Cancer-Related Lymphedema Risk Factors, Diagnosis, Treatment, and Impact: A Review.

Sept 24, 2012

Paskett ED, Dean JA, Oliveri JM, Harrop JP.

Source

All authors: The Ohio State University, Columbus, OH.

Abstract

PURPOSE: 

Cancer-related lymphedema (LE) is an incurable condition associated with lymph-involved cancer treatments and is an increasing health, quality of life (QOL), and cost burden on a growing cancer survivor population. This review examines the evidence for causes, risk,  prevention, diagnosis,  treatment, and impact of this largely unexamined survivorship concern.

METHODS: 

PubMed and Medline were searched for cancer-related LE literature published since 1990 in English. The resulting references (N = 726) were evaluated for strength of design, methods, sample size, and recent publication and sorted into categories (ie, causes/prevention, diagnosis, treatment, and QOL). Sixty studies were included.

RESULTS: 

Exercise and physical activity and sentinel lymph node biopsy reduce risk, and overweight and obesity increase risk. Evidence that physiotherapy reduces risk and that lymph node status and number of malignant nodes increase risk is less strong. Perometry and bioimpedence emerged as attractive diagnostic technologies, replacing the use of water displacement in clinical practice.

Swelling can also be assessed by measuring arm circumference and relying on self-report. Symptoms can be managed, not cured, with complex physical therapy,   low level laser therapy, pharmacotherapy, and surgery. Sequelae of LE negatively affect physical and mental QOL and range in severity. However, the majority of reviewed studies involved patients with breast cancer; therefore, results may not be applicable to all cancers. 

CONCLUSION

Research into causes, prevention, and effect on QOL of LE and information on LE in cancers other than breast is needed. Consensus on definitions and measurement, increased patient and provider awareness of signs and symptoms, and proper and prompt treatment/access, including psychosocial support, are needed to better understand, prevent, and treat LE.

PubMed

Massive localized lymphedema of the male external genitalia: a clinicopathologic study of 6 cases.

Massive localized lymphedema of the male external genitalia: a clinicopathologic study of 6 cases.

Sept 2012

Lee S, Han JS, Ross HM, Epstein JI.

Source

Department of Pathology, The Johns Hopkins Hospital, Baltimore, MD 21287, USA.

Abstract

Massive localized lymphedema is a reactive pseudotumor strongly associated with obesity. The tumor most commonly presents as pendulous masses in the lower limbs with only 3 reported cases involving external male genitalia. In this study, we report an additional 6 cases localized to the external male genitalia. The cases were retrospectively identified from the surgical pathology database of the Johns Hopkins Hospital. All 6 patients were obese (5 presented with diffuse scrotal edema and 1 with a penile mass). 

In all cases, the clinical impression was of a benign chronic process developing over 3 months to 1 year. All 3 cases from outside institutions were referred with benign pathologic diagnoses. The lesions ranged in size from 4 to 55 cm. Microscopically, all cases exhibited stromal fibrosis and edema, multinucleated stromal cells, perivascular chronic inflammation, and lymphangiectasia. Entrapped fat was a minor feature and seen in only 3 cases. Variable hyperplasia and hypertrophy of dartos muscle were noted in 6 lesions. Three cases showed prominent microvascular proliferation around the edge of individual dartos muscle bundles. 

In summary, diagnosis of massive localized lymphedema requires appropriate correlation between clinical and microscopic findings. Lesions in the male external genitalia share many microscopic findings with massive localized lymphedema at other sites, although entrapped adipose tissue is not prominent. Additional, although not specific, findings include variably hyperplastic and hypertrophic dartos muscle and capillary neoangiogenesis at the interface between smooth muscle bundles and stroma.

PubMed

see also: Male Genital Lymphedema

Evaluation of a new approach to the treatment of lymphedema resulting from breast cancer therapy.

Sept 2012

Pereira de Godoy JM, Guerreiro Godoy MD.

Abstract

PURPOSE:

The aim of this study was to evaluate a new form of intensive treatment for arm lymphedema.

METHODS:

A prospective study of 66 patients with breast cancer-related lymphedema was performed. The ages of the patients ranged from 35 to 83years old with a mean of 58.8years. Diagnosis of lymphedema was made by physical examination and water-displacement volumetry (a difference of ≥200mL between arms). All the patients were submitted to clinical treatment in an outpatient setting which involved a once-weekly session of 3 to 4h of manual and mechanical lymph drainage, myolymphokinetic activities and exercising using facilitating apparatuses and the use of a medical compression sleeve. Monthly volumetry evaluations were routinely performed. The Student t-test was employed for statistical analysis with an alpha level of 5% being considered significant.

RESULTS:

The mean follow-up time between cancer treatment and this study was 12.3months. A significant reduction in the size of the arms was observed for all patients. The mean difference between the lymphedematous and normal arms of all patients was 553.8mL at the start of treatment and a mean reduction of 70.1% (388.7mL) of the edema was achieved (p=0.0001).

CONCLUSION:

In our experience, this model of treatment appeared efficacious in decreasing and maintaining the reduction in volume of arm in breast cancer-related lymphedema.

PubMed

Management of lymphedema.

Jul 2012

Vojáčková N, Fialová J, Hercogová J.

Source

Dermatovenereology Department, Charles University 2nd Medical School and Bulovka Hospital, Prague, Czech Republic.

Abstract

The basic principle of the management of lymphedema is so called complex decongestive physical therapy. This therapy is divided into two phases: (i) edema reduction phase - an initial intensive treatment phase aiming for limb volume reduction; and (ii) maintenance phase - following long-term phase to sustain a manageable limb volume. The first phase consists of a number of physical therapeutic approaches which are: manual lymph drainage, pneumatic pump drainage, low-stretch bandaging, exercises, and skin care. Long-term maintenance phase consists of self-lymph drainage, low-stretch bandaging, or compressive garments, and sometimes when indicated pneumatic pump drainage, exercises, and skin care.

Wiley OnLine

Low-invasive lymphatic surgery and lymphatic imaging for completely healed intractable pudendal lymphorrhea after gynecologic cancer treatment.

Sept 2012

Mihara M, Hara H, Narushima M, Mitsui K, Murai N, Koshima I.

Source

Department of Plastic Surgery and Reconstructive Surgery, University of Tokyo, Tokyo, Japan.

Abstract

Lower limb lymphedema and an accompanying lymphatic fistula (lymphorrhea) occur as complications after gynecologic surgery to treat cancer. Herein, we report the case of a 68-year-old woman who underwent resection and radiotherapy because of uterine cervical cancer (stage 2a) 20 years previously. Left lower limb and pudendal lymphedema and continuous lymphorrhea developed soon after surgery. Conservative treatment was administered; however, the edema increased, and a pudendal lymphatic fistula and cellulitis developed repeatedly. Lymphovascular anastomosis (LVA) and lymph vessel ligation were performed after preoperative evaluation via lymphoscintigraphy and indocyanine green (ICG) lymphography. A radioisotope injected into the first interdigit pedal region flowed into the pudendal region via the inguinal lymph nodes at preoperative lymphoscintigraphy. Linear patterns were observed up to the half level of the crus, and stardust patterns occurred over the lower abdominal and pudendal regions at ICG lymphography. During surgery, ICG lymphography was also used to identify the site of the fistula. With the patient under local anesthesia, LVA was applied in the half crus and left inguinal regions, followed by ligation and division of lymph vessels flowing into the fistula. The region around the fistula was excised as a 1 × 3-cm tissue block. As of 5 months after surgery, no recurrence of lymphatic fistula or exacerbation of lymphedema has occurred. This case shows the effectiveness of preoperative ICG lymphography and lymphoscintigraphy followed by treatment via lymph vessel ligation and LVA for curative resolution of a lymphatic fistula.

PubMed

For further information on Lymphoscintigraphy