Lymphedema Status Research Articles

Lymphedema following breast cancer: The importance of surgical methods and obesity.

Breast cancer-related arm lymphedema is a serious complication that can adversely affect quality of life. Identifying risk factors that contribute to the development of lymphedema is vital for identifying avenues for prevention. The aim of this study was to examine the association between the development of arm lymphedema and both treatment and personal (e.g., obesity) risk factors. Women diagnosed with breast cancer in Iowa during 2004 and followed through 2010, who met eligibility criteria, were asked to complete a short computer assisted telephone interview about chronic conditions, arm activities, demographics, and lymphedema status. Lymphedema was characterized by a reported physician-diagnosis, a difference between arms in the circumference (> 2cm), or the presence of multiple self-reported arm symptoms (at least two of five major arm symptoms, and at least four total arm symptoms). Relative risks (RR) were estimated using logistic regression. Arm lymphedema was identified in 102 of 522 participants (19.5%). Participants treated by both axillary dissection and radiation therapy were more likely to have arm lymphedema than treated by either alone. Women with advanced cancer stage, positive nodes, and larger tumors along with a body mass index > 40 were also more likely to develop lymphedema. Arm activity level was not associated with lymphedema. Surgical methods, cancer characteristics and obesity were found to contribute to the development of arm lymphedema. Vigorous arm activity post-surgery was not found to increase the risk of arm lymphedema.

Guidelines for teaching yoga to women with breast cancer-related lymphoedema: an evidence-based approach.

Breast cancer-related lymphoedema (BCRL) is a chronic condition that requires lifelong management to prevent the condition worsening and to reduce the threat of infection. Women are affected in all domains of their life. As a holistic practice, yoga may be of benefit by reducing both the physical and psychosocial effects of lymphoedema. Women with BCRL are attending yoga classes in increasing numbers, so it is essential that yoga be based on principles that ensure lymphoedema is controlled and not exacerbated. Two Randomised Controlled Trials with a yoga intervention have had positive results after an 8-week intervention (n=28) and 6-months after a 4-week intervention (n=18). The first study had several significant results and women reported increased biopsychosocial improvements. Both studies showed trends to improved lymphoedema status. The yoga interventions compromised breathing, physical postures, meditation and relaxation practices based on Satyananda Yoga®, with modifications to promote lymphatic drainage and following principles of best current care for those with BCRL. Individual needs were considered. The yoga protocol that was used in the 8-week trial is presented. Our aim is to provide principles for yoga teachers/therapists working with this clientele that can be adapted to other yoga styles. Further, these principles may provide a basis for the development of yoga programs for people with secondary lymphoedema in other areas of their body as the population requiring cancer treatment continues to increase. Whilst the style of yoga presented here has had positive outcomes, further application and research is needed to fully demonstrate its effectiveness.

Segmental Bioimpedance Informs Diagnosis of Breast Cancer-Related Lymphedema.

Detection of lymphedema, particularly its mild stage, is clinically challenging. The aim of this study was to determine whether segmental bioimpedance spectroscopy (BIS) provided additional information to whole arm BIS in assessing women with or at risk of lymphedema following breast cancer. Participants (n = 66), aged 61.6 ± 10.5 years (mean ± standard deviation [SD]), were grouped according to lymphedema status: (1) at-risk (n = 24) had no indicators of lymphedema and (2) lymphedema (n = 42) were suspected to be developing lymphedema or had previously met lymphedema diagnostic criteria and undergone treatment. For each upper limb, impedance was measured for the whole arm, hand and four 10 cm segments of the arm, commencing at the ulnar styloid. Interlimb impedance ratios for corresponding locations were calculated and compared to previously determined, normatively based thresholds based on 2SD and 3SD above the mean. Segmental BIS classified 19% more women with lymphedema than 3SD whole arm thresholds and the same number as 2SD whole arm thresholds. Segmental BIS identified localized lymphedema and patterns in lymphedema distribution that were undetectable by whole arm BIS. Neither 3SD whole arm nor segmental BIS thresholds found lymphedema where it was not present; however, 2SD whole arm thresholds alone classified one woman in the at-risk group as having lymphedema. Segmental BIS classified as many or more cases of lymphedema than whole arm BIS thresholds without finding lymphedema where it was likely not present while also providing additional information regarding the distribution of lymphedema within the limb.

