Friday, July 06, 2007

The Lymphatics and Inflammation

The primary valves in the initial lymphatics during inflammation.

"More substantiation on the involvment of lymphedema and the body's inflammatory response system."

Lymphat Res Biol. 2007

Lynch PM, Delano FA, Schmid-Schönbein GW. Department of Bioengineering, University of California San Diego, La Jolla, California 92093-0412, USA. g...@bioeng.ucsd.edu

BACKGROUND: The primary valve system in the initial lymphatics prevents fluid transport from the initial lymphatics back into the interstitium. The authors hypothesize that since the primary valves are made up of an extraordinarily thin endothelium, they are readily compromised by mechanical or biochemical inflammatory stimuli. Thus, the opening dimension of the primary valves and their ability to prevent reflux into the interstitium during inflammation were investigated.

METHODS AND RESULTS: Acute inflammation was generated in the intact rat spinotrapezius muscle by suffusion of f-Met-Leu-Phe and platelet-activating factor. Once inflamed, the effective opening dimensions of the primary valves and the transport back out of the initial lymphatics were determined by examining the transport of fluorescent tracers from the interstitium to the lymphatics. Quantum dots and fluorescently labeled albumin readily enter initial lymphatics from the interstitium. The maximum diameter of microspheres that enter the initial lymphatics is between 0.5 microm and 0.8 microm in both control and inflamed tissue. While under control conditions no quantum dots escaped from initial lymphatics back into the interstitium, during inflammation there was extensive escape of quantum dots.

CONCLUSIONS: These results suggest that, in acute inflammation, the function of the endothelial barriers in the initial lymphatics may be compromised. A failure of the primary lymphatic valves has two consequences. First, fluid clearance from the tissue is less efficient, which causes the level of edema to increase. Second, the leaking initial lymphatics allow inflammatory mediators to accumulate in the tissue, therefore enhancing interstitial and lymphatic inflammatory reactions.

Article

*********

Inflammation, lymphatic function, and dendritic cell migration.

Lymphat Res Biol. 2006

Angeli V, Randolph GJ. Department of Gene and Cell Medicine, Mount Sinai School of Medicine, New York, New York, USA. micva@nus.edu.sg

The lymphatic system is not only essential for maintenance of normal fluid balance, but also for proper immunologic function by providing an extensive network of vessels, important for cell trafficking and antigen delivery, as well as an exclusive environment, the lymph node (LN), where antigen-presenting cells (APCs) and lymphocytes can encounter and interact. Among APCs, dendritic cells (DCs) have a remarkable capacity to traffic from peripheral tissues to the draining LN, which is critical for execution of their functions.

To reach the LN, DCs must migrate towards and enter lymphatic vessels. Here, the authors review what is known about the factors that drive this process. They touch particularly on the topic of how DC migration is affected by inflammation and discuss this in the context of lymphatic function.

Traditionally, inflammatory mediators are regarded to support DC migration to LNs because they induce molecules on DCs known to guide them to lymphatics. The authors recently showed that inflammatory signals present in a strong vaccine adjuvant induce swelling in LNs accompanied by lymphangiogenesis in the draining LN and radius of peripheral tissue. These increased lymphatics, at least for several days, lead to a more robust migration of DCs.

However, the density of lymphatic vessels can become overly extended and/or their function impaired as observed during lymphedema and various chronic inflammatory reactions. Diseases characterized by chronic inflammation often present with impaired DC migration and adaptive immunity. Gaining a better understanding of how lymphatic vessel function may impact adaptive immunity by, for example, altering DC migration will benefit clinical research aiming to manipulate immune responses and manage chronic inflammatory diseases.

Article

*********

Inflammatory manifestations of experimental lymphatic insufficiency.

PLoS Med. 2006 Jul

Tabibiazar R, Cheung L, Han J, Swanson J, Beilhack A, An A, Dadras SS, Rockson N, Joshi S, Wagner R, Rockson SG. Stanford Center for Lymphatic and Venous Disorders, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, United States of America.

BACKGROUND: Sustained lymph stagnation engenders a pathological response that is complex and not well characterized. Tissue inflammation in lymphedema may reflect either an active or passive consequence of impaired immune traffic.

METHODS AND FINDINGS: We studied an experimental model of acute post-surgical lymphedema in the tails of female hairless, immunocompetent SKH-1 mice. We performed in vivo imaging of impaired immune traffic in experimental, murine acquired lymphatic insufficiency. We demonstrated impaired mobilization of immunocompetent cells from the lymphedematous region. These findings correlated with histopathological alterations and large-scale transcriptional profiling results. We found intense inflammatory changes in the dermis and the subdermis. The molecular pattern in the RNA extracted from the whole tissue was dominated by the upregulation of genes related to acute inflammation, immune response, complement activation, wound healing, fibrosis, and oxidative stress response.

CONCLUSIONS: We have characterized a mouse model of acute, acquired lymphedema using in vivo functional imaging and histopathological correlation. The model closely simulates the volume response, histopathology, and lymphoscintigraphic characteristics of human acquired lymphedema, and the response is accompanied by an increase in the number and size of microlymphatic structures in the lymphedematous cutaneous tissues. Molecular characterization through clustering of genes with known functions provides insights into processes and signaling pathways that compose the acute tissue response to lymph stagnation. Further study of genes identified through this effort will continue to elucidate the molecular mechanisms and lead to potential therapeutic strategies for lymphatic vascular insufficiency.

Article

The Dragon Boat Ladies and Lymphedema

Awaken the dragon at Portage

Lakes Friday, June 8, 2007

A Dragon Boat is coming to the Portage Lakes Saturday. The traditional Dragon Dance will be performed during the "Awakening The Dragon Ceremony" at 1:30 p.m. Saturday in Craftsmen Park at 4450 Rex Lake Dr. The new Dragon Dream Team is sponsored by Dr. Douglas Wagner.


The group will include paddlers and nonpaddling members who are breast cancer survivors. No other qualification is needed. Dragon Boat teams were launched in 1996 by Dr. Don McKenzie, a sports medicine physician at the University of British Columbia.

