Extremity Lymphedema Research Articles

Postural stability, spinal alignment, mobility, and postural competency in women with unilateral lower extremity lymphedema after radical hysterectomy following gynecologic cancer: A case-control study

PurposeTo compare postural stability, spinal alignment, mobility, and postural competency in women with unilateral lower extremity lymphedema after radical hysterectomy following gynecologic cancer with a matched control group. MethodsTwenty-seven women with unilateral lower extremity lymphedema (lymphedema group, age: 54.14 ± 5.80 years) and 30 healthy women (control group, age: 51.90 ± 6.54 years) were included. The lymphedema severity was evaluated with circumferential measurements. Postural stability with the Biodex Balance System SD and the spinal alignment, mobility, and postural competency with the Spinal Mouse device were assessed. ResultsIn the lymphedema group, it was found that 3.7% of the women had mild lymphedema, 7.4% had moderate lymphedema, and 88.9% had severe lymphedema. Static eyes open (EO) (overall, medio-lateral and antero-posterior) and eyes closed (EC) (antero-posterior) stability scores and dynamic EO and EC stability scores (overall and antero-posterior) were detected to be higher in the lymphedema group than in the controls (p < 0.05). Spinal mobility and postural competency scores were lower in the lymphedema group than in the control group (p < 0.05). In other parameters, there were no significant differences between the groups (p > 0.05). ConclusionDecreased postural stability, spinal mobility, and postural competency were detected in women with unilateral lower extremity lymphedema; however, no difference was seen in spinal alignment. These changes should be taken into account in the assessment and the treatment of unilateral lower extremity lymphedema.

Clinical application of magnetic resonance lymphangiography in the vascularized omental lymph nodes transfer with or without lymphaticovenous anastomosis for cancer-related lower extremity lymphedema.

The recent increase in the number of patients with lower extremities lymphedema and the development of microsurgery techniques have led to a rise in lymphedema treatment. Vascularized omental lymph node transfer (VOLT), an emerging treatment modality for extremity lymphedema, has shown its unique advantages in reconstructing lymphatic circulation and absorbing exudated lymphatic fluid. Patients who underwent radical tumor resection with/without radiation therapy treatment often present with impairment or degeneration of the inguinal lymph nodes. For such cases, VOLT could provide adequate lymph nodes and tissue to absorb edema fluid in these areas. Therefore, we analyzed the operative outcomes of VOLT under the guidance of magnetic resonance lymphangiography (MRL) in this study, as this individualized and precise surgical procedure could benefit patients and improve their quality of life. From November 2021 to September 2022, a total of 14 patients' 19 legs with extremity lymphedema underwent a VOLT with or without lymphaticovenous anastomosis (LVA). Outcomes, including circumference reduction rates, preoperative and postoperative MRL results, and other complications, were analyzed. The mean follow-up period was 8.86±1.41 months (range, 7-11 months). The mean circumference reduction rates {circumference reduction rate (%) = [1 - (postoperative affected limb - healthy limb)/(preoperative affected limb - healthy limb)] × 100%} of different planes (i.e., ankle, 10 cm above the knee, 10 cm below the knee, 10 cm above the ankle, and 20 cm above the knee) were 15.64%±40.08%, 11.79%±30.69%, 20.25%±24.94%, 7.73%±30.05%, -1.517%±16.75%. Notably, one patient had multi-drug-resistant gram-negative infections, which resulted in the loss of three flaps. The postoperative MRL showed improved lymphatic drainage and lower extremity volume in the remaining 13 cases. The precision evaluation of inguinal lymph nodes and lower extremities lymphatic system through MRL using VOLT can provide surgeons with a comprehensive understanding and reliable evidence for the treatment of cancer-related lower extremity lymphedema.

Association of limb morphometric and biokinetic anatomical changes with quality of life in lymphedema patients undergoing physiotherapy: a systematic review

Introduction: Lymphedema is a common complication of patients receiving cancer treatment. It has serious effects on mobility, self-care, functionality and quality of life. The purpose of this review was to show the effect of lymphedema on the morphometric and biokinematic characteristics of the limb and the quality of life of the patients. Methods: A systematic review of the literature was performed using the PRISMA statement. The search included studies from online databases, PubMed, Scopus and Google Scholar, which were published from 2000 to 2022. Studies assessed outcome variables such as range of motion, strength, sensation, body composition, quality of life. The screening process resulted in a total of 23 studies that met the inclusion criteria. Results: Of the 23 studies that met the inclusion criteria, seventeen referred to upper extremity lymphoedema and six referred to lower extremity lymphoedema. There was a variety of methods for identifying lymphedema between studies. Studies have shown reduced grip strength, range of motion, sensory perception, changes in body composition have been observed with fat tissue being increased compared to muscle tissue. The majority of studies reported reduced patient quality of life. The areas most affected were body image, role, mental health and sociability. Conclusions: Findings indicate that lymphedema has a high incidence among people treated for cancer, and has a significant impact on patients functionality and quality of life.

Quality of life assessed by quality adjusted life year weights in endometrial carcinoma survivors: Association with self-reported lower extremity lymphedema (1165)

Quality of life assessed by quality adjusted life year weights in endometrial carcinoma survivors: Association with self-reported lower extremity lymphedema (1165)

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

The study involved 17 BCRL patients, 18 limbs. All patients had International Society of Lymphology stage-2 lymphedema, but they had no compression: six patients had difficulty by other diseases to undergo compression, and other 11 patients refused any compression usage because of the burden of the treatment itself. Three dynamic LVAs were performed in each patient. Patients' mean age was 60.4 ± 10.1, and mean body mass index was 24.0 ± 3.3. The mean follow-up period was 25.5 ± 9.2 months. The volume of the lymphedematous limb, according to the upper extremity lymphedema (UEL) index, was reduced in all 18 limbs postoperatively (postoperative UEL index 101.8 ± 9.4 versus preoperative UEL index 116.0 ± 20.1; P < 0.01). Twelve of the 18 limbs were cured without edema. Even without compression therapy, International Society of Lymphology stage-2 BCRL patients can be treated by the dynamic LVA method.

Quantitative evaluation of primary lower extremity lymphedema staging using MRI: a preliminary study.

The staging of primary lower extremity lymphedema (LEL) is difficult yet vital in clinical work, and magnetic resonance imaging (MRI) can be used for quantitative assessment of primary LEL due to its high resolution for soft tissues. In this study, we evaluated the value of MRI-based soft tissue area measurements for staging primary LEL. A total of 90 consecutive patients with clinically diagnosed primary lower limb lymphoedema from January 2017 to December 2019 in Beijing Shijitan Hospital were enrolled retrospectively. Short time inversion recovery (STIR) sequence was applied to measure the total, muscle, bone, and subcutaneous areas in the upper 1/3 level of the bilateral lower calf. The difference between the affected and unaffected calf regarding the subcutaneous area was obtained, and (subcutaneous area)/(bone area) and (subcutaneous area)/(muscle area) were calculated. According to the International Society of Lymphology (ISL) clinical staging standard established in 2020, all patients were divided into stages I, II, and III, accordingly. Statistical analysis was performed to determine the validity of MRI measurements in staging LEL. There were 33 patients classified as stage I clinically, 44 patients as stage II, and 13 patients as stage III. There were significant differences in total, subcutaneous, the difference in subcutaneous area of limbs, subcutaneous/bone (S/B), and subcutaneous/muscle (S/M) between stage I and II as well as between stage I and III (P<0.001), but not between stage II and III (P=0.706, 0.329, and 0.229, respectively). A positive correlation was detected between the clinical stage and difference in subcutaneous area of limbs (rho =0.752, P<0.001), S/B (rho =0.747, P<0.001), S/M (rho =0.709, P<0.001), and subcutaneous (rho =0.723, P<0.001). For staging primary LEL, receiver operating characteristic (ROC) curves indicated that the difference in subcutaneous area of limbs had the best discrimination ability among parameters [area under the ROC curve (AUC) =0.950; 95% confidence interval (CI): 0.875-0.987; sensitivity: 95.45%; specificity: 84.85%], followed by S/B (AUC =0.930; 95% CI: 0.848-0.975; sensitivity: 77.27%; specificity: 93.94%) and S/M (AUC =0.895; 95% CI: 0.804-0.953; sensitivity: 77.27%; specificity: 90.91%). The ROC curves indicated that subcutaneous area (AUC =0.927; 95% CI: 0.844-0.974; sensitivity: 84.09%, specificity: 90.91%) and total (AUC =0.852; 95% CI: 0.753-0.923; sensitivity: 70.45%; specificity: 90.91%) also had discrimination ability between stage I and II. The measurement of the soft tissue area of the calf may be used as an auxiliary method for staging primary LEL. For patients with unilateral primary LEL, the difference in subcutaneous area of limbs could be a specific indicator to distinguish clinical stage I from II.

