Surgical management strategies include: (i) ablative surgical methods (i.e., Charles procedure, suction-assisted lipectomy/liposuction) and (ii) physiologic surgical methods (i.e., lymphaticolymphatic bypass, lymphaticovenular anastomosis, vascularized lymph node transfer, vascularized omental flap transfer. While these surgical management strategies can result in dramatic improvement in extremity-related symptomology and improve quality of life for these cancer patients, many formidable ...
Oncology (5) Lymphedema (4), Neoplasms (3), Lymphoma (1), more mentions
We developed a novel surgical method of shaping the lower abdomen and debulking suprapubic lymphedema with simultaneous reconstruction of lymphatic flow in case of LEL.A skin incision in a ... After resection and debulking of the suprapubic region, a lymphaticovenular anastomosis (LVA) between the efferent lymphatic vessel of the groin node and ...
No associations were found between the limb affected (upper or lower limb), clinical stage of lymphoedema, duration of lymphoedema or type of surgery (SLNB or CLND) and HRQoL. We found an interaction with age and gender in the associations between lymphoedema and HRQoL: younger patients and women with lymphoedema had worse social functioning and women had significantly more impaired body ...
Oncology (10), Neuroscience (1) Melanoma (7), Neoplasms (2), Breast Neoplasms (1), more mentions
Images analysis criteria included: (A) before surgery: a) severity of lymphedema graded as absent, mild, moderate, and severe; b) involvement of the muscular compartment; c) distal dilated lymphatic vessels; (B) after surgery: a) visualization of site of transplantation; b) visualization of transplanted lymph nodes; c) severity of lymphedema with regard ...
Oncology (1) Lymphedema (11), Breast Neoplasms (1), more mentions
AbstractText: Breast cancer related lymphedema (BCRL) remains one of the major long-term complications after surgery. Many reports showed the effectiveness of compression in BCRL treatment but randomized controlled trials evaluating compression garments for postoperative prevention are lacking AbstractText: The aim of the study was to evaluate the potential role of light arm compression sleeves for reducing the incidence of ...
Oncology (3) Lymphedema (4), Breast Neoplasms (3), Edema (2), more mentions
Secondary lymphedema of the upper limb is a common sequela following lymphadenectomy during oncologic surgery. The gold standard for evaluating treatment outcomes in upper limb lymphedema is limb volume measurement. However, current techniques lack sensitivity to localized changes. In this study, the Vectra 3D imaging system was utilized to accurately and precisely obtain volume measurements of the upper limb in ...
INTRODUCTION: The aim of our study was to analyze the risk of lymphedema (LE) according to the clinicopathologic factors and to investigate the serial change in body weight during neoadjuvant anthracycline plus cyclophosphamide followed by taxane and its correlation with the incidence of LE.
PATIENTS AND METHODS: We performed a retrospective 2-center study of 406 patients who had undergone neoadjuvant chemotherapy (NAC) followed by surgery from 2007 to 2014. The regimen included 4 cycles of anthracycline plus cyclophosphamide, followed by 4 cycles of taxane. We investigated the presence and degree of LE using a telephone questionnaire assessment. Weight changes were calculated at each cycle of NAC, and the baseline and preoperative body weights were used to calculate the rate of change to account for the change in weight before and after NAC.
RESULTS: Of the 406 patients, 270 answered the questionnaires, of whom 97 (35.9%) experienced LE. The increase in body weight was significant during the 4 cycles of taxane, but the change in weight was not significant during the 4 cycles of anthracycline plus cyclophosphamide. The change in body weight was most significant just after the fourth cycle of taxane (P < .001). The body mass index (BMI) was an independent factor of LE occurrence on multivariate analysis. However, the change in body weight was not a significant factor for the incidence of LE.
CONCLUSION: Because a BMI ≥ 25 kg/m(2) was an independent factor of LE occurrence on multivariate analysis, patients with a preoperative BMI ≥ 25 kg/m(2) should be closely monitored for LE given their increased risk, and monitoring and education should be initiated before surgery and continued throughout the course of NAC.
Oncology (2), Anti-Obesity and Weight Loss (1) Lymphedema (3), Breast Neoplasms (2), more mentions
BACKGROUND: Breast cancer-related lymphedema (BCRL) is a significant complication for women undergoing treatment. We assessed BCRL incidence and risk factors in a large population-based cohort.
