Early Diagnosis and Risk Factors for Lymphedema following Lymph Node Dissection for Gynecologic Cancer

Early Diagnosis and Risk Factors for Lymphedema following Lymph Node Dissection for Gynecologic Cancer.

**My only concern here is the way they reported one stat. In reporting that 50 individuals had dermal backflow (triggering swelling?). They weren't clear about this AND they reported all had symptoms go away within 3 months.  What that tells me (just a humble patient) is that these individual are very likely going to show up with lower limb LE during their life time.  The over all stats for gynecological cancer does in some cases, run about 50%. - Pat**

Early Diagnosis and Risk Factors for Lymphedema following Lymph Node Dissection for Gynecologic Cancer.

Feb 2013

Akita S, Mitsukawa N, Rikihisa N, Kubota Y, Omori N, Mitsuhashi A, Tate S, Shozu M, Satoh K.

Source

Chiba City, Japan From the Departments of Plastic, Reconstructive, and Aesthetic Surgery and Reproductive Medicine, Chiba University, Faculty of Medicine.

Abstract

BACKGROUND:
Although early diagnosis is important for selecting an effective surgical treatment for secondary lymphedema, an efficient screening test for detecting early-stage lymphedema has not yet been established. Serial changes of lymphatic function before and after lymph node dissection and risk factors for secondary lymphedema are important indicators.

METHODS:
A prospective cohort observational study was conducted with 100 consecutive gynecologic cancer patients who underwent pelvic lymph node dissection. Lymphatic function was assessed by noninvasive lymphography using indocyanine green fluorescence imaging on a routine schedule. Earliest findings after lymphadenectomy and risk factors for lower leg lymphedema were investigated.

RESULTS:
Atypical transient dermal backflow patterns were observed in an early postoperative period in 50 cases, all of which disappeared within 3 months. Of these patterns, the splash pattern was observed in 31 patients, of which five improved to normal following a natural course. In contrast, the stardust pattern was observed in 27 patients, and none had improved with conservative therapy. Postoperative radiotherapy was a significant risk factor for the stardust pattern.

CONCLUSIONS:
All patients who undergo lymphadenectomy for gynecologic malignancies should be examined for secondary lower extremity lymphedema by qualitative evaluation methods on a routine schedule to determine the earliest possible diagnosis. Because the splash pattern on indocyanine green lymphography is a reversible lymphatic disorder following a natural course, surgical treatments are not recommended. The decision regarding surgical treatment can be made after observing the stardust pattern.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Diagnostic, IV.

Pub Med

Complex Decongestive Physiotherapy Treats Skin Changes like Hyperkeratosis Caused by Lymphedema.

2012

Kaba H, Bakar Y, Ozdemir OÇ, Sertel S.

Source

School of Physical Therapy and Rehabilitation, Abant Izzet Baysal University, 14280 Bolu, Turkey.

Abstract

Lymphedema is a chronic, progressive, and often debilitating condition. Primary lymphedema is a lymphatic malformation developing during the later stage of lymph angiogenesis. Secondary lymphedema is the result of obstruction or disruption of the lymphatic system, which can occur as a consequence of tumors, surgery, trauma, infection, inflammation, and radiation therapy. Here, we report a 64-year-old woman presenting with hyperkeratosis, a lymphedema due to metastatic uterus carcinoma. In this paper, we present the effects of complex decongestive physiotherapy on lymphedema and hyperkeratosis. For further information:

PubMed

For further information:

Lymphedema Skin Conditions and Skin Growths

Possible Genetic Predisposition to Lymphedema after Breast Cancer

Possible Genetic Predisposition to Lymphedema after Breast Cancer

Lymphat Res Biol. 2012

Beth Newman, Ph.D.,¹ Felicity Lose, Ph.D.,² Mary-Anne Kedda, Ph.D.,¹ Mathias Francois, Ph.D.,³ Kaltin Ferguson,² Monika Janda, Ph.D.,¹ Patsy Yates, Ph.D.,⁴ Amanda B. Spurdle, Ph.D.,^2,* and Sandra C. Hayes, PhD^1,*

^Abstract

Background

Known risk factors for secondary lymphedema only partially explain who develops lymphedema following cancer, suggesting that inherited genetic susceptibility may influence risk. Moreover, identification of molecular signatures could facilitate lymphedema risk prediction prior to surgery or lead to effective drug therapies for prevention or treatment. Recent advances in the molecular biology underlying development of the lymphatic system and related congenital disorders implicate a number of potential candidate genes to explore in relation to secondary lymphedema.