His team, Abreast In A Boat, tested the myth that repetitive upper-body exercise in women treated for breast cancer encourages lymphedema. "Dr. McKenzie believed that by following a special exercise and training program, women could avoid lymphedema and enjoy active, full lives," explains the Web site A Breast In A Boat "

As we followed his program, we were carefully monitored by a sports medicine physician, a physiotherapist and a nurse. Dr. McKenzie's theory was proven correct. No new cases of lymphedema occurred and none of the existing cases became worse." The Dragon Boat being launched Saturday at Portage Lakes is a 20-paddler boat (10 sit side-by-side at port and starboard, who use a canoe- type paddle. They follow the commands of a coach who sits in the back. Dragon Boat teams now are located throughout the world, and hold national and international competitions. For information, visit Dragon Dream Team.com


At Portage Lakes, the Dragon Boat team will share facilities with Portage Lakes Rowing Association. NATURE CENTER

***********

Area Paddlers Honour Breast Cancer Pioneer Adam Peck

Guelph June 12, 2007

A local group of breast cancer survivors is joining the University of Guelph in honouring sports medicine doctor Dr. Don McKenzie. The BreastStrokes Dragon Boat Team feels that it's McKenzie's work that has empowered them and given them hope in dealing with breast cancer. "After you have breast cancer you tend to feel quite isolated," said Marlene Jofriet, a team member. "He actually did us a great service. We call it a floating support group because you have the camaraderie and the social aspect of it," she said. The BreastStrokes team is completely made up of breast cancer survivors.

Formed in 1998, the team has 30 members of all ages and competes each summer in dragon boat festivals around the province. Following Tuesday's convocation ceremony, where McKenzie will receive an honourary doctorate, he will be presented with Jofriet's painting "Beginnings," commemorating his pioneering work for breast cancer survivors. Jofriet said dragon boating empowered her and other survivors to take action in their recovery. "After you have that, you're not quite sure what you can do.

You can either sit there and mope or be active. I choose to be active," she said. Enter McKenzie and his work. Prior to 1996, doctors told breast cancer patients to avoid strenuous activity and exercise, because it could lead to lymphedema - swelling under the arms where lymphnodes have been removed. Going against the medical science of the day, McKenzie theorized that intense exercise would not cause lymphedema and formed a dragon boat team in 1996 to test his theory.

After the summer's paddling season, the most evident effects the team felt were stronger arms and improved mental health. From those ripples, hundreds of survivor teams now flood dragon boat festivals around the world. Jofriet's painting symbolizes the struggle of breast cancer.

The dark water represents the unknown, the blue sky represents hope and the yellow dragon represents the life line. Jofriet, who has been a team member since 2001, says the team always paddles to win. "I believe in pushing the limits. So that, I do."

Thursday, June 28, 2007

Lower Limb Lymphedema Common in Survivors of Gynecological Cancer

Lower Limb Lymphedema Common in Survivors of Gynecological Cancer

NEW YORK JUN 27, 2007 (Reuters Health) - A significant proportion of gynecological cancer survivors develop lower limb lymphedema, according to results of a study published in the June 15th issue of Cancer.

"Lower limb lymphedema is one of the most disabling side effects of surgical and radiotherapy treatment for gynecological cancer," note Dr. Vanessa Beesley, of the Queensland Institute of Medical Research, Australia, and colleagues. "For many gynecological cancer patients, lymph node dissection is an integral part of cancer treatment and surgical staging, and this procedure has been associated with lymphedema development."

The researchers conducted a population-based cross-sectional mail survey of gynecological cancer survivors in 2004. The questionnaire, which was completed by 802 women, included items on demographics, supportive care needs, and lymphedema-related needs.
Overall, 10% of subjects reported a
diagnosis of lymphedema. Another 15% reported undiagnosed symptomatic lower leg swelling. The prevalence of diagnosed lymphedema was higher among survivors of vulvar cancer (36%) than all other gynecological cancer subgroups.
Multivariate analysis revealed that for cervical cancer survivors, the odds of developing lower limb swelling were 3.5 times higher if they ha
d
radiotherapy and 3.3 times higher if they had lymph nodes removed. The odds of developing lymphedema were higher for survivors of uterine and ovarian cancer who had lymph node dissection or who were overweight or obese.

"Whereas 31% reported being informed about lymphedema before their cancer treatment, 34% of women did not recall being informed about this condition until they were diagnosed," Dr. Beesley and colleagues report. "Others (30%) were informed after their cancer treatment but before symptoms arose, or they could not remember when they were informed (5%)."

The researchers note that supportive care needs in the information and symptom management domains were higher in gynecological cancer survivors with lymphedema than in those with no swelling.

"Women at risk for lymphedema would benefit from instructions about early signs and symptoms and provision of referral information," the team concludes.

SOURCE:

Cancer 2007;109:2607-2614.

Cancer Page

Sunday, June 24, 2007

Complete decongestive therapy for arm lymphedema

Efficacy of complete decongestive therapy and manual lymphatic drainage on treatment-related lymphedema in breast cancer.

Int J Radiat Oncol Biol Phys. 2007 Mar Koul R, Dufan T, Russell C, Guenther W, Nugent Z, Sun X, Cooke AL. Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada. rashmi.koul@cancercare.mb.ca

OBJECTIVE: To evaluate the results of combined decongestive therapy and manual lymphatic drainage in patients with breast cancer-related lymphedema.

METHODS AND MATERIALS: The data from 250 patients were reviewed. The pre- and posttreatment volumetric measurements were compared, and the correlation with age, body mass index, and type of surgery, chemotherapy, and radiotherapy was determined. The Spearman correlation coefficients and Wilcoxon two-sample test were used for statistical analysis.

RESULTS: Of the 250 patients, 138 were included in the final analysis. The mean age at presentation was 54.3 years. Patients were stratified on the basis of the treatment modality used for breast cancer management. Lymphedema was managed with combined decongestive therapy in 55%, manual lymphatic drainage alone in 32%, and the home program in 13%. The mean pretreatment volume of the affected and normal arms was 2929 and 2531 mL. At the end of 1 year, the posttreatment volume of the affected arm was 2741 mL. The absolute volume of the affected arm was reduced by a mean of 188 mL (p < p =" 0.0142)," p =" 0.0354),">

CONCLUSION: Combined decongestive therapy and manual lymphatic drainage with exercises were associated with a significant reduction in the lymphedema volume.

Keywords: Lymphedema, Breast cancer, Combined decongestive therapy, Manual lymphatic drainage

Red Journal

******

Long-term management of breast cancer-related lymphedema after intensive decongestive physiotherapy.