Conservative treatment versus lymphaticovenular anastomosis for early-stage lower extremity lymphedema

ObjectiveSeveral options for the treatment of lower extremity lymphedema (LEL) can be broadly classified into conservative treatment, such as compression garments and decongestive lymphatic therapy, and surgical treatment, such as lymphaticovenular anastomosis (LVA). The purpose of our study was to clarify the superiority of these treatments by comparing the outcomes of LVA with those of conservative treatment for early-stage LEL. MethodsWe performed a single-center, retrospective cohort study. The patients with LEL who presented to our department between January 2015 and December 2022 were identified and classified into two groups: conservative treatment and surgical treatment. The LEL indexes, calculated from the four lower extremity circumferences and the body mass index, were compared at the 6-, 12-, and 24-month follow-up between the two groups. ResultsOf the 101 patients with LEL, 53 with 72 affected limbs (conservative treatment, 39 patients and 53 affected limbs; surgical treatment, 15 patients and 19 affected limbs) were included in the present analysis. The therapeutic effect for reducing edema, as determined by comparing the corrected LEL index at 12 months (103.7 ± 12.7 vs 91.9 ± 10.7; P = .005) and 24 months (103.1 ± 12.9 vs 83.8 ± 7.2; P < .001), was significantly higher in the surgical treatment group than that in the conservative treatment group. The conservative treatment group showed little change in the corrected LEL index at ≤24 months of follow-up (+3.1%; P = .299). In contrast, the surgical treatment group showed a significant reduction in edema at 24 months according to the corrected LEL index (−16.2%; P = .019). ConclusionsIn early-stage LEL, conservative treatment centered on compression therapy alone only maintained edema (ie, edema did not worsen or improve). In contrast, LVA with compression therapy reduced edema.

Coping Mechanisms for Lymphedema: An Analysis of Patient Experiences.

Background and objective Lymphedema is a condition caused by impaired lymphatic function. Acquired lymphedema is often due to neoplasia, infection, trauma, or radiation damage. Most patients rely on advice from fellow patients and personal research to manage their symptoms. We believe coping mechanisms for lymphedema can be more streamlined and made easily accessible if the most common effective strategies are determined and collected in a single repository for reference. To that end, we aimed to assess the experiences of lymphedema patients and the coping mechanisms they employed. Methods Feedback from lymphedema patients was obtained using a 19-item questionnaire-based survey distributed to multiple online lymphedema support groups. It focused on the type of lymphedema and its effect on the respondents and sought data to characterize coping mechanisms that individuals with lymphedema use and their effectiveness. Results The respondents (n=400) had a median age of 55 years (range: 18-83 years). The overall mean BMI was 35.8 kg/m2, with respondents with lower extremity (LE) lymphedema having a greater mean BMI (38.4 vs. 31.0, p<0.05). Most of the respondents were female (n=382, 95.5%). LElymphedema was more common (n=280, 70%) than the upper extremity (UE) variant (n=120, 30%). Within the LE group, 99 were unilateral (35.4%) and 181 were bilateral (64.6%). Moderate restriction was the most reported level with 44% in the unilateral group and 64% in the bilateral group. Stretching, low-impact exercise, manual lymphatic drainage (MLD), and compression bandages were the most commonly used coping methods and most of the respondentsrated them as somewhat effective. Of note, 30% of respondents in either group rated increased water intake as either slightly, moderately, or very helpful; 25% of respondents also rated decreased alcohol intake as very helpful. The use of a therapist and familyand doctor support was rated as extremely helpful. Within the UE group, 105 were unilateral (87.5%) and 15 were bilateral (12.5%). The most common cause of UE lymphedema was breast cancer-related (98/120, 81.7%) followed by melanoma treatment. Mild restriction was the most reported level (n=48, 45.7%). The UE group had similar results as the LE group in terms of coping mechanisms, dietary changes, and psychosocial support. Conclusion Based on the experiences of the lymphedema patients surveyed, the management of the condition is multifactorial and hence not compatible with a one-size-fits-all strategy. LE lymphedema was more common than the UE variant; but both groups reported engaging in stretching, low-impact exercise, manual lymphatic drainage, and compression bandages with similar rates of satisfaction reported in both groups. Dietary changes were not commonly employed. Therapy, doctor, and family support were the most commonly used support mechanisms, with high satisfaction among both groups. The overall coping mechanisms and their ratings in terms of efficacy between UE and LE groups were similar although the impact of quality of life was greater for bilateral conditions. We believe our findings represent the first steps to providing information potentially useful to aid future and current lymphedema patients in finding the coping methods that work best for them.

