Background
Materials and methods
Study design
Primary outcome
Eligibility criteria
Study definitions
ISL classification
Data collection
Variables
Statistics
Results
Study sites and population
Demographics
Characteristic(s) | Number of patients (%) |
---|---|
Clinical area | |
Community care | 1 (0.05) |
Hospital services | 238 (11.02) |
Lymphoedema specialist | 1917 (88.75) |
Other | 4 (0.19) |
missing | 0 |
Age, mean (sd) | 60.79 (12.89) |
missing | 0 |
Female | 2063 (95.51) |
missing | 0 |
Weight category | |
Underweight | 23 (1.07) |
Normal weight | 1430 (66.30) |
Obesity | 635 (29.44) |
Morbid obesity | 69 (3.20) |
missing | 3 |
Concomitant disease | |
Diabetes | 210 (9.72) |
missing | 0 |
Heart failure/ ischemic heart disease | 102 (4.72) |
missing | 0 |
Neurological disease | 52 (2.41) |
missing | 3 |
Classification of lymphoedema | |
Primary | 48 (2.23) |
Secondary (all causes) | 2107 (97.77) |
missing | 5 |
Non-cancer secondary causes of lymphoedema | 99 (4.71) |
Trauma or surgical procedures | 25 |
Venous disorder incl. thrombotic | 10 |
Immobility | 8 |
Skin disorders incl. cellulitis | 11 |
Obesity | 1 |
Multiple contributing factors | 10 |
Other or unknown | 29 |
missing | 5 |
Cancer-related secondary lymphoedema | 2000 (95.28) |
missing | 8 |
Cancer treatment | 1947 (97.50) |
missing | 3 |
Metastatic disease | 72 (3.61) |
missing | 3 |
Cancer type | |
Breast | 450 |
Bladder | 7 |
Melanoma | 4 |
Endometrial | 1 |
Head and neck | 1 |
Ovarian | 1 |
Other | 3 |
missing | 0 |
Duration of arm lymphoedema | |
< 1 year | 515 (23.86) |
1–2 years | 349 (16.17) |
2–5 years | 557 (25.81) |
> 5–10 years | 445 (20.62) |
> 10 years | 292 (13.53) |
missing | 2 |
General Mobility | |
Normal | 1992 (92.31) |
Walking aid | 136 (6.30) |
Chair/ bed bound | 30 (1.39) |
missing | 2 |
Arm mobility | |
Full | 1586 (73.49) |
Limited/ none | 573 (26.51) |
missing | 2 |
Lifetime cellulitis | 483 (22.36) |
missing | 0 |
Recent cellulitis (< 12 months) | 243 (11.25) |
missing | 0 |
Upper torso swelling | 679 (31.44) |
missing | 0 |
Presence of an arm wound | 15 (0.70) |
missing | 4 |
Treatment with compression therapy | |
Compression garment | 1731 (80.32) |
Multilayer bandage | 725 (33.46) |
Compression wrap | 114 (5.27) |
At least one of the above | 1782 (82.58) |
No compression | 376 (17.42) |
missing | 2 |
Good control of lymphoedema (well-controlled swelling) | 1364 (74.09) |
missing | 319 |
Frequency of cellulitis
Country | Total number of patients with lymphoedema of the arm | History of cellulitis (< 12 months) | Percentage |
---|---|---|---|
Australia | 1 | 0 | 0 |
Ireland | 3 | 0 | 0 |
United Kingdom | 991 | 91 | 9.18 |
Italy | 545 | 58 | 10.64 |
Japan | 27 | 3 | 11.11 |
Turkey | 433 | 59 | 13.63 |
France | 129 | 24 | 18.60 |
Denmark | 31 | 7 | 22.58 |
Total | 2160 | 242 | 11.20 |
Factors associated with cellulitis: univariate analysis
Risk factor | No cellulitis N (%) | Cellulitis N (%) | OR 95% CI | P-value |
---|---|---|---|---|
Sex | ||||
Female | 1830 (95.41) | 233 (96.28) | 1.00 | |
Male | 88 (4.59) | 9 (3.72) | 0.80 (0.40, 1.62) | 0.54 |
Age | ||||
< 45 years | 193 (10.07) | 16 (6.64) | 1.00 | |
45–64 years | 977 (50.97) | 126 (52.28) | 1.56 (0.90, 2.68) | |
65–74 years | 432 (22.54) | 65 (26.97) | 1.81 (1.02, 3.22) | 0.27 |
75–84 years | 262 (13.67) | 28 (11.62) | 1.30 (0.68, 2.45) | |
85 + years | 53 (2.76) | 6 (2.49) | 1.37 (0.51, 3.66) | |
Weight category | ||||
Normal weight | 1274 (66.49) | 156 (64.73) | 1.00 | |
Under weight | 22 (1.15) | 1 (0.41) | 0.37 (0.05, 2.77) | |
Obesity | 559 (29.18) | 76 (31.54) | 1.11 (0.83, 1.49) | 0.66 |
Morbid obesity | 61 (3.18) | 8 (3.32) | 1.07 (0.50, 2.28) | |
Leg mobility | ||||
Walks unaided | 1760 (91.81) | 231 (95.85) | 1.00 | |
Walks with aid | 131 (6.83) | 6 (2.49) | 0.35 (0.15, 0.80) | 0.03 |
Chair/bed bound | 26 (1.36) | 4 (1.66) | 1.17 (0.41, 3.39) | |
Arm mobility | ||||
Full | 1410 (73.55) | 176 (73.03) | 1.00 | |
Limited/ none | 507 (26.45) | 65 (27.69) | 1.03 (0.76, 1.39) | 0.86 |
Diabetes | ||||
Absent | 1730 (90.20) | 220 (90.91) | 1.00 | |
Present | 188 (9.80) | 23 (9.09) | 0.92 (0.58, 1.46) | 0.73 |
Heart failure/ ischemic heart disease | ||||
Absent | 1827 (95.26) | 231 (95.45) | 1.00 | |
Present | 91 (4.74) | 11 (4.55) | 0.96 (0.50, 1.81) | 0.89 |
Neurological disease | ||||
Absent | 1863 (97.28) | 242 (100.00) | ||
Present | 52 (2.72) | 0 (0)* | 0.009 |
No cellulitis N (%) | Cellulitis N (%) | OR 95% CI | P-value | |
---|---|---|---|---|
Lymphoedema duration n = 2158 | ||||
< 1 year | 485 (25.31) | 30 (12.40) | 1.00 | |
1–2 years | 310 (16.18) | 39 (16.12) | 2.03 (1.24, 3.34) | |
2–5 years | 478 (24.95) | 79 (32.64) | 2.67 (1.72, 4.14) | < 0.001 |
5–10 years | 378 (19.73) | 67 (27.69) | 2.87 (1.83, 4.50) | |
> 10 years | 265 (13.83) | 27 (11.16) | 1.65 (0.96, 2.83) | |
Classification of lymphoedema n = 2155 | ||||
Primary | 41 (2.14) | 7 (2.89) | 1.00 | |
Secondary | 1872 (97.86) | 235 (97.11) | 0.74 (0.33, 1.66) | 0.46 |
Secondary lymphoedema n = 2099 | ||||
Cancer-related | 1778 (95.28) | 222 (95.28) | 1.00 | |
Non-cancer-related | 88 (4.72) | 11 (4.72) | 1.00 (0.52, 1.90) | 0.99 |
Cancer-related secondary lymphoedema n = 1997 | ||||
Cancer treatment | ||||
Absent | 45 (2.54) | 5 (2.25) | 1.00 | |
Present | 1730 (97.46) | 217 (97.75) | 1.13 (0.44, 2.87) | 0.80 |
Cancer metastatic | ||||
Absent | 1709 (96.28) | 216 (97.30) | 1.00 | |
Present | 66 (3.72) | 6 (2.70) | 0.72 (0.31, 1.68) | 0.44 |
Concomitant upper torso swelling | ||||
Absent | 1311 (68.35) | 170 (70.25) | 1.00 | |
Present | 607 (31.65) | 72 (29.75) | 0.91 (0.68, 1.22) | 0.55 |
Arm wound | ||||
Absent | 1902 (99.32) | 239 (99.17) | 1.00 | |
Present | 13 (0.68) | 2 (0.83) | 1.22 (0.27, 5.46) | 0.79 |
Treatment with compression n = 2159 | ||||
Absent | 348 (18.16) | 28 (11.59) | 1.00 | |
Present | 1568 (81.84) | 214 (88.43) | 1.69 (1.12, 2.56) | 0.011 |
Control of lymphoedema n = 1841 | ||||
Not controlled | 402 (24.71) | 75 (35.05) | 1.00 | |
Good control | 1225 (75.29) | 139 (64.95) | 0.62 (0.46, 0.83) | 0.001 |
Factors associated with cellulitis: multivariable analysis
OR 95% CI | P-value | |
---|---|---|
Lympoedema duration | ||
< 1 year | 1.00 | |
1–2 years | 2.15 (1.74, 3.72) | |
2–5 years | 2.86 (1.76, 4.65) | < 0.001 |
5–10 years | 3.15 (1.92, 5.17) | |
> 10 years | 1.70 (0.93, 3.09) | |
Control of lymphoedema | ||
Not controlled | 1.00 | |
Good control | 0.54 (0.39, 0.73) | < 0.001 |
Lymphoedema-related factors associated with cellulitis
No cellulitis N (%) | Cellulitis N (%) | OR 95%CI | P-value | |
---|---|---|---|---|
Pitting (n = 459) | ||||
Non pitting | 232 (58.44) | 29 (46.77) | 1.00 | |
Pitting | 165 (41.56) | 33 (53.23) | 1.60 (0.93, 2.74) | 0.085 |
Tissue quality (n = 459) | ||||
Soft | 314 (79.09) | 42 (67.74) | 1.00 | |
Hard (fibrotic) | 83 (20.91) | 20 (32.26) | 1.80 (1.00, 3.23) | 0.046 |
Stemmer’s sign (n = 458) | ||||
Negative | 217 (54.80) | 18 (29.03) | 1.00 | |
Positive | 179 (45.20) | 44 (70.97) | 2.96 (1.65, 5.31) | < 0.001 |
ISL scale* (n = 460) | ||||
Stage I | 139 (34.92) | 5 (8.06) | 1.00 | |
Stage II | 240 (60.30) | 50 (80.65) | 5.79 (2.26, 14.87) | < 0.001 |
Stage III | 19 (4.77) | 7 (11.29) | 10.24 (2.95, 35.53) | |
ISL scale* after adjustment for lymphoedema duration and control by logistic regression (n = 326) | ||||
Stage I | 1.00 | |||
Stage II | 5.44 (1.59, 18.60) | 0.002 | ||
Stage III | 9.13 (1.99, 41.84) |