Re: “Establishing Standards for Centers of Excellence for the Diagnosis and Treatment of Lymphatic Disease” by Chang et al.

Dear Editor:

We read with great interest the article “Establishing Standards for Centers of Excellence for the Diagnosis and Treatment of Lymphatic Disease” by Dr. Chang and colleagues, published online on February 5, 2021. ¹

In this interesting article, the authors provided the requirements for the institution of center of excellence (COE) for lymphatic diseases (LDs). As the authors pointed out, even if LDs have an extremely wide diffusion and a dramatic impact on patients' lives, they are often underrated and misdiagnosed, mainly due to the lack of specific knowledge and training of physician and health care professionals.

In Western countries, most LD cases consist of secondary lymphedema due to oncologic therapies, but as cancer survival rates continuously increase, a greater focus should be put on post-treatment patients' quality of life. ² Patients often lack a referral center, where they can perform a physical assessment, disease classification and staging, targeted imaging, conservative and surgical treatments, and postsurgical follow-up, with trained and certified physicians and therapists.

Even in Italy, where we practice, there is a lack of real points of reference for patients with LD. Therefore, for some years we have created a multidisciplinary team of specialists experienced in LD diagnosis, management, and treatment. We have worked and continue to work to provide the patient with a complete, guided, and easily accessible pathway, which includes diagnostic confirmation of LD through clinical and imaging assessments, patient education for disease management and self-care at home, different types of conservative therapies, imaging guidance for surgical planning (e.g., ultrasound or computed tomography mapping of the most suitable areas of flap harvesting for the autologous lymph node transplantation), various surgical treatment options, and clinical and radiological follow-ups. We directly provide part of the services and, in part, we rely on a network of LD specialists to allow optimal management of the disease (e.g., several physiotherapists distributed all over our region to facilitate access to patients). Another pivotal part of our work consists of research and publication activities, continuous updating on the literature, periodic multidisciplinary meetings for the discussion of clinical cases, reporting of patients' outcomes, participation in lymphatic congresses/events to improve our skills, but also in conferences of other medical specialties to raise awareness among colleagues on the issue of LDs.

We congratulate Dr. Chang and colleagues for their excellent article and for their commitment to improving the management and standard of care of patients affected by LD. This article provides a precious list of criteria to organize and check the adequacy of a COE for LD: the standards are high, but we are ready to take up the challenge to offer an ever-better service to our patients, and we hope that other teams and centers around the world will want to do the same.