Ultrasound: Assessment of breast dermal thickness: Reliability, responsiveness to change, and relationship to patient-reported outcomes

Sharon L Kilbreath, Nicola R Fearn, Elizabeth S Dylke, Sharon L Kilbreath, Nicola R Fearn, Elizabeth S Dylke

Abstract

Background: The current study assessed the level of reliability of ultrasound to assess dermal thickness, a clinical feature of breast lymphedema. Additionally, the relationship of dermal thickness to patient-reported outcomes was investigated.

Methods: Women (n = 82) with unilateral breast edema secondary to treatment of breast cancer were randomized to an exercise or control group. Ultrasound measurements of the unaffected and affected breasts were taken at baseline and 12 weeks later at 3-4 cm superior, medial, inferior, and lateral to the nipple. Additionally, women completed breast-related questions from the European Organization Research and Treatment Committee Quality of Life breast cancer module (EORTC-BR23) and Lymphedema Symptom Intensity and Distress Questionnaire (LSIDS). Reliability of ultrasound measurements was determined on the unaffected breast.

Results: Intraclass correlation coefficients (2,1) ranged from 0.66 (95% CI: 0.52-0.77) for the lateral location to 0.84 (0.77-0.90) for the superior location. Percent close agreement (80%) on the unaffected breast ranged from 0.20 to 0.27 mm compared to 0.57 to 0.93 mm on the affected breast. The standard error of measurement (%) on the unaffected breast varied from 9% to 13% with smallest real difference 0.34-0.41 mm. Dermal thickness of the affected breast was not-to-poorly associated with EORTC BR23 and LSIDS scores.

Conclusion: Reliability of dermal thickness measurements of the breast was excellent for the superior, medial, and inferior locations, and fair to good for the lateral location. However, these measurements were not related to the symptom's women perceive and measured with the EORTC BR23 or LSIDS.

Keywords: breast; lymphedema; reliability; smallest real difference; standard error of measurement.

© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Figures

FIGURE 1
FIGURE 1
Bland–Altman plots for measurements of dermal thickness using ultrasound for the unaffected (left) and affected (right) breast regions
FIGURE 2
FIGURE 2
Percent close agreement for dermal thickness measures for each breast location. Unaffected breast measurements (solid black line), affected breast measurements (dotted black line); 80% close agreement (gray short dash line)
FIGURE 3
FIGURE 3
Responsiveness of affected breast dermal thickness for the exercise group (n = 39) and usual care group (n = 43). Change in dermal thickness categorized as increased; no change; or decreased based on whether the change exceeded the smallest real difference

