Ultrasound Examination of Skin, Fasciae and Subcutaneous Tissue: Optimizing Rehabilitation for Secondary Upper Limb Lymphedema

Abstract

Background: Lymphedema represents a frequent cause of disability for patients undergoing oncological treatments and, being a chronic, non-reversible pathology, requires targeted and continuous rehabilitation treatments. To date, the studies available on the use of ultrasound in patients with lymphedema mainly report descriptive data; therefore, with this study, we wanted to describe in a more objective way the typical ultrasound alterations found in these patients, measuring the thickness of the different superficial structures, and defining subcutis echogenicity. Methods: 14 patients affected by secondary lymphedema of the upper limbs were enrolled in this cross-sectional observational study (12 had breast cancer and 2 with melanoma as their primary diagnosis). All patients were classified as stage II according to the ISL classification. Patients were examined between March and July 2023 with a clinical and an ultrasound evaluation. Ultrasound evaluation was performed following a protocol and took into consideration thickness of the cutis, subcutis, superficial and deep fascia, and subcutis echogenicity. Results: The cutis of the affected limbs was thicker in the distal anterior region of the arm and throughout the anterior region of the forearm. The subcutaneous tissue was thicker in the posterior region of the distal arm and throughout the forearm, including the dorsum of the hand and excluding only the proximal posterior region of the forearm. Fascial structures did not demonstrate statistically significant differences in thickness between pathological and healthy limbs, despite undergoing significant changes from a qualitative point of view (loss of the trilaminar skin appearance and the development of anechoic areas due to fluid accumulation around the hyperechoic adipose lobule). A statistically significant difference in the echogenicity of subcutaneous tissue was found at the distal anterior region of the arm and at the entire anterior forearm. Conclusions: High-resolution ultrasound has been confirmed to be a tool capable of supporting the diagnosis of lymphedema and identifying the most compromised regions of the limb. A tailored rehabilitation plan can be developed based on the non-uniform alterations in subcutaneous tissue, where some areas are affected earlier than others. This compartmentalization should be considered in lymphedema staging and management. Ultrasound may provide early detection of these changes, guiding a more precise therapeutic approach.