Breast Cancer Res Treat. 2007 Mar

Vignes S, Porcher R, Arrault M, Dupuy A. Department of Lymphology, Hôpital Cognacq-Jay, Site Broussais, 102 rue Didot, 75014, Paris, France, stephane.vignes@hopital-cognacq-jay.fr.

Keywords: Breast cancer - Lymphedema - Physiotherapy - Compliance - Elastic garment - Low stretch bandage

BACKGROUND: Treatment of lymphedema is based on intensive decongestive physiotherapy followed by a long-term maintenance treatment. We analyzed the factors influencing lymphedema volume during maintenance treatment.

METHOD: Prospective cohort of 537 patients with secondary arm lymphedema were recruited in a single lymphology unit and followed for 12 months. Lymphedema volume was recorded prior to and at the end of intensive treatment, and at month 6 and month 12 follow-up visits. Multivariate models were fitted to analyze the respective role of the three components of complete decongestive therapy, i.e. manual lymph drainage, low stretch bandage, and elastic sleeve, on lymphedema volume during the 1-year maintenance phase therapy.

RESULTS: Mean volume of lymphedema was 1,054 +/- 633 ml prior and 647 +/- 351 ml after intensive decongestive physiotherapy. During the 1-year maintenance phase therapy, the mean lymphedema volume slightly increased (84 ml-95% confidence interval [CI]: 56-113). Fifty-two percent of patients had their lymphedema volume increased above 10% from their value at the end of the intensive decongestive physiotherapy treatment phase. Non-compliance to low stretch bandage and elastic sleeve were risk factors for an increased lymphedema after 1-year of maintenance treatment (RR: 1.55 [95% CI: 1.3-1.76]; P < p =" 0.002," p =" 0.91).">

CONCLUSION: During maintenance phase after intensive decongestive physiotherapy, compliance to the use of elastic sleeve and low stretch bandage should be required to stabilize lymphedema volume.

Springer Link

******

Predictive factors of response to intensive decongestive physiotherapy in upper limb lymphedema after breast cancer treatment: a cohort study.

Breast Cancer Res Treat. 2006

Vignes S, Porcher R, Champagne A, Dupuy A. Department of Lymphology, Hôpital Cognacq-Jay, Université Paris, France. stephane.vignes@hopital-cognacq-jay.fr

Key words: breast cancer - lymphedema - physiotherapy - predictive factors

BACKGROUND: Lymphedema is a frequent complication after breast cancer treatment. Reduction of lymphedema volume is obtained during an intensive phase with daily physiotherapy. Response to treatment remains unknown prior treatment. We purposed to analyze predictors of response of lymphedema treatment throughout the first course of physiotherapy.

DESIGN: Patients with secondary arm lymphedema were recruited in a single lymphology unit between 2001 and 2004. For each patient, the following data were recorded: characteristics of breast cancer treatment, patient characteristics, body mass index and lymphedema volume prior and at the end of treatment.

RESULTS: Three hundred and fifty-seven women (mean age: 53+/-11 years) were included. Initial excess volume of lymphedema was correlated to body mass index and duration of lymphedema. Mean duration of intensive decongestive therapy was 11.8+/-3.3 days. Mean excess volume of lymphedema was 1067+/-622 ml prior treatment and 663+/-366 ml after treatment (p<0.001),>

CONCLUSION: Duration of lymphedema from cancer treatment and body mass index were the only two predictors of absolute reduction of lymphedema volume after intensive decongestive physiotherapy. For all patients this latter treatment is highly effective in management of secondary upper limb lymphedema after breast cancer.

Springer Link

******

Breast cancer-related lymphedema--what are the significant predictors and how they affect the severity of lymphedema?

Breast J. 2006 Nov-Dec Soran A, D'Angelo G, Begovic M, Ardic F, Harlak A, Samuel Wieand H, Vogel VG, Johnson RR. Magee-Womens Hospital, Pittsburgh, Pennsylvania 15213, USA. asoran@magee.edu

According to the American Cancer Society, there are currently 2 million breast cancer (BC) survivors in the USA and 20% of them cope with lymphedema (LE). The primary aim of this study was to determine the predictive factors of BC-related LE. The secondary aim was to investigate the impact of predictors on the severity of LE. The study design was intended to be a 1:2 matched case-control study. Instead, we stratified on age (+/-10 years), radiation therapy (y/n), and type of operation (SM/MRM/MRM with tram).

Patients who underwent BC surgery between 1990 and 2000 at UPMC Magee-Womens Hospital were reviewed for LE. Data were collected on 52 women with LE and 104 female controls. Logistic regression was utilized to assess the relationship between risk factors and LE. Ordinal logistic regression was performed to determine the association between risk factors and severity of LE.

Severity was defined according to the volume difference between affected and unaffected limbs. Risk factors considered were occupation/hobby (hand use), TNM stage, number of dissected nodes, number of positive nodes, tumor size, infection, allergy, diabetes mellitus, hypertension, hypothyroidism, chronic obstructive pulmonary disease, and body mass index (BMI). LE was mild in 43 patients and was moderate/severe in nine patients. The level of hand use in the control group was categorized as low in 56 (54%), medium in 15 (14%), and high in 33 (32%) patients.

The corresponding frequencies were 14 (33%), 6 (14%) and 23 (53%) for patients with mild LE and 3 (33%), 1 (11%), 5 (56%) for patients with moderate/severe LE (p <>

The results of this stratified case-control study demonstrated that the risk and severity of LE was statistically related to infection, BMI, and level of hand use.

Blackwell

******

Complex decongestive physiotherapy for patients with chronic cancer-associated lymphedema.

J Formos Med Assoc.

2004 May Liao SF, Huang MS, Li SH, Chen IR, Wei TS, Kuo SJ, Chen ST, Hsu JC. Department of Physical Medicine and Rehabilitation, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua 500, Taiwan.

BACKGROUND AND PURPOSE: Lymphedema of the limbs after cancer therapy is the most common cause of lymphedema in developed countries. There is no cure for chronic cancer-associated lymphedema. Multidisciplinary complex decongestive physiotherapy (CDP) is commonly used as a primary treatment. This prospective study assessed the efficacy of intensive CDP treatment in chronic cancer-associated lymphedema.

METHODS: Thirty women who had unilateral upper or lower limb chronic lymphedema after breast or pelvic cancer therapy were enrolled in the study. All patients received CDP once per day, in consecutive full treatment sessions, which took place between 4 and 21 times. Assessment of the results of therapy included measuring the circumference, calculated volume, and edema ratio (excess volume/unaffected side volume) of the limb volume. The main outcome measure was the percentage reduction in excess limb volume.

style="color:#ff6600;">RESULTS: The pretreatment edema ratio demonstrated a high correlation with the patient's age (r = 0.508, p = 0.004) and the duration of the lymphedema (r = 0.634, p <>

CONCLUSIONS: Intensive CDP was effectively able to reduce the limb volume of patients with chronic cancer-associated lymphedema. Further follow-up study is needed to confirm the effectiveness of CDP in the maintenance phase, and its long-term effectiveness in Taiwanese.

PMID: 15216399 [PubMed - indexed for MEDLINE]

Monday, June 18, 2007

Functional magnetic resonance evidence of cortical alterations in a case of reversible congenital lymphedema of the lower limb: a pilot study.

Functional magnetic resonance evidence of cortical alterations in a case of reversible congenital lymphedema of the lower limb: a pilot study.
Lymphology. 2007

Pardini M, Bonzano L, Roccatagliata L, Boccardo F, Mancardi G, Campisi C.

Magnetic Resonance Research Centre on Nervous System Diseases, University School of Medicine and Surgery, San Martino Hospital, Genoa, Italy.
pardini82@yahoo.it

We report the first application of brain functional Magnetic Resonance Imaging (fMRI) to congenital peripheral lymphedema patients before and after microsurgical treatment. Our aim was to evaluate the effects of limb shape change on cortical organization of the motor system and how the cortical sensorimotor network restructures after microsurgical therapy. We acquired fMRI during active motor and motor imagery tasks before surgery and six months after surgery in a patient with congenital lymphedema of the left leg. fMRI data revealed activation differences in primary and secondary motor areas between the two scanning sessions for both tasks and also between the patient's and a healthy volunteer's activations. We suggest that these alterations could be related to changes in body schema representation due to the congenital lymphedema.

PMID: 17539461 [PubMed - in process]

Tuesday, June 12, 2007

Comparison of upper limb volume measurement techniques and arm symptoms between healthy volunteers and individuals with known lymphedema.

Comparison of upper limb volume measurement techniques and arm symptoms between healthy volunteers and individuals with known lymphedema.

Lymphology. 2007 Mar

Ridner SH, Montgomery LD, Hepworth JT, Stewart BR, Armer JM.

School of Nursing, Vanderbilt University, Nashville, Tennessee 37240, USA. sheila.ridner@vanderbilt.edu

Lymphedema is a problem for breast cancer survivors. The proliferation of limb measurement techniques makes it difficult to know how best to measure an at-risk limb. Using a sample of healthy volunteers and individuals with lymphedema, this study: 1) examined the relationship between more commonly used circumferential limb measurement methods and newer measurement methods of infrared laser perometry and bioelectrical impedance; 2) compared self-reported arm symptoms in healthy volunteers and breast cancer survivors with known lymphedema; and 3) explored the relationships among self-reported arm symptoms and circumferential tape measurement, infrared laser (perometry), and single and multi-frequency bioelectrical impedance.

Lymphedema index ratios were calculated to allow comparison among measurement methods. Measurement methods correlated strongly with each other. Fourteen symptoms were reported by one or more participants in the lymphedema group while participants in the healthy volunteer group reported only eight symptoms over the same time frames. Using p <>

Future research needs to include serial arm measurements to explore arm volume variation in healthy and lymphedema volunteers and to further investigate possible lymphedema index ratios cut points as lymphedema diagnostic criteria.

PMID: 17539463 [PubMed - in process]

Monday, June 11, 2007

Integrated management of filarial lymphedema for rural communities.

Integrated management of filarial lymphedema for rural communities.

Lymphology. 2007 Mar
Narahari SR, Ryan TJ, Mahadevan PE, Bose KS, Prasanna KS. Institute of Applied Dermatology, Kasaragod, India.
srnarahari@satyam.net.in


The Global Alliance for the Elimination of Lymphatic Filariasis (GAELF) has recommended exploring local health traditions of skin care and a low cost treatment paradigm for rural communities has been proposed by Vaqas and Ryan. Our case study incorporates these promising treatments for use in treating filariasis in rural communities.


Patients having lymphedema of one or both lower limbs (skin: normal, thickened or with trophic/warty changes) received treatment components from ayurveda, yoga and biomedicine simultaneously: including soap wash, phanta soaking, Indian manual lymph drainage (IMLD), pre- and post-IMLD yoga exercises, and compression using bandages for 194 days, along with diet restrictions and oral herbal medicines indicated for "elephantiasis" in Ayurveda. Entry points when infected were treated with biomedical drugs.

The study was conducted in the reverse pharmacology design. 112 patients and 149 lower limbs completed 194 days of treatment during 2003-2006. Significant improvements were observed in the limb circumference measurements and the frequency of acute dermatolymphangioadenitis, use of preventive antibiotics, and reduction in the number of entry points were also improved.

The objective to obtain significant benefit for a common problem using locally available, sustainable and affordable means has been achieved. It has not been our purpose to show that the regimen employed is better than another but the results do pose the question--"Are there components of Ayurvedic medicine that deserve further study?"

It is important to understand that the regimen has been delivered mostly at home and that participants we have treated, representing a population suffering from a common problem, have not had access to effective conservative therapy that is culturally acceptable, safe, and efficacious.

PMID: 17539459 [PubMed - in process]

Sunday, June 10, 2007

Upper extremity lymphedema after treatment for breast cancer: a review of the literature.

Upper extremity lymphedema after treatment for breast cancer: a review of the literature.

Ostomy Wound Manage. 2007 May
Dow Meneses K, McNees MP.

College of Nursing, University of Central Florida, Florida;Email: kdow@mail.ucf.edu.

Upper extremity lymphedema - a common, poorly understood, and relatively understudied complication of cancer therapy - is a progressive and debilitating condition for which no cure is available. While advances in cancer treatment have lowered the incidence of lymphedema, lymph node trauma is often inevitable and the number of cancer survivors and elderly are increasing. A review of the literature suggests that research is needed to better understand the incidence and magnitude of upper extremity lymphedema; develop reliable and valid lymphedema risk assessment instruments; improve collaborative research efforts among skin, wound, and cancer investigators; and develop evidence-based lymphedema prevention and treatment protocols. Currently available evidence also indicates that increased clinician and patient awareness and education may help reduce the risk of lymphedema-associated complications through early detection and prompt interventions.


PMID: 17551172 [PubMed - in process]

Upper limb swelling following mastectomy: lymphedema or not?
Oncology (Williston Park). 2007 Apr

Armer J.
Sinclair School of Nursing, University of Missouri at Columbia, USA.

Having experienced an excisional biopsy, sentinel lymph node biopsy, and mastectomy, BH is at lifetime risk of developing post-breast cancer lymphedema in the arm on the side where her breast cancer was treated. She has two additional risk factors, among those documented in the literature: history of an infection (specifically a systemic infection, significant in that it required hospitalization for intravenous antibiotics) in the postsurgery period, and a moderate increase in bilateral limb volume and weight (body mass index) over the months and years following the breast cancer diagnosis. Further, the patient-reported transient hand swelling on the affected side and gradual weight increase are cues indicating a need for patient vigilance and careful monitoring by the health-care team. Preventing future infections, managing weight at an optimal level, and preventing trauma or injury to the affected arm and chest are important self-management precautions to reduce risk of chronic lymphedema development. BH needs continued support in reviewing evidence-based risk-reduction guidelines and understanding ways to apply them to her lifestyle.

In the absence of preoperative baseline or contralateral limb measurements (with circumferences or perometry or water displacement), assessment of limb change at a level identified as diagnostic of lymphedema (commonly, 200-mL volume or 2-cm girth increase from baseline or as compared to the contralateral limb) is very challenging. Without bilateral preop limb measurements for baseline and contralateral limb comparisons, BH might have been diagnosed with lymphedema at postop or at 48 months, when both limbs increased symmetrically. Symptom assessment is also crucial, as symptom report of heaviness and swelling is found to be associated with limb volume changes indicative of lymphedema.

Transient hand swelling may be evidence of latent lymphedema and cause for increased risk-reduction education and vigilance in assessment for emergence of nonresolving chronic lymphedema. million American women are breast cancer survivors.

According to the American Cancer Society, every person treated for cancer with lymph node removal, surgery, or radiation has a lifetime risk for lymphedema, swelling caused by an increase in protein-rich interstitial fluid. Some will develop lymphedema soon after cancer treatment (within weeks or months) and others may not experience.

PMID: 17508496 [PubMed - in process]

Saturday, June 02, 2007

Lymphedema: an unusual complication of sirolimus therapy

Lymphedema: an unusual complication of sirolimus therapy
May 2007

Al-Otaibi T, Ahamed N, Nampoory MR, Al-Kandari N, Nair P, Hallm MA, Said T, Samhan M, Al-Mousawi M.
Hamed Al-Essa Organ Transplant Centre, Kuwait.


INTRODUCTION: Lymphedema is an increasingly observed complication of sirolimus (SIR) therapy. In this report, we describe four renal recipients with SIR-induced lymphedema of varying severity.

CASES REPORTS: Patient 1, a 38-year-old man developed lymphedema of the left upper limb after being exposed to SIR for 30 months (mean daily Rapamune dose, 3 mg; trough level, 10-18 ng/mL). Venography and duplex ultrasound were normal. Lymphangiography was showed delayed lymphatic drainage. SIR was replaced with Prograf with significant improvement in the lymphedema over the next 6 months. Patient 2, a 26-year-old woman, developed lymphedema of the left lower limb at 24 months after starting SIR (mean daily dose, 3 mg; trough level, 10-15 ng/mL). Lymphangiography showed delayed drainage of lymphatics in the left lower limb. The patient was shifted to Prograf and there was some improvement over the next 4 months. Patient 3, a 28-year-old man, developed lymphedema of the left upper limb at 24 months after the start of SIR (mean daily dose, 2 mg, trough level, 6-15 ng/mL). Lymphangiography showed evidence of lymphatic obstruction. SIR was changed to cyclosporine with only mild improvement in lymphedema over the next 6 months. Patient 4, a 46-year-old man, developed lymphedema of the right upper limb at 7 months after starting SIR (mean daily dose, 6 mg; trough level, 10-16 ng/mL). Lymphangiography showed complete blockage of the lymphatic channels. SIR was changed to cyclosporine and there was mild improvement in lymphedema over the next 8 to 10 months.

CONCLUSION: The exact mechanism of SIR-induced lymphedema is unknown. The absence of other demonstrable etiologies and spontaneous improvement after discontinuation of SIR suggest that this drug was the responsible factor in these four patients. It occurred 7 to 30 months after transplantation. This is the fourth such report in the literature to the best of our knowledge.

ELSEVIER

Lymphedema associated with sirolimus in renal transplant recipients.

Severe limb lymphedema in sirolimus-treated patients.

Transplant Proc. 2005 Mar

Romagnoli J, Citterio F, Nanni G, Tondolo V, Castagneto M. Department of Surgery, Organ Transplantation, Policlinico Gemelli, Rome, Italy.

We report two kidney transplant recipients who developed severe limb lymphedema under sirolimus (SRL) immunosuppression. The patients received SRL 10 and 2 mg/d to achieve target levels of 10 to 20 ng/mL with tapering doses of prednisone. Renal function and drug levels were monitored monthly. Patient 1 developed lymphedema of the left upper limb 3 years posttransplantation, after having been exposed to high SRL doses in the preceding 2 years (mean SRL dose-9.5 mg/d, mean trough level-26.3 ng/mL, mean serum creatinine-1.63 mg/dL). In patient 2 lymphedema of both upper and lower right limbs occurred 18 months posttransplantation (mean SRL dose-3.2 mg/d, mean trough level-8.8 ng/ mL, mean serum creatinine-2.9 mg/dL).

Hypercholesterolemia and hypertriglyceridemia were also observed in both patients before SRL reduction/conversion. No signs of hematopoietic toxicity were observed. In both patients magnetic resonance (MR) angiography of the limb was negative for vascular obstruction, and lymphoscintigraphy revealed lymphatic obstruction. In patient 1 lymphedema improved significantly following SRL reduction and lymphatic drainage massage therapy. Patient 2 was converted to cyclosporine (CsA) improving markedly after conversion. Hypercholesterolemia and hypertriglyceridemia also improved significantly in both patients after reduction/conversion.

We conclude that SRL may facilitate the occurrence of lymphatic obstruction by mechanisms that are presently unexplained. Lymphedema of the limbs in renal transplant recipients under SRL treatment, especially if on the same side as the hemodialysis access, should warn the transplant physician to rapidly reduce or withdraw SRL before the occurrence of complete obstruction.

Transplantation Proceedings

Sunday, May 27, 2007

Lighthouse Lymphedema Network Lymphedema Education & Awareness Program Schedule

Lighthouse Lymphedema Network Lymphedema Education & Awareness Program

3 DAY SCHEDULE

Friday, October 5, 2007

1:00-4:00 PM Pre-conference Tour of garment manufacturing plant sponsored by Sigvaris, Inc. Limited to the first 30 who sign up.

5:00-7:00 PM Kick Off Party - includes Style Show and Silent Auction Registration/Check-in * Exhibits

Saturday, October 6, 2007

7:00-7:40 AM Late Registration * Continental Breakfast * Exhibits

7:45-8:30 AM Welcome: Joan White Keynote Speaker: Elizabeth McMahon, PhD

8:30-10:15 AM Plenary Session - Moderator: Nicole Gergich, PT, CLT- LANA

* Exercise Shelley Smith, PT, CSLT Bernice Cohen, PT, CLST

* Overview of the Lymphatic System Paul Stewart, MD, CLT-LANA

* Differential Diagnosis Kathleen Francis, MD

* Diagnosis of Lymphedema through Lymphoscintigraphy Sabah Tumeh, MD

* Imaging - MRI - CAT - Ultra Sound


10:15- 10:45 AM Break

10:34-12:30 PM Plenary Session - Moderator: Elaine Gunter, BS MT (ASCP)

* Exercise Shelley Smith, PT, CSLT Bernice Cohen, PT, CSLT


* Parent, her Story on How Her Son was Diagnosed with Lymphedema Debbie Miles

* Cause of Primary Lymphedema - VEGF Research on Generating Lymphatics David Finegold, MD


* What a Genetic Counselor ddoes and how to find one. Nikki Justice, MS CGC

* How to Evaluate Research Dolores Bradley, PhD

* Lymphatic Research Foundation (LRF) Wendy Chaite, JD, Founder


12:30 - 2:00 PM Lunch * Exhibits

2:00 - 3:30 PM Instructional Sessions

(1) Manual Lymphatic Drainage for the Person with newly Diagnosed Lymphedema Carmelita Rifkin, PT, CLT-LANA

(2) History and Science of Manual Lymphatic Drainage DeCourcy Squire, PT, CLT-LANA Kathryn Thrift, BS, CLT-LANA

(3) Insurance/Medicare Issues Robert Weiss; Cheri Hoskins, CCT

(4) Expert Panel Discussion David Finegold, MD Elizabeth McMahon, PhD

(5) * Professional Session Kathleen Francis, MD


3:30 - 4:00 Break * Exhibits

4:00 - 5:00 PM Instructional Sessions

(6) Lymphedema Advocacy and Awareness Joan White Cheri Hoskins, CCT Pat O'Connor

(7) Exercise Lebed Method: Sherry LeBed Davis Pilates: Maria Elena Grogan, PT Yoga: Neely Sullivan, MPT, CLT

(8) Teen Networking Nicole Gergich, PT, CLT-LANA

(9) * Professional Session: Reducing pereioperative complications in patients with Lymphedema Wade Farrow, MD, CWS, FCCWS

Pain Management Paula Stewart, MD, CLT-LANA


Sunday, October 7, 2007

7:30 9:00 AM Early Morning Breakout Sessions:

Special interest topics - Signup when submitting form. Attendees may also sign-up on site:

* Head and Face Lymphedema - DeCourcy Squire, PT, CLT-LANA
* Genital Lymphedema, Men - Pat O'Connor
* Genital Lymphedema, Women - Shelley Smith, PT, CSLT
* Truncal Lymphedema - Nicole Gergicj, PT, CLT-LANA
* Parent to Parent Networking - Jennifer Fortener


7:30 - 9:00 AM Continental Breakfast * Exhibits

9:00 - 10:30 AM Instructional Sessions

(10) Basic Lymphedema Exercise - Pool Exercises
Janet Wolfson, PT, CSLT Gwen Forbes Kirby, PT, CLT-LANA


(11) Compression Physiology Basics, Bandaging for arms and legs Barry Creighton, DPM, FCCWS, APWCA, CHT Janie Smith, PT, CLT Kim Mainer, OTR/L, CLT-LANA

(12) Expert Panel Discussion Kathleen Francis, MD Paujla Stewart, MD, CLT-LANA

(13) Alternative Treatments: Do they really work? DeCourcy Squire, PT, CLT-LANA Dolores Bradley, PhD


10:30 - 11:00 Break * Exhibits

11:00 - 12:00 PM Instructional Sessions

(14) Obesity and Lymphedema: Difference between Obesity and Lipedema, Bariatric Surgery, Nutritionist Kathryn Thrift, BS, CLT-LANA Christopher J. Hart, MD, FACS Neely Sullivan, MPT, CLT

(15) Compression Garment Problem Solving DeCourcy Squire, PT, CLT-LANA Laura Hoffman; Tammy Malone

(16) Self-Care Arm and Leg Lymphedema Carmelita Rifkin, PT, CLT-LANA

(17) Treatment for Newborns and Children Kathy Kearse, PT, CLT-LANA


12:30 - 2:00 PM Lunch * Exhibits

* Exercise - Janet Wolfson, PT, CSLT; Neely Sullivan, MPT, CLT
* Wound Care and Lymphedema Wade Farrow, MD, CWS, FCCWS
* Foot and Nail Care Barry Creightonm, DPM< FCCWS, APWCA, CHT
* Living Well with Lymphedema Elizabeth McMahon, PhD


EXPLANATION OF PLENARY SESSION:

On Saturday morning during the Plenary Session, physicians will discussthe lymphatic system, the differential diagnoses and the various diagnostic tools. Foot and Nail Care and patient Issues.

EXPLANATION OF BREAKOUT/INSTRUCTIONAL SESSIONS:


(1) For participants with little knowledge of Complete Decongestive Therapy, learn about Manual Lymphatic Draingage, breathing, strokes, explaination of watershed and much more.

(2) For participants who have knowledge of the treatment protocol called Complete Decongestive Therapay: learn about the history and science of Manual lymphatic Drainage

(3) Learn from the nation's leading lymphedema experts what is going on nationally and locally with medicare and state lymphedema bills and how you can become involved.