METHODS: We utilized the Olmsted County Rochester Epidemiology Project Breast Cancer Cohort from 1990-2010 and ascertained BCRL and risk factors. The cumulative incidence estimator was used to estimate the rate of BCRL; competing risks regression was used for multivariable analysis.
RESULTS: A total of 1794 patients with stage 0-3 breast cancer with a median of 10 years follow-up were included. The cumulative incidence of BCRL diagnosis within 5 years was 9.1% [95% confidence interval (CI) 7.8-10.5%]. No BCRL events occurred among patients without axillary surgery. In the axillary surgery subset (n = 1512), the 5-year incidence of BCRL was 5.3% in sentinel lymph node (SLN) surgery and 15.9% in axillary dissection (ALND) patients (p < 0.001). In patients treated with surgery only, BCRL rates were not different between ALND versus SLN (3.5 and 4.1% at 5 years, p = 0.36). Addition of breast or chest wall radiation more than doubled the BCRL rate in ALND patients (3.5 vs. 9.5% at 5 years, p = 0.01). The groups with highest risk (>25% at 5 years) all involved ALND with nodal RT and/or anthracycline/cytoxan + taxane chemotherapy. In multivariable analysis of patients with any axillary surgery factors significantly associated with BCRL were ALND, chemotherapy, radiation, and obesity.
CONCLUSIONS: BCRL is a sequelae of multimodal breast cancer treatment and risk is multifactorial. BCRL rates are higher in patients receiving chemotherapy, radiation, ALND, more advanced disease stage, and higher body mass index.
Oncology (5), Anti-Obesity and Weight Loss (2) Breast Neoplasms (5), Lymphedema (2), Obesity (1), more mentions
The Oncology Section of the American Physical Therapy Association (APTA) developed a clinical practice guideline to aid the clinician in diagnosing secondary upper quadrant cancer-related lymphedema. Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in the diagnostic process. Overall clinical practice recommendations were formulated based on the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility. In an effort to maximize clinical applicability, recommendations were based on the characteristics as to the location and stage of a patient's upper quadrant lymphedema.
BACKGROUND: One promising surgical treatment of lymphedema is the VLNT. Lymph nodes can be harvested from different locations; inguinal, axillary, and supraclavicular ones are used most often. The aim of our study was to assess the surgical anatomy of the lateral thoracic artery lymph node flap.
MATERIALS AND METHODS: In total, 16 lymph node flaps from nine cadavers were dissected. Flap markings were made between the anterior and posterior axillary line in dimensions of 10 × 5 cm. Axillary lymph nodes were analyzed using high-resolution ultrasound and morphologically via dissection. The cutaneous vascular territory of the lateral thoracic artery was highlighted via dye injections, the pedicle recorded by length, and diameter and its location in a specific coordinate system.
RESULTS: On average, 3.10 ± 1.6 lymph nodes were counted per flap via ultrasound. Macroscopic inspection showed on average 13.40 ± 3.13. Their mean dimensions were 3.76 ± 1.19 mm in width and 7.12 ± 0.98 mm in length by ultrasonography, and 3.83 ± 2.14 mm and 6.30 ± 4.43 mm via dissection. The external diameter of the lateral thoracic artery averaged 2.2 ± 0.40 mm with a mean pedicle length of 3.6 ± 0.82 cm. 87.5% of the specimens had a skin paddle.
CONCLUSIONS: The lateral thoracic artery-based lymph node flap proved to be a suitable alternative to other VLNT donor sites.
BACKGROUND: We aimed to understand the curative effect of liposuction curettage (LC) in the treatment of bromhidrosis.
METHODS: Relevant studies published before January 2017were searched from the PubMed, Embase, Cochrane Library, Wanfang, VIP, and China National Knowledge Infrastructure databases. Parameters including recurrence, complications, complete response, and overall response were assessed. Meta-analysis was performed using the R 3.12 statistical package. Odds ratio (OR) and 95% confidence interval (95% CI) were used for dichotomous data. Heterogeneity was assessed using Cochran's Q-statistic and I test. In addition, Egger's test was conducted to detect publication bias.
RESULTS: Ten studies with a total of 1124 participants (545 cases and 579 controls) were included. There was no statistical difference in recurrence (OR = 1.19, 95% CI: 0.51-2.74), complete response (OR = 0.66, 95% CI: 0.25-1.74), or overall response (OR = 0.63, 95% CI: 0.21-1.87) between the case and control groups. The incidence of complications in the case group was lower than that in the control group (OR = 0.24, 95% CI: 0.08-0.67) and open excision group (OR = 0.11, 95% CI: 0.07-0.19). Publication bias existed for the recurrence index in the open excision group (t = 3.3979, P = .04), but no publication bias was found in other subgroups, indicating stable results.
CONCLUSIONS: LC, which has fewer complications, can be considered the primary choice in the treatment of patients with bromhidrosis compared with other surgical procedures.
BACKGROUND: Cryolipolysis is a noninvasive subcutaneous fat removal technique. Its efficacy has been demonstrated on various fatty areas but not yet on saddlebags. The main objective of this study was to demonstrate the efficacy, patient tolerance, and safety of cryolipolysis on the saddlebags.
METHODS: This prospective study enrolled 53 patients with saddlebags. Patients with a history of liposuction or other surgical procedure on the saddlebag area and those on diet pills were excluded. The primary endpoint was a decrease in fat thickness at 3 and 6 months, as assessed by thigh circumference measurement and by ultrasound evaluation of subcutaneous fat. Pain associated with cryolipolysis was assessed using a visual analogue scale. Body mass index at the different time points and adverse events were recorded. All patients completed a satisfaction questionnaire at the end of the study.
RESULTS: At 6 months, there was a mean decrease of 5.63 cm in thigh circumference; the mean decrease in fat layer thickness measured by ultrasound was 1.31 cm. The satisfaction questionnaire showed that 93.75 percent of patients were satisfied with the results. The mean visual analogue scale score was 1.66 of 10 after the session. Reversible skin changes such as postprocedure postinflammatory hyperpigmentation were observed in 8.33 percent of patients.
CONCLUSIONS: Cryolipolysis is an effective technique for reducing saddlebag fat and is well tolerated by patients. A substantial risk of skin lesions, including postinflammatory hyperpigmentation that resolved after a few months, was observed. Cryolipolysis is a good alternative to liposuction in women with moderate, well-localized saddlebags.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
Anti-Obesity and Weight Loss (1) Hyperpigmentation (2), more mentions
BACKGROUND: Fifteen million U.S. patients each year seek medical care abroad; however, there are no data on outcomes and follow-up of these procedures. This study aims to identify, evaluate, and survey patients presenting with complications from aesthetic procedures abroad and estimate their cost to the U.S. health care system.
METHODS: A single-center retrospective review was conducted. A cohort of patients presenting with complications from aesthetic procedures performed abroad was generated. Demographic, complication, and cost data were compiled. Patients were surveyed to assess their overall experience.
RESULTS: Over a 36-month period, 42 patients met inclusion criteria (one man and 41 women), with an average age of 35 ± 11.4 years (range, 20 to 60 years). Comorbidities included four active smokers, two patients with hypertension, and one patient with diabetes. Average body mass index was 29 ± 4.4 kg/m (range, 22 to 38 kg/m). Procedures performed abroad included abdominoplasty (n = 28), liposuction (n = 20), buttock augmentation (n = 10), and breast augmentation (n = 7), with several patients undergoing combined procedures. Eleven patients presented with abscesses and eight presented with wound dehiscence. Eight of the 18 patients who were surveyed were not pleased with their results and 11 would not go abroad again for subsequent procedures. Average cost of treating the complications was $18,211, with an estimated cost to the U.S. health care system of $1.33 billion. The main payer group was Medicaid.
CONCLUSIONS: Complications from patients seeking aesthetic procedures abroad will continues to increase. Patients should be encouraged to undergo cosmetic surgery in the United States to improve patient outcomes and satisfaction and because it is economically advantageous.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
Cardiovascular Diseases (1), Endocrine Disorders (1), Anti-Obesity and Weight Loss (1) Abscesses (1), Hypertension (1), Diabetes Mellitus (1), more mentions
BACKGROUND: This analysis was performed to assess the impact of early intervention following prospective surveillance using bioimpedance spectroscopy (BIS) to detect and manage breast cancer-related lymphedema (BCRL).
METHODS: From 8/2010 to 12/2016, 206 consecutive patients were evaluated with BIS. The protocol included pre-operative assessment with L-Dex as well as post-operative assessments at regular intervals. Patients with L-Dex scores >10 from baseline were considered to have subclinical BCRL and were treated with over-the-counter (OTC) compression sleeve for 4 weeks. High-risk patients were defined as undergoing axillary lymph node dissection (ALND), receiving regional nodal irradiation (RNI), or taxane chemotherapy. Chronic BCRL was defined as the need for complex decongestive physiotherapy (CDP).
