Limb Lymphedema Research Articles

The effects of lumbar sympathetic ganglion block therapy on secondary lower limb lymphedema among patients with gynecologic cancer surgery

The effects of lumbar sympathetic ganglion block therapy on secondary lower limb lymphedema among patients with gynecologic cancer surgery

Effect of scapular and shoulder strengthening exercises on prevention of upper limb lymphedema – a pilot study

Background. The most frequent type of cancer among women is breast cancer. According to the report published by Indian Council for Medical Research (ICMR, 2019), there are 1.5 lakh new instances of breast cancer nationwide and around 70,000 people in India die from breast cancer each year. Secondary lymphedema (SL) following breast cancer surgery can occur due to the removal of lymph nodes during breast cancer surgery. Objective. This pilot study was done with the objectives to improve the strength of scapular and shoulder muscles, increase the shoulder range of motion, prevent the development of upper limb lymphedema, to reduce shoulder pain and disability and to improve the quality of life among women who underwent breast cancer surgery. Methodology. Ten patients with a mean age of 49.9 ± 8.6 and mean Body mass index (BMI) of 28.4 ± 3.9 were included according to the inclusion and exclusion criteria. They were randomized into interventional group (Group A n = 5) and conventional group (Group B n = 5). The interventional group performed the routine exercises prescribed along with the scapular and shoulder muscle strengthening exercises, while the conventional group performed only the routine exercises for 12 weeks. Result. The mean change score values of the outcome variables of both the groups were analyzed using Independent ‘t’ test. Discussion. Arm circumference measurement, shoulder pain, disability and quality of life measures showed significant difference between groups at p < 0.05. Shoulder range of motion, muscle strength and arm volumetry did not show much difference between groups indicating the need for long term continuation of the exercises to produce improvement in those parameters. Conclusion. Long term effect of strengthening exercises will have an effect on improvement of shoulder range of motion, arm volume and muscle strength among the women following breast cancer surgery. Strengthening exercises should be recommended as a part of breast cancer rehabilitation protocol to prevent secondary lymphedema and other postsurgical complications.

Reliability, concurrent validity and clinical feasibility of measurement methods determining local tissue water in patients with lower limb lymphedema and healthy controls

Purpose To investigate reliability, concurrent validity and clinical feasibility of local tissue water measurements in patients with lower limb lymphedema and healthy controls. Methods In this cross-sectional study the Moisture Meter D Compact device® (MMDC) measurement and “pitting test” were performed three times by two assessors to test intra- and inter-rater reliability in 47 patients and 30 healthy controls. To investigate the between-session reliability, 29 patients and 21 healthy controls were reassessed two weeks later. Time efficiency and practical limitations were evaluated. The concurrent validity was investigated between the two tests. Clinical trial registration number: NCT:05269264. Results Of the MMDC values, 58% showed strong to very strong intra-rater reliability, 32% showed strong to very strong inter-rater reliability and 36% had strong to very strong between-session reliability. Absolute values had generally a higher reliability than inter-limb or leg-to-arm ratio values. The pitting test had nil to perfect agreement between assessments (Cohen’s kappa = −0.03–1.00) with fewer practical limitations and shorter performance time than the MMDC. Between both tests nil to a moderate relationship was found (Kendall’s tau c = 0.00–0.60). Conclusion The MMDC and pitting test are reliable and feasible measurements to assess local tissue water depending on the location, but should not be used interchangeably.

Nutritional assessment of Chinese gynecologic cancer survivors with post-surgical lower limb lymphedema: a cross-sectional study

ObjectiveThis study aims to evaluate the nutritional status of Chinese gynecologic cancer survivors with post-surgical lower limb lymphedema (LLL) by analyzing serum albumin levels and the prognostic nutritional index (PNI).MethodsA retrospective cross-sectional study was conducted at two Chinese medical centers. The cohort comprised 155 gynecologic cancer survivors who developed symptomatic unilateral LLL post-surgery, during the period from September 2021 to June 2024. Nutritional status was assessed by measuring serum albumin and PNI. Statistical analysis was performed using univariate and multivariate logistic regression models to identify factors associated with low serum albumin and PNI.ResultsThe mean age of the cohort was 55.47 ± 10.56 years, and the median total survival time was 72.0 months (36.5, 111.5 months). The prevalence of low serum albumin (< 40 g/L) was 40.0%, and low PNI (< 45) was 80.6%. Significant associations were found between low hemoglobin levels and both low serum albumin (OR = 1.05, 95% CI: 1.02–1.08, p < 0.001) and low PNI (OR = 1.09, 95% CI: 1.04–1.13, p < 0.001). Advanced International Society of Lymphology stage 3 was also associated with low albumin (OR = 0.18, 95% CI: 0.03–0.99, p < 0.05).ConclusionThe study highlights a significant prevalence of high risk of malnutrition among Chinese gynecologic cancer survivors with LLL, underscoring the need for regular nutritional assessments and interventions.

Chylous Reflux in Pediatric Primary Lymphedema of the Lower Limbs and Genitalia: A Retrospective Study of 167 Patients.

Background: Chylous reflux (CR) in primary lymphedema (PL) of the lower extremities is rare and requires particular diagnostic procedures. This study aimed to determine clinical and lymphoscintigraphic traits for efficient screening. Methods and Results: Pediatric patients with PL of lower extremities treated in our institution between January 2020 and December 2023 were reviewed. The medical history, lymphoscintigraphy, non-contrast MR lymphography, and direct lymphangiography were analyzed. Lymphoscintigraphic visual patterns were classified to detect CR. Patients with CR showed significantly higher proportions of childhood symptom onset (65.63% vs. 25.19%, p < 0.01), genital lymphedema (62.50% vs. 19.26%, p < 0.01), and proximal-to-distal swelling (31.25% vs. 8.89%, p < 0.01). Eight patients without skin lesions had milk discharge after acupuncture or skin breakdown. Pattern 4 shows diffused dermal backflow of the leg and an absence of superficial lymphatic drainage, or normal initial cephalad flow with subsequent reflux of tracer into the affected limb. CR showed significantly higher percentages of pattern 4 (87.50% vs. 12.59%, p < 0.01), normal/widened iliac lymphatics (78.13% vs. 11.11%, p < 0.01), and thigh/calf outlining (87.50% vs. 29.63%, p < 0.01). Genital swelling preceding limb swelling and genital radioactivity were more common in the CR group. Conclusions: CR tends to occur in childhood initially, begin centrally and progress distally, and involve genitals prior to lower extremities. Milk discharge after acupuncture or skin breakdown is important for screening CR without chylous vesicles. The patterns with typical "profiling of the leg" and normal or widened iliac lymphatic trunks strongly correlate with CR. Genital lymphedema with increased radioactivity indicates CR.

EDITORIAL: RETURNING THE CENTRAL LYMPHATIC SYSTEM TO THE CENTER OF LYMPHOLOGY

After the introduction of conventional oil contrast lymphography and the founding of the discipline of lymphology, great impetus was given to investigating central lymphatic system and its disorders along with lymphatic involvement and specifically lymphostasis in common diseases of major organs such as the liver (cirrhosis) and heart (heart failure). Gradually interest shifted to more peripheral disorders such as limb lymphedema and its treatment by physical and surgical measures. At the same time, basic lymphology turned to the study of isolated ex vivo and in vitro, including lymphatic endothelial models and more recently, molecular lymphology focusing on lymphatic growth and modulating factors, genes and proteins underlying primary lymphedema, and more potential biomarkers of lymphatic disease have gained prominence. However, it has been advances in lymphatic imaging, namely lymphoscintigraphy with SPECT-CT high resolution 3-D pictures and magnetic resonance imaging (contrast and non-contrast) of the peripheral and particularly central lymphatic system by more invasive means combined with endovascular interventional techniques to treat complex and life-threatening lymphatic disorders that has returned the central lymphatic system to the center of lymphology, where the journey began.

Breast cancer-related upper limb lymphoedema: an overview

Melanie Thomas provides an update on management of lympoedema in those with breast cancer

The“Overlapping”Lymphaticovenous Anastomosis: an overlapped end-to-end anastomosis supermicrosurgical technique

ObjectiveLymphaticovenular anastomosis (LVA) is increasingly utilized in the treatment of lymphedema. This study aims to assess the efficacy and safety of the “Overlapping” LVA technique, which addresses the size mismatch between lymphatic and venous vessels in lymphedema treatment.MethodsBetween August 2022 and April 2023, seventeen patients diagnosed with lymphedema were enrolled in this study. The severity of lymphedema in these patients was classified according to the International Society of Lymphology (ISL) staging system.All patient underwent LVA procedures, anastomosis techniques including the Overlapping, end-to-end and octopus anastomosis. The techniques of anastomosis, anastomosis time, patency rate, and volume of limb lymphedema were evaluated.ResultsOur study enrolled 17 lymphedema patients who underwent the LVA procedure. All patients showed significant postoperative improvement in limb edema. The mean drainage volume was 472.29 ml. The Overlapping technique demonstrated a 100% success rate as assessed by clinical observation and intraoperative Indocyanine Green (ICG) lymphography. The average anastomosis time was 5.3 min, reducing operative time compared to traditional methods.ConclusionsThese findings suggest that the Overlapping technique could serve as a valuable addition to the current LVA technique. This Overlapping anastomosis technique provides a wide range of applications for lymphatic anastomosis treatment and prevention of lymphedema.

Case report: A Large Fibroepithelial Polyp of the Vulva

Fibroepithelial polyps are one of the most common benign masses of the vulva and are characterized by relatively small size, vague symptomatology, and morphological diversity. These lesions mainly affect women of reproductive age and are hormone dependent. They are usually found around the urogenital area. A biopsy and histological examination are necessary to exclude the possibility of malignant neoplasm. The pathophysiology of the disease appears to be associated with the coexistence of diabetes mellitus, chronic inflammation and chronic friction. Below we will describe the case of a 17-year-old Somali patient who had undergone female genital mutilation type IIb tyand who presented to the regular clinic with a reported unspecified vulvar mass with coexisting chronic lower limb lymphedema.

LEDoxy-SL: A Placebo-Controlled, Double-Blind, Randomized, 24-Month Trial of Six Weeks of Daily Doxycycline Plus Hygiene-Based Essential Care for Reducing Progression of Filarial Lymphedema in Sri Lanka.

Morbidity management of filarial lymphedema remains a challenge even during the post-lymphatic filariasis elimination era in Sri Lanka despite provision of the predominantly hygiene-based WHO Essential Package of Care. Because prior studies have suggested that 6 weeks of doxycycline may reduce progression of limb lymphedema, we conducted a randomized, placebo-controlled, superiority study to evaluate this possibility in Sri Lanka. Patients aged 14 to 65 years with lymphedema in one or both legs received either 200 mg of doxycycline daily for 6 weeks or matching placebo. The primary efficacy endpoint was improvement or lack of progression in lymphedema stage at 24 months postenrollment. Secondary endpoints included change in lymphedema stage at 12 and 24 months, frequency of acute adenolymphangitis episodes, and perceived disability measured by the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). Training and supplies for limb hygiene were provided throughout the study. Two hundred participants (100 in each arm) with lymphedema of Dreyer stages 1 to 3 were enrolled. By the end of the 2-year study, 29% of the doxycycline patients and 34% of those on placebo showed improvement (i.e., a decrease in lymphedema stage), whereas 11% and 15% of the two groups showed worsening of the lymphedema. Adenolymphangitis rates were comparable in the two groups (43 doxycycline and 38 placebo recipients), although attacks lasted slightly longer in placebo patients (6.5 days versus 5.2 days). In both groups, perceived disability improved initially, with partial rebound in the second year. Only 34 adverse events affecting 24 patients (11%) occurred during the 6-week treatment period. Although doxycycline did not significantly impact lymphedema progression in this study, the results clearly indicate that clinical and personal benefits can be obtained from intensive hygiene management alone.

Translation, Cross-Cultural Adaptation and Validation of the Lymphedema Quality of Life Questionnaire (LYMQOL) in German-Speaking Patients with Upper Limb Lymphedema.

Objectives: The LYMQOL is the most frequently translated, validated, objective tool for assessing Health-Related Quality of Life (HRQoL) in individuals with upper limb lymphedema (ULL). There have been adaptations and validations in a number of different countries. While a German version of LYMQOL Leg for lower limb lymphedema is available, a validated translation of LYMQOL Arm to German is lacking. We aimed to perform a cross-cultural adaption and translation according to ISPOR principles. Methods: Patients suffering from ULL from Germany, Austria, and Switzerland (n = 52) were questioned twice using the translated LYMQOL Arm, SF-36, and an evaluation questionnaire. The assessment of the content validity and face validity proved this version of LYMQOL Arm to be acceptable for interviewing German-speaking patients with ULL in Germany. Results: Comparison of LYMQOL Arm and SF-36 demonstrated good construct validity. Test-retest reliability was moderate to good (intraclass correlation coefficients 0.66-0.73). Cronbach's alpha values varied between 0.79 and 0.89 in both interviews, indicating good internal consistency. Factor analysis revealed a cumulative variance of 59.5% for the four domains of the questionnaire. Conclusion: There was no significant association between lymphedema stage and LYMQOL Arm score. This trial tested the appropriateness of the German version of the LYMQOL Arm for measuring HRQoL in German-speaking individuals with ULL.

Lymphatic Mapping with Multi-Lymphosome Indocyanine Green Lymphography in Legs with Lymphedema

AbstractIt is observed that the locations of the most functional lymphatic vessels in the lymphedematous limbs can differ significantly from those in healthy limbs. The aim of this study was to elucidate the lymphatic map of lymphedematous limbs. We retrospectively analyzed 59 patients (118 limbs) with lower limb lymphedema. Fifty-five were women and four were men. The mean age and duration of lymphedema was 62.4 and 7.7 years, respectively. For the lateral thigh lymphosome, we injected indocyanine green (ICG) at the lateral knee and measured the distance (Dt) between the anterior superior iliac spine (ASIS) and the point where the lymphatic vessels crossed the reference line (the line connecting the ASIS and the patellar center). For the lateral calf lymphosome, we injected ICG at the lateral ankle and measured the distance (Dc) between the inferior patellar border and the point where the lymphatic vessels crossed the reference line (the anterior border of the tibia). In the lateral thigh, the mean Dt was 30.4 ± 0.6 cm (range, 0–41 cm) and the distribution peaked at approximately 30 cm from the ASIS. In the calf, the mean Dc was 13.1 ± 0.9 cm (range, −11 to 32 cm). The distribution of lymphatic vessel locations was highly variable. We could establish the lymphatic map in the lymphedematous legs. The distribution of lymphatic vessels in the thigh and lower legs had one and two peaks, respectively.

Lymphomyokinetic exercises and activities for treatment of lower limb lymphedema: review

Lymphomyokinetic exercises and activities for treatment of lower limb lymphedema: review

ThP8.8 - Role of Lymphoscintigraphy in Lymphoedema

Abstract Aim Lymphoscinigraphy (LSG) is a gold standard of investigation in patients with Lymphoedema, though not all patients with Lymphoedema are offered LSG and some who are offered decline to have the test. The aim of the present study was to do a clinico-radiological correlation of Lymphoscintigraphic findings. Methods All patients who underwent Lymphoscinti scans at a tertiary vascular centre over a 3 year period were included in the study. The technique was standardised and involved injection of a radioactive tracer in the Ist web space of both feet and uptake of the tracer at the groin at 2 hours was determined. Uptake less than 8% at 2 hours was considered abnormal. Clinical findings were compared with scan findings. Results 207 patients underwent LSG scans for suspected lower limb lymphoedema. 53 (26%) scans were normal. Of those with abnormal scans, 24 had mild lymphatic dysfunction (uptake 5-8%); 57 (28%) had moderate lymphatic dysfunction (uptake 2-5%) and 73 (35%) had severe lymphatic dysfunction with an uptake of &amp;lt;2%. Male to female ratio was 1:3. Median age at presentation was 60 years (range 3-89). Median BMI was 37Kg/m2 (range 17-71). Clinical profile based on the worst leg having moderate to severe Lymphatic dysfunction on LSG showed a 78-93% match between the leg affected and the LSG findings. This dropped to 29% in those with mild dysfunction. Conclusion Lymphoscintigraphy can objectively confirm and grade lymphoedema. It can be used to guide patients and their carers in following preventative measures to prevent complications.

Development and Validation of Upper Limb Lymphedema in Patients After Breast Cancer Surgery Using a Practicable Machine Learning Model: A Retrospective Cohort Study.

Upper limb lymphedema is one of the most common adverse events related to surgery owing to the large gap between guideline implementation and the intended clinical outcomes. However, the monitoring of limb lymphedema remains challenging because of vague clinical presentations. This study aimed to develop and validate practical predictive models for upper limb lymphedema through machine learning. We retrospectively collected clinical data to develop models for early risk prediction of upper limb lymphedema based on a single-center electronic health record data from patients who underwent breast cancer surgery from June 2021 through June 2023. For prediction model building, 70% and 30% of the data were randomly split into training and testing sets, respectively. We then developed an upper limb lymphedema prediction model using machine learning algorithms, which included random forest model (RFM), generalized logistic regression model (GLRM), and artificial neural network model (ANNM). For evaluating the model's performance, we used the area under the receiver operating characteristic curve (AUROC), calibration curve to compare different models. The potential clinical usefulness of the best model at the best threshold was assessed through a net benefit approach using a decision curve analysis (DCA). Of the 3201 patients screened for eligibility, 3160 participants were recruited for the prediction model. Among these, Body Mass Index (BMI), hypertension, TNM, lesion site, level of lymph node dissection(LNMD), treatment, and nurse were independent risk factors for upper limb lymphedema and were listed as candidate variables of ML-based prediction models. The RFM algorithm, in combination with seven candidate variables, demonstrated the highest prediction efficiency in both the training and internal verification sets, with an area under the curve (AUC) of 0.894 and 0.889 and a 95% confidence interval (CI) of 0.839-0.949 and 0.834-0.944, respectively. The other two types of prediction models had prediction efficiencies between AUCs of 0.731 and 0.819 and 95% CIs of 0.674-0.789 and 0.762-0.876, respectively. The interpretable predictive model helps physicians more accurately predict the upper limb lymphedema risk in patients undergoing breast cancer surgery. Especially for the RFM, this newly established machine learning-based model has shown good predictive ability for distinguishing high risk of upper limb lymphedema, which could facilitate future clinical decisions, hospital management, and improve outcomes.

Analysis and relationship between the volume of upper limb lymphoedema and pressure pain threshold, neural range of motion, pain intensity, kinesiophobia, pain hypervigilance and catastrophizing in breast cancer survivors.

Lymphedema of the upper limbs and persistent pain are frequent sequelae after surgical treatment of breast cancer. The aim of this paper was to analyze the upper limb volume, pressure pain threshold, neural range of motion, pain intensity, kinesiophobia, pain hypervigilance and catastrophizing in patients with and without lymphoedema after breast cancer surgery. Secondly, we aimed to investigated the association between upper limb volume and these variables. Descriptive observational study. Faculty of Health Sciences of the University of Granada. Fifty-eight post-surgical breast cancer survivors, 29 with upper limb lymphoedema and 29 without lymphoedema. We measured upper limb volume (perimetric method). Also, pressure pain thresholds were assessed with a digital algometer, neural range of motion (neurodynamic test for radial, ulnar and median nerves), pain intensity (visual analogue scale), kinesiophobia, pain hypervigilance and catastrophizing (validated tests). To detect differences between the groups for the measurement variables we performed a t-test for independent samples analysis. A simple linear regression analysis adjusting for age and body mass index was performed to check the association among upper limb volume and pain variables in the group with lymphoedema. The analysis showed that lymphoedema group had lower pressure pain threshold bilaterally in the masseter (origin P≤0.036; insertion P≤0.046), temporalis (insertion P≤0.021), suboccipitalis (P≤0.036); second (P≤0.014), third (P≤0.001) and tenth rib (P≤0.001); affected side of the temporalis (origin P=0.025); temporomandibular joint (P=0.024); neural range of motion in the median nerve (P=0.047), ulnar (P=0.042) on the affected side and radial (P=0.039) on the unaffected side; and greater kinesiophobia (P=0.042). Linear regression analysis only showed a significant association between upper limb volume and neural range of motion in the radial nerve (P=0.020) in the lymphedema group. No significant associations were obtained for the rest of variables. These findings suggest that the presence of lymphoedema may contribute to an increased level of generalized mechanosensitivity and fear to movement in this population. Upper limb lymphedema can lead to heightened mechanosensitivity and movement-related fear in breast cancer survivors. Therefore, fast track rehabilitation approach should be focus in screening and rehabilitation methods for detection and control this sequalae.

Optimizing strategies for lymphaticovenular anastomosis in lower secondary extremity lymphedema

BackgroundLymphovenous anastomosis (LVA) has become an increasingly common treatment for patients with secondary extremity lymphedema. The objective of this study was to optimize strategies for lower secondary extremity lymphedema using LVA techniques, with the aim of enhancing patient outcomes. MethodsWe conducted a retrospective analysis of 121 patients who underwent LVA at Taizhou Hospital of Zhejiang Province from January 2020 to December 2023. Preoperative and postoperative assessments included intraoperative observations, functional parameters, and clinical outcomes. The efficacy of LVA was evaluated based on circumferential reduction, quality of life improvements (Lymphoedema Quality of Life Questionnaire), and postoperative complications. ResultsThis study enrolled 121 patients with lower secondary extremity lymphedema, with an average age of 58.19 years. The results revealed significant associations between incision depth, lymphatic vessel size, the number of LVAs performed, and the number of incisions per patient, all of which correlated with postoperative volume reduction. The resulted analysis that identified optimal incision depths of 10 to 15 mm, lymphatic vessel size of 0.4 to 0.6 mm, and a recommended number of 6 to 8 LVAs. After LVA, there was a marked improvement in patient quality of life, with particularly notable enhancements in functionality and appearance. ConclusionsThis study’s findings optimizing the strategy for LVA surgery recommend the depth of incision, the size of lymphatic vessels, and the number of anastomoses to improve the quality of life and limb volume in patients with secondary lymphedema of the lower limbs.

CN78 The effects of lumbar sympathetic ganglion block therapy on secondary lower limb lymphedema

CN78 The effects of lumbar sympathetic ganglion block therapy on secondary lower limb lymphedema

Efficacy of intermittent pneumatic compression on breast cancer-related upper limb lymphedema: a systematic review and meta-analysis in clinical studies.

Complete decongestive therapy (CDT) and intermittent pneumatic compression (IPC) are the most common combination of treatments in breast cancer-related upper limb lymphedema. The effects of IPC as an addition to CDT are inconsistent in different studies. This meta-analysis aimed to explore whether IPC could bring additional benefits to CDT. Literatures were retrieved from databases with full-text publications ranging from January 1995 to March 2024. Fixed-effect models were applied to subsequent analysis if no heterogeneity was detected by using the Inverse formula. Publication bias was assessed using the Begg's test and Eagger's test. Twelve studies were finally included for further analysis. Results showed that additional application of IPC to CDT could further improve lymphedema within 4 weeks after the treatment period [standard mean difference (SMD) =-0.2 mL, 95% confidence interval (CI): -0.33 to -0.07 mL]. However, this additional benefit was weakened within about 9.4±2.6 weeks' follow-up duration after ceasing physical therapy (SMD =-0.15 mL, 95% CI: -0.33 to 0.04 mL). Periodically continuous treatment should be suggested to maintain the effect of CDT + IPC to promote lymph drainage and lymphedema improvement. Nonetheless, the treatment involved in the studies ranged from 4 to 12 weeks, therefore potential bias might exist.

DIAGNOSTIC COMPARABILITY OF RATIO OF TISSUE DIELECTRIC CONSTANT (TDC) BETWEEN PATIENTS WITH LIPEDEMA AND THOSE WITH LOWER LIMB LYMPHEDEMA (LLL): A PROSPECTIVE OBSERVATIONAL STUDY

Lipedema is usually thought of as a disease of women. Potentially diagnostic comparative data is needed between patients with lipedema and those with lower limb lymphedema (LLL). Since there is no gold standard to diagnose lipedema, some promising modalities such as Tissue Dielectric Constant (TDC) need to be investigated among patients with lipedema and lymphedema. This study was completed with a total of 26 patients (14 lipedema, 12 LLL). Local tissue water was assessed with Moisture MeterD compact (DelfinTech, Kuopio, Finland) according to the TDC method at 300 MHz within a 2.5 mm tissue penetration depth via the following reference points: Thigh, calf (20 cm upper and lower point of knee level, respectively), and malleoli (5 cm upper point of medial malleolus). Patients with LLL showed significantly higher TDC values and interlimb TDC ratios in all affected points and unaffected malleolus points compared to patients with lipedema. No significant difference was achieved between genders with LLL in all reference points. The area under the curve (AUC) for thigh, calf, and malleolus reference points were found as 0.851 (95%CI .678-1.00), 0.801 (95%CI 0.612-0.989) and 0.786 (95%CI 0.596- 0.976), respectively. Patients with LLL showed significantly higher TDC values compared to patients with lipedema, these differences should be carefully interpreted in patients with bilateral LLL and those with lipo-lymphedema.