Guidelines for teaching yoga to women with breast cancer-related lymphoedema: an evidence-based approach

Breast cancer-related lymphoedema (BCRL) is a chronic condition that requires lifelong management to prevent the condition worsening and to reduce the threat of infection. Women are affected in all domains of their life. As a holistic practice, yoga may be of benefit by reducing both the physical and psychosocial effects of lymphoedema. Women with BCRL are attending yoga classes in increasing numbers, so it is essential that yoga be based on principles that ensure lymphoedema is controlled and not exacerbated. Two Randomised Controlled Trials with a yoga intervention have had positive results after an 8-week intervention (n=28) and 6-months after a 4-week intervention (n=18). The first study had several significant results and women reported increased biopsychosocial improvements. Both studies showed trends to improved lymphoedema status. The yoga interventions compromised breathing, physical postures, meditation and relaxation practices based on Satyananda Yoga®, with modifications to promote lymphatic drainage and following principles of best current care for those with BCRL. Individual needs were considered. The yoga protocol that was used in the 8-week trial is presented. Our aim is to provide principles for yoga teachers/therapists working with this clientele that can be adapted to other yoga styles. Further, these principles may provide a basis for the development of yoga programs for people with secondary lymphoedema in other areas of their body as the population requiring cancer treatment continues to increase. Whilst the style of yoga presented here has had positive outcomes, further application and research is needed to fully demonstrate its effectiveness.

Aquatic Therapy for People with Lymphedema: A Systematic Review and Meta-analysis.

Aquatic therapy has several proposed benefits for people with lymphedema. A systematic review of the evidence for aquatic therapy in lymphedema management has not been conducted. Systematic review and meta-analysis were conducted. Five electronic databases were searched to identify randomized controlled trials (RCTs) of people with lymphedema, which compared aquatic therapy with other lymphedema interventions. Qualitative analysis was undertaken where quantitative analysis was not possible. Study quality was assessed using physiotherapy evidence database (PEDro) scores. The strength of evidence was evaluated using the Grades of Recommendations Assessment, Development and Evaluation (GRADE) approach. Four RCTs of moderate quality (average PEDro score 6.5/10) were included in the review. Two studies provided results for inclusion in meta-analysis. There was moderate-level evidence of no significant short-term differences in lymphedema status (as measured by lymphedema relative volume) between patients who completed aqua lymphatic therapy (ALT) compared to land-based standard care (standardized mean difference [SMD]: 0.14; 95% confidence interval [CI]: -0.37 to 0.64, I2 = 0%, p = 0.59); and low-quality evidence of no significant difference between ALT and standard care for improving upper limb (UL) physical function (SMD -0.27, 95% CI: -0.78 to 0.23, I2 = 0%, p = 0.29). No adverse events reported. Current evidence indicates no significant benefit of ALT over standard land-based care for improving lymphedema status or physical function in people with UL lymphedema. Patient preference should guide the choice of care to facilitate adherence. Further research is required to strengthen the evidence from four studies in people with UL lymphedema, and to establish the efficacy of this intervention in people with lower limb lymphedema. Review registration: PROSPERO (CRD42015019900).

A Randomized Trial on the Effect of Exercise Mode on Breast Cancer-Related Lymphedema.

Breast cancer-related lymphedema is a common and debilitating side effect of cancer treatment. This randomized trial compared the effect of progressive resistance- or aerobic-based exercise on breast cancer-related lymphedema extent and severity, as well as participants' muscular strength and endurance, aerobic fitness, body composition, upper-body function, and quality of life. Women with a clinical diagnosis of stable unilateral, upper-limb lymphedema secondary to breast cancer were randomly allocated to a resistance-based (n = 21) or aerobic-based (n = 20) exercise group (12-wk intervention). Women were assessed preintervention, postintervention, and 12 wk postintervention, with generalized estimating equation models used to compare over time changes in each group's lymphedema (two-tailed P < 0.05). Lymphedema remained stable in both groups (as measured by bioimpedance spectroscopy and circumferences), with no significant differences between groups noted in lymphedema status. There was a significant (P < 0.01) time-group effect for upper-body strength (assessed using four to six repetition maximum bench press), with the resistance-based exercise group increasing strength by 4.2 kg (95% confidence interval [CI] = 3.2-5.2) postintervention compared with 1.2 kg (95% CI = -0.1 to 2.5) in the aerobic-based exercise group. Although not supported statistically, the aerobic-based exercise group reported a clinically relevant decline in number of symptoms postintervention (-1.5, 95% CI = -2.6 to -0.3), and women in both exercise groups experienced clinically meaningful improvements in lower-body endurance, aerobic fitness, and quality of life by 12-wk follow-up. Participating in resistance- or aerobic-based exercise did not change lymphedema status but led to clinically relevant improvements in function and quality of life, with findings suggesting that neither mode is superior with respect to lymphedema effect. As such, personal preferences, survivorship concerns, and functional needs are important and relevant considerations when prescribing exercise mode to those with secondary lymphedema.

