The ALERT model of care for the assessment and personalized management of patients with lymphoedema.

BACKGROUND: This study documents the development and evaluation of a comprehensive multidisciplinary model for the assessment and personalized care of patients with lymphoedema. METHODS: The Australian Lymphoedema Education Research and Treatment (ALERT) programme originated as an advanced clinic for patients considering surgery for lymphoedema. The programme commenced liposuction surgery in May 2012 and then introduced lymph node transfer in 2013 and lymphovenous anastomosis (LVA) in 2016. An outpatient conservative treatment clinic was established in 2016. ALERT commenced investigations with indocyanine green (ICG) lymphography in late 2015, leading to the creation of a diagnostic assessment clinic offering ICG in 2017. RESULTS: Since 2012, 1200 new patients have been referred to ALERT for assessment of lymphoedema for a total of 5043 episodes of care. The introduction of ICG lymphography in 2015 initially allowed better screening for LVA, but is now used not only to guide surgical options, but also as a diagnostic tool and to guide manual lymphatic drainage massage. The total number of new patients who attended the surgical assessment clinic to December 2018 was 477, with 162 patients (34·0 per cent) undergoing surgery. CONCLUSION: The ALERT programme has developed a multidisciplinary model of care for personalized lymphoedema treatment options based on clinical, imaging and ICG lymphography. Patients are selected for surgery based on several individual factors.

ANTECEDENTES: Este estudio presenta el desarrollo y valoración de un modelo multidisciplinario integral para la evaluación y atención personalizada de pacientes con linfedema. MÉTODOS: El programa australiano de educación en investigación y tratamiento del linfedema (Australian Lymphoedema Education Research and Treatment, ALERT) se originó como un centro clínico avanzado para pacientes que consideran la cirugía como tratamiento para el linfedema. El programa se inició en mayo del 2012 con la cirugía de liposucción, introduciendo la cirugía de transferencia ganglionar (lymph node transfer, LNT) en 2013 y la anastomosis linfovenosa (lymphovenous anastomosis, LVA) en 2016. En 2016 se estableció una clínica de tratamiento conservador ambulatorio. ALERT comenzó las investigaciones con la linfografía con verde de indocianina (indocyanine green, ICG) a fines del 2015, lo que se siguió de la creación de una clínica de evaluación diagnóstica que ofrece ICG en 2017. RESULTADOS: Desde el 2012, 1.200 pacientes nuevos han sido referidos a ALERT para la evaluación de un linfedema, con un total de 5.043 episodios atendidos. La introducción inicialmente de linfografía con ICG en 2015 permitió un mejor cribaje para LVA, pero actualmente se utiliza no solo como guía de las opciones quirúrgicas, sino también como herramienta diagnóstica y como guía del masaje de drenaje linfático manual (manual lymphatic drainage, MLD). El número total de pacientes nuevos atendidos en la clínica de evaluación quirúrgica hasta diciembre de 2018 fue de 477, con 122 pacientes (34%) tratados quirúrgicamente. El modelo tal como se ha descrito, ha atraído a pacientes de toda Australia y Nueva Zelanda. CONCLUSIÓN: El programa ALERT ha desarrollado un modelo multidisciplinario de atención para las opciones de tratamiento personalizado del linfedema basado en la evaluación clínica, por imagen (MRI y LSG) y linfografía con ICG. Los pacientes se seleccionan cuidadosamente para el tratamiento quirúrgico en función de varios factores relacionados con el paciente, el tumor, los linfáticos y las opciones terapéuticas, y se someten a una evaluación detallada después de cualquier procedimiento.

Confirmation of the reference impedance ratios used for assessment of breast cancer-related lymphedema by bioelectrical impedance spectroscopy.

BACKGROUND: Breast cancer-related lymphedema in the arm is commonly detected by bioelectrical impedance spectroscopy as an increased inter-arm impedance ratio due to the presence of excess lymph in the at-risk arm relative to that of the unaffected arm. The presence of lymphedema is determined by a value of this ratio greater than the mean ratio, plus three standard deviations observed in a comparable healthy population. This threshold value has not been established using the measurement protocols in current practice. The aim of the present study was to determine the reference range of the inter-arm impedance ratio to allow a cut-off value to be established as a criterion for the detection of breast cancer-related lymphedema. METHODS: The mean and variation (3 SD) of the inter-arm impedance ratio for the arms of 172 healthy female control participants were determined from an accumulated database of impedance data obtained using present generation impedance instrumentation and methodology. This reference range and threshold value was compared to the original threshold ratio determined a decade ago but still in current use. RESULTS: The presence of lymphedema is indicated when the impedance ratio exceeded 1.106 when the nondominant limb is at risk, and 1.134 when the dominant limb is at risk compared with the currently used values of 1.066 and 1.139, respectively. Although the difference in these values was statistically significant, this difference was determined to be of minor importance to clinical practice. CONCLUSIONS: The impedance ratio thresholds for early detection of lymphedema remain suitable for clinical use with present day bioimpedance spectroscopy analyzers and measurement protocols.

