{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T01:04:05Z","timestamp":1790643845899,"version":"4.1.0"},"reference-count":39,"publisher":"MDPI AG","issue":"24","license":[{"start":{"date-parts":[[2024,12,15]],"date-time":"2024-12-15T00:00:00Z","timestamp":1734220800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>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.<\/jats:p>","DOI":"10.3390\/diagnostics14242824","type":"journal-article","created":{"date-parts":[[2024,12,16]],"date-time":"2024-12-16T09:17:58Z","timestamp":1734340678000},"page":"2824","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["Ultrasound Examination of Skin, Fasciae and Subcutaneous Tissue: Optimizing Rehabilitation for Secondary Upper Limb Lymphedema"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0119-6549","authenticated-orcid":false,"given":"Carmelo","family":"Pirri","sequence":"first","affiliation":[{"name":"Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chiara","family":"Ferraretto","sequence":"additional","affiliation":[{"name":"Physical Medicine and Rehabilitation School, University of Padova, Via Nicol\u00f2 Giustiniani, 2, 35128 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nina","family":"Pirri","sequence":"additional","affiliation":[{"name":"Department of Medicine\u2014DIMED, School of Radiology, Radiology Institute, University of Padova, 35122 Padova, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lara","family":"Bonaldo","sequence":"additional","affiliation":[{"name":"Department of Neuroscience, Section of Rehabilitation, University of Padova, 35121 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2307-0277","authenticated-orcid":false,"given":"Raffaele","family":"De Caro","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0361-4898","authenticated-orcid":false,"given":"Stefano","family":"Masiero","sequence":"additional","affiliation":[{"name":"Department of Neuroscience, Section of Rehabilitation, University of Padova, 35121 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8767-4555","authenticated-orcid":false,"given":"Carla","family":"Stecco","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,12,15]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1016\/j.suronc.2020.09.005","article-title":"Epidemiology of Lymphedema-related admissions in the United States: 2012\u20132017","volume":"35","author":"Lopez","year":"2020","journal-title":"Surg. Oncol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"500","DOI":"10.1016\/S1470-2045(13)70076-7","article-title":"Incidence of unilateral arm lymphoedema after breast cancer: A systematic review and meta-analysis","volume":"14","author":"DiSipio","year":"2013","journal-title":"Lancet Oncol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1016\/j.jpainsymman.2006.10.015","article-title":"Symptom prevalence in patients with incurable cancer: A systematic review","volume":"34","author":"Teunissen","year":"2007","journal-title":"J. Pain Symptom Manag."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"468","DOI":"10.1089\/lrb.2021.0062","article-title":"LIMPRINT in Italy","volume":"19","author":"Cestari","year":"2021","journal-title":"Lymphat. Res. Biol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1007\/s12032-024-02472-9","article-title":"Current diagnostic and quantitative techniques in the field of lymphedema management: A critical review","volume":"41","author":"Vargo","year":"2024","journal-title":"Med. Oncol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2003","DOI":"10.1161\/CIRCRESAHA.121.318307","article-title":"Advances in Lymphedema","volume":"128","author":"Rockson","year":"2021","journal-title":"Circ. Res."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"321","DOI":"10.1177\/1358863X9700200408","article-title":"Lymphedema: Anatomy, physiology and pathogenesis","volume":"2","author":"Szuba","year":"1997","journal-title":"Vasc. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1038\/s41572-019-0072-5","article-title":"Cancer-associated secondary lymphoedema","volume":"5","author":"Rockson","year":"2019","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"731","DOI":"10.1093\/qjmed\/hcg126","article-title":"Lymphoedema: An underestimated health problem","volume":"96","author":"Moffatt","year":"2003","journal-title":"QJM Mon. J. Assoc. Physicians"},{"key":"ref_10","first-page":"101","article-title":"Usefulness of Ultrasound Examination in Evaluation of Breast Cancer-Related Lymphedema","volume":"35","author":"Han","year":"2011","journal-title":"J. Korean Acad. Rehab. Med."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Executive Committee of the International Society of Lymphology (2020). The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology. Lymphology, 53, 3\u201319.","DOI":"10.2458\/lymph.4649"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1016\/j.jvsv.2016.10.083","article-title":"New diagnostic modalities in the evaluation of lymphedema","volume":"5","author":"Rasmussen","year":"2017","journal-title":"J. Vasc. Surg. Venous Lymphat. Disord."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1458385","DOI":"10.3389\/fneur.2024.1458385","article-title":"Fascia as a regulatory system in health and disease","volume":"15","author":"Slater","year":"2024","journal-title":"Front Neurol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1111\/srt.13084","article-title":"Elastic Fibres in the subcutaneous tissue: Is there a difference between superficial and muscular fascia? A cadaver study","volume":"28","author":"Pirri","year":"2022","journal-title":"Skin Res. Technol."},{"key":"ref_15","first-page":"319","article-title":"Role of physiotherapy and patient education in lymphedema control following breast cancer surgery","volume":"11","author":"Lu","year":"2015","journal-title":"Ther. Clin. Risk Manag."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"380","DOI":"10.1159\/000487428","article-title":"Does Exercise Have a Preventive Effect on Secondary Lymphedema in Breast Cancer Patients Following Local Treatment?\u2014A Systematic Review","volume":"13","author":"Baumann","year":"2018","journal-title":"Breast Care"},{"key":"ref_17","first-page":"103","article-title":"Efficacy of manual lymphatic drainage in preventing secondary lymphedema after breast cancer surgery","volume":"45","author":"Zimmermann","year":"2012","journal-title":"Lymphology"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1007\/s12032-024-02447-w","article-title":"The effect of compression therapies and therapeutic modalities on lymphedema secondary to cancer: A rapid review and evidence map","volume":"41","author":"McNeely","year":"2024","journal-title":"Med. Oncol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/s10549-023-06947-7","article-title":"Advances in the prevention and treatment of breast cancer-related lymphedema","volume":"200","author":"Donahue","year":"2023","journal-title":"Breast Cancer Res. Treat."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"S26","DOI":"10.12968\/bjcn.2024.0107","article-title":"Breast cancer-related lymphoedema: Advances and outstanding issues","volume":"29","author":"Greener","year":"2024","journal-title":"Br. J. Community Nurs."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Pirri, C., Pirri, N., Guidolin, D., Macchi, V., De Caro, R., and Stecco, C. (2022). Ultrasound Imaging of the Superficial Fascia in the Upper Limb: Arm and Forearm. Diagnostics, 12.","DOI":"10.3390\/diagnostics12081884"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Pirri, C., Pirri, N., Porzionato, A., Boscolo-Berto, R., De Caro, R., and Stecco, C. (2022). Inter- and Intra-Rater Reliability of Ultrasound Measurements of Superficial and Deep Fasciae Thickness in Upper Limb. Diagnostics, 12.","DOI":"10.3390\/diagnostics12092195"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"344","DOI":"10.1016\/j.jclinepi.2007.11.008","article-title":"STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies","volume":"61","author":"Altman","year":"2008","journal-title":"J. Clin. Epidemiol."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"(2013). World Medical Association declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA, 310, 2191\u20132194.","DOI":"10.1001\/jama.2013.281053"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1016\/j.apmr.2018.08.185","article-title":"Intra- and Interrater Reliability and Concurrent Validity of a New Tool for Assessment of Breast Cancer-Related Lymphedema of the Upper Extremity","volume":"100","author":"Spinelli","year":"2019","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"334","DOI":"10.23736\/S0392-9590.19.04176-2","article-title":"Upper limb secondary lymphedema ultrasound mapping and characterization","volume":"38","author":"Mander","year":"2019","journal-title":"Int. Angiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"157","DOI":"10.5694\/mja16.00416","article-title":"Pitting and non-pitting oedema","volume":"205","author":"Whiting","year":"2016","journal-title":"Med. J. Aust."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1111\/j.1365-2354.1995.tb00047.x","article-title":"Volume measurement in lymphoedema treatment: Examination of formulae","volume":"4","author":"Sitzia","year":"1995","journal-title":"Eur. J. Cancer Care"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1304","DOI":"10.1037\/0003-066X.45.12.1304","article-title":"Things I have learned (so far)","volume":"45","author":"Cohen","year":"1990","journal-title":"Am. Psychol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1111\/j.1075-122X.2004.21458.x","article-title":"Dual-frequency ultrasound examination of skin and subcutis thickness in breast cancer-related lymphedema","volume":"10","author":"Mellor","year":"2004","journal-title":"Breast J."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"757","DOI":"10.1007\/s40477-021-00633-4","article-title":"From physical to ultrasound examination in lymphedema: A novel dynamic approach","volume":"25","author":"Ricci","year":"2022","journal-title":"J. Ultrasound"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1089\/lrb.2013.0028","article-title":"Postoperative evolution of thickness and echogenicity of cutis and subcutis of patients with and without breast cancer-related lymphedema","volume":"12","author":"Devoogdt","year":"2014","journal-title":"Lymphat. Res. Biol."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Rehnke, R.D. (2024). Clinical Implications of the Fascial System: A Commentary on One Surgeon\u2019s Journey. Life, 14.","DOI":"10.3390\/life14010089"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"518","DOI":"10.1089\/lrb.2018.0053","article-title":"Interrater and intrarater reliability of subcutaneous echogenicity grade and subcutaneous echo-free space grade in breast cancer-related lymphedema","volume":"17","author":"Giray","year":"2019","journal-title":"Lymphat. Res. Biol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1054\/brst.2000.0256","article-title":"A key to understanding postoperative lymphoedema: A study on the evolution and consistency of oedema of the arm using ultrasound imaging","volume":"10","author":"Vermeiren","year":"2001","journal-title":"Breast."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"525","DOI":"10.1089\/lrb.2017.0090","article-title":"Characterizing lower extremity lymphedema and lipedema with cutaneous ultrasonography and an objective computer-assisted measurement of dermal echogenicity","volume":"17","author":"Iker","year":"2019","journal-title":"Lymphat. Res. Biol."},{"key":"ref_37","unstructured":"Standring, S. (2016). Gray\u2019s Anatomy: The Anatomical Basis of Clinical Practice, Elsevier Churchill Livingstone. [41st ed.]."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1965","DOI":"10.2522\/ptj.20150412","article-title":"Measurement Properties of Instruments for Measuring of Lymphedema: Systematic Review","volume":"96","author":"Hidding","year":"2016","journal-title":"Phys. Ther."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1089\/lrb.2019.0082","article-title":"Estimates for Assessment of Lymphedema: Reliability and Validity of Extremity Measurements","volume":"20","author":"Houwen","year":"2022","journal-title":"Lymphat. Res. Biol."}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/14\/24\/2824\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T16:52:36Z","timestamp":1760115156000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/14\/24\/2824"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,15]]},"references-count":39,"journal-issue":{"issue":"24","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["diagnostics14242824"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics14242824","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,12,15]]}}}