Methods and Results

We undertook a nested case-control study, with participants who had developed lymphedema after surgical intervention within the first 18 months of their breast cancer diagnosis serving as cases (n=22) and those without lymphedema serving as controls (n=98), identified from a prospective, population-based, cohort study in Queensland, Australia. TagSNPs that covered all known genetic variation in the genes SOX18, VEGFC, VEGFD,VEGFR2, VEGFR3, RORC, FOXC2, LYVE1, ADM, and PROX1 were selected for genotyping. Multiple SNPs within three receptor genes, VEGFR2, VEGFR3, and RORC, were associated with lymphedema defined by statistical significance statistical significance  or extreme risk estimates

Conclusions

These provocative, albeit preliminary, findings regarding possible genetic predisposition to secondary lymphedema following breast cancer treatment warrant further attention for potential replication using larger datasets.

NIH

Lymphedema treatment in palliative care: a case study.

Lymphoedema treatment in palliative care: a case study.

August 2012

Cooper G.

Abstract

This article will focus on the evidence to support the treatment of a palliative patient who was diagnosed with cancer-related secondary lymphoedema. A case study approach has been adopted, which focuses on the anatomy and physiology oflymphoedema and how this is treated through an analysis of the treatment regimens. To establish the effectiveness of these treatment regimes, the use of objective and subjective tools will also be analysed to ascertain their importance within care. The findings of this case study and the supporting evidence indicate a positive correlation between the use of lymphoedematreatment methods in both limb volume reduction and quality-of-life outcomes. However, robust evidence is required to expand the importance of each treatment used in the area of lymphoedema management.

Internurse

Secondary Lymphedema From Infections

Lymphedema Caused by Infections Cellulitis and Erysipelas

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Persistent Periorbital and Facial Lymphedema Associated With Group A beta-Hemolytic Streptococcal Infection (Erysipelas).

Ophthal Plast Reconstr Surg. 2007 March/April Buckland GT 3rd, Carlson JA, Meyer DR. *Department of Ophthalmology; and daggerPathology, Division of Dermatology and Dermatopathology, Albany Medical College, Albany, New York, U.S.A.

Chronic lymphedema is both a risk factor for and consequence of erysipelas (cellulitis). We report a case of a 62-year-old woman with rheumatoid arthritis treated with etanercept and prednisone, who developed chronic periorbital lymphedema 2 months after Group A beta- hemolytic streptococcus infection of the face. She had significant ptosis OS and thickened, hyperpigmented periorbital skin. Biopsies were consistent with chronic lymphedema. Of note, on 6 months follow- up, the patient's appearance was improved though she still had residual ptosis. A period of extended observation may be warranted in these cases. PMID: 17413641

[PubMed - as supplied by publisher]

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Edema as a risk factor for multiple episodes of cellulitis/erysipelas of the lower leg

Date: 4/9/07 9:36 AM EST

2006 Nov CLINICAL AND LABORATORY INVESTIGATIONS Cox NH. Dermatology Department, Cumberland Infirmary, Carlisle CA2 7HY, UK. neil.cox@ncumbria-acute.nhs.uk

BACKGROUND: Cellulitis of the lower leg is a common problem with considerable morbidity. Risk factors are well identified but the relationship between consequences of cellulitis and further episodes is less well understood.

OBJECTIVES: To review risk factors, treatment and complications in patients with lower leg cellulitis, to determine the frequency of long-term complications and of further episodes, and any relationship between them, and to consider the likely impact of preventive strategies based on these results.

METHODS: Patients with ascending, presumed streptococcal, cellulitis of the lower leg were identified retrospectively from hospital coding. Hospital records, together with questionnaires to both general practitioners and patients, were used to record subsequent complications and identifiable risk factors for further episodes.

RESULTS: Of 171 patients, 81 (47%) had recurrent episodes and 79 (46%) had chronic oedema. The concurrence of these two factors was strongly correlated.

CONCLUSIONS: This study demonstrates that the true frequency of postcellulitic oedema, as well as that of further episodes, is probably underestimated. Furthermore, there is a strong association between these factors, each of which is both a risk factor for, and a consequence of, each other, and for which intervention (reduction of oedema or more prolonged antibiotic therapy) may reduce the risk of recurrent infection. By contrast, self-reporting of toeweb maceration is low, so attempts to reduce the risk of recurrent cellulitis by treatment of tinea pedis or bacterial intertrigo may fail.

Blackwell Synergy

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Persistent Periorbital and Facial Lymphedema Associated With Group A beta-Hemolytic Streptococcal Infection (Erysipelas).

Ophthal Plast Reconstr Surg. 2007 March/April
Buckland GT 3rd, Carlson JA, Meyer DR. *Department of Ophthalmology; and daggerPathology, Division of Dermatology and Dermatopathology, Albany Medical College, Albany, New York, U.S.A.