The Deciding Factors of Flow Direction in Lymphovenous Anastomosis for Extremity Lymphedema.

While using lymphovenous anastomosis (LVA) to treat extremity lymphedema, an antegrade lymphatic-to-venous flow is usually considered to indicate a functional and effective anastomosis. The authors analyzed the characteristics of lymphovenous anastomoses in patients with extremity lymphedema to look for the deciding factors of the flow direction. A total of 45 patients (15 arms and 42 legs) undergoing LVA for extremity lymphedema were reviewed. Only the anastomoses with intraoperatively confirmed patent flow or clear visualization of vessel lumens during anastomosis were included for analysis. Multivariate logistic regression was used to identify the contributing factors of intraoperative washout phenomenon or venous reflux. A total of 105 eligible LVAs were included for analysis. Anastomosis with a more sclerotic lymphatic duct is statistically significantly associated with more venous reflux (OR, 2.82; P = 0.003). Larger diameter difference between lymphatic duct and recipient vein (OR, 12.8; P = 0.02) and less sclerotic lymphatic duct (OR, 0.47; P = 0.03) are statistically significantly associated with more washout phenomena. The deciding factors of flow direction in LVA are difference of diameters between lymphatic duct and recipient vein, and the severity of lymphosclerosis. To obtain favorable antegrade lymph-to-vein flow, a less sclerotic lymphatic duct with larger diameter and a recipient vein with smaller diameter should be chosen for anastomosis. Risk, III.

Application of indocyanine green lymphography combined with methylene blue staining in lymphaticovenular anastomosis of lower limb vessels: A prospective study.

Methylene blue (MB) is a conventional lymphatic tracer. We evaluated the application of indocyanine green (ICG) lymphography combined with MB staining in lower limb lymphaticovenular anastomosis (LVA). A total of 49 patients with lower limb lymphedema were selected as the study subjects and divided into the research (n = 27) and control groups (n = 22). The patients were treated with LVA using ICG lymphography combined with MB staining and simple ICG lymphography as the positioning method, respectively. The number of lymphatic vessels anastomosed and the operating time were compared between the groups. Lower Extremity Lymphedema Index (LEL index) and Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL) were used as prognostic indices; 6months after LVA, both groups were evaluated for the symptomatic relief of lymphedema. The number of anastomotic lymphatic vessels in the study group was higher than that in the control group (p < .05), and their procedural time was shorter than that in the control group. The two groups had no significant difference in lymphatic anastomosis time (p > .05). The LEL index and Lymph-ICF-LL of the research and control groups at 6-month follow-up after LVA were lower than those before the operation (p < .05). The circumference of the affected limb is reduced after LVA in patients with lower extremity lymphedema with a favorable prognosis. ICG lymphography combined with MB staining has the advantages of real-time visualization and accurate localization.