References

    1. Dylke ES, Ward LC, Meerkin JD, Nery L, Kilbreath SL. Tissue composition changes and secondary lymphedema. Lymphat Res Biol. 2013;11(4):211–8.
    1. Rockson SG, Keeley V, Kilbreath S, Szuba A, Towers A. Cancer‐associated secondary lymphoedema. Nat Rev Dis Primers. 2019;5(1):22.
    1. Iyer D, Jannaway M, Yang Y, Scallan JP. Lymphatic valves and lymph flow in cancer‐related lymphedema. Cancers. 2020;12(8):2297.
    1. Dylke ES, Benincasa Nakagawa H, Lin L, Clarke JL, Kilbreath SL. Reliability and diagnostic thresholds for ultrasound measurements of dermal thickness in breast lymphedema. Lymphat Res Biol. 2018;16(3):258–62.
    1. Suami H. Anatomical theories of the pathophysiology of cancer‐related lymphoedema. Cancers. 2020;12(5):1338.
    1. Devoogdt N, Pans S, De Groef A, Geraerts I, Christiaens MR, Neven P, et al. Postoperative evolution of thickness and echogenicity of cutis and subcutis of patients with and without breast cancer‐related lymphedema. Lymphat Res Biol. 2014;12(1):23–31.
    1. Naouri M, Samimi M, Atlan M, Perrodeau E, Vallin C, Zakine G, et al. High‐resolution cutaneous ultrasonography to differentiate lipoedema from lymphoedema. Br J Dermatol. 2010;163(2):296–301.
    1. Sierla R, Lee TS, Black D, Kilbreath SL. Lymphedema following breast cancer: regions affected, severity of symptoms, and benefits of treatment from the patients' perspective. Clin J Oncol Nurs. 2013;17(3):325–31.
    1. Verbelen H, De Vrieze T, Van Soom T, Meirte J, Van Goethem M, Hufkens G, et al. Development and clinimetric properties of the Dutch Breast Edema Questionnaire (BrEQ‐Dutch version) to diagnose the presence of breast edema in breast cancer patients. Qual Life Res. 2020;29(2):569–78.
    1. Ridner SH, Deng J, Doersam JK, Dietrich MS. Lymphedema Symptom Intensity and Distress Surveys—Truncal and Head and Neck, Version 2.0. Lymphat Res Biol. 2020;19:240–248.
    1. Kovacs L, Eder M, Hollweck R, Zimmermann A, Settles M, Schneider A, et al. Comparison between breast volume measurement using 3D surface imaging and classical techniques. Breast. 2007;16(2):137–45.
    1. Longo B, Farcomeni A, Ferri G, Campanale A, Sorotos M, Santanelli F. The BREAST‐V: a unifying predictive formula for volume assessment in small, medium, and large breasts. Plast Reconstr Surg. 2013;132(1):1e–7e.
    1. Degnim AC, Hoskin TL, Cheville AL, Miller JP, Gamble GL, Baddour LM, et al. Skin thickness as a measure of breast lymphedema. Cancer Research. Conference: 31st Annual San Antonio Breast Cancer Symposium. San Antonio, TX, United States. Sponsor: UT Health Science Center San Antonio School of Medicine, American Association for Cancer Research, Baylor College of Medicine . 2009.
    1. Schack LH, Alsner J, Overgaard J, Andreassen CN, Offersen BV. Radiation‐induced morbidity evaluated by high‐frequency ultrasound. Acta Oncol. 2016;55(12):1498–500.
    1. Wratten CR, O'Brien P C, Hamilton CS, Bill D, Kilmurray J, Denham JW. Breast edema in patients undergoing breast‐conserving treatment for breast cancer: assessment via high frequency ultrasound. Breast J. 2007;13(3):266–73.
    1. Kilbreath SL, Ward LC, Davis GM, Degnim AC, Hackett DA, Skinner TL, et al. Reduction of breast lymphoedema secondary to breast cancer: a randomised controlled exercise trial. Breast Cancer Res Treat. 2020;184(2):459–67.
    1. Hjermstad MJ, Fossa SD, Bjordal K, Kaasa S. Test/retest study of the European Organization for Research and Treatment of Cancer Core Quality‐of‐Life Questionnaire. J Clin Oncol. 1995;13(5):1249–54.
    1. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al. The European Organization for Research and Treatment of Cancer QLQ‐C30: a quality‐of‐life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993;85(5):365–76.
    1. Ridner SH, Dietrich MS. Development and validation of the Lymphedema Symptom and Intensity Survey‐Arm. Support Care Cancer. 2015;23(10):3103–12.
    1. Fleiss JL. The design and analysis of clinical experiments. New York: John Wiley Sons; 1986.
    1. de Vet H, Terwee C, Mokkink L, Knol D. Measurement in medicine: a practical guide. New York: Cambridge University Press; 2011.
    1. Lexell JE, Downham DY. How to assess the reliability of measurements in rehabilitation. Am J Phys Med Rehabil. 2005;84(9):719–23.
    1. Akoglu H. User's guide to correlation coefficients. Turk J Emerg Med. 2018;18(3):91–3.
    1. Nedelec B, Forget NJ, Hurtubise T, Cimino S, de Muszka F, Legault A, et al. Skin characteristics: normative data for elasticity, erythema, melanin, and thickness at 16 different anatomical locations. Skin Res Technol. 2016;22(3):263–75.
    1. Adriaenssens N, Belsack D, Buyl R, Ruggiero L, Breucq C, De Mey J, et al. Ultrasound elastography as an objective diagnostic measurement tool for lymphoedema of the treated breast in breast cancer patients following breast conserving surgery and radiotherapy. Radiol Oncol. 2012;46(4):284–95.
    1. Van Mulder TJ, de Koeijer M, Theeten H, Willems D, Van Damme P, Demolder M, et al. High frequency ultrasound to assess skin thickness in healthy adults. Vaccine. 2017;35(14):1810–15.
    1. Phillips J, Reynolds KJ, Gordon SJ. Dermal thickness and echogenicity using DermaScan C high frequency ultrasound: methodology and reliability testing in people with and without primary lymphoedema. Skin Res Technol. 2020;26(6):813–23.
    1. Mi HN, Jung CY, Sun HJ, Dong KH, Yeol CG. Usefulness of ultrasound examination in evaluation of breast cancer‐related lymphedema. J Korean Acad Rehabil Med. 2011;35(1):101–9.
    1. Lucas VS, Burk RS, Creehan S, Grap MJ. Utility of high‐frequency ultrasound: moving beyond the surface to detect changes in skin integrity. Plast Surg Nurs. 2014;34(1):34–8.
    1. Mellor RH, Bush NL, Stanton AW, Bamber JC, Levick JR, Mortimer PS. Dual‐frequency ultrasound examination of skin and subcutis thickness in breast cancer‐related lymphedema. Breast J. 2004;10(6):496–503.
    1. Pezner RD, Patterson MP, Robert Hill L, Desai KR, Vora N, Lipsett JA. Breast edema in patients treated conservatively for stage I and II breast cancer. Int J Radiat Oncol Biol Phys. 1985;11(10):1765–8.
    1. Ronka RH, Pamilo MS, von Smitten KA, Leidenius MH. Breast lymphedema after breast conserving treatment. Acta Oncol. 2004;43(6):551–7.
    1. Tassenoy A, De Mey J, De Ridder F, Van Schuerbeeck P, Vanderhasselt T, Lamote J, et al. Postmastectomy lymphoedema: different patterns of fluid distribution visualised by ultrasound imaging compared with magnetic resonance imaging. Physiotherapy. 2011;97(3):234–43.
    1. Wratten C, Kilmurray J, Wright S, O'Brien P, Back M, Hamilton C, et al. A study of high frequency ultrasound to assess cutaneous oedema in conservatively managed breast. Front Radiat Ther Oncol. 2002;37:121–7.
    1. Hacard F, Machet L, Caille A, Tauveron V, Georgescou G, Rapeneau I, et al. Measurement of skin thickness and skin elasticity to evaluate the effectiveness of intensive decongestive treatment in patients with lymphoedema: a prospective study. Skin Res Technol. 2014;20(3):274–81.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren