top of page
Singhal lab
Research
Treatment of Lymphedema
Home
Kim C, Ali H, Tsai LL, Bulman J, Singhal D, Carroll B, Ahmed M, Weinstein J.
Abstract
Purpose: There are limited existing data on the lymphatic anatomy of patients with primary lymphedema (LED), which is caused by aberrant development of lymphatic channels. In addition, there is a paucity of contemporary studies that use groin intranodal lymphangiography (IL) to evaluate LED anatomy. The purpose of this retrospective observational study was to better delineate the disease process and anatomy of primary LED using groin IL.
Materials and methods: We identified common groin IL findings in a cohort of 17 primary LED patients performed between 1/1/2017 and 1/31/2022 at a single institution. These patients were clinically determined to have primary lymphedema and demonstrated associated findings on lower extremity MR and lymphoscintigraphy.
Results: Ten patients (59%) demonstrated irregular lymph node morphology or a paucity of lymph nodes on the more symptomatic laterality. Eight patients (47%) demonstrated lymphovenous shunting from pre-existing anastomoses between the lymphatic and venous systems. Eight patients (47%) demonstrated passage of contrast past midline to the contralateral lymphatics. Finally, 12 patients (71%) failed to opacify the cisterna chyli and thoracic duct on their initial lymphangiograms. Delayed computed tomography of 3 patients showed eventual central lymphatic opacification up to the renal veins, but none of these patients showed central lymphatic opacification to the thorax.
Conclusion: This descriptive, exploratory study demonstrates common central groin IL findings in primary LED to highlight patterns interventional radiologists should identify and report when addressing primary LED.
Friedman R, Johnson AR, Shillue K, Fleishman A, Mistretta C, Magrini L, Tran BNN, Rockson SG, Lu W, Yeh GY, Singhal D.
Abstract
Background: Methods of conservative management for breast cancer-related lymphedema (BCRL) are burdensome in terms of time, cost, and convenience. In addition, many patients are not candidates for surgical treatment. Preliminary results have demonstrated possible beneficial effects of acupuncture for patients with BCRL. In this small pilot study, we examined the safety and feasibility of an acupuncture randomized control trial (RCT) in this patient cohort, utilizing a battery of standardized clinical and patient-centered outcome measures.
Methods and Results: Patients with BCRL were randomized 2:1 to the acupuncture (n = 10) or the control (n = 4) group. Patients received acupuncture to the unaffected extremity biweekly for 6 weeks. Feasibility was defined as enrollment ≥80%, completion of ≥9 of 12 acupuncture sessions per person, and ≥75% completion of three of three measurement visits. To inform a future adequately powered RCT, we describe within-group changes in patient-centered outcomes, including circumferential measurements, bioimpedance spectroscopy, perometry, cytokine levels, and patient quality of life. Adverse events were systematically tracked. Fourteen patients completed the study. Of those who received acupuncture (n = 10), 8 completed all 12 acupuncture sessions, and 2 patients completed 11 sessions. Ninety-three percent of all participants completed all three measurement visits. There was no consistent improvement in arm volumes. Inflammatory marker levels had inconclusive fluctuations among both groups. All patients receiving acupuncture demonstrated an improvement in their functional quality-of-life score. No severe adverse events occurred.
Conclusions: A randomized controlled study of acupuncture for BCRL is feasible. The acupuncture intervention is acceptable in this population, without safety concerns in a small sample and warrants further investigation.
DOI: 10.1089/lrb.2022.0001
Friedman R, Ismail Aly ME, Singhal D.
Abstract
No abstract available.
Johnson AR, Otenti D, Bates KD, Repicci W, Dallow K, Deterling W, Lee BT, Singhal D.
Abstract
This article describes the key stakeholders and process involved in developing an insurance policy in the United States to establish medical necessity criteria for lymphatic surgery procedures. Lymphedema is a chronic health issue that impacts over 1.2 million patients and is associated with lifelong health, economic, and psychosocial costs.
Patients affected have been described as "medical nomads," as they often interface with multiple providers before receiving an accurate diagnosis and treatment. This underscores the lack of attention and understanding about this disease across all sectors of the medical system. Unlike nations including Sweden and the United Kingdom, which provide insurance coverage for treatment, the United States has lagged behind. As a country, we have neglected to fully recognize the consequences of inadequate treatment of lymphedema, including chronic morbidities such as loss of mobility, psychosocial sequelae, recurrent infections, and even death.
Recently, the authors' lymphatic center had the unique opportunity to help develop a policy that merged their clinical experience, recently established lymphatic care center of excellence criteria, and third-party payer policy expertise. This experience spanned 1 year from June of 2018 to June of 2019. The authors identify how key partnerships helped fill evidentiary gaps that ultimately resulted in policy change.
Bustos VP, Friedman R, Pardo JA, Granoff M, Fu MR, Singhal D.
Abstract
Purpose: Lymphedema negatively impacts patients from a psychosocial standpoint and consequently affects patient's quality of life. Debulking procedures using power-assisted liposuction (PAL) are currently deemed an effective treatment for fat-dominant lymphedema and improves anthropometric measurements as well as quality of life. However, there have been no studies specifically evaluating changes in symptoms related to lymphedema after PAL. An understanding of how symptoms change after this procedure would be valuable for preoperative counseling and to guide patient expectations.
Methods: A cross-sectional study was performed in patients with extremity lymphedema who underwent PAL from January 2018 to December 2020 at a tertiary care facility. A retrospective chart review and follow-up phone survey were conducted to compare signs and symptoms related to lymphedema before and after PAL.