Self-reported lower extremity lymphedema and quality of life after surgical staging of endometrial carcinoma: A population based cross-sectional study

ObjectivesSentinel lymph node biopsy (SLN) has replaced lymphadenectomy in staging of endometrial carcinoma. The aims of the study were to explore the prevalence of self-reported lymphedema (LEL), identify factors associated with LEL, compare quality of life (QoL) scores using thresholds of clinical importance, and assess correlation between different questionnaires. MethodsWomen who underwent staging for endometrial carcinoma from 2006 to 2021 were invited to complete the Lower Extremity Lymphedema Screening Questionnaire (LELSQ), EORTC QLQ-C30, QLQ-EN24 and EQ-5D-5L. ResultsOf 2156 invited survivors, 61% participated in the study, whereof 1127 were evaluable by LELSQ. The LEL prevalence was 51%, 36% and 40% after lymphadenectomy, SLN and hysterectomy, respectively (p < 0.001). Higher BMI, undergoing lymphadenectomy and receiving adjuvant chemotherapy were associated with LEL; odds ratios 1.07 (95% CI 1.05–1.09), 1.42 (95% CI 1.03–1.97) and 1.43 (95% CI 1.08–1.89) respectively. QoL was lower for women with LEL compared to those without. In women with musculoskeletal complaints the prevalence of LEL was 59%, 50% and 53% after lymphadenectomy, SLN and hysterectomy (p = 0.115), respectively, compared to 39%, 17% and 18% (p < 0.001) in women without musculoskeletal complaints. Spearman's correlation was moderate to strong between the questionnaires. ConclusionSLN implementation is not associated with increased LEL prevalence compared to hysterectomy alone, but is associated with a significantly lower prevalence compared to lymphadenectomy. LEL is associated with lower QoL. Our study demonstrates moderate to strong correlation between self-reported LEL and QoL scores. Available questionnaires may not distinguish between symptoms caused by LEL and musculoskeletal disease.

Evidence Summary of Stress Intervention in Patients with Gynecologic Malignant Tumor Related Lower Extremity Lymphedema

Evidence Summary of Stress Intervention in Patients with Gynecologic Malignant Tumor Related Lower Extremity Lymphedema

Pneumatic Compression-Assisted Lymphoscintigraphy for Quantitative Evaluation of Breast Cancer-Related Lymphedema.

Acquired lymphedema of upper extremity is a chronic pathologic status that frequently occurs after breast cancer treatment. Reliable and quantitative evaluation of lymphedema is crucial for successful management of patients. Although lymphoscintigraphy is the primary investigation for the confirmation and evaluation of lymphedema, the specific protocol of stress intervention is not well established. This study aims to introduce intermittent pneumatic compression (IPC) as a part of stress lymphoscintigraphy and compare the effectiveness of conventional stress lymphoscintigraphy (CSL) and pneumatic compression-assisted lymphoscintigraphy (PCAL). Our study was designed as a retrospective analysis of 85 breast cancer patients with lymphedema who underwent lymphoscintigraphy utilizing either IPC device or conventional stress maneuver and received complex decongestive therapy. The flow extent of the lymphatic fluid (FE) was evaluated using a 0- to 4-point scale based on lymphoscintigraphic images. The visualization of lymph nodes was also assessed. The clinical outcomes were evaluated by changes in side-to-side circumferential and volume differences of upper extremities and compared between groups. Of 85 patients, 47 underwent CSL, and 38 underwent PCAL. Participants with relatively preserved flow extent of the lymphatic fluid (FE 3) showed a significant difference in percentage reduction of volume (PRV) between CSL and PCAL groups ( P = 0.036). In the other groups, CSL and PCAL demonstrated comparable differences in PRV without statistical significance. Our study suggests that participants in the PCAL group with relatively preserved lymphatic flow extent (FE 3) had better PRV compared with those in the CSL group. The use of IPC devices in lymphoscintigraphy with the novel stress maneuver can help in the quantitative description of lymphedema status and the selection of an appropriate treatment method.

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

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

Efficacy of Lymphaticovenular Anastomosis for Secondary Upper Extremity Lymphedema: Treatment Strategies with Effects of Compression Therapy Discontinuation and Site-Specific Evaluation of the Upper Extremity.

Background: Lymphaticovenular anastomosis (LVA) has recently become a mainstream surgical treatment for lymphedema and is a useful treatment option in addition to conservative therapies such as compression therapy, exercise therapy, and lymphatic drainage. We performed LVA with the goal of stopping compression therapy and report the effect of LVA on secondary lymphedema of the upper extremities. Methods and Results: The participants were 20 patients with secondary lymphedema of the upper extremities categorized as stage 2 or 3 according to the International Society of Lymphology classification. We measured and compared the upper limb circumference at six locations before and 6 months after LVA. Significant decreases in circumference after surgery were observed at 8 cm proximal to the elbow, the elbow joint, 5 cm distal to the elbow, and the wrist joints, but not at 2 cm distal to the axilla or the dorsum of the hand. At more than 6 months postoperatively, eight patients who had been wearing compression gloves were no longer required to wear them, and three patients who had been wearing both sleeves and gloves were no longer required to wear them. Conclusions: LVA is effective in the treatment of secondary lymphedema of the upper extremities, particularly in improving elbow circumference, and is one of the treatments that contributes significantly to the improvement of quality of life. For severe cases with limited range of motion of the elbow joint, LVA should be performed first. Based on these results, we present an algorithm for upper extremity lymphedema treatment.

A Novel Handheld Spectroscopy Tool for Detection of Lymphedema

The abstract provides an overview of lymphedema, a chronic and progressive lymphatic disorder that affects millions of people globally. This condition is associated with high costs and comorbidity, with limited treatment options available. Phlebolymphedema, a common form of secondary lymphedema, is linked to the combined effects of lymphatic and chronic venous insufficiencies. Early intervention is crucial to managing the condition; however, early detection remains challenging due to the lack of reliable diagnostic tools. This case study evaluates the clinical utility of a portable tissue analytical tool in a subject with bilateral lower extremity lymphedema undergoing a 60-day self-management program. The study includes details of the subject's profile, the intervention, and the measurements taken with the novel tool.

First experience of lymphaticovenular anastomosis using BHC RobotiScope: A case report.

The RoboticScope (BHS Technologies GmbH, Innsbruck, Austria) is a robotic exoscope, which consists of a robotic arm that holds a 3-dimensional camera. It has an advantage that a surgeon can perform an operation comfortably with a favorable ergonomic position. Also, it allows the delivery of clear and high-quality visualization for surgeons. In this study, we would like to share our initial experience with this newly developed microscope technology in lymphaticovenular anastomosis (LVA). To the best of our knowledge, it is the first experience of LVA using this microscope in Asia. A 65-year-old woman presented with bilateral lower extremity lymphedema after a hysterectomy that was performed 25 years back. Despite complex decongestive physiotherapy, an edematous symptom in both legs worsened. In lymphoscintigraphy, a decreased visualization of main lymphatic flow in both the lower extremities was evident which was further suggestive of lymphatic obstruction. Although both sides showed edematous symptoms, we decided to proceed with the surgery on the left side first, because of the worsened condition. Four LVAs were performed at the dorsum of the foot (×2), ankle, and the superior edge of the knee using RoboticScope. At 6-months follow-up after operation, the postoperative circumference diameters were improved than preoperative in 10 cm above the knee (45 cm vs 49 cm), 10cm below the knee (37 cm vs 41 cm) and lateral malleolus (25 cm vs 28 cm). The lower extremity lymphedema index was also improved from 346.7 to 287.4 postoperatively. The RoboticScope provided a high-resolution image and a favorable ergonomic position during an operation. The results represent the possibility of the application of a robotic microscope in the field of microsurgery, and further studies are necessitated to confirm the efficacy of this system.