Chronic lymphedema is both a risk factor for and consequence of erysipelas (cellulitis). We report a case of a 62-year-old woman with rheumatoid arthritis treated with etanercept and prednisone, who developed chronic periorbital lymphedema 2 months after Group A beta- hemolytic streptococcus infection of the face. She had significant ptosis OS and thickened, hyperpigmented periorbital skin. Biopsies were consistent with chronic lymphedema. Of note, on 6 months follow- up, the patient's appearance was improved though she still had residual ptosis. A period of extended observation may be warranted in these cases.

PMID: 17413641 [PubMed - as supplied by publisher]

Preliminary experience with a novel fluorescence lymphography using indocyanine green in patients with secondary lymphedema

Preliminary experience with a novel fluorescence lymphography using indocyanine green in patients with secondary lymphedema.

J Vasc Surg. 2007 Mar 27

Unno N,
Inuzuka K,
Suzuki M,
Yamamoto N,
Sagara D,
Nishiyama M,
Konno H.
Division of Vascular Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan; Second Department of Surgery, Hamamatsu University School of MedicineShizuoka, Japan.

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BACKGROUND: Lymphoscintigraphy has largely been performed to diagnose lymphedema. It is, however a time-consuming and expensive technique, which has not been covered by Japanese medical insurance since the year 2002. In this report we introduce a new imaging technique of fluorescent lymphography to diagnose lymphedema.

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METHODS: Fluorescence images of subcutaneous lymphatic drainage after subcutaneous injection of indocyanine green (ICG) at the foot were obtained using a newly developed near-infrared camera system. ICG fluorescent lymphography was performed in 12 patients with secondary lymphedema and 10 healthy volunteers. The 12 patients were diagnosed with secondary lymphedema according to the medical history and lymphoscintigram, of which 11 had a history of hysterectomy with extended lymph node dissection and local radiation therapy for uterine cancer. Lymphedema developed in one patient after femorotibial artery bypass for peripheral artery occlusive disease.

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RESULTS: Four abnormal fluorescent patterns of the lymph drainage were observed in lymphedema: dermal backflow (an abnormal filling of the lymph capillaries), extended fluorescent signal at the dorsum and plantar region of the foot, dilated lymph channels with proximal obliteration, and diffuse glittering of fluorescent signals with scattered twinkling of the dye. Continuous lymph channels from the injection site of the foot to the groin were observed along the medial aspect of thigh in healthy subjects.

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CONCLUSION: ICG fluorescence lymphography is safe, simple, and minimally invasive. The device is portable and easy to use. The technique may be useful in clinical practice to identify presence of lymphatic disorder.

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PMID: 17391894 [PubMed - as supplied by publisher]

Regulation of Lymphatic Capillary Regeneration by Interstitial Flow in Skin.

Regulation of Lymphatic Capillary Regeneration by Interstitial Flow in Skin.

Goldman J,
Conley KA,
Raehl A,
Bondy DM,
Pytowski B,
Swartz MA,
Rutkowski JM,
Jaroch DB,
Ongstad EL.
Biomedical Engineering, Michigan Technological University, Houghton, Michigan, United States.

* To whom correspondence should be addressed. E-mail: jgoldman@mtu.edu

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Decreased interstitial flow (IF) in secondary lymphedema is coincident with poor physiological lymphatic regeneration. However, both the existence and direction of causality between IF and lymphangiogenesis remain unclear. This is primarily because the role of IF and its importance relative to the action of the pro-lymphangiogenic growth factor VEGF-C (which signals primarily through its receptor VEGFR-3) are poorly understood. To clarify this, we explored the cooperative roles of VEGFR-3 and IF in a mouse model of lymphangiogenesis in regenerating skin. Specifically, a region of lymphangiogenesis was created by substituting a portion of mouse tail skin with a collagen gel within which lymphatic capillaries completely regenerate over a period of 60 days. The relative importance of IF and VEGF-C signaling were evaluated by either inhibiting VEGFR-3 signaling with antagonistic antibodies or by reducing IF. In some cases, VEGF-C signaling was then increased with exogenous protein. In order to clarify the role of IF, the distribution of endogenous matrix metalloproteinases (MMPs) and VEGF-C within the regenerating region were determined. It was found that inhibition of either VEGFR-3 or IF suppressed endogenous lymphangiogenesis. Reduction of IF was found to decrease lymphatic migration and transport of endogenous MMP and VEGF-C through the regenerating region. Therapeutic VEGF-C administration restored lymphangiogenesis following inhibition of VEGFR-3 but did not increase lymphangiogenesis following inhibition of IF. These results identify IF as an important regulator of the pro-lymphangiogenic action of VEGF-C. Key words: VEGFR-3, endothelial , lymphangiogenesis, Interstitial Flow.

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