RESULTS: Median follow-up was 25.9 months. Overall, 17% of patients had one high-risk feature, 8% two, and 7% had three. 9.8% of patients were diagnosed with subclinical BCRL with highest rates seen following ALND (23 vs. 7%, p = 0.01). Development of subclinical BCRL was associated with ALND and receipt of RNI. At last follow-up, no patients (0%) developed chronic, clinically detectable, BCRL. Subset analysis was performed of the 30 patients undergoing ALND. Median number of nodes removed was 18 and median number of positive nodes was 2. 77% received taxane chemotherapy, 62% axillary RT, and 48% had elevated BMI. Overall, 86% of patients had at least one additional high-risk feature, 70% at least two, and 23% had all three. Seven patients (23%) had abnormally elevated L-Dex scores at some point during follow-up. To date, none has required CDP.
CONCLUSIONS: The results of this study support prospective surveillance utilizing BIS initiated pre-operatively with subsequent post-operative follow-up measurements for the detection of subclinical BCRL. Intervention triggered by subclinical BCRL detection with an elevated L-Dex score was associated with no cases progressing to chronic, clinically detectable BCRL even in very high-risk patients.
PURPOSE: Musculoskeletal events (MEs) resulting from breast cancer treatment can significantly interfere with the quality of life (QOL) of older adults. We evaluated the incidence of MEs in women 65 years and older who had surgery and adjuvant chemotherapy for breast cancer, and the impact of treatment on MEs and arm function.
PATIENTS AND METHODS: Patient-reported data in Alliance/CALGB 49907 were collected using the EORTC QLQ-BR23 and physician-reported adverse events to characterize self-reported MEs and incidence of lymphedema. EORTC QLQ-BR23 items related to musculoskeletal events were analyzed in this study and data collected at study entry (post-operative) and 12 and 24 months post-entry.
RESULTS: Lymphedema, arm function, and ME data were available for 321 patients. One or more MEs were reported by 87% (median number = 3) and 64% (median number = 1) of patients post-operatively and at 24 months. At 24 months 2% had persistence of six MEs. Seventy-four percent experienced at least ≥3/6 types of MEs over the 24-month period. Detection of lymphedema at any time during the study was noted in 7.5% of the patients and appeared to be associated with the type of chemotherapy given: CMF 16.4%, capecitabine 5.8%, and AC 4%. Mastectomy and axillary node dissection were associated with the most MEs. LROM correlated with poorer arm function at all time periods.
CONCLUSION: Potentially debilitating MEs occur in three-fourths of elderly women undergoing standard therapy for breast cancer. Emphasis should be placed on prevention, identification, and treatment of these MEs to improve QOL.
PURPOSE: The study aim was to develop a mobile application (app) supported by user preferences to optimise self-management of arm and shoulder exercises for upper-limb dysfunction (ULD) after breast cancer treatment.
METHODS: Focus groups with breast cancer patients were held to identify user needs and requirements. Behaviour change techniques were explored by researchers and discussed during the focus groups. Concepts for content were identified by thematic analysis. A rapid review was conducted to inform the exercise programme. Preliminary testing was carried out to obtain user feedback from breast cancer patients who used the app for 8 weeks post surgery.
RESULTS: Breast cancer patients' experiences with ULD and exercise advice and routines varied widely. They identified and prioritised several app features: tailored information, video demonstrations of the exercises, push notifications, and tracking and progress features. An evidence-based programme was developed with a physiotherapist with progressive exercises for passive and active mobilisation, stretching and strengthening. The exercise demonstration videos were filmed with a breast cancer patient. Early user testing demonstrated ease of use, and clear and motivating app content.
CONCLUSIONS: bWell, a novel app for arm and shoulder exercises, was developed by breast cancer patients, health care professionals and academics. Further research is warranted to confirm its clinical effectiveness.
IMPLICATIONS FOR CANCER SURVIVORS: Mobile health has great potential to provide patients with information specific to their needs. bWell is a promising way to support breast cancer patients with exercise routines after treatment and may improve future self-management of clinical care.
PURPOSE: The purpose of the present study was to analyse the performance of non-contrast MR lymphography for the classification of primary lower limb lymphoedema in 121 consecutive patients with 187 primary lower limb lymphoedemas.