SP33. Optimizing Patient Selection for Lympha in Patients with Inflammatory Breast Cancer

PURPOSE: Patients with inflammatory breast cancer (IBC) are at high risk for lymphedema due to their need for axillary lymph node dissection (ALND) and high-dose regional nodal radiation. LYMPHA (Lymphatic Microsurgical Preventive Healing Approach) is increasingly offered for prevention of upper extremity lymphedema after breast cancer treatment. Prior studies focus on intraoperative and postoperative lymphedema risk factors, some of which are unknown preoperatively when the decision to perform LYMPHA is made. This study aimed to identify preoperative lymphedema risk factors in the high-risk IBC population. METHODS: Retrospective review of our institution’s IBC program database was conducted. All patients with IBC who underwent neoadjuvant chemotherapy (NAC) and modified radical mastectomy (MRM) with adjuvant radiation were reviewed. The primary outcome was self-reported lymphedema development. Secondary endpoints were time from IBC diagnosis, mastectomy, or radiation completion to lymphedema diagnosis. Multivariable logistic regression analysis was used to identify preoperative lymphedema risk factors, while controlling for number of lymph nodes removed during ALND, number of positive lymph nodes, presence of residual disease on final pathology, and need for adjuvant systemic therapy. Additionally, the subset of patients who underwent breast reconstruction was reviewed and descriptive statistics of reconstructive techniques performed. RESULTS: Of 356 patients (86% Stage 3, 14% Stage 4) who underwent NAC, MRM and radiation, complete data on risk factors were available for 134 (37.6%). Mean age at diagnosis was 51 years (range 22-89 years). Forty-seven percent of patients developed lymphedema during treatment and 87% had ≥5 lymph nodes removed. Four percent developed lymphedema preoperatively (mean 138 days, median 149 days after IBC diagnosis), 14.6% developed lymphedema after surgery and before radiation (mean 51 days, median 45 days postoperatively), and 81.7% developed lymphedema after radiation (mean 470 days, median 271 days after radiation). Obesity (BMI > 30) (OR 2.7, CI 1.2-6.4, p = 0.02) and non-white race (OR 4.5, CI 1.2-23, p = 0.04) were preoperative risk factors for lymphedema. Reconstruction data was available for 91.3% of patients (n=325). Of these, 78.5% (n=255) did not receive reconstruction. Among those who underwent reconstruction (n=70, 21.5%), most patients were younger than 50 years (n=41, 58.6%). Most who underwent reconstruction were white (n=63, 90.0% versus n=2, 2.86% black and n=5, 7.14% other). Ethnicity data was available for 48 patients (68.6%). The majority of patients were non-Hispanic (n=46, 95.83%). BMI data was available for 48 patients and the majority had BMI <30 (n=29, 60.42%). CONCLUSION: Patients with IBC are at high risk of lymphedema, with 47% of patients in our study developing self-reported lymphedema. While need for NAC, ALND, and PMRT are known risk factors, we identified obesity and non-white race as additional lymphedema risk factors in this population. Given this high prevalence, LYMPHA should be considered for all patients with IBC. Larger, prospective studies are needed to further evaluate potential racial disparities in lymphedema development.

SP45. Systemic Lymphatic Improvement after Liposuction for Primary Extremity Lymphedema

SP45. Systemic Lymphatic Improvement after Liposuction for Primary Extremity Lymphedema

Skin microbiome alterations in upper extremity secondary lymphedema.

Lymphedema is a chronic condition that commonly occur from lymphatic injury following surgical resection of solid malignancies. While many studies have centered on the molecular and immune pathways that perpetuate lymphatic dysfunction, the role of the skin microbiome in lymphedema development remains unclear. In this study, skin swabs collected from normal and lymphedema forearms of 30 patients with unilateral upper extremity lymphedema were analyzed by 16S ribosomal RNA sequencing. Statistical models for microbiome data were utilized to correlate clinical variables with microbial profiles. Overall, 872 bacterial taxa were identified. There were no significant differences in microbial alpha diversity of the colonizing bacteria between normal and lymphedema skin samples (p = 0.25). Notably, for patients without a history of infection, a one-fold change in relative limb volume was significantly associated with a 0.58-unit increase in Bray-Curtis microbial distance between paired limbs (95%CI = 0.11,1.05, p = 0.02). Additionally, several genera, including Propionibacterium and Streptococcus, demonstrated high variability between paired samples. In summary, we demonstrate high compositional heterogeneity in the skin microbiome in upper extremity secondary lymphedema, supporting future studies into the role of host-microbe interactions on lymphedema pathophysiology.