Breast Cancer-Related Lymphedema and Resistance Exercise: A Systematic Review.

Nelson, NL. Breast cancer-related lymphedema and resistance exercise: a systematic review. J Strength Cond Res 30(9): 2656-2665, 2016-Breast cancer-related lymphedema (BCRL) is characterized by the accumulation of fluid in the interstitial tissues in the arm, shoulder, neck, or torso and attributed to the damage of lymph nodes during breast cancer treatments involving radiation and axillary node dissection. Resistance exercise training (RET) has recently shown promise in the management of BCRL. The aims of this review were twofold: (a) To summarize the results of recent randomized controlled trials (RCTs) investigating the effect of resistance exercise in those with, or at risk for, BCRL. (b) To determine whether breast cancer survivors can perform RET at sufficient intensities to elicit gains in strength without causing BCRL flare-up or incidence. A search was performed on the electronic databases PubMed, MEDLINE, SPORT Discus, and Science Direct, up to July 10, 2015, using the following keywords: breast cancer-related lymphedema, strength training, resistance training, systematic review, and breast cancer. Manual searches of references were also conducted for additional relevant studies. A total of 6 RCTs, involving 805 breast cancer survivors, met the inclusion criteria and corresponded to the aims of this review. The methodological quality of included RCTs was good, with a mean score 6.8 on the 10-point PEDro scale. The results of this review indicate that breast cancer survivors can perform RET at high-enough intensities to elicit strength gains without triggering changes to lymphedema status. There is strong evidence indicating that RET produces significant gains in muscular strength without provoking BCRL.

Acute Inflammatory Response to Low-, Moderate-, and High-Load Resistance Exercise in Women With Breast Cancer-Related Lymphedema.

Background. Resistance exercise is emerging as a potential adjunct therapy to aid in the management of breast cancer–related lymphedema (BCRL). However, the mechanisms underlying the relationships between the acute and long-term benefits of resistance exercise on BCRL are not well understood. Purpose. To examine the acute inflammatory response to upper-body resistance exercise in women with BCRL and to compare these effects between resistance exercises involving low, moderate, and high loads. The impact on lymphedema status and associated symptoms was also compared. Methods. A total of 21 women, 62 ± 10 years old, with BCRL participated in the study. Participants completed low-load (15-20 repetition maximum [RM]), moderate-load (10-12 RM), and high-load (6-8 RM) exercise sessions consisting of 3 sets of 6 upper-body resistance exercises. Sessions were completed in a randomized order separated by a 7- to 10-day wash-out period. Venous blood samples were obtained to assess markers of exercise-induced muscle damage and inflammation. Lymphedema status was assessed using bioimpedance spectroscopy and arm circumferences, and associated symptoms were assessed using Visual Analogue Scales for pain, heaviness, and tightness. Measurements were conducted before and 24 hours after the exercise sessions. Results. No significant changes in creatine kinase, C-reactive protein, interleukin-6, and tumor necrosis factor-α were observed following the 3 resistance exercise sessions. There were no significant changes in arm swelling or symptom severity scores across the 3 resistance exercise conditions. Conclusions. The magnitude of acute exercise-induced inflammation following upper-body resistance exercise in women with BCRL does not vary between resistance exercise loads.

Self-Care for Management of Secondary Lymphedema: A Systematic Review

BackgroundLymphedema is a debilitating and disfiguring sequela of an overwhelmed lymphatic system. The most common causes of secondary lymphedema are lymphatic filariasis (LF), a vector-borne, parasitic disease endemic in 73 tropical countries, and treatment for cancer in developed countries. Lymphedema is incurable and requires life-long care so identification of effective lymphedema management is imperative to improve quality of life, reduce the burden on family resources and benefit the local community. This review was conducted to evaluate the evidence for effective lymphedema self-care strategies that might be applicable to management of all types of secondary lymphedema.Methodology/Principal FindingsSearches were conducted in Medline, CINAHL and Scopus databases in March 2015. Included studies reported before and after measures of lymphedema status or frequency of acute infections. The methodological quality was assessed using the appropriate Critical Appraisal Skills Program checklist. Descriptive synthesis and meta-analysis were used to evaluate effectiveness of the outcomes reported. Twenty-eight papers were included; two RCTs were found to have strong methodology, and overall 57% of studies were rated as methodologically weak. Evidence from filariasis-related lymphedema (FR-LE) studies indicated that hygiene-centred self-care reduced the frequency and duration of acute episodes by 54%, and in cancer-related lymphedema (CR-LE) home-based exercise including deep breathing delivered significant volume reductions over standard self-care alone. Intensity of training in self-care practices and frequency of monitoring improved outcomes. Cultural and economic factors and access to health care services influenced the type of intervention delivered and how outcomes were measured.Conclusions/SignificanceThere is evidence to support the adoption of remedial exercises in the management of FR-LE and for a greater emphasis on self-treatment practices for people with CR-LE. Empowerment of people with lymphedema to care for themselves with access to supportive professional assistance has the capacity to optimise self-management practices and improve outcomes from limited health resources.

Compression use during an exercise intervention and associated changes in breast cancer-related lymphedema.

This study assessed the association between compression use and changes in lymphedema observed in women with breast cancer-related lymphedema who completed a 12-week exercise intervention. This work uses data collected from a 12 week exercise trial, whereby women were randomly allocated into either aerobic-based only (n = 21) or resistance-based only (n = 20) exercise. Compression use during the trial was at the participants discretion. Differences in lymphedema (measured by lymphedema index [L-Dex] score and interlimb circumference difference [%]) and associated symptoms between those who wore, and did not wear compression during the 12-week intervention were assessed. We also explored participants' reasons surrounding compression during exercise. No significant interaction effect between time and compression use for lymphedema was observed. There was no difference between groups over time in the number or severity of lymphedema symptoms. Irrespective of compression use, there were trends for reductions in the proportion of women reporting severe symptoms, but lymphedema status did not change. Individual reasons for the use of compression, or lack thereof, varied markedly. Our findings demonstrated an absence of a positive or negative effect from compression use during exercise on lymphedema. Current and previous findings suggest the clinical recommendation that garments must be worn during exercise is questionable, and its application requires an individualized approach.

Lymphedema surgery: Patient selection and an overview of surgical techniques

Evaluation of the lymphedema patients with appropriate staging is fundamental for further treatment. Treatment includes compressive decongestive therapy for stage 0 and 1 patients, lymphovenous anastomosis for stage 1 and 2 patients, vascularized lymph node transfer for stage 2 and above patients. Wedge resection, liposuction, and the Charles procedure are alternatives or additions to physiological procedures. The selection of donor lymph node flap and recipient site depends on the patient's lymphedema status and surgeon's expertise. J. Surg. Oncol. 2016;113:923-931. © 2016 Wiley Periodicals, Inc.

The prevalence of lymphoedema in women who attended an information and exercise class to reduce the risk of breast cancer-related upper limb lymphoedema.

Breast cancer-related upper limb lymphoedema (BCRL) affects approximately 20 % of women undergoing axillary intervention. Women who attended a “reducing your risk of lymphoedema” class, including exercise instruction, anecdotally reported positive BCRL outcomes. The aim of this study was to examine BCRL outcomes and perceived benefit for attendees at a “reducing your risk of lymphoedema” class between 2000 and 2005. A cross-sectional study was conducted in two parts: (1) self-report questionnaire regarding lymphoedema status and benefit received from class and exercise programme; (2) clinical evaluation and objective measurement to confirm BCRL. 46 women completed questionnaires; 40 continued to clinical evaluation and objective measurement. BCRL prevalence defined as ≥10 % excess limb volume was only 5 %, although clinician judgement identified 23 % with arm lymphoedema and 8 % with lymphoedema limited to the hand. Clinician judgement correlated highly with patient self-report (Kappa = 0.833, p = 0.000). All women found the class beneficial, reporting increased confidence to return to normal life and a wide range of activities/exercise. We conclude that prevalence of BCRL should be determined by both clinical judgement and objective measurement to avoid underestimation. The benefit of group education with a lymphoedema expert and of exercise instruction should be further explored, and the potential for exercise to reduce BCRL prevalence should be examined.

