Lymphedema Seminar Boca Raton Florida

Lymphedema Seminar Boca Raton Florida

For our friends in south Florida:

Living Well with Lymphedema

10 a.m. to 1 p.m. April 12

Ruth Rales Jewish Family Service will host the event at the Jerusalem Room of the Jewish Community Center 9801 Donna Klein Blvd. Boca Raton, FL.

Seminar will feature Dr. Harvey Mayrovitz, professor, and Susan Lanham, a physical therapist at Boca Raton Community Hospital.

Call (561) 852-3330 to register.

For more information, visit Ruth Rales Jewish Family Service Center

One-sided limb lymphedema in a liver transplant recipient receiving sirolimus

One-sided limb lymphedema in a liver transplant recipient receiving sirolimus
Acta Gastroenterol Belg. 2007 Oct-Dec
van Onna M, Geerts A, Van Vlierberghe H, Berrevoet F, de Hemptinne B, Troisi R, Colle I.
Department of Gastroenterology and Hepatology, Ghent University Hospital, Belgium.

Sirolimus (SRL) is associated with many side effects including hypercholesterolemia, anaemia, impaired wound healing and abnormal liver function tests. Limb lymphedema has only been reported several times in renal transplant recipients. We present a case of lower limb lymphedema that occurred in a 59-year-old liver transplant recipient after being on a SRL regimen for seven months. Extensive diagnostic investigations could not reveal signs of infection, venous obstruction or malignancy. After discontinuation of SRL, the lymphedema gradually resolved during the next three months. The pathologic mechanism behind this phenomenon is unknown, but antiangiogenetic and antiproliferative properties of SRL have been hold responsible. Further studies are necessary to explain this rare side effect.

PMID: 18330092 [PubMed - in process]

For further information, please see:

Lymphedema From Sirolimus Treatment

The management of genital lymphedema.

The management of genital lymphedema.

BJU Int.

2008 Mar 4

Garaffa G, Christopher N, Ralph DJ.
St Peter’s Department of Andrology, and The Institute of Urology, London, UK.

OBJECTIVES

To report our experience and management of genital lymphoedema, as this condition can be extremely debilitating and difficult to manage.

PATIENTS AND METHODS

The clinical records of 90 patients with genital lymphoedema who presented between 1998 and 2007 were retrospectively reviewed. The surgical management of 34 patients consisted of the excision of the affected skin and of the subcutaneous layers. This involved scrotal excision in 15 patients with primary closure. Skin grafts were required in seven patients for penile shaft cover. The results for cosmesis, recovery of sexual function, patient's satisfaction and complications are discussed.

RESULTS

In all, 56 patients were successfully managed conservatively by treating the underlying condition, antibiotic administration, compression and elevation of the genitalia. The remaining 34 patients required surgical management with an overall excellent cosmetic result and a significant improvement in sexual function.

CONCLUSIONS

When surgery is necessary for genital lymphoedema, the new techniques described provide excellent cosmetic and functional results.

Blackwell

For additional Information:

Female Genital Lymphedema

Male Genital Lymphedema

Learning from a lymphedema clinic: an algorithm for the management of localized swelling.

Learning from a lymphedema clinic: an algorithm for the management of localized swelling.

Plast Reconstr Surg. 2008 Feb

Garfein ES, Borud LJ, Warren AG, Slavin SA.
Boston, Mass. From the Harvard Plastic Surgery Program, Harvard Medical School, and the Division of Plastic Surgery, Beth Israel Deaconess Medical Center.

BACKGROUND: Lymphedema is a chronic disease causing significant morbidity for affected patients. It can be difficult to diagnose, and patients are often frustrated by multiple referrals and inadequate therapies. Centralized, comprehensive care for the patient presenting with lymphedema or other causes of localized swelling allows for appropriate evaluation and provides improved management and treatment.

METHODS: A 4-year review of the first 100 patients seen at the Beth Israel Deaconess Medical Center Lymphedema Clinic was performed. On the basis of the clinical experience from these patients, an algorithm for diagnosing and managing patients with localized swelling was developed.

RESULTS: The mean age of the patients was 50 years, and 81 percent of the patients were women. On average, patients had experienced their symptoms for 11.6 years (range, 3 months to 60 years). Lymphoscintigraphy was performed on 43 patients, 81 percent of whom showed lymphatic obstruction or dysfunction. In total, 75 percent of patients were diagnosed with lymphedema based on clinical presentation or additional testing. Fourteen of these patients underwent subsequent excisional procedures, whereas the rest were managed conservatively with compression garments.

CONCLUSIONS: Patients presenting with swollen extremities can frequently be diagnosed through history and physical examination alone, but many patients require more extensive diagnostic workup. An algorithm for the management of these patients can facilitate evaluation and treatment.

Plastic and Reconstructive Surgery

Risk factors for arm lymphedema following breast cancer diagnosis in Black women and White women

Risk factors for arm lymphedema following breast cancer diagnosis in Black women and White women

Breast Cancer Res Treat. 2008 Feb 24

Meeske KA, Sullivan-Halley J, Smith AW, McTiernan A, Baumgartner KB, Harlan LC, Bernstein L.
Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.

Purpose

Lymphedema of the arm is a potential complication of breast cancer therapy. This study examines pre-disposing factors that may operate in conjunction with treatment-related factors in the development of arm lymphedema in a large cohort of White and Black breast cancer survivors. Methods 494 women (271 White and 223 Black) with in situ to Stage III-A primary breast cancer completed a baseline interview within 18 months of diagnosis. Information on lymphedema was collected during a follow-up interview, conducted on average 50 months after diagnosis. Self-reported data were used to classify women with or without lymphedema. Multivariable logistic regression models were developed to identify risk factors for arm lymphedema. Results Arm lymphedema was associated with younger age at diagnosis (odds ratio, OR per year of age = 0.96; 95% confidence interval, CI = 0.93-0.99), positive history of hypertension (OR = 2.31; 95% CI = 1.38-3.88), obesity (OR for body mass index, BMI>/=30 = 2.48; 95% CI = 1.05-5.84) and having had surgery where 10 or more lymph nodes were excised (OR = 2.16; 95% CI = 1.12-4.17). While Black women had higher prevalence of arm lymphedema than White women (28% vs. 21%), race was not associated with lymphedema risk in models adjusted for multiple factors (adjusted OR = 1.01; 95% CI = 0.63-1.63). Conclusion Risk of arm lymphedema did not differ significantly for Black and White women. Risk factors identified in this study offer opportunities for interventions (weight loss, control of blood pressure, use of sentinel node biopsy where possible) for reducing incidence of lymphedema or controlling the symptoms associated with this condition.

SpringerLink

A Way to Help Prevent Arm Lymphedema - Fine Needle Aspiration

Accuracy of fine-needle aspiration cytology of axillary lymph nodes in breast cancer patients: a study of 115 cases with cytologic- histologic correlation.

Cancer. 2008 Feb 19 Alkuwari E, Auger M.
Department of Pathology, McGill University Health Center, McGill University, Montreal, Quebec, Canada.

BACKGROUND: Fine-needle aspiration (FNA) cytology of axillary lymph nodes is a simple, minimally invasive technique that can be used to improve preoperative determination of the status of the axillary lymph nodes in patients with breast cancer, thereby serving as a tool with which to triage patients for sentinel versus full lymph node dissection procedures. The aim of the current study was to determine the sensitivity and specificity of FNA cytology to detect metastatic breast carcinoma in axillary lymph nodes.

METHODS: A total of 115 FNAs of axillary lymph nodes of breast cancer patients with histologic follow-up (subsequent sentinel or full lymph node dissection) were included in the current study.

The specificity and sensitivity, as well as the positive and negative predictive values, were calculated.

RESULTS: The positive and negative predictive values of FNA cytology of axillary lymph nodes for metastatic breast carcinoma were 1.00 and 0.60, respectively. The overall sensitivity of axillary lymph node FNA in all the cases studied was 65% and the specificity was 100%. The sensitivity of FNA was lower in the sentinel lymph node group than in the full lymph node dissection group (16% vs 88%, respectively), which was believed to be attributable to the small size of the metastatic foci in the sentinel lymph node group (median, 0.25 cm). All false-negative FNAs, with the exception of 1 case, were believed to be the result of sampling error. There was no 'true' false-positive FNA case in the current study.

CONCLUSIONS: FNA of axillary lymph nodes is a sensitive and very specific method with which to detect metastasis in breast cancer patients. Because of its excellent positive predictive value, full axillary lymph node dissection can be planned safely instead of a sentinel lymph node dissection when a preoperative positive FNA result is rendered. Cancer (Cancer Cytopathol) 2008. (c) American Cancer Society.

PMID: 18286535 [PubMed - as supplied by publisher]

GROUNDBREAKING MEDICARE APPEALS COUNCIL DECISION COMPRESSION GARMENTS USED IN LYMPHEDEMA TREATMENT MEET MEDICARE DEFINITION OF PROSTHETIC DEVICES

GROUNDBREAKING MEDICARE APPEALS COUNCIL DECISION COMPRESSION GARMENTS USED IN LYMPHEDEMA TREATMENT MEET MEDICARE DEFINITION OF PROSTHETIC DEVICES

On February 20, 2008 a Medicare Administration Appeals Judge affirmed an earlier Administrative Law Judge's determination that compression garments used as part of the medical treatment of lymphedema meet the definition of “prosthetic devices” in the Social Security Act, and are coverable by Medicare.

This most recent case follows two earlier cases where the Appeals Council reversed two different ALJs who supported providers who denied reimbursement based on the unsubstantiated claim that compression garments “were not covered by Medicare”. Three other ALJs decided in favor of three different Medicare Beneficiaries, finding that the compression bandages, sleeves, stockings, devices and directional flow garments were medically necessary and coverable in the treatment of lymphedema as “prosthetic devices”.

Unfortunately these cases are not precedent-setting, and there is no desire by the Centers for Medicare and Medicaid Services (CMS) to change their medically unsound policies. CMS has also recently denied a formal request to change their HCPCS Coding manual to recognize the function of these items in the treatment of lymphedema, and to code them as prosthetic devices.

What actions can be taken to move CMS into action?

Every denial of compression bandages or compression garments must be appealed by the patient. The procedures for appeal are found in the denial letter. The appeal process will involve a redetermination appeal and a reconsideration appeal to Medicare Administrative Contractors, who will side with the denial, and then to an Administrative Law Judge where a fair hearing can be obtained.

Every lymphedema supply manufacturer must make a formal request to CMS for a recoding of their products with an “L-Code” as prosthetic devices when used in the treatment of lymphedema.

And every affected citizen, whether suffering for or at risk for lymphedema must write his of her Congress Member requesting that CMS revise their policies to cover the treatment of lymphedema according to current standards.

Since CMS has refused repeatedly to even consider a change, urge your legislator to consider sponsoring the proposed “Lymphedema Diagnosis and Treatment Cost-Saving Act” which has been presented to legislators over the last 5 years.

I am prepared to help in all these matters, and have materials which will be helpful. Please contact Robert Weiss at: LymphActivist@aol.com

Lymphatