Breast Cancer-related Lymphedema Research Articles

Factors Influencing the Self-management of Breast Cancer-Related Lymphedema: A Meta-synthesis of Qualitative Studies.

Patients with breast cancer have an estimated 14% to 60% risk of developing lymphedema after treatment. Self-management behavior strategies regarding lymphedema are essential in preventing and alleviating the severity of lymphedema. The aim of this study was to evaluate qualitative research evidence on the potential influencing factors for self-management behaviors of lymphedema in patients with breast cancer. A systematic search of 10 electronic databases was conducted to identify qualitative studies on patient experience of lymphedema self-management. The following databases were included and appraised using the Joanna Briggs Institute Critical Appraisal Checklist: Cochrane Library, PubMed, EMBASE, Web of Science, PsycINFO, Scopus, Cumulative Index to Nursing and Allied Health Literature, China National Knowledge Infrastructure, Wanfang Med Online, and Chinese Biomedical Database. The literature search yielded 5313 studies, of which only 22 qualitative studies fulfilled the eligibility criteria. Five synthesized findings were derived encompassing personal characteristics, personal knowledge and experience, personal health beliefs, self-regulation skills and abilities, and social influences and support. Patients with breast cancer are confronted with many challenges when performing self-management of lymphedema. Therefore, it is important to recognize potential facilitators and barriers to further offer practical recommendations that promote self-management activities for lymphedema. Healthcare professionals should receive consistent training on lymphedema management. On the basis of individual patient characteristics, tailored education and support should be provided, including transforming irrational beliefs, and improving related knowledge and skills, with the aim to promote self-management behaviors with respect to lymphedema.

Abstract PO3-12-07: Utility of Volumetric Measurement for Clinical Diagnosis of Breast Cancer-Related Lymphedema

Abstract Background: Early detection of Breast cancer-related lymphedema (BCRL) is crucial since it can significantly reduce the negative impact on a patient’s quality of life after breast cancer treatment. Several objective screening methods have been used in prior studies but have not proven accurate due to a lack of standardization. Bioimpedance spectroscopy (BIS), which assesses tissue resistance to an electric current and converts it into a score to measure interstitial fluid content, has proven to be an accurate tool in diagnosing lymphedema. SOZO® is a BIS device that generates quantitative results in real time and provides a Lymphedema Index (L-Dex) score by measuring the patient's extracellular fluid volume. However, there is a paucity of literature highlighting its clinical applicability. Thus, we aimed to evaluate the clinical utility of SOZO® in diagnosing BCRL in patients undergoing breast cancer surgery. Materials & Methods: A retrospective chart review was carried out of patients who underwent axillary surgery from January 2019 to December 2022. Demographic information such as age, body mass index (BMI), gender, ethnicity, disease pathology, cancer stage, type of axillary surgery, neoadjuvant and adjuvant treatment received was recorded. Patients undergoing sentinel lymph node biopsy (SLNB) and/or axillary lymph node dissection (ALND) were assessed for their preoperative L-Dex score, and they were followed up postoperatively with repeated measurements of their L-Dex score to diagnose lymphedema for a year at 3 months intervals. Clinical lymphedema was defined as those having an absolute L-Dex score of more than +10 and an increase in L-Dex score by 6.5 from the baseline. SOZO® scores measured at each follow-up were compared to their preoperative baseline scores. Results: A total of 200 patients’ data was evaluated whose mean age and BMI were 57.5+10.9 years and 29.6+5.6 kg/m2, respectively. Eighty-five percent of the patients belonged to ethnic minority groups. Furthermore, 84.5% (n=169) of the patients had SLNB, and 15.5% (n=31) had ALND. All the patients included in the study had their preoperative and postoperative quarterly L-Dex scores recorded. Pre- and post-operative L-Dex scores had a mean of -0.20+6.6 and 0.61+6.8, respectively. A total of 20 (10%) patients developed lymphedema without symptoms detected by SOZO®, with 19 (9.5%) resolving at their respective 3-month follow-up and 1 (0.5%) patient with persistent lymphedema at the end of the 24-month follow-up. All 20 patients were treated with a compression sleeve. Of the 20 patients with lymphedema, 4 patients underwent ALND, whereas 16 patients had SLNB. When compared to their preoperative baseline scores, all patients' SOZO® measurements had an absolute score of more than 10 and an increase of 6.5 from their baseline score. Additionally, 21 other patients had an increase in score of 6.5 from their baseline measurements but did not meet the cut-off range of an absolute score of +10. Therefore, we excluded them from the diagnosis of BCRL, and none of these patients later developed any signs of BCRL, such as swelling, pain, or discomfort. Conclusion: SOZO® procedure can accurately detect BCRL. In our study, 1 patient developed clinical lymphedema after undergoing SLNB and was diagnosed using SOZO®. Additionally, 19 patients who were initially diagnosed with lymphedema were later categorized as transient due to the resolution of lymphedema on follow-up. Early identification of transient lymphedema using SOZO® resulted in the prevention of a potentially life-long debilitation in our patients. Moreover, our findings underscore that an increase in SOZO® score from the baseline by > 6.5 with an absolute score of more than +10 should be the threshold to clinically diagnose lymphedema. Future studies with larger sample sizes and longer follow-up duration are necessary to understand better the utility of SOZO® in diagnosing BCRL. Table 1: Baseline characteristics and follow-up data of the patients included in the study. Citation Format: Fardeen Bhimani, Sheldon Feldman, Yu Chen, Anjuli Gupta, Jessica Pastoriza, Areej Shihabi, Maureen McEvoy. Utility of Volumetric Measurement for Clinical Diagnosis of Breast Cancer-Related Lymphedema [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-12-07.

Abstract PO3-11-09: Cross-cultural adaptation and psychometric validation of lymphedema patient-reported outcome measurements in Chinese breast cancer patients

Abstract Background: Lymphedema is one of the most common complains reported by breast cancer survivors, which negatively affects the quality of life (QoL). Various internationally recognized patient-reported outcome measurements (PROMs), such as the Upper Limb Lymphedema 27 (ULL-27), Lymphoedema Functioning, Disability and Health questionnaire (Lymph-ICF), Lymphedema Quality of Life Questionnaire for upper limbs (LYMQOL-ARM), and Lymphedema Life Impact Scale Version 2 (LLIS), have been translated into different languages and widely used to assess QoL in patients with breast cancer-related lymphedema (BCRL). However, limited evidence has proved the efficiency of these tools in Chinese patients. In this study, we performed cross-cultural adaptation and psychometric validation of these four PROMs within the Chinese context. Additionally, we also compared the accuracy in detecting BCRL for early diagnosis. Methods: A process of forward–backward translation and cultural adaptation was conducted based on international standards. Content validity was assessed through patient interviews. Internal consistency was evaluated by Cronbach’s alpha coefficient. The correlation analysis of the MOS item short from health survey (SF-36) and each BCRL QoL questionnaires was utilized to indicate the convergent and divergent validity. Clinical validity was assessed by comparing scores among patients with different BCRL stages. Furthermore, questionnaires scores and the known group of lymphedema or not were compared to generate receiver operator characteristic (ROC) curves of these instruments. Results: A total of 204 female breast cancer patients were recruited in this study. Among them, 104 patients (61 with lymphedema and 43 without lymphedema) finished LYMQOL-ARM and ULL-27 questionnaire, while 100 patients (59 with lymphedema and 41 without lymphedema) were assessed by Lymph-ICF and LLIS. The internal consistency was high, with Cronbach's alpha coefficients above 0.9 for all subscales and global scales. The content validity was generally good, except for a few issues reported by the patients. Convergent and divergent validity confirmed the hypotheses of correlation between the tested questionnaire and SF-36 to varying degrees: 100% for ULL-27, 80% for Lymph-ICF, nearly 70% for LLIS, and only 50% for LYMQOL-ARM. LLIS and Lymph-ICF demonstrated strong clinical validity, with significant differences found in total and subscale scores among participants in different BCRL stages (P< 0.05). There were no significant differences between stages for the mood dimension (P=0.132) of LYMQOL-ARM, psychological dimension (P=0.506), social dimension (P=0.083), and total score (P=0.057) of ULL-27. Only the physical concerns and global scale of LLIS and the symptom subscale of Lymph-ICF exhibited acceptable AUC values near 0.7 (AUC 0.725, 95% CI 0.625-0.825, p< 0.029; AUC 0.680, 95% CI 0.573-0.787, p< 0.002; AUC 0.734, 95% CI 0.633-0.834, p< 0.001, respectively). In contrast, other subscales and questionnaires displayed lower AUC values. Conclusion: Lymphedema is a chronic disease that has a relatively low mortality risk but significantly affects the quality of life. Therefore, it is crucial to prioritize patient-reported outcomes in the assessment of lymphedema. Among the four PROMs, LLIS not only showed high internal consistency and content validity more suitable for Chinese patients, but also exhibited better performance in reflecting the presence and severity of lymphedema patients. Consequently, the validated and reliable Chinese version of LLIS is recommended for clinical and scientific practices in the assessment of BCRL, which will help to provide better interventions with a patient-centered focus. Citation Format: Yue Zhou, Bingqiu Xiu, Qi Zhang, Jiong Wu. Cross-cultural adaptation and psychometric validation of lymphedema patient-reported outcome measurements in Chinese breast cancer patients [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-11-09.

Abstract PO5-11-11: Risk Assessment, Prevention and Early Detection of Breast Cancer Related Lymphedema – Objective Measurements and Patient Reported Outcomes

Abstract Background Breast cancer-related lymphedema (BCRL) affects the quality of life, but there is no consensus regarding early detection and monitoring. Patient-reported outcomes (PROs) are important in assessing cancer survivor outcomes, and different questionnaires have been developed. LYMPHA (Lymphatic Microsurgical Preventive Healing Approach) and S-LYMPHA (Simplified LYMPHA) have reduced BCRL rates. This study aims to identify the most reliable PRO in a South Florida multi-ethnic population and to study correlations between PROs and objective measurements in the first 6 months after axillary surgery. Methods Patients undergoing axillary lymph node dissection (ALND) or axillary radiation were included. L-Dex score (Bioimpedance Spectroscopy) and three validated questionnaires (LyQLI, Lymphedema Quality of Life Inventory; LyQOL, Lymphedema Quality of Life and FACT-B4+ Functional Assessment of Cancer Therapy – Lymphedema) were recorded at baseline, and 6 months post-surgery to assess the agreement between patient-reported symptoms and BCRL. L-Dex score outside the normal range or a 10 unit increase above baseline was considered lymphedema. Additional variables such as demographics, tumor characteristics, and treatment modalities were recorded. Results Out of 40 recruited patients, 39 were analyzed (excluding one deceased patient). Patient and treatment characteristics are described in Table 1. Patients were divided into three cohorts (Figure 1) for analysis: ALND with no axillary radiation (7.69%; n=33), Sentinel Lymph Node Biopsy (SLNB) with axillary radiation (7.69 %; n=3), and ALND with axillary radiation (85%; n=3). In the first cohort, LYMPHA or S-LYMPHA were associated with lower rates of lymphedema (19% vs, 50%) (p=0.116). No patients in the second or third cohort developed lymphedema. There were 4 out of 20 (20%) patients with lymphedema with scores above the median for FACT B4+ (p= 0.480) and a lower score (higher quality of life) correlated with lower L-Dex (p=0.76). The higher value in the physical domain of LyQLI showed higher L-Dex (p=0.826). There was a significant inter-domain correlation in LyQLI and LyQOL (p= < 0.001). Conclusion These results validate the use of PROs alongside objective measurements to assess BCRL. In addition, LYMPHA and S-LYMPHA significantly reduce lymphedema rates. Larger numbers will be necessary to reach statistical significance and to identify the best PRO. Figure 1 Division of patient population into three cohorts Table 1 Demographic and Treatment Summary Citation Format: Anshumi Desai, Orli-Friedman Eldar, Gili Halfteck, Mecker Moller, Susan Kesmodel, Dido Franceschi, Neha Goel, Jessica Crystal, Laura Huang, Jennifer Hu, Koru-Sengal Tulay, Wei Zhao, Alexis Narvaez-Rojas, Eli Avisar. Risk Assessment, Prevention and Early Detection of Breast Cancer Related Lymphedema – Objective Measurements and Patient Reported Outcomes [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-11-11.

Abstract PO3-12-03: SAFETY AND TOLERABILITY OF SHOCKWAVE THERAPY FOR TREATMENT OF BREAST CANCER-RELATED LYMPHEDEMA: A SYSTEMATIC REVIEW

Abstract Introduction: Breast cancer is currently the most common malignancy among women, after non-melanoma skin cancer. Upper limb lymphedema is the most feared complication of breast cancer treatment. Currently, the approach described in the literature as the most effective for the treatment of lymphedema is Complex Physical Therapy. In the search for more efficient therapeutic actions, Shockwave Therapy emerges as an alternative in the treatment of upper limb lymphedema secondary to breast cancer. Objective: to systematically review the available literature and verify the safety, tolerance and efficacy of using Shockwave Therapy (ESWT) in the treatment of upper limb lymphedema secondary to breast cancer. Methods: The following databases were used: PubMed; PEDro, The Cochrane Library, EMBASE, Web of science and Scopus and through manual search of articles. The PICO research method was adopted, and the descriptors adjusted according to the respective database. This study was registered in PROSPERO: CRD42020209588. Results: Combined searches, including reference lists, manual searches, and database searches, yielded 64 articles, of which 35 articles were duplicates, 23 studies were excluded by title, abstract, or full reading. Six full-text articles were selected. Of these, only 3 randomized clinical trials and 3 non-randomized clinical trials met all established inclusion criteria and were analyzed in this systematic review. Two more RCTs were added by manual search of references from other articles. None of the studies found had safety and tolerability as their primary objective, and one reported transient redness with the use of the device. Shockwave Therapy, combined with other resources, can significantly improve lymphedema volume and shoulder range of motion, but there is not enough evidence to support the use of ESWT as a substitute for complex physical therapy (CPT). Final considerations: There is evidence that it can improve ROM and upper limb volume when used in association with CPT, which is the gold standard for the treatment of lymphedema. Keywords: Lymphedema, Breast Cancer, Extracorporeal Shockwave Therapy. Citation Format: Patricia Lima Ventura, Cinira Haddad, Afonso Nazário, Gil Facina, Vanessa Sanvido, Amanda Estevao, Samantha Lopes de Almeida Rizzi. SAFETY AND TOLERABILITY OF SHOCKWAVE THERAPY FOR TREATMENT OF BREAST CANCER-RELATED LYMPHEDEMA: A SYSTEMATIC REVIEW [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-12-03.

Abstract PO4-12-03: PATIENT REPORTED OUTCOMES IN TERMS OF ARM AND SHOULDER FUNCTIONS AND QUALITY OF LIFE AND LYMPHEDEMA ARE AFFECTED BY THE STAGE, AND EXTENT OF AXILLARY SURGERY IN THE EARLY POSTOPERATIVE PERIOD OF PATIENTS WITH BREAST CANCER

Abstract This study evaluated whether lymphedema, patient-reported arm and shoulder morbidity and quality of life one year after axillary surgery are affected by stage or axillary surgery type between early stage patients and patients with locally advanced breast cancer who underwent surgery following neoadjuvant therapy. By determining the risk factors associated with severe lymphedema and deterioration of patient-reported outcomes, lymphedema could be prevented by early intervention to improve the prognosis of lymphedema and quality of life. Material and Methods: Between January 2021 and May 2022, a total of 253 breast cancer patients, 128 early stage and 125 locally advanced stage who underwent surgery including sentinel lymph node biopsy (SLNB) with/without axillary lymph node dissection (ALND) following neoadjuvant therapy were included in this study. The patients who underwent upfront surgery were defined as early-stage, and those who underwent surgery following neoadjuvant chemotherapy were considered as having locally advanced breast cancer (LABC) who have also participated in the prospective MF18-03 registry trial. Patients were prospectively evaluated by the SF-12 quality of life and QUICK-DASH hand, arm, and shoulder range of motion questionnaires and circumferential tape measurements of the arm width to evaluate the lymphedema before surgery, and 6 month- and 12-month assessments. The volume difference of 10% or more in the operated arm compared to the healthy arm was considered as lymphedema. Results: In the assessment of SF-12 quality of life questionnaire, there was a decrease in physical function scores at the 6th month despite recovery at the 12th month in both groups compared to the initial preoperative scores (p< 0,001). Moreover, patients with locally advanced breast cancer were found to have decreased SF-12 general health (p=0.024), vitality (p=0.034), and mental health scores in one year after surgery (p=0.004). Patients with mastectomy and locally advanced breast cancer were more likely to have a diminished arm and shoulder function as assessed with the QUICK-DASH questionnaire at the 6th and 12th months compared to those with breast conservation (6. month, p=0,009, 12. month, p=0.004), and early breast cancer, respectively (6. month, p=0.014, 12. month, p< 0.001) In the present cohort, lymphedema was detected in 19 (7.5%) patients including 16 cases with mild (11-20%), 2 cases with moderate (21-40%), and one case with severe (41-80%) lymphedema one year after surgery. Axillary dissection was found to be associated with an increased risk of lymphedema (SLNB, 5.0% vs ALND, 17.6%; p=0.005). Similarly, removal of >6 lymph nodes was also associated with an increased risk of lymphedema that was not statistically significant (<6 LNs, 6.4% vs >6LNs, 10.8%; p=0.277). Among those with LABC, however, patients with removal >6 LNs were more likely to have lymphedema (>6 LNs, 15.4% vs <6 LNs, 5.8%; p=0.096). Conclusion: These findings suggest that only an extensive axillary surgery was associated with an increased risk of breast cancer-related lymphedema. Patients with a mastectomy were more likely to have diminished arm and shoulder function compared to those with breast conservation. Furthermore, patients with locally advanced breast cancer were more likely to have a dispaired quality of life score and a limited arm and shoulder function regardless of the presence of lymphedema. Early prompt diagnosis and therapy of lymphedema can therefore potentially improve quality of life. Citation Format: Halime Gul Kilic, Selman Emiroglu, Ekin Ozgorgu, Mustafa Tukenmez, Atilla Bozdogan, Mahmut Muslumanoglu, Vahit Ozmen, Dilsad Sindel, Abdullah Igci, Aydan Oral, Neslihan Cabıoğlu. PATIENT REPORTED OUTCOMES IN TERMS OF ARM AND SHOULDER FUNCTIONS AND QUALITY OF LIFE AND LYMPHEDEMA ARE AFFECTED BY THE STAGE, AND EXTENT OF AXILLARY SURGERY IN THE EARLY POSTOPERATIVE PERIOD OF PATIENTS WITH BREAST CANCER [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-12-03.

Conservative medical intervention as a complement to CDT for BCRL therapy: a systematic review and meta-analysis of randomized controlled trials

BackgroundThe effect of first-line complex decongestive therapy (CDT) for breast cancer-related lymphedema (BCRL) depending on various factors forces patients to seek additional treatment. Therefore, this meta-analysis was conducted to evaluate the effect of different conservative medical interventions as a complement to CDT. This is the first meta-analysis that includes various kinds of conservative treatments as adjunctive therapy to get broader knowledge and improve practical application value, which can provide recommendations to further improve BCRL patients’ health status.MethodsRCTs published before 18 December 2023 from PubMed, Embase, Cochrane Library, and Web of Science databases were searched. RCTs that compared the effects of conservative medical intervention were included. A random-effects or fixed-effects model was used based on the heterogeneity findings. Study quality was evaluated using the Cochrane risk of bias tool.ResultsSixteen RCTs with 690 participants were included, comparing laser therapy, intermittent pneumatic compression (IPC), extracorporeal shock wave therapy (ESWT), electrotherapy, ultrasound, diet or diet in combination with synbiotic supplement, traditional Chinese medicine (TCM), continuous passive motion (CPM), and negative pressure massage treatment (NMPT). The results revealed that conservative medical intervention as complement to CDT had benefits in improving lymphedema in volume/circumference of the upper extremity [SMD = −0.30, 95% CI = (−0.45, −0.15), P < 0.05, I2 = 51%], visual analog score (VAS) for pain [SMD = −3.35, 95% CI (−5.37, −1.33), P < 0.05, I2 = 96%], quality of life [SMD = 0.44, 95% CI (0.19, 0.69), P < 0.05, I2 = 0], and DASH/QuickDASH [SMD = −0.42, 95% CI (−0.70, −0.14), P < 0.05, I2 = 10%] compared with the control group. Subgroup analysis revealed that laser therapy and electrotherapy are especially effective (P < 0.05).ConclusionCombining conservative medical interventions with CDT appears to have a positive effect on certain BCRL symptoms, especially laser therapy and electrotherapy. It showed a better effect on patients under 60 years old, and laser therapy of low to moderate intensity (5–24 mW, 1.5–2 J/cm2) and of moderate- to long-term duration (≥36–72 sessions) showed better effects.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=354824, identifier CRD42022354824.

Primary surgical prevention of lymphedema.

Lymphedema in the upper and lower extremities can lead to significant morbidity in patients, resulting in restricted joint movements, pain, discomfort, and reduced quality of life. While physiological lymphatic reconstructions such as lymphovenous anastomosis (LVA), lymphovenous implantation (LVI), and vascularized lymph node transfer (VLNT) have shown promise in improving patients' conditions, they only provide limited disease progression control or modest reversal. As lymphedema remains an incurable condition, the focus has shifted towards preventive measures in developed countries where most cases are iatrogenic due to cancer treatments. Breast cancer-related lymphedema (BCRL) has been a particular concern, prompting the implementation of preventive measures like axillary reverse mapping. Similarly, techniques with lymph node-preserving concepts have been employed to treat lower extremity lymphedema caused by gynecological cancers. Preventive lymphedema measures can be classified into primary, secondary, and tertiary prevention. In this comprehensive review, we will explore the principles and methodologies encompassing Lymphatic Microsurgical Preventive Healing Approach (LYMPHA), lymphovenous anastomosis (LVA), lymphaticolymphatic anastomosis (LLA), vascularized lymph node transfer (VLNT), and lymph-interpositional-flap transfer (LIFT). By evaluating the advantages and limitations of these techniques, we aim to equip surgeons with the necessary knowledge to effectively address patients at high risk of developing lymphedema.

Lymphovenous Bypass for Immediate Lymphatic Reconstruction in Breast Cancer Patients Undergoing Axillary Lymph Node Dissection: Minimizing the Risk of Upper Extremity Lymphedema.

Studies have shown a significant reduction in breast cancer-related lymphedema (BCRL) rates in patients undergoing complete axillary lymph node dissection (cALND) combined with immediate lymphatic reconstruction (ILR) using lymphovenous bypass (LVB).The purpose of this study was to determine if ILR with LVB at the time of cALND results in a decreased incidence of BCRL and its impact on patient quality of life (QOL). In this prospective cohort study, patients ≥ 18 years requiring cALND underwent ILR from 2019 to 2021. The primary outcome was bilateral upper limb volumes measured by Brørson's truncated cone formula and the Pero-System (3D Körper Scanner). The secondary outcome was QOL measured by the Lymphedema Quality of Life (LYMQOL) arm patient-reported outcome measurement. Forty-two patients consented to ILR using LVB. ILR was completed in 41 patients with a mean of 1.9 ± 0.9 lymphovenous anastomosis performed. Mean age of patients was 52.4 ± 10.5 years with a mean body mass index of 27.5 ± 4.9 kg/m2. All patients (n = 39, 100%) received adjuvant therapy after ILR. Mean follow-up was 15.2 ± 5.1 months. Five patients met criteria for lymphedema throughout the duration of the study (12.8%), with two patients having resolution, with an overall incidence of 7.7% by the end of the study period. Patients with lymphedema were found to have statistically significant lower total LYMQOL values at 18 months (8.44 ± 1.17 vs. 3.23 ± 0.56, p < 0.001). A mean increase of 0.73 ± 3.5 points was observed for overall QOL average for upper limb function at 18 months compared with 3 months (t = 0.823, p = 0.425). This study showed an incidence of 7.7% lymphedema development throughout the duration of study. We also showed that ILR has the potential to reduce the significant long-term adverse outcomes of lymphedema and improve QOL for patients undergoing cALND.

Improving quality of life after breast cancer: a comparison of two microsurgical treatment options for breast cancer-related lymphedema (BCRL)

PurposeVascularized lymph node transfer (VLNT) entails the autologous relocation of lymph nodes to a lymphedematous region of the body, whereas lymphaticovenous anastomosis (LVA) creates a direct bypass between the lymphatic and venous system. Both techniques are meant to lastingly bolster the local lymphatic drainage capacity. This study compared safety and effectiveness of VLNT and LVA in patients with chronic breast cancer related lymphedema (BCRL).MethodsA retrospective cohort study was conducted using data from our encrypted database composed of patients with chronic BCRL who were treated with either VLNT or LVA and had a minimum follow-up of two years. Patient-specific variables analyzed included pre- and postoperative arm circumferences, lymphedema stages and postoperative complications.ResultsA total of 105 patients met the inclusion criteria, of which 96 patients demonstrated a complete follow-up period of two years. The VLNT group displayed larger preoperative circumferential measurements, evident in both in the isolated examination of the affected arm, as well as when adjusted for the contralateral unaffected arm. Significant reduction in arm volume was achieved by both groups. However, VLNT demonstrated superior relative reduction rates than LVA, neutralizing any significant arm size disparities after 24 months. Surgery duration was slightly longer for VLNT than LVA. Postoperative complications, predominantly minor, were exclusively observed in the VLNT group.ConclusionsBoth VLNT and LVA offer significant improvement for patients suffering from chronic BCRL. VLNT shows an even greater potential for improvement in more severe cases of BCRL, but involves a higher risk for (mostly minor) complications.

The Impact of Sleep on the Lives of Women Who Have Breast Cancer-Related Lymphedema: A Qualitative Exploration.

Background: Breast cancer survivors (BCSs) have many lifelong symptoms of anxiety, depression, lymphedema, and fatigue that can be exacerbated by sleep disturbance. However, little is known about unique factors contributing to sleep disturbance among BCSs with lymphedema; this requires further investigation to offer appropriate support and treatment to these individuals. Therefore, the objective of this study was to capture perceptions and experiences of lymphedema and sleep among BCSs with lymphedema. Methods and Results: Qualitative description guided data collection and analysis as part of a mixed-methods investigation to characterize sleep disturbance among BCSs with and without lymphedema. The participants were interviewed one-on-one using a semistructured interview guide. Inductive content analysis was completed using an iterative coding approach, condensing, and categorizing to develop four themes. Seven BCSs with lymphedema participated. From their narratives, four themes were developed: (1) mind and body fatigue are exacerbated by sleep disturbance; (2) fatigue impacted fragile coping and support systems; (3) fatigue influenced self-identity and roles in society; and (4) self-management strategies were used for sleep health. Conclusion: The participants' perceptions of sleep disturbances' impact on their lives endorse further investigation into optimal interventions to improve sleep quality and modify these impactful findings to create a higher quality of life for survivorship.

Time trend of breast cancer-related lymphedema according to body mass index

PurposeTo clarify how body mass index (BMI) affects the development and temporal trend of breast cancer-related lymphedema (BCRL). MethodsThis is a prospective study in which patients with operable breast cancer were registered in a single institute between November 2009 and July 2010. The incidence of lymphedema at 1, 3, and 5 years after surgery was assessed according to BMI, and the trend of newly developed BCRL was examined. Obesity was defined as BMI ≥25 in accordance with the Japan Society for the Study of Obesity. ResultsA total of 368 patients were included in this study. The multivariate analysis of the whole population showed that high BMI, axillary dissection, and radiotherapy remained as risk factors for BCRL. Patients with high BMI showed a significantly higher incidence of new lymphedema than those with low BMI at 1 year (p < 00.001) regardless of axillary procedures (39.1 % vs 16.3 % for axillary dissection; 15.6 % vs 1.5 % for sentinel lymph node biopsy) but not at 3 and 5 years. Once BCRL developed, patients with high BMI showed slow recovery and 50.0 % of the patients retained edema at 5 years while patients with low BMI showed rapid recovery and 26.7 % retained after 3 years (p = 0.04). ConclusionThe preoperative BMI affected the incidence and temporal trend of BCRL regardless of axillary procedures or radiotherapy. Patients with high BMI should be given appropriate information about BCRL before surgery with careful follow-up for BCRL after treatment.

Psychometric Evaluation of the Bahasa Malaysia Version of the Lymphedema Functioning, Disability, and Health Questionnaire for Upper Limb Lymphedema in Patients with Breast Cancer-Related Lymphedema.

Background: Breast cancer-related lymphedema (BCRL) is the most prevalent comorbidity that occurs following breast cancer treatments and has negative impact on the patients' quality of life (QoL). The Lymphedema Functioning, Disability, and Health Questionnaire for Upper Limb Lymphedema (Lymph-ICF-UL) is a valid and reliable instrument in assessing the QoL of patients with BCRL. However, the Bahasa Malaysia (BM) version is not available yet. This study aimed to translate the Lymph-ICF-UL into BM and to evaluate its validity and reliability. Methods and Results: A forward-backward translation was performed based on Sousa's guideline, and then, the face, content, construct validity, internal consistency, and test-retest reliability were tested. Face validity was assessed by five patients, and content validity was evaluated by six experts. Then, construct validity and internal validity were assessed in 107 patients. Finally, test-retest reliability was analyzed in 21 patients. Two items were eliminated following suggestions from the patients and experts. All patients found the scoring system and items clear and relevant. The results showed sufficient content validity index and modified kappa statistics value. Confirmatory factor analysis showed acceptable fit indices. Cronbach's alpha values ranged from 0.67 to 0.95, intraclass correlation coefficient ranged from 0.88 to 0.99, standard error measurement was 2.29-6.15, and the Bland-Altman plot showed an agreement between two test occasions. Conclusion: These results suggested that the Lymph-ICF-UL BM has good validity and reliability in evaluating the QoL of patients with BCRL in Malaysia.

Two birds one stone: lymphatic and breast reconstruction with autologous tissue

Patients with breast cancer-related lymphedema (BCRL) commonly present with both debilitating upper extremity symptoms and the need for breast reconstruction. By combining autologous flaps with physiologic lymphatic surgery, postmastectomy patients with BCRL can obtain aesthetic breast reconstruction and lymphedema management in a single operation. Lymph node transfer to an area of lymphatic obstruction creates a healthy lymphatic bridge and restores physiologic flow. Early success and improved understanding of vascularized lymph node transfer (VLNT) physiology have led to the rapid development of numerous flap options and modalities. Several studies have shown the efficacy of combining autologous breast reconstruction with VLNT. Chimeric flaps using inguinal nodes, lateral thoracic nodes, or omentum aim to construct an aesthetic breast and improve lymphatic function. In this article, we will detail the surgical options that accomplish autologous breast reconstruction and restore the lymphatic network in a single operation.

Comparison of Volume Measurements and Bioimpedance Spectroscopy Using A Stand-on Device for Assessment of Unilateral Breast Cancer-Related Lymphedema.

Breast cancer related lymphedema (BCRL) may be assessed through objective measurement of limb swelling with common techniques including volumetric measurement using a tape measure or perometry, and measurement of extracellular water using bioimpedance spectroscopy (BIS). This study aimed to evaluate the performance of a stand-on BIS device for detection of BCRL, introduce a novel graphical method to compare volumetric and BIS methods alongside traditional specificity and sensitivity analysis, and determine and compare BIS thresholds with those published previously. Female participants with indocyanine green lymphography confirmed unilateral arm lymphedema (n = 197) and healthy controls (n = 267) were assessed using a cross-sectional study design. BIS and volumetric measures were obtained in a single session. The BIS lymphedema index (L-Dex) method had a significantly higher sensitivity than the excess volume approach (area under the curve = 0.832 vs. 0.649, p = 0.0001). A threshold of L-Dex 6.5 had a higher true positive rate (70.6%) than L-Dex 10 (68.5%) although false positive rate increased from 0.4% to 2.6%. A threshold of 5% excess volume improved the true positive rate (68.5%) compared with 10% excess volume (49.7%) however the false positive rate increased to an unacceptable 47%. The L-Dex ranges in this study were not significantly different from previously published ranges. BIS was superior for identifying BCRL compared with volume measurements, reaffirming the value of this technique. However, it is recommended that BIS be used in conjunction with comprehensive evaluation of symptoms and clinical presentation. The proposed graphical method provides a simple and easily interpretable approach to compare and define concordance between the two commonly used methods for BCRL assessment namely limb volume and BIS L-Dex indices. The existing BIS (L-Dex) thresholds for presence of BCRL were also validated.

Immediate Lymphatic Reconstruction: Lessons Learned Over Eight Years

Immediate lymphatic reconstruction (ILR) is recognized as a surgical approach to reduce the risk of developing secondary lymphedema and evidence demonstrating the efficacy of ILR is favorable. Our Lymphatic Center has become a centralized location offering ILR for the risk-reduction of breast cancer related lymphedema (BCRL) in New England. Over the course of our experience, we have made several modifications and adapted our approach to enhance the operative success of this procedure. These include advancements in our use of ICG imaging to identify baseline lymphatic anatomical variation, the utilization of fluorescein isothiocyanate for lymphatic vessel visualization, application of the lymphosome concept to guide arm injection sites, verification of anastomotic patency (using ICG), localization of reconstruction to guide radiation therapy, incorporation of intraoperative tools to facilitate better anatomic visualization of the axilla, and the addition of a lower extremity vein graft for mitigation of venous-related complications. Collecting information from each surgery in a standardized manner, including intraoperative lymphatic channel measurements and deployment of clips for possible future radiation exposure, enables future studies of ILR patient outcomes. In this contribution, we aim to share our institutional modifications with the surgical community to facilitate further adoption, conversation, and advancement of ILR for the risk-reduction of BCRL.

Prevention, Surveillance, and Treatment of Breast Cancer-Related Lymphedema: The Role of the Advanced Practice Provider.

Breast cancer-related lymphedema is a lifelong disease associated with decreased quality of life and increased healthcare costs. Evidence supports early detection and prompt treatment through prospective surveillance models.

Effect of &lt;italic&gt;Hwanggigyejiomul-tang&lt;/italic&gt; on Postoperative Breast Cancer-related Lymphedema (BCRL): A Systematic Review and Meta-analysis

Objectives: This study assessed the effectiveness of &lt;i&gt;Hwanggigyejiomul-tang&lt;/i&gt; for postoperative breast cancer-related lymphedema (BCRL) by a systematic review and meta-analysis of randomized controlled trials (RCTs).Methods: A search was conducted using keywords such as “breast cancer”, “lymphedema”, “edema”, “Huangqi Guizhi Wuwu decoction”, “Huangqi Guizhi Wuwu tang”, and “Hwanggigyejiomul tang” in 10 databases (PubMed, Cochrane, ScienceDirect, CNKI, CiNii, RISS, KISS, ScienceON, OASIS, DBpia) on February 11, 2024. There were no limits on the publication period and language, and the quality of the studies was evaluated using Cochrane’s risk of bias tool. A meta-analysis was performed based on the outcome measurements, such as total effective rate (TER), increase in shoulder joint mobility (flexion, extension, abduction, adduction), Fugl-Meyer assessment (FMA), and visual analog scale (VAS) using Review Manager Web.Results: Eleven RCTs were selected. The treatment group (&lt;i&gt;Hwanggigyejiomul-tang-gagambang&lt;/i&gt; or &lt;i&gt;hapbang&lt;/i&gt; with control group intervention) showed a more statistically significant effect compared with the control group (physical therapy or western medicine) in TER (upper limb circumference change), TER (upper limb edema grade change), increase in flexion angle, increase in extension angle, increase in adduction angle, FMA, and VAS.Conclusions: &lt;i&gt;Hwanggigyejiomul-tang&lt;/i&gt; is effective in treating postoperative BCRL. However, because of the low quality of the included studies, more clinical studies are required to increase the possibility of clinical use.

The Effect of Exercise on Reducing Lymphedema Severity in Breast Cancer Survivors.

Exercise has been repeatedly shown to be safe and beneficial for cancer survivors. However, there is no normative guideline for exercise prescription, and it is still under exploration. Therefore, this literature review aims to provide some advice for the formulation of exercise prescriptions for patients with breast cancer-related lymphedema (BCRL) from the perspective of reducing lymphedema severity. A review of relevant studies published before November 2023 was conducted using three scientific databases: PubMed, Embase, and Scopus. A total of 2696 articles were found. Eventually, 13 studies fulfilled the inclusion criteria and were included in this literature review. We concluded that daily, or nearly daily, exercise at home can be recommended. Moreover, reduced lymphedema severity may not be maintained after ceasing the exercise program, so exercise should be a lifelong practice.

Progression of fluid infiltration on non-contrast magnetic resonance imaging in breast cancer-related lymphedema: A comparative analysis with indocyanine green lymphography

BackgroundNon-contrast magnetic resonance imaging (NMRI) has been reported as valuable for the assessment of lymphedema. However, the correlation between NMRI findings and indocyanine green lymphography (ICG-L) findings remains elusive. MethodsThis single-center retrospective study included 26 patients diagnosed with breast cancer-related lymphedema. We examined the prevalence of fluid infiltration in eight regions of the upper extremity, the type of fluid distribution, and the dominant segment of edema on NMRI in comparison to the ICG-L stage. Statistical analysis was performed using the Cochran–Armitage trend test, Spearman’s rank correlation test, and Fisher’s exact test. ResultsThe regional fluid infiltration significantly increased with the progression of the ICG-L stage (hand, forearm, elbow, and upper arm: p = 0.003, <0.001, <0.001, and <0.001, respectively). The fluid distribution significantly advanced with the progression of the ICG-L stage as follows (rs = 0.80; p < 0.001): no edema in ICG-L stage 0, edema in either the hand or elbow in ICG-L stage I, edemas in both the elbow and hand in ICG-L stage II, three segmental edemas centered on the forearm or elbow in ICG-L stage III, and edema encompassing the entire upper limb in ICG-L stage IV-V. Additionally, the dominant segment of edema tended to shift from the hand to the elbow and further to the forearm as the ICG-L stage progressed (p < 0.001). ConclusionsFluid infiltration observed on NMRI exhibited distinct patterns with the progression of the ICG-L stage. We believe that anatomical information regarding fluid distribution would potentially contribute to optimizing surgical efficacy.