(4) Expert Panel Discussion: A question and answer time from patient to physician or therapist.

(5) * Professional Session

(6) Starting a lymphedema support group in your community: how to sponsor educational.awareness event; legislation; finding lymphedema on the web; tips for success.

(7) Exercise Techniques: Lebed Method, Pilates, Yoga

{8} Teen networking.

(9) *Professional Session: In depth discussion of wound care, avoiding infections, cellulitis, pre-signs to look for in organ failure. Pain Managment techniques.

(10) basic lymphedema exercise/pool exercises via closed circuit TV.

(11) Importance of short stretch bandages: bandaging for both upper and lower extremity lymphedema.

(12) Expert Panel Discussion: Another opportunity to ask questions of the professionals.

(13) Accessing a new product: Could it help your lymphedema?

(14) Weight Control: Why it is important not to be overweight. Discussion will include bariatric surgery, nutrition and lipedema.

(15) What to look for in a garment.

(16) The precautions, skin inspection/skin care, and other self-care techniques for the arm and leg.

(17) Treatment for newborns and children.

Lighthouse Lymphedema Netowrk Lymphedema Education & Awareness Program

LIGHTHOUSE LYMPHEDEMA NETWORK

INVITES YOU TO OUR 10th ANNUAL

LYMPHEDEMA EDUCATION & AWARENESS PROGRAM:


“Lymphedema: Empowerment through Knowledge"

October 5-7, 2007


Renaissance Waverly Hotel
2450 Galleria Parkway
Atlanta GA 30339


The Lighthouse Lymphedema Network is pleased to invite you to an outstanding educational and awareness conference this fall! Continuing our annual efforts to increase awareness about lymphedema, we have assembled a terrific group of speakers to provide information on a wide variety of topics for patients, family, caregivers, and professionals. We will also have a large number of our excellent vendor associates present to demonstrate current products for lymphedema care and treatment.

Whether you are newly-diagnosed with lymphedema and eager to get more information about what it is and how it can be treated, or perhaps you are interested in learning what the latest research in this field promises, attendance at our program will definitely be beneficial. [Professionals, remember LLN offers CEUs for attendance.]

Our program starts Friday afternoon, October 5, with a pre-conference tour of Sigvaris’ garment manufacturing plant here in Atlanta, and will be followed by a Kick-Off Party from 5:00-7:00 PM. Saturday and Sunday are full of plenary sessions open to everyone, with instructional sessions for both professionals and all other conference attendees.


Lighthouse Information Page

Schedule and Registration Brochure

Information Forum on Lymphedema People

Saturday, May 19, 2007

Benzo-pyrones for reducing and controlling lymphoedema of the limbs.

We hear so much in the lymphedema world ab out benzo-pyrones (flavanoids) and how they help reduce and/or control lymphedema. Sometimes, we are even told taht there have been studies done that verify their effectiveness. I ran across this study in 2004 that reviewed numerous some of these studies and the validity of the info from them. One of the reviewing participants was Dr. Peter Mortimer, th well respected lymphedema doctor in the UK. Interesting.

-------------


Benzo-pyrones for reducing and controlling lymphoedema of the limbs.

Cochrane Database Syst Rev. 2004

BACKGROUND: Lymphoedema is the accumulation of excess fluid in the body caused by obstruction of the lymphatic drainage mechanisms. It can be caused by a number of factors, including congenital predisposition, parasitic infection or surgery. Lymphoedema is chronic and progressive and affects a significant proportion of the population. The standard treatment regimes include compression hosiery, skin care and exercise. The use of drugs in treatment, particularly benzo-pyrones, has gained favour over the last ten years. Benzo-pyrones, originally developed for use in vascular medicine, are prescribed to reduce vascular permeability and thus the amount of fluid forming in the subcutaneous tissues. Advocates for this treatment method believe that, as a result of reducing filtration, the drugs have some beneficial effect on pain and discomfort in the swollen areas. Proponents also claim that these drugs increase macrophage activity, encouraging the lysis of protein, which in turn reduces the formation of fibrotic tissue in the lymphoedematous limb.

OBJECTIVES: To assess the effectiveness of benzo-pyrones compared to placebo or to different benzo-pyrones in reducing limb volume, pain and discomfort in lymphoedematous limbs. To assess the effect of benzo- pyrones on the quality of affected tissues and on the patient's quality of life and, finally, to establish the incidence of adverse effects.

SEARCH STRATEGY: We searched the Cochrane Breast Cancer Group register (September 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4,2003), MEDLINE, EMBASE, CINAHL, UnCover, PASCAL, SIGLE, reference lists produced by The British Lymphology Society, the National Research Register (NRR) and The International Society of Lymphology congress proceedings.


SELECTION CRITERIA: Types of studies considered for review were randomised controlled trials testing Paroven, coumarin, Venastat, Cyclo 3 Fort or Daflon versus placebo (with both groups having or not having standard physical treatment DATA COLLECTION AND ANALYSIS: Eligibility for inclusion was confirmed by two blinded reviewers who screened the papers independently using a checklist of criteria relating to the randomisation and blinding of the trial. Both reviewers extracted data from the eligible studies using a data extraction form.

MAIN RESULTS: Overall, 15 trials were included that evaluated the role of benzo-pyrones. Three trials of oxerutin were found. Each tested the drug over 6 months using the same dose of drug against placebo. Two were crossover trials and one a parallel group trial with a total number of 127 participants and data available for only 81 of them. There were insufficient data provided in any of the trials to calculate the per cent reduction or increase in baseline excess limb volume. Standard deviations or confidence intervals and the numbers in the groups at the different stages of the trial were missing for all the data in two of the reports and for much of the data in the third, making any attempt at meta-analysis impossible.One trial testing Cyclo 3 Fort (approved name) over 3 months was found and involved 57 patients but provided insufficient data to allow a proper analysis of its findings. A single trial of Daflon (approved name) was found, lasting 6 months and involving 104 participants; once again there was insufficient information provided in the report to reach a conclusion about the effectiveness of the drug.

Three trials of coumarin combined with troxerutin were found and tested two different doses of the drug against each other with no placebo, however, numbers of participants in the trial groups and baseline data were not provided. Eight trials of coumarin were identified. Two of the reports were confirmed as reporting the same trial and a further trial potentially also referred to the same trial but this was unconfirmed. A further two papers appeared to refer to the same trial but this was not confirmed. Three trials involved the same researcher. Five studies were conducted in India or China and they added anti-filarial dia or China and they added anti-filarial drugs to the interventions tested. The numbers of participants withdrawn and the numbers included in the analyses in all these trials were not extractable; the reporting of outcome measures in most of the trials was not clear.