Resistance exercise and secondary lymphedema in breast cancer survivors—a systematic review

The aim of the present review was to determine effects of strength exercise on secondary lymphedema in breast cancer patients. Research was conducted by using the databases PubMed/Medline and Embase. Randomized controlled trials published from January 1966 to May 2015 investigating the effects of resistance exercise on breast cancer patients with or at risk of secondary lymphedema in accordance with the American College of Sports Medicine exercise guidelines for cancer survivors were included in the present study. Nine original articles with a total of 957 patients met the inclusion criteria. None of the included articles showed adverse effects of a resistance exercise intervention on lymphedema status. In all included studies, resistance exercise intensity was described as moderate to high. Strength exercise seems not to have negative effects on lymphedema status or might not increase risk of development of lymphedema in breast cancer patients. Further research is needed in order to investigate the effects of resistance exercise for patients suffering from lymphedema.

Abstract 11422: Aligned Nanofibrillar Collagen Scaffold Guide Therapeutic Lymphangiogenic Repair in Secondary Lymphedema

Background: As a mechanical adjunct to therapeutic lymphatic repair in acquired lymphedema, we have investigated the applicability of guided lymphatic regeneration, through the introduction of a biological scaffold consisting of aligned collagen fibrils. These fibrils provide for cell attachment, alignment, and migration. Methods: We refined a large animal model using minipigs (n=16). We resected the inguinal and popliteal lymphatic system and irradiated the groin area to reproduce the conditions encountered in human cancer-related lymphedema. We assessed the status of lymphedema by detecting interstitial fluid accumulation through bioimpedance, the number of major lymphatic collectors by contrast-enhanced CT, and presence of lymphatic dermal backflow by contrast-enhanced MRI. Results: Three months after lymphatic resection and irradiation, animal subjects were randomized to: (1) scaffolds only, (2) scaffolds impregnated with VEGF-C, and (3) VEGF-C-scaffolds with additional transplantation of autologous lymph node fragments. The control group (4) did not receive any treatment. Seven animals out of 16 developed chronic lymphedema by the pre-defined bioimpedance threshold. The number of lymphatic collectors, as determined by CT, correlated with bioimpedance data. In group 1, there was slight improvement of bioimpedance ratios. In groups 2 and 4 (control), lymphedema persisted. In group 3 lymphedema was reversed in all subjects at post-Rx time-point 6 months. Macroscopic analysis of collectors in the implantation area after intradermal injection of blue dye showed newly developed lymphatic collectors aligned in the direction of the implanted collagen scaffolds. Conclusions: In this porcine acquired lymphedema model, implantation of aligned nanofibrillar collagen scaffolds facilitates the ingrowth of lymphatics across the treatment field. Moreover, simultaneous transplantation of autologous lymph node fragments improves lymphatic regeneration. The biocompatibility of these surgical approaches suggests their potential as an effective treatment option for the human disease.

Differences of symptoms in head and neck cancer patients with and without lymphedema.

Head and neck cancer (HNC) patients are at risk for developing external and internal lymphedema. Currently, no documentation of symptom differences between individuals with and without head and neck lymphedema is available. The purpose of this analysis was to examine symptom differences among HNC patients with and without lymphedema. Data were drawn from three cross-sectional studies of HNC patients >3months post-cancer treatment (total N = 163; 128 patients with lymphedema, 35 without lymphedema). External lymphedema was evaluated via physical examination; internal lymphedema was identified through endoscopic examination. Participant's head and neck lymphedema status was categorized into two groups: no indication of external or internal lymphedema and at least some indication of external or internal lymphedema. Lymphedema Symptom Intensity and Distress Survey-Head and Neck (LSIDS-H&N) was used to assess symptom burden. Descriptive statistics, McNemar, chi-squared, Wilcoxon signed-ranks, and Mann-Whitney tests were used. Twenty-three pairs of patients were identified and matched on the age, primary tumor site, tumor stage, and time since end of cancer treatment. Relative to patients without lymphedema, matched patients with lymphedema reported either increased symptom prevalence or severity or distress level for the following symptoms (prevalence differences of at least 15% between the matched groups and p < 0.05): (1) numbness; (2) tightness; (3) heaviness; (4) warmth; (5) pain without head/neck movement; (6) problems swallowing mashed or pureed foods; (7) trouble breathing; (8) blurred vision; (9) feel worse when flying in an airplane; and (10) swelling. Findings suggest that HNC-related lymphedema may be associated with substantial symptom burden. Studies with larger sample sizes are needed to replicate the findings.

P0089 Prognostic factors for node-positive breast cancer after surgery, chemotherapy, and radiotherapy

Background Breast cancer is the most common cancer among women. Surgery plus chemotherapy and radiotherapy is the major treatment used for node-positive breast cancer. The purpose of this study was to analyse the prognostic and predictive factors that relate to outcome in node-positive breast cancer after surgery, chemotherapy, and radiotherapy. Methods Patients diagnosed with node-positive breast cancer and who received surgery, neoadjuvant, or adjuvant chemotherapy plus adjuvant radiotherapy at our institution (Changhua Christian Hospital, Changhua, Taiwan) from June 2008, to March 2011, were surveyed retrospectively. Factors such as age at diagnosis, histological grade, T stage, N stage, types of surgery, some pathological factors, hormone receptor status, history of diabetes mellitus or hypertension, body mass index, radiotherapy technique, and treatment related side-effects were reviewed from the patient’s chart record and analysed using Kaplan–Meier method and Cox regression to estimate the association between locoregional recurrence (LRR), distant metastasis (DM), and overall survival (OS). Findings The study enrolled 165 patients and had a median follow up of 56 months (range 13–79). Five-year LRR, DM, and OS rates were 7%, 17%, and 72%, respectively. Univariate analysis showed neoadjuvant chemotherapy, margin of 1 mm or less, ER negative, PR negative, and lymphoedema significantly influenced the LRR rate. Neoadjuvant chemotherapy, surgery with mastectomy, more than 50% positive of dissected lymph nodes, margin of 1 mm or less, PR negative, lymphoedema, and LRR all significantly influenced the DM rate. T stage (stage 3 or 4), neoadjuvant chemotherapy, more than 50% positive of dissected lymph nodes, grade 3 tumour, ER negative, PR negative, lymphoedema, LRR and DM significantly influenced the survival of patients. Multivariate analysis showed grade 3 tumour, margin 1 mm or less, lymphoedema significantly influenced the LRR rate. Only those with more than 50% positive of dissected lymph nodes and LRR significantly influenced the DM rate. Neoadjuvant chemotherapy, ER negative, PR negative, HER2 negative, and DM all significantly influenced OS. Interpretation In patients with node-positive breast cancer after surgery, chemotherapy, and radiotherapy, a grade 3 tumour, margin of 1 mm or less, more than 50% positive of dissected lymph nodes, lymphoedema, and hormone status might be important factors to predict a patient’s outcome.

Development and preliminary testing of head and neck cancer related external lymphedema and fibrosis assessment criteria

PurposeTo develop assessment criteria for evaluating and documenting status of external lymphedema and fibrosis in patients with head and neck cancer (HNC). MethodsThis was a two-phase instrument development study. In Phase I, initial assessment criteria for head and neck external lymphedema and fibrosis were generated based on a conceptual framework developed to describe the continuum of lymphedema – fibrosis in HNC patients. The initial Head and Neck External Lymphedema and Fibrosis (HN-ELAF) Assessment Criteria with three components were revised based on expert feedback. In Phase II, a pilot study was conducted to evaluate the revised assessment criteria through direct physical examination of 30 HNC patients with facial swelling and/or scar-like tissue >3 months post-treatment. The following statistical methods were used to evaluate interrater reliability in Phase II: simple percent agreement, the Kappa statistic, and the concordance correlation coefficient. Then, a post-test revision was made to further modify the tool based on the results of the pilot test. ResultsIn Phase I, the initial HN-ELAF was revised including deleting Grade 0 (subclinical disease) and two components (i.e., symptoms and functional impairments). The revised HN-ELAF Assessment Criteria demonstrated good content/face validity. In Phase II, the assessment criteria had an acceptable interrater reliability, e.g., 83% exact agreement on grading lymphedema and fibrosis severity; and kappa = 0.75 (p < .001). The assessment criteria were further modified including three dimensions: type, severity, and anatomical sites of lymphedema and fibrosis. ConclusionsValidation of the modified HN-ELAF Assessment Criteria in larger sample sizes is ongoing.

Factors Associated with Reported Infection and Lymphedema Symptoms among Individuals with Extremity Lymphedema.

This study aimed to examine factors associated with reported infection and symptoms among individuals with extremity lymphedema. A cross-sectional study was used. Data were collected from a survey supported by the National Lymphedema Network from March 2006 through January 2010. A total of 1837 participants reported having extremity lymphedema. Logistic regression analyses were used. Factors associated with reported infection among individuals with extremity lymphedema included male gender, decreased annual household income, decreased self-care, self-report of heaviness, and lower extremity as opposed to upper extremity. Factors associated with symptoms included infection, decreased self-care, lower knowledge level of self-care, decreased annual household income, and presence of secondary lower extremity lymphedema. Select factors of income, self-care status, and site of lymphedema were associated with increased occurrence of infection and symptoms among individuals with extremity lymphedema. Longitudinal studies are needed to identify risk factors contributing to infections and symptoms in individuals with lymphedema.

The psychosocial impact of lymphedema‐related distress among breast cancer survivors in the WHEL Study

Lymphedema is a distressing and chronic condition affecting up to 30% of breast cancer survivors. Using a cross-sectional study design, we examined the impact of self-reported lymphedema-related distress on psychosocial functioning among breast cancer survivors in the Women's Healthy Eating and Living Study. The Women's Healthy Eating and Living Study has a dataset that includes self-report data on lymphedema status, symptoms, and distress. Chi-square tests and binary logistic regression models were used to examine how specific participant characteristics, including lymphedema-related distress, were associated with physical health and mental health as measured by the SF-36-Item Health Survey and depressive symptoms assessed by the Center for Epidemiologic Studies Depression Scale screening form. Of the 2431 participants included in the current study population, 692 (28.5%) self-reported ever having lymphedema. A total of 335 (48.9%) women reported moderate to extreme distress as a result of their lymphedema and were classified as having lymphedema-related distress. The logistic regression models showed that women with lymphedema-related distress had 50% higher odds of reporting poor physical health (p = 0.01) and 73% higher odds of having poor mental health (p < 0.01) when compared with women without lymphedema. In contrast, even though lymphedema-related distress was significantly associated (p = 0.03) with elevated depressive symptoms in the bivariate analyses, it was not significant in the logistic regression models. Breast cancer survivors with lymphedema-related distress had worse physical health and mental health outcomes than women with lymphedema who were not distressed and women with no lymphedema. Our findings provide further evidence of the relationship between lymphedema and psychosocial outcomes in breast cancer survivors.

A New Soft Tissue Volume Measurement Strategy Using Ultrasonography

Abstract Various techniques are available for measuring the status of lymphedema. A modified imaging technique using ultrasonography was developed to measure the structure of soft tissue area in a cost-effective manner. The purpose of this study was to measure the reliability and the accuracy of this new method. Ultrasonography was performed on both arms of twenty healthy female participants. At 10 cm above (AE) and below (BE) the elbow crease, soft tissue thickness at medial, lateral, inferior, and superior locations were measured by two examiners with minimal unnecessary pressure. After measuring twice on 16 sites for each participant, the amount of soft tissue in the cross-sectional area (ΔCSA) was acquired by a designed formulation. The ΔCSA was also compared with volumetry data (Perometer(®)). Cronbach's alpha coefficient test was used for statistics. The intra-class and inter-class reliability measurements for all soft tissue areas were very strong (α=0.980 and 0.960, respectively; p<0.01). All AE and BE reliabilities showed very strong correlation and strong correlation of inter-BE measurement. All reliabilities of ΔCSA were very strong (≥0.950). All CCs (correlation coefficients) between ΔCSA, circumference, and volumetry were strong for AE and BE measurements, except for ΔCSA and circumference at BE. The strongest CC was between volumetry and circumference measurements. This study suggests that measuring the ΔCSA by ultrasonography could be an alternative way to measure the status of soft tissue indirectly with structural consideration.