Reference ranges for assessment of unilateral lymphedema in legs by bioelectrical impedance spectroscopy.

BACKGROUND: Secondary unilateral lymphedema in the leg may occur as a consequence of pelvic surgery and/or radiation therapy, which causes damage to the pelvic lymphatic system. To date, assessment has been typically by manual measurement of the volume excess of the affected leg compared to the contralateral leg. In contrast, the assessment of unilateral arm lymphedema is readily accomplished by the use of bioelectrical impedance spectroscopy (BIS) as an increased inter-arm impedance ratio due to the presence of excess lymph in the affected arm relative to that of the unaffected arm. The presence of lymphedema is defined by a value of this ratio greater than the mean ratio plus three standard deviations (SD) observed in a comparable healthy population. The aim of the present study was to determine the equivalent reference range of the impedance ratio for the legs. This would allow a cut-off value to be established as a criterion for the detection and assessment of lower limb lymphedema. METHODS: The impedances of the legs of 172 healthy females and 150 healthy males, measured by BIS, were extracted from an accumulated database of impedance data. These data were used to determine the normal distribution of inter-leg impedance ratios and the reference range and threshold value (mean + 3 SD). RESULTS: The presence of lymphedema is indicated when the impedance ratio exceeds 1.167 in males and 1.136 in females. Unlike in the arms, the effect of limb dominance in the legs is minimal and it is suggested that no correction for limb dominance is warranted. CONCLUSIONS: The impedance ratio thresholds for lymphedema of the legs have been established, opening the way for BIS to become established clinically for the early detection and assessment of lower limb lymphedema.

Assessment of breast cancer-related arm lymphedema--comparison of physical measurement methods and self-report.

PURPOSE: To determine the relationship between physical methods of measuring lymphedema and self-reported swelling, their reliability, and standard error of measurement. METHOD: Lymphedema in each arm of women with (n = 33) and without (n = 18) unilateral arm lymphedema, secondary to breast cancer was measured by self-report, bioimpedance spectroscopy (BIS), perometer, and the truncated cone method. RESULTS: The physical measurement tools were highly reliable (ICC((2,1)): 0.94 to 1.00) with high concordance (r(c): 0.89 to 0.99). Self-report correlated moderately with physical measurements (r = 0.65 to 0.71) and was moderately reliable (ICC((2,1)): 0.70). CONCLUSIONS: Lymphedema assessment methods are concordant and reliable but not interchangeable.

Single frequency versus bioimpedance spectroscopy for the assessment of lymphedema.

BACKGROUND: The aims were to determine (i) whether single frequency bioimpedance analysis (SFBIA) is as accurate as bioimpedance spectroscopy (BIS) in measurement of extracellular fluid and (ii) whether change in extracellular fluid was specific to only the limb directly affected by surgery. METHODS: Arms of the control (n = 28) and arm lymphedema group (n = 28) and legs of the leg lymphedema group (n = 16) were assessed with SFBIA. All four limbs in all participants were assessed with BIS. All measurements occurred in a single session. RESULTS: BIS-measured ratios were highly concordant with those obtained with SFBIA (r (c) = 0.99, P < 0.001). Repeated measures ANOVA revealed that the ratio involving the lymphedema limb was different to the ratio of the non-oedematous limbs which was not significantly different to the arm or leg ratios of the control group. CONCLUSIONS: SFBIA is a simple accurate alternative to BIS for the clinical assessment of unilateral lymphedema. BIS discriminates those with clinical diagnosis of unilateral lymhoedema from those without the diagnosis.

Quantitative bioimpedance spectroscopy for the assessment of lymphoedema.

The aim was to make bioimpedance spectroscopy (BIS) quantitative for assessment of lymphoedema. Apparent resistivity coefficients were determined for the intra- and extracellular water of arms in a control cohort of women (n = 66). These coefficients were used to predict water volumes in the arms of women with lymphoedema (n = 23) and a separate control group without lymphoedema (n = 13) and to compare these with total arm size measured by perometry. Total arm volume was highly correlated (r = 0.80-0.90) with arm fluid volumes predicted by BIS and the proportional increase in arm size predicted by BIS was not significantly different to that measured by perometry. BIS predicted that the increased volume in the women with lymphoedema was predominantly (60%) due to increase in extracellular fluid. BIS is capable of quantifying the volume increase in limb size seen in lymphoedema.