedema and CDT characteristics were collected and assessed for their prognostic value. The influence of certain predictors on the degree of lymphoedema reduction was evaluated by multivariate linear regression analysis. Results: Mean age was 58.1 ± 8.0 (95 % CI: 55.8 - 60.3), median of BMI was 28.4 kg/m2 (95 % CI: 27.2 - 29.6). The average duration of lymphoedema was 36.5 ± 43.9 months (95 % CI: 24.1 - 48.8). The mean size of lymphoedema before CDT was 6.99 ± 5.36 %, and the mean degree of lymphoedema reduction was 63.7 ± 28.6 %. The mean compliance to bandages was 217.5 ± 97.8 hours (95 % CI: 190.0 - 245.0) and 7 (13.7 %) patients had a history of erysipelas of the ipsilateral arm. When observing each individual predictor, statistically most significant contribution showed the size of lymphoedema before the therapy (p < 0.001), then history of erysipelas (p < 0.01), and patients' age (p < 0.05). Conclusion: Size of lymphoedema before treatment is the most crucial prognostic factor of the efficacy of CDT in the patients with breast cancer-linked arm lymphoedema. The present study also identified history of erysipelas and patients age as independent predictors of the CDT efficacy.

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.

Intensive Treatment of Lower-Limb Lymphedema and Variations in Volume Before and After: A Follow-Up

Background and objective

Lymphedema is a clinical condition resulting from a failure in the drainage of the lymphatic system and the consequent formation of edema. The aim of the present study was to report the results of five days of intensive treatment for lymphedema and the maintenance of such results at the first follow-up evaluation.

Method

A clinical trial was conducted involving 409 patients with primary or secondary unilateral, lower-limb lymphedema who underwent intensive treatment with the Godoy method. The treatment consisted of eight hours per day of mechanical lymphatic drainage, 15 minutes per day of cervical stimulation, and compression mechanics involving the use of laced grosgrain (non-elastic) stockings alternated with bandages. Volumetric evaluations were performed at baseline, after five days of intensive treatment, and at the first follow-up evaluation performed one to three months after intensive treatment.

Results

The mean volume was 2,083.43 ml at baseline and 937.55 ml after five days of intensive treatment, corresponding to a 55% reduction. The mean was 800.83 ml at the follow-up evaluation, corresponding to a reduction of 137 ml [17.12 non-significant difference (p = 0.1)].

Conclusion

The intensive treatment of lymphedema leads to considerable reductions in edema within a short period of time, facilitating the continuity of treatment and demonstrating the credibility of the method.

Biomaterial Based Strategies for Engineering New Lymphatic Vasculature

The lymphatic system is essential for tissue regeneration and repair due to its pivotal role in resolving inflammation, immune cell surveillance, lipid transport, and maintaining tissue homeostasis. Loss of functional lymphatic vasculature is directly implicated in a variety of diseases, including lymphedema, obesity, and the progression of cardiovascular diseases. Strategies that stimulate the formation of new lymphatic vessels (lymphangiogenesis) could provide an appealing new approach to reverse the progression of these diseases. However, lymphangiogenesis is relatively understudied and stimulating therapeutic lymphangiogenesis faces challenges in precise control of lymphatic vessel formation. Biomaterial delivery systems could be used to unleash the therapeutic potential of lymphangiogenesis for a variety of tissue regenerative applications due to their ability to achieve precise spatial and temporal control of multiple therapeutics, direct tissue regeneration, and improve the survival of delivered cells. In this review, the authors begin by introducing therapeutic lymphangiogenesis as a target for tissue regeneration, then an overview of lymphatic vasculature will be presented followed by a description of the mechanisms responsible for promoting new lymphatic vessels. Importantly, this work will review and discuss current biomaterial applications for stimulating lymphangiogenesis. Finally, challenges and future directions for utilizing biomaterials for lymphangiogenic based treatments are considered.

Chubby Infant - Should One Worry? An Infant with Primary lymphedema - Mini Review and Case Report

