Lymphedema Patient Research Articles

Timing of Lymphedema After Treatment for Breast Cancer: When Are Patients Most At Risk?

The purpose of the study was to determine when the risk of lymphedema is highest after treatment of breast cancer and which factors influence the time course of lymphedema development. Between 2005 and 2017, 2171 women (with 2266 at-risk arms) who received surgery for unilateral or bilateral breast cancer at our institution were enrolled. Perometry was used to objectively assess limb volume preoperatively, and lymphedema was defined as a ≥10% relative arm-volume increase arising >3months postoperatively. Multivariable regression was used to uncover risk factors associated with lymphedema, the Cox proportional hazards model was used to calculate lymphedema incidence, and the semiannual hazard rate of lymphedema was calculated. With a median follow-up of 4years, the overall estimated 5-year cumulative incidence of lymphedema was 13.7%. Significant factors associated with lymphedema on multivariable analysis were high preoperative body mass index, axillary lymph node dissection (ALND), and regional lymph node radiation (RLNR). Patients receiving ALND with RLNR experienced the highest 5-year rate of lymphedema (31.2%), followed by those receiving ALND without RLNR (24.6%) and sentinel lymph node biopsy with RLNR (12.2%). Overall, the risk of lymphedema peaked between 12 and 30months postoperatively; however, the time course varied as a function of therapy received. Early-onset lymphedema (<12months postoperatively) was associated with ALND (HR [hazard ratio], 4.75; P<.0001) but not with RLNR (HR, 1.21; P=.55). In contrast, late-onset lymphedema (>12months postoperatively) was associated with RLNR (HR, 3.86; P=.0001) and, to a lesser extent, ALND (HR, 1.86; P=.029). The lymphedema risk peaked between 6 and 12months in the ALND-without-RLNR group, between 18 and 24months in the ALND-with-RLNR group, and between 36 and 48months in the group receiving sentinel lymph node biopsy with RLNR. The time course for lymphedema development depends on the breast cancer treatment received. ALND is associated with early-onset lymphedema, and RLNR is associated with late-onset lymphedema. These results can influence clinical practice to guide lymphedema surveillance strategies and patient education.

How Registry Data Will Change Our Approach to Lymphedema Research and Clinical Management

In 2018 the American Physical Therapy Association officially launched the Physical Therapy Outcomes Registry (PTOR). The purpose of the registry is to accumulate clinical data from therapists around the country in order to analyze aggregate information on patient populations. Such an approach can help our profession better understand how to optimize treatment outcomes and can enhance data-driven clinical decision making. Additionally, a recent collaborative effort between Stanford University and the Lymphatic Education & Research Network (LE&RN) has created The International Lymphatic Disease and Lymphedema Patient Registry and Biorepository, a patient registry that aims to collect information about individuals who are diagnosed with a lymphatic disease or lymphedema. While these efforts are both Registries of condition-specific data, they are different in how they collect data and produce information. Researchers and clinical providers should have an understanding of what registry data currently exists and what the opportunities are to support clinical lymphedema management and lymphedema-focused research efforts by leveraging registry data.

Efficient activation of the lymphangiogenic growth factor VEGF-C requires the C-terminal domain of VEGF-C and the N-terminal domain of CCBE1

The collagen- and calcium-binding EGF domains 1 (CCBE1) protein is necessary for lymphangiogenesis. Its C-terminal collagen-like domain was shown to be required for the activation of the major lymphangiogenic growth factor VEGF-C (Vascular Endothelial Growth Factor-C) along with the ADAMTS3 (A Disintegrin And Metalloproteinase with Thrombospondin Motifs-3) protease. However, it remained unclear how the N-terminal domain of CCBE1 contributed to lymphangiogenic signaling. Here, we show that efficient activation of VEGF-C requires its C-terminal domain both in vitro and in a transgenic mouse model. The N-terminal EGF-like domain of CCBE1 increased VEGFR-3 signaling by colocalizing pro-VEGF-C with its activating protease to the lymphatic endothelial cell surface. When the ADAMTS3 amounts were limited, proteolytic activation of pro-VEGF-C was supported by the N-terminal domain of CCBE1, but not by its C-terminal domain. A single amino acid substitution in ADAMTS3, identified from a lymphedema patient, was associated with abnormal CCBE1 localization. These results show that CCBE1 promotes VEGFR-3 signaling and lymphangiogenesis by different mechanisms, which are mediated independently by the two domains of CCBE1: by enhancing the cleavage activity of ADAMTS3 and by facilitating the colocalization of VEGF-C and ADAMTS3. These new insights should be valuable in developing new strategies to therapeutically target VEGF-C/VEGFR-3-induced lymphangiogenesis.

Greater Omental Lymph Node Flap for Upper Limb Lymphedema with Lymph Nodes–depleted Patient

The greater omentum is supplied by the right, middle, and left omental arteries, which arise from the right and left gastroepiploic arteries. All or part of the greater omentum can be harvested based on this blood supply for free tissue transfer. It has stimulated new interest in its use as the donor site in the treatment of lymphedema. For patients who have failed other management options or have limited peripheral lymph node donor sites, the greater omental lymph node flap may offer the best chance for lymphedema treatment. We report a 59-year-old woman with a history of left breast cancer who was treated with left modified radical mastectomy and axillary lymph node dissection and developed left upper extremity Grade IV lymphedema. She received vascularized groin lymph node transfer and lymphaticovenous anastomosis, but the result was not satisfactory. She also had nasopharyngeal cancer that was treated with radiotherapy to the head and neck, making use of the submental lymph nodes flap impossible. Due to a lack of other options of lymph node donor sites, the split greater omental lymph node flap (GOLF) was used. After surgery, it showed an arm circumference reduction of 42.9% above the elbow and 36.4% below the elbow at an 8-month follow-up. There was no intraabdominal complication. The split GOLF has shown good results in a peripheral lymph node-depleted lymphedema patient. Using a laparoscopic technique for flap harvest has less risk of donor site morbidity and hides scarring.

Review of Therapeutic Exercise for Upper Lymphedema Patients Following Mastectomy

PURPOSE: The purpose of this review was to summarize some of traditional and recent rehabilitation exercise program to provide basic data and effective treatment guidelines that are applicable to evidence-based clinical practice. METHODS: The abnormal accumulation of tissue proteins due to lymphedema causes the lack of muscle flexibility and weakness, which subsequently causes limitations in performing exercises. However, exercise therapy, which is recommended as a combination therapy, not only overlooks the accompaniment of upper-extremity exercise disorders by the nature of breast cancer, but also does not take into account the pain occurring during exercises. Thus, we reviewed previous studies as many as on therapeutic exercise in upper- limb lymphedema patient at MEDLINE, PubMed, KISS, and RISS. RESULTS: We introduced brief etiology on upper limb lymphedema following mastectomy in breast cancer with general symptoms and characteristics. We also summarized detail therapeutic exercise programs on the exercise intensity, frequency, and time to suggest effective treatment guidelines. CONCLUSIONS: The appropriate exercise rehabilitation programs are effective to recovery from upperlimb lymphedema, and beside it resulted in elevation of functional abilities.

Lipidomic Profiling of Adipose Tissue Reveals an Inflammatory Signature in Cancer-Related and Primary Lymphedema.

Cancer-related and primary lymphedema (LE) are associated with the production of adipose tissue (AT). Nothing is known, however, about the lipid-based molecules that comprise LE AT. We therefore analyzed lipid molecules in lipoaspirates and serum obtained from LE patients, and compared them to lipoaspirates from cosmetic surgery patients and healthy control cohort serum. LE patient serum analysis demonstrated that triglycerides, HDL- and LDL-cholesterol and lipid transport molecules remained within the normal range, with no alterations in individual fatty acids. The lipidomic analysis also identified 275 lipid-based molecules, including triacylglycerides, diacylglycerides, fatty acids and phospholipids in AT oil and fat. Although the majority of lipid molecules were present in a similar abundance in LE and non-LE samples, there were several small changes: increased C20:5-containing triacylglycerides, reduced C10:0 caprinic and C24:1 nervonic acids. LE AT oil also contained a signature of increased cyclopropane-type fatty acids and inflammatory mediators arachidonic acid and ceramides. Interestingly C20:5 and C22:6 omega-3-type lipids are increased in LE AT, correlating with LE years. Hence, LE AT has a normal lipid profile containing a signature of inflammation and omega-3-lipids. It remains unclear, however, whether these differences reflect a small-scale global metabolic disturbance or effects within localised inflammatory foci.

Experience of early digital-control pressure treatment on postoperative limb edema in breast cancer patients

Objective To investigate the clinical efficacy of early digital-control pressure treatment for upper limb lymphedema in post-operative breast cancer patients. Methods A total of 60 breast cancer patients selected for nursing interventions according to operation time sequence number by simple random sampling and were equally divided into control group (routine care) and experimental group (early digital-control pressure treatment, set pressure range according to the instrument manual settings and refering to patients′ feel ). We measured and recorded the operative side of arm circumference which was 10 cm above limb cubital fossa before and after treatment. The nursing intervention effects of upper limb lymphedema was compared after 15 days. Results 15 days after the surgery, the upper extremity lymphedema patient had 16 cases accounting for 53.3%, within which 11 cases (36.7%) had mild one, 3 cases (10%) as moderate one, and 2 cases (6.7%) severe one in the control group. However, there was just 4 cases mild edema without moderate and severe one in the experimental group. The difference was statistically significant in the comparing of upper extremity lymphedema rate (χ2=13.16, P<0.01). Conclusions Early application of digital-control pneumatic instrument for nursing intervention in post-operative breast cancer patients can significantly reduce the occurrence degree of limb lymphedema and reduce its incidence. Key words: Breast cancer; Lymphedema; Early digital pressure treatment

Vascularized Free Lymph Node Flap Transfer in Advanced Lymphedema Patient after Axillary Lymph Node Dissection

Lymphedema is a condition characterized by tissue swelling caused by localized fluid retention. Advanced lymphedema is characterized by irreversible skin fibrosis (stage IIIb) and nonpitting edema, with leather-like skin, skin crypts, and ulcers with or without involvement of the toes (stage IVa and IVb, respectively). Recently, surgical treatment of advanced lymphedema has been a challenging reconstructive modality. Microvascular techniques such as lymphaticovenous anastomosis and vascularized lymph node flap transfer are effective for early stage lymphedema. In this study, we performed a two-stage operation in an advanced lymphedema patient. First, a debulking procedure was performed using liposuction. A vascularized free lymph node flap transfer was then conducted 10 weeks after the first operation. In this case, good results were obtained, with reduced circumferences in various parts of the upper extremity noted immediately postoperation.

Lenfodem ve Kronik Staz Ulseri Olan Toksik Hepatitli Bir Olguda Tedavi Yaklasimi

Chronic lymphedema hold an important place among the reasons of leg ulcers other than venous disorders, and leg ulcers in patients with lymphedema are seen frequently . Primarily wound maintenance, pneumatic compression and vacuum assisted wound closure systems should be used in stasis ulcers developing due to lymphedema. When systematic antibiotic treatments are used irregularly and without function, it can harm the patient rather than benefit. In this article we present a chronic lymphedema patient in whom toxic hepatitis developed due to irregular antibiotic and analgesic usage in order to treat leg ulcers.

A case of effective wound care combined with complex physical therapy for a lymphedema patient

A case of effective wound care combined with complex physical therapy for a lymphedema patient

A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema.

The authors prospectively evaluated the efficacy of lymphovenous bypass in patients with lymphedema secondary to cancer treatment. The authors prospectively enrolled 100 consecutive patients with extremity lymphedema secondary to cancer treatment. Sixty-five patients underwent lymphovenous bypass with indocyanine green fluorescent lymphangiography. Evaluation included qualitative assessment and quantitative volumetric analysis before and 3, 6, and 12 months after bypass. Lymphovenous bypass was performed in 89 upper extremities and 11 lower extremities. For upper extremity lymphedemas, the mean preoperative volume differential was 32 percent. Symptom improvement was reported by 96 percent of patients and quantitative improvement was noted by 74 percent. The overall mean volume differential reduction was 33 percent at 3 months, 36 percent at 6 months, and 42 percent at 12 months after surgery. The mean volume differential reductions at 3, 6, and 12 months after lymphovenous bypass in patients with stage 1 or 2 lymphedema (58, 52, and 61 percent, respectively) were significantly larger than those in the patients with stage 3 or 4 lymphedema (12, 16, and 17 percent, respectively). Eleven bypasses were performed in seven patients with lower extremity lymphedema, with a mean preoperative volume differential of 38 percent. Only four (57 percent) of these patients reported symptom improvement; postoperative volume measurements were available for only two of these four. Lymphovenous bypass can be effective in reducing lymphedema severity, particularly in patients with early-stage upper extremity lymphedema. Indocyanine green lymphangiography accurately identified functional lymphatic vessels and may have a role in objectively assessing lymphedema severity and patient selection. Therapeutic, IV.

Modified lambda-shaped lymphaticovenular anastomosis with supermicrosurgical lymphoplasty technique for a cancer-related lymphedema patient

Supermicrosurgical lymphaticovenular anastomosis (LVA) has become a useful option for the treatment of compression-refractory lymphedema with its effectiveness and less invasiveness. It is important to make as many bypasses as possible for better treatment results of LVA operation. We report a secondary lymphedema case successfully treated using a modified lambda-shaped LVA. A 62-year-old female with secondary lower extremity lymphedema (LEL) refractory to conservative treatments underwent LVA operation. A modified lambda-shaped LVA was performed at the left groin. In modified lambda-shaped LVA, two lymphatic vessels were transected, and both ends of the proximal and distal sides were converged respectively for an end-to-side and end-to-end anastomoses to one vein. Using modified lambda-shaped LVA, four lymph flows of two lymphatic vessels could be bypassed into a vein. Six months after the LVA surgery, her left LEL index decreased from 261 to 247, indicating edematous volume reduction. Modified lambda-shaped LVA effectively bypasses all lymph flows from two lymphatic vessels, when only one large vein can be found in the surgical field.

Effect of Kinesiology Taping on Breast Cancer-Related Lymphedema: A Randomized Single-Blind Controlled Pilot Study

The aim of the study was to assess the efficacy of Kinesiology Taping (KT) for treating breast cancer-related lymphedema. Sixty-five women with unilateral stage II and III lymphedema were randomly grouped into the KT group (K-tapes, n = 20), the Quasi KT group (quasi K-tapes, n = 22), or the MCT group (multilayered compression therapy group, n = 23). Skin care, 45 min pneumatic compression therapy, 1 h manual lymphatic drainage, and application of K-tape/Quasi K-tapes/multilayered short-stretch bandages were given every treatment session, 3 times per week for 1 month. Patient evaluation items included limb size and percentage edema. Comparing the changes in K-tapes with quasi K-tapes changes, there were no significant differences (P > 0.05). The edema reduction of multilayered bandages was much better than in results observed in taping groups. The KT appeared to be ineffective at secondary lymphedema after breast cancer treatment. The single-blind, controlled pilot study results suggest that K-tape could not replace the bandage, and at this moment it must not be an alternative choice for the breast cancer-related lymphedema patient. The trial is registered with ACTRN12613001173785.

Trends in Risk Reduction Practices for the Prevention of Lymphedema in the First 12 Months after Breast Cancer Surgery

Lymphedema is a feared complication of breast cancer surgery. We evaluated the trends in lymphedema development, patient worry, and risk reduction behaviors. We prospectively enrolled 120 women undergoing sentinel node biopsy (SLNB) or axillary node dissection (ALND) for breast cancer and assessed lymphedema by upper extremity volume preoperatively and at 6 and 12 months postoperatively. We defined lymphedema as a >10% volume change from baseline relative to the contralateral upper extremity. Patients completed a validated instrument evaluating lymphedema worry and risk reducing behaviors. Associations were determined by Fisher's exact and signed rank tests. At 6 months, lymphedema was similar between ALND and SLNB patients (p = 0.22), but was higher in ALND women at 12 months (19% vs 3%, p = 0.005). A clear relationship exists between relative change in upper extremity volume at 6 and 12 months (Kendall tau coefficient 0.504, p < 0.001). Among the women with 0 to 9% volume change at 6 months, 22% had progressive swelling, and 18% resolved their volume changes at 12 months. Overall, 75% of ALND and 50% of SLNB patients had persistent worry about lymphedema at follow-up, and no difference existed in the number of risk reducing behaviors practiced among the 2 groups (p > 0.34). Upper extremity volumes fluctuate, and there is a period of latency before development of lymphedema. Despite the low risk of lymphedema after SLNB, most women worry about lymphedema and practice risk reducing behaviors. Additional study into early upper extremity volume changes is warranted to allay the fears of most women and better predict which women will progress to lymphedema.

Breast Cancer Survivors With Lymphedema

Breast cancer survivors with lymphedema experience physical, psychosocial, and quality-of-life difficulties. Cancer treatment-related lymphedema often is viewed as a disabling condition, and that assumption has fostered an environment in which oncology nurses are not actively involved in the care of patients with lymphedema. Little is known about how breast cancer survivors with lymphedema structure their daily lives. This article describes an effort to determine whether lymphedema truly is a disabling condition by collecting symptom data and self-generated narratives from breast cancer survivors with lymphedema regarding their eating habits, daily activities, substance use, and future plans. Although the sample experienced multiple symptoms, lymphedema duration and degree of extracellular arm fluid did not appear to influence those symptoms. In addition, participants led full, rich, busy lives. The findings do not support the notion that patients with lymphedema live as disabled people. A disability model may not be optimal to guide research design or patient care; rather, a symptom management model better explains the findings and implies that active involvement by nurses in lymphedema patient care and education is indicated.

Assessment of Configuration of Thoracic Duct Using Magnetic Resonance Thoracic Ductography in Idiopathic Lymphedema

The structure and the function of the peripheral lymph channels have been investigated, but the thoracic duct has not. This study used magnetic resonance thoracic ductography for 2 patients with idiopathic lymphedema to evaluate the configuration of the thoracic duct in these patients. Anomalies of the thoracic duct were detected in both cases. This result suggests that deformity of the thoracic duct is one of the causes of idiopathic lymphedema. Characterization of the etiology could lead to a breakthrough in resolving the occurrence of idiopathic lymphedema and developing a treatment procedure for it. In addition, visualization of the thoracic duct may assist in selecting the optimal therapy for each idiopathic lymphedema patient.

Quality of Life, Upper Extremity Function and the Effect of Lymphedema Treatment in Breast Cancer Related Lymphedema Patients

ObjectiveTo evaluate quality of life (QOL), upper extremity function and the effect of lymphedema treatment in patients with breast cancer related lymphedema.MethodThe basic data comprised medical records (detailing age, sex, dominant side, location of tumor, cancer stage, operation record, cancer treatment and limb circumferences) and questionnaires (lymphedema duration, satisfaction, self-massage). Further to this, we measured upper extremity function and QOL, administered the DASH (Disabilities of Arm Shoulder and Hand outcome measure) and used the EORTC (European Organization for Research and Treatment of Cancer)-QLQ-C30 and the EORTC-QLQ-Br23. Results of these were calculated as main outcome variables.ResultsThe questionnaire responses and arm circumferences of 59 patients with breast cancer related lymphedema were analyzed. In the DASH questionnaire, it was found that the older the lymphedema patient was, the lower their upper extremity function. On the EORTC-QLQ, patients with metastasis had significantly lower scores in physical functioning and role functioning. In terms of upper extremity circumference, there was a significant upper extremity size reduction after lymphedema treatment.ConclusionThere were several dissociations between some subscales of quality of life questionnaires and those of upper extremity functions. Upper extremity function was correlated with the age of breast cancer patients and QOL was influenced by M-stage. Lymphedema treatment was found to be effective in reducing edema in patients with breast cancer related lymphedema.

A randomized trial of exercise on well-being and function following breast cancer surgery: the RESTORE trial

This study aimed to determine the effect of a moderate, tailored exercise program on health-related quality of life, physical function, and arm volume in women receiving treatment for nonmetastatic breast cancer. Women who were within 4-12 weeks of surgery for stage I-III breast cancer were randomized to center-based exercise and lymphedema education intervention or patient education. Functional assessment of cancer therapy-breast cancer (FACT-B), 6-min walk, and arm volume were performed at 3-month intervals through 18 months. Repeated measures analysis of covariance was used to model the total meters walked over time, FACT-B scores, and arm volume. Models were adjusted for baseline measurement, baseline affected arm volume, number of nodes removed, age, self-reported symptoms, baseline SF-12 mental and physical component scores, visit, and treatment group. Of the recruited 104 women, 82 completed all 18 months. Mean age (range) was 53.6 (32-82) years; 88% were Caucasian; 45% were employed full time; 44% were overweight; and 28% obese. Approximately, 46% had breast-conserving surgery; 79% had axillary node dissection; 59% received chemotherapy; and 64% received radiation. The intervention resulted in an average increase of 34.3 ml (SD = 12.8) versus patient education (p = 0.01). Changes in FACT-B scores and arm volumes were not significantly different. With this early exercise intervention after breast cancer diagnosis, a significant improvement was achieved in physical function, with no decline in health-related quality of life or detrimental effect on arm volume. Starting a supervised exercise regimen that is tailored to an individual's strength and stamina within 3 months following breast cancer surgery appears safe and may hasten improvements in physical functioning.

A prospective cohort study defining utilities using time trade‐offs and the Euroqol‐5D to assess the impact of cancer‐related lymphedema

The devastating impact of lymphedema on cancer survivors' quality of life has prompted consideration of several changes in medical and surgical care. Unfortunately, our understanding of the benefits gained from these approaches relative to their cost remains limited. This study was designed to estimate utilities for lymphedema and characterize how utilities differ between subgroups defined by lymphedema etiology and distribution. A consecutive sample of 236 subjects with lymphedema seen at a lymphedema clinic completed both a time trade-off (TTO) exercise and the Euroqol 5D. Responses were adjusted in multivariate regression models for demographic factors, comorbidities, and lymphedema severity/location. Most participants (167 of 236, 71%) had lymphedema as a consequence of cancer treatment; 123 with breast cancer and upper extremity involvement. Mean TTO utility estimates were consistently higher than Euroqol 5D estimates. Unadjusted TTO (0.85; standard deviation [SD], 0.21) and Euroqol 5D (0.76; SD, 0.18) scores diminished with increasing lymphedema stage and patient body mass index (BMI). Adjusted utility scores were lowest in patients with cancer-related lower extremity lymphedema (TTO=0.82; SD, 0.04 and Euroqol 5D=0.80; SD, 0.03). Breast cancer patients also had lower adjusted Euroqol 5D scores (0.80; SD, 0.02). Lymphedema-associated utilities are in the range of 0.80. Lower utilities are observed for patients with higher lymphedema stages, elevated BMI, and cancer-related lymphedema. Greater expenditures for the prevention and treatment of cancer-related lymphedema are warranted.

Could Kinesio tape replace the bandage in decongestive lymphatic therapy for breast-cancer-related lymphedema? A pilot study

The purpose of this study is to compare the treatment and retention effects between standard decongestive lymphatic therapy (DLT) combined with pneumatic compression (PC) and modified DLT, in which the use of a short-stretch bandage is replaced with the use of Kinesio tape (K-tape) combined with PC. Forty-one patients with unilateral breast-cancer-related lymphedema for at least 3 months were randomly grouped into the DLT group (bandage group, N = 21) or the modified DLT group (K-tape group, N = 20). Skin care, 30-min manual lymphatic drainage, 1-h pneumatic compression therapy, application of a short-stretch bandage or K-tape for each group, and a 20-min physical therapy exercise were given during every treatment session. Patient evaluation items included physical therapy assessment, limb size, water composition of the upper extremity, lymphedema-related symptoms, quality of life, and patients' acceptance to the bandage or tape. There was no significant difference between groups in all outcome variables (P > 0.05) through the whole study period. Excess limb size (circumference and water displacement) and excess water composition were reduced significantly in the bandage group; excess circumference and excess water composition were reduced significantly in the tape group. The acceptance of K-tape was better than the bandage, and benefits included longer wearing time, less difficulty in usage, and increased comfort and convenience (P < 0.05). The study results suggest that K-tape could replace the bandage in DLT, and it could be an alternative choice for the breast-cancer-related lymphedema patient with poor short-stretch bandage compliance after 1-month intervention. If the intervention period was prolonged, we might get different conclusion. Moreover, these two treatment protocols are inefficient and cost time in application. More efficient treatment protocol is needed for clinical practice.