MATERIALS AND METHODS: 121 consecutive patients with clinically diagnosed primary lower limb lymphoedema underwent non-contrast MR lymphography with a free-breathing 3D fast spin-echo sequence with a very long TR/TE (4000/884 ms). MR examinations were retrospectively reviewed for severity of lymphoedema (absent, mild, moderate, severe) and characteristics of inguinal lymph nodes and iliac and inguinal lymphatic trunks graded as aplasic (no lymph nodes or lymphatic trunks), hypoplasic (less lymph nodes or lymphatic trunks), normal and hyperplasic (more lymph nodes or more and/or dilated trunks).
RESULTS: There was an excellent correlation between clinical stage and severity of lymphoedema (Cramer's V of 0,73 (p < 0.001)). Differentiation was feasible between inguinal lymphatic vessel aplasia (21%), hypoplasia (15%), normal pattern (53%) and hyperplasia (11%). Severe lymphoedema was observed in 46% of aplasic patterns and in 37% of hyperplasic patterns, but in only 15% of hypoplasic patterns and never observed in normal patterns (p < 0.001).
CONCLUSION: Non-contrast MR lymphography is able to classify primary lower limb lymphoedemas into hyperplasic, aplasic, hypoplasic and normal patterns.
KEY POINTS: • Non-contrast MR lymphography is able to classify primary lower limb lymphoedemas. • Lymphoedema can be classified in hyperplasic, aplasic, hypoplasic and normal patterns. • Non-contrast MR lymphography can optimize clinical management of primary lower limb lymphoedemas.
BACKGROUND: This study evaluated the long-term clinical outcomes among different vascularized lymph node transfers (VLNT) used at our institution.
METHODS: Between July 2010 and July 2016, all patients with International Society of Lymphology (ISL) stages II-III who underwent VLNT were evaluated. Demographic and clinical data (limb circumference, infectious episodes, lymphoscintigraphic studies) were recorded pre-operatively. Clinical outcomes, complications, and additional excisional procedures were analyzed post-operatively. At least 2-year follow-up was required for inclusion.
RESULTS: Overall, 83 patients (Stage II:47, Stage III:36) met the inclusion criterion. Mean follow-up was 32.8 months (range, 24-49). Lymph node flaps used were groin (n = 13), supraclavicular (n = 25), gastroepiploic (n = 42), ileocecal (n = 2), and appendicular (n = 1). Total mean circumference reduction rate was 29.1% (Stage II) and 17.9% (Stage III) (P < 0.05). A paired t-test showed that VLNT significantly decreased the number of infections (P < 0.05). Three patients reported no improvement of the symptoms. Major complications included one flap loss and one donor site hematoma. After the period of follow-up, 18 patients (21.7%) underwent additional excisional procedures.
CONCLUSION: VLNT is a promising technique used for the treatment of lymphedema and appears to be more effective in moderate stages (Stage II). Patients with advanced stage lymphedema (Stage III) may benefit from additional excisional procedures.
BACKGROUND: Sentinel lymph node (SLN) biopsy is the current prognostic tool for clinically node-negative breast cancer patients. If the SLN reveals macrometastasis, axillary lymph node dissection (ALND) is recommended. However, the use of ALND in patients with micrometastasis is debated. The objective of this study was to assess the utilization of ALND in the treatment of micrometastatic breast cancer.
METHODS: An IRB approved, retrospective study of a pooled dataset of breast cancer patients with micrometastatic disease on SLN biopsy was performed. Patients diagnosed from 1999-2016 were identified via query of a single-institution National Comprehensive Cancer Network (NCCN) breast cancer database as well as a prospective tumor board.
RESULTS: A total of 91 patients were diagnosed with micrometastatic nodal disease. The median age at diagnosis was 56 y (range: 31-85); median follow-up time was 47 mo (range: 0-203 mo). 42/91(46.2%) patients had ALND of which 37/42 (88.1%) were a second operation; 3/42(7.1%) patients had additional positive nodes found at ALND. 44/91 (48.4%) patients received radiation. 7/91 (7.7%) patients had a recurrence, 5/7 local, including one axillary (2.1%; patient declined ALND).
CONCLUSIONS: Given that the risk of lymphedema after ALND ranges between 20%-53%, the morbidity of ALND may far exceed the likelihood of detecting further nodal involvement in women with micrometastatic disease: 7.1% in this series.
Oncology (7) Breast Neoplasms (6), Lymphedema (2), Neoplasms (2), more mentions