Lymphedema is a localized form of tissue swelling, characterized by a progressive accumulation of a tissue fluid in the interstitial compartment as a result of the lymphatic system dysfunction. It is a rare disease in the pediatric population and in the majority of cases it is a consequence of an abnormal formation of the lymphatic system, which is called primary lymphedema. Although its epidemiology is not precise, it is assumed that 1:100 000 children suffer from primary lymphedema. The diagnosis can be made by a proper clinical examination after ruling out secondary causes of lymphedema, particularly in cases with a more asymmetric swelling of the extremities. In this very article we present a case report of an 8-months-old infant with primary lymphedema, who had presented swelling of the extremities from birth and yet no pathology was suspected before. The purpose of this article is to draw attention to the fact that a baby with excessive subcutaneous tissue is not always a healthy, chubby infant with considerable amount of fat tissue.Das Lymphödem ist eine lokalisierte Form des Gewebeödems, die durch eine fortschreitende Ansammlung von Gewebeflüssigkeit im Interstitialraum infolge einer Funktionsstörung des Lymphsystems gekennzeichnet ist. Dies ist eine seltene Erkrankung in der pädiatrischen Bevölkerung und in den meisten Fällen eine Folge der fehlerhaften Bildung des Lymphsystems, das als primäres Lymphödem bezeichnet wird. Obwohl die Epidemiologie nicht genau ist, wird angenommen, dass 1: 100 000 Kinder an einem primären Lymphödem leiden. Die Diagnose kann auf der Grundlage einer geeigneten klinischen Untersuchung gestellt werden, nachdem sekundäre Ursachen für Lymphödeme ausgeschlossen wurden, insbesondere bei asymmetrischeren Ödemen der Gliedmaßen. In diesem Artikel präsentieren wir den Fallbericht eines 8 Monate alten Kindes mit primärem Lymphödem, dessen Ödem der Gliedmaßen seit der Geburt aufgetreten ist, bei dem aber keine Pathologien vermutet wurde. Der Zweck dieses Artikels ist es, die Aufmerksamkeit auf die Tatsache zu lenken, dass ein Kind mit übermäßigem Unterhautgewebe nicht immer ein gesundes, molliges Kind mit übermäßigem Körperfett bedeutet.

Comprehensive Decongestive Therapy as a Treatment for Secondary Lymphedema of the Lower Extremity and Quality of Life of Women After Gynecological Cancer Surgery

Background

Lymphedema is a clinical manifestation of lymphatic system failure, caused by an imbalance between the transport capacity of the lymphatic system and the volume of the produced lymph. Lymphedema is complication and significantly worsens quality of life (QoL).

Material/Methods

There were 50 patients diagnosed with secondary lymphedema of the lower extremities after gynecological cancer followed by radiotherapy included in this study. The average age was 57.76 years (standard deviation±10.08). Patients were treated at the Department of Physiotherapy, Balneology and Medical Rehabilitation, in hospital NsP in Bardejov. During therapy, we applied manual lymphatic drainage, instrumental lymphatic drainage, multilayer bandage, vascular gymnastics (with loaded external compression), hydrotherapy, and patient education on the adjustment necessary for a life-long regimen. The circumference of the limb was measured using the Kuhnkes disk method, QoL was assessed using the LYMQOL LEG questionnaire, and for assessment of pain the Visual Analogue Scale (VAS) was used.

Results

After treatment, we found a reduction in lymphedema (P<0.001), an increase in QoL (P<0.001), and a reduction in pain (P<0.001). We found a significant relationship between QoL change and pain in the domains of symptoms, function, and overall QoL (P<0.005). The results showed that reduction of lymphedema was not a significant predictor of QoL (P>0.001).

Conclusions

We found a positive effect in the treatment of secondary lymphedema of the lower extremity on the QoL of women after uterine cancer surgery, and also found that reduction of lymphedema and age were not predictors of improvement in QoL.

A quasi-randomized clinical trial: virtual reality versus proprioceptive neuromuscular facilitation for postmastectomy lymphedema

BACKGROUND

Postmastectomy lymphedema can be considered the main cause of upper extremity functional impairment in patients with breast cancer. Fatigue, pain, and limited range of motion are common symptoms. If left untreated, lymphedema causes cellulitis, which can lead to gangrene in rare cases. This study was carried out to identify and compare the therapeutic advantages of virtual reality-based exercises and proprioceptive neuromuscular facilitation for postmastectomy lymphedema. Thus, a quasi-randomized comparative study of thirty female patients with unilateral postmastectomy lymphedema was conducted. Fifteen patients performed virtual reality-based exercises as well as manual lymphatic drainage, pneumatic compression, and home programs, while the other fifteen patients performed proprioceptive neuromuscular facilitation as well as manual lymphatic drainage, pneumatic compression, and home programs. The excess arm volume between the healthy and affected limbs was estimated before and after eight sessions of treatment for both groups. In addition, the affected limb functional score was calculated. Arm volume was calculated by the truncated cone formula and girth measurements obtained by the circumferential method. The Arabic version of the QuickDASH-9 scale was used to assess extremity function.

RESULTS

The excess arm volume significantly decreased in both the virtual reality group (p = 0.001) and proprioceptive neuromuscular facilitation group (p = 0.005), and there was no significant difference between the two groups (p = 0.902). Age was inversely related to the improvement percentage of the QuickDASH-9 score in the virtual reality group. The functional improvement percentage was statistically significantly different between the two groups (p = 0.045).

CONCLUSION

It can be concluded that both virtual reality and proprioceptive neuromuscular facilitation have a beneficial therapeutic effect on edema in patients with unilateral postmastectomy lymphedema; neither method was found to be superior, except virtual reality was found to be superior to proprioceptive neuromuscular facilitation in motivating patients and providing visual feedback.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04185181 Registered 4 December 2019 - Retrospectively registered.

Role of Bioelectrical Impedance Analysis in the Evaluation of Patients with Upper Limb Lymphedema

Background: Monofrequency bioelectrical impedance analysis (BIA) protocols seek to further quantify changes in lymphedema compared with traditional circumferential evaluations. Complex decongestive therapy (CDT) is an effective method of reducing unilateral upper limb lymphedema secondary to breast cancer treatments. Comparing lymphedema measurements between segmental tetrapolar BIA, total body BIA, and circumferential measurements during therapeutic changes can improve our quantitative assessment ability for this prevalent medical complication. Methods and Results: Twenty-two patients with breast-cancer-related unilateral upper limb lymphedema participated in this prospective observational study. Circumferential measurements, segmental tetrapolar BIA, and total body BIA were obtained and compared before CDT, immediately after 10 sessions of CDT, and 30 days post-CDT to assess lymphedema. The segmental tetrapolar BIA correlated well with improvements in circumferential measurements of the limb. We found that the resistance value cutoff point of 237 Ω could indicate a recurrence of lymphedema. Conclusions: Segmental, tetrapolar monofrequency BIA provides a simple method to monitor and evaluate the efficacy of therapy in the outpatient setting by operators with minimal training. This protocol could aid quantitative evaluations of unilateral upper limb lymphedema.

Predictive Factors of Deep Vein Thrombosis in Gynecologic Cancer Survivors with Lower Extremity Edema: A Single-Center and Retrospective Study

This study was conducted to examine predictive factors of deep vein thrombosis (DVT) in gynecologic cancer survivors with lower extremity edema (LEE). In the current single-center, retrospective study, there was a total of 315 eligible patients, including 80 patients with DVT and 235 without DVT. They were therefore divided into two groups: the DVT group (n = 80) and the non-DVT group (n = 235). Then, baseline and clinical characteristics of the patients were compared between the two groups. In our study, distant organ metastasis, advanced stage, lymphadectomy, and amount of intraoperative blood loss had a positive predictive value for the occurrence of DVT in gynecologic cancer survivors presenting LEE. In conclusion, our results indicate that it is necessary to consider the possibility of LEE arising from DVT in gynecologic cancer survivors with advanced-stage cancer, distant organ metastasis, lymphadectomy, and intraoperative blood loss over 1500 mL.

Physical Activity of Women After Radical Unilateral Mastectomy and Its Impact on Overall Quality of Life

Radical unilateral mastectomy is an acknowledged source of traumatic experience for women, adversely affecting their behavioral and emotional paradigm. The present study aimed to assess the quality of life in physically active and inactive postmastectomy women. Population sample involved 100 women, aged 50 to 60 years, having undergone radical unilateral mastectomy, allocated into 2 groups, upon assumption of undertaking physical activity. The abbreviated version of WHOQOL-BREF questionnaire was a research tool of choice. The data were analyzed with the aid of χ² test, Kruskal-Wallis test, and Mann-Whitney U test. Statistically significant dependence was established between physical activity actually pursued and self-assessment of overall quality of life (P = .014) and overall the self-rated perception of health (P < .001). In the group of physically inactive women, physical health was a variable dependent upon individual level of education (P = .031). The highest scores in this domain were noted in the women boasting secondary education, whereas the lowest in the ones with vocational education. Social domain was the highest rated aspect of quality of life in both the physically active and inactive postmastectomy women, while the physical health domain was rated the lowest. Both in the case of physically active and inactive postmastectomy women, the quality of life in the respective domains, as listed in the WHOQOL-BREF questionnaire, was found independent of the living environment.

LIMPRINT Study: The Turkish Experience

Background: Lymphedema and chronic edema is a major health care problem in both developed and nondeveloped countries The Lymphoedema Impact and Prevelance - International (LIMPRINT) study is an international health service-based study to determine the prevalence and functional impact in adult populations of member countries of the International Lymphoedema Framework (ILF). Methods and Results: A total of 1051 patients from eight centers in Turkey were recruited using the LIMPRINT study protocol. Data were collected using the core and module tools that assess the demographic and clinical properties as well as disability and quality of life (QoL). Most of the Turkish patients were recruited from specialist lymphedema services and were found to be women, housewives, and having secondary lymphedema because of cancer treatment. The duration of lymphedema was commonly <5 years and most of them had International Society of Lymphology (ISL) grade 2 lymphedema. Cellulitis, infection, and wounds were uncommon. The majority of patients did not get any treatment or advice before. Most of the patients had impaired QoL and decreased functionality, but psychological support was neglected. Although most had social health security access to lymphedema centers, nevertheless access seemed difficult because of distance and cost. Conclusion: The study has shown the current status and characteristics of lymphedema patients, treatment conditions, the unmet need for the diagnosis and treatment, as well as burden of the disease in both patients and families in Turkey. National health policies are needed for the prevention, diagnosis, and treatment in Turkey that utilize this informative data.