Loprinzi's 1999 trial in the USA reported the conduct of the trial and its findings with more detail, however, its conclusions were very much at odds with the findings of the other trials, finding that no difference was observed between those on the active preparation (coumarin) and placebo in any of the outcomes under investigation. This trial also reported a case of hepato-toxicity in a patient receiving the active preparation.

REVIEWERS' CONCLUSIONS: Meta-analysis was not performed due to the poor quality of the trials. It is not possible to draw conclusions about the effectiveness of Benzopyrones in reducing limb volume, pain, or discomfort in lymphoedematous limbs from these trials.

Plain language summary


Currently there is not enough evidence from research to show that benzo-pyrones are either beneficial or unhelpful in reducing lymphoedema.

Lymphoedema is an accumulation of excess fluid, mainly in the arms and legs. It can occur in several ways: from birth; as a result of a parasitic infection; or as a complication of cancer surgery. The most common treatments are compression hosiery (e.g. bandaging, sleeves, etc.), skin care and exercise. The drugs commonly known as benzo- pyrones have been prescribed to prevent the fluid leakage and collection which characterises lymphoedema.

This review found that there was not enough good quality evidence to draw conclusions about whether benzo-pyrones are useful either in reducing lymphoedema or the pain and discomfort associated with it.

The Cochrane Library

Friday, May 11, 2007

Lymphedema Affects Quality Of Life




Lymphedema Affects Quality Of Life


May 10, 2007

Lymphedema

Almost one-third of young breast cancer survivors surveyed by researchers at the Ohio State University Comprehensive Cancer said their quality of life suffered because they experienced lymphedema, an often debilitating consequence of breast cancer treatment.

The findings are significant because they point to the need for preventive education, says principal investigator Electra Paskett, associate director of population sciences at Ohio State's Comprehensive Cancer Center.

"This is the first study in the United States to look at the incidence, prevalence and persistence of lymphedema among young breast cancer survivors, and how having lymphedema negatively affects their quality of life," says Paskett. "We found that the women who reported persistent swelling of their arms or hands after surgery or radiation were more likely to report poorer quality of life."

The research involved 622 breast cancer survivors who were 45 years or younger at diagnosis. They were monitored with semiannual questionnaires for 36 months after breast cancer surgery to determine the incidence of lymphedema, prevalence of swelling, factors associated with each and quality of life.

The study is published in the April issue of the Journal of Cancer Epidemiology Biomarkers & Prevention.

Lymphedema is a common complication of cancer therapy and is characterized by an accumulation of lymphatic fluid, which causes swelling, most often in the arms or legs. Lymphedema can occur anywhere lymph nodes have been surgically removed or lymph flow has been disturbed.

The study found that 54 percent of participants reported at least one incidence of swelling of the arm or hand within 36 months after surgery, with 32 percent reporting persistent swelling. Swelling was reported to in the upper arm by 43 percent of the women; in the hand only by 34 percent; and in both arm and hand in 22 percent of participants.

Factors associated with an increased risk of developing swelling included having a greater number of lymph nodes removed, receiving chemotherapy and being obese. Factors associated with persistent swelling included having more lymph nodes removed and being obese. Weight management may be a potential intervention for those at greatest risk of lymphedema to maintain optimal health-related quality of life among survivors, Paskett says.

Women who reported swelling had significantly lower quality of life compared to women without swelling, Paskett says.

"These are the women we are most concerned about," says Paskett, a two- time breast cancer survivor who struggles with a mild case of lymphedema. She does daily exercises and occasionally wears a pressure sleeve and glove to control her swelling.

"If we can identify women who are at greatest risk of developing lymphedema, then we can educate them about the problem, so they can watch for symptoms and seek early treatment," Paskett says.

The majority of women in the study reported mild swelling. But even that can interfere with daily activities and negatively affect quality of life, she says.

"Some women must buy larger clothing because of the swelling, while others can't wear rings or button their blouses because their fingers are swollen," Paskett says. "For many, lymphedema is a constant reminder that they had cancer."

Paskett also is the principal investigator of a major, multicenter clinical trial that will enroll 500 women nationwide in the Lymphedema and Education Awareness Program. The ongoing study will test a program to prevent lymphedema in women who have been treated for breast cancer.
There is always a risk of developing lymphedema after the removal of lymph nodes during breast cancer surgery, and the condition can develop immediately, in months or even years later, Paskett says.

"It is important for women to recognize the signs and symptoms of lymphedema and seek treatment immediately to lessen the severity," Paskett says.

Saturday, May 05, 2007

Microsurgery for treatment of peripheral lymphedema: Long-term outcome and future perspectives.

Microsurgery for treatment of peripheral lymphedema: Long-term outcome and future perspectives.

Microsurgery. 2007 May 3

Campisi C,
Eretta C,
Pertile D,
Da Rin E,
Campisi C,
Maccio A,
Campisi M,
Accogli S,
Bellini C,
Bonioli E,
Boccardo F.
Department of Surgery, Unit of Lymphatic Surgery and Microsurgery, San Martino Hospital, University of Genoa, Genoa, Italy.

Authors report over 30 years of their own clinical experience in the treatment of chronic peripheral lymphedemas by microsurgical techniques performed at the Center of Lymphatic Surgery of the University of Genoa, Italy. Over 1,500 lymphedema patients were treated with microsurgical techniques. Derivative lymphatic-venous techniques were most often used. For those cases where a venous disease was associated to lymphedema, reconstructive lymphatic microsurgery techniques were performed (lymphatic-venous-lymphatic-plasty).

Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Volume changes showed a significant improvement in over 83%, with an average follow-up of more than 10 years. There was an 87% reduction in the incidence of cellulitic attacks after microsurgery.

Microsurgical lymphatic-venous anastomoses have a place in the treatment of peripheral lymphedema and should be the therapy of choice in patients who are not sufficiently responsive to nonoperative treatment. Improved results can be expected with operations performed at earlier lymphedema stages. (c) 2007 Wiley-Liss, Inc. Microsurgery 2007.

PMID: 17477420 [PubMed - as supplied by publisher]