Results: Forty-five patients were included in this study. Of these, 27 patients (60%) underwent upper extremity PAL and 18 patients (40%) underwent lower extremity PAL. The mean follow-up time was 15.5±7.9 months. After PAL, patients with upper extremity lymphedema reported having resolved heaviness (44%), as well as improved achiness (79%) and swelling (78%). In patients with lower extremity lymphedema, they reported having improved all signs and symptoms, particularly swelling (78%), tightness (72%), and achiness (71%).
Conclusions: In patients with fat-dominant lymphedema, PAL positively impacts patient-reported outcomes in a sustained fashion over time. Continuous surveillance of postoperative studies is required to elucidate factors independently associated with the outcomes found in our study. Moreover, further studies using a mixed method approach will help us better understand patient's expectations to achieve informed decision and adequate treatment goals.
Abstract
Breast lymphedema is a type of breast cancer related lymphedema that leads to significant discomfort and negative impact on body image. Conservative therapy and lymphovenous bypass have been previously described as possible treatment methods for breast lymphedema, however, a unified approach to treatment is lacking. The current report describes a case of breast lymphedema successfully treated with vascularized lymph node transfer (VLNT) after failed attempt at management with conservative therapy.
The patient is a 48-year-old female with right-sided breast cancer who underwent breast conservation therapy in 2015 and subsequently developed pain and swelling of the right breast. The diagnosis of breast lymphedema was supported by clinical evaluation as well as MRI, lymphoscintigraphy, and lymphography. In consultation with a breast surgeon, breast lymphedema was determined not to be an indication for mastectomy. The patient was offered and underwent an omental VLNT to the right breast. A 20 cm segment of omentum with associated gastroepiploic vessels and lymph nodes was harvested, transferred to the right axilla and gastroepiploic vessels were anastomosed to the recipient thoracodorsal vessels. The patient tolerated the procedure well and there were no complications. Additional donor sites were considered, such as the groin and submental regions, but an omental flap was favored in this case because of the lower risk of donor site lymphedema. In the years following, the patient reported significant improvement in symptoms as well as objective reduction of edema on MRI. We propose the consideration of VLNT for breast lymphedema refractory to other methods of management.
Kim G, Adondakis M, Smith MP, Singhal D, Tsai LL.
Rate of Incidental Edema in the Contralateral Arm of Patients with Unilateral Postsurgical Secondary Upper Extremity Lymphedema
Abstract
Background: Secondary upper extremity lymphedema occurs after an insult such as surgery. One theory suggests underlying lymphatic dysfunction predisposing certain patients into developing secondary lymphedema. We aim to determine the rate of incidental edema in the contralateral upper extremity of patients with secondary unilateral lymphedema.
Methods and Results: MRI of the upper extremities were obtained in patients with lymphedema who were referred by a lymphedema clinic from 2017 to 2019. Axial short-tau inversion recovery MR images of the symptomatic and contralateral arms were retrospectively reviewed and edema severity was graded. Interobserver agreement was calculated. Indocyanine green (ICG) lymphography was compared against MRI stage in symptomatic and contralateral. Age, symptom duration, body mass index (BMI), and history of chemotherapy were compared between patients with and without contralateral limb lymphedema. ICG severity was compared against MRI stage. Seventy-eight patients were analyzed. The MRI stages of symptomatic versus contralateral arms were 1.7 ± 1.1 versus 0.1 ± 0.4 (p < 0.00001). Interobserver agreement was 0.86 (0.79-0.94). Of the patients with MRI Stage 1 or above in the symptomatic arm (n = 64), 55 (82.1%) patients demonstrated no abnormality in the contralateral arm. Nine patients (14.1%) demonstrated asymptomatic edema (MRI Stage 1). The mean ICG lymphography stage of symptomatic versus contralateral arms was 1.83 ± 0.96 versus 0.04 ± 0.25 (p < 0.00001). There was no difference in the age, symptom duration, BMI, or history of chemotherapy between patients with or without edema in the contralateral arm.
Conclusion: Asymptomatic contralateral edema was detected in 14.1% of patients with unilateral secondary upper extremity lymphedema using MRI modality.
DOI: 10.1089/lrb.2021.0022
Bloom, Joshua A. MD; Granoff, Melisa D. BA; Karlsson, Tobias MD; Greene, Arin K. MD, MMSc; Brorson, Håkan, MD, PhD; Chatterjee, Abhishek, MD, MBA; Singhal, Dhruv MD
Power-assisted Liposuction for Lymphedema: A Cost-utility Analysis
Background: Lymphedema is a chronic, debilitating disease that has been described as the largest breast cancer survivorship burden. Debulking surgery has been shown to improve extremity volume, improve patient quality of life, and decrease the incidence of cellulitis in the literature. This procedure is routinely covered in numerous other developed countries, yet it is still inconsistently covered in the United States.
Methods: Extremity volumes from all patients who underwent debulking surgery of the upper extremity at two institutions between December 2017 and January 2020 with at least 12 months follow-up were included. Procedural costs were calculated using Medicare reimbursement data. Average utility scores were obtained for each health state using a visual analog scale, then converted to quality-adjusted life years. A decision tree was generated, and incremental cost-utility ratios were calculated. Sensitivity analyses were performed to evaluate our findings.
Results: Debulking surgery is associated with a higher clinical effectiveness (quality-adjusted life year) of 27.05 compared to conservative management (23.34), with a relative cost reduction of $74,487. Rollback analysis favored debulking surgery as the cost-effective option compared to conservative management. The resulting
negative incremental cost-utility ratio of −20,115.07 favored debulking surgery and indicated a dominant strategy.
Conclusion: Our study supports the use of debulking surgery for the treatment of chronic
lymphedema of the upper extremity. (Plast Reconstr Surg Glob Open 2022;10:e4671; doi:
10.1097/GOX.0000000000004671; Published online 18 November 2022.)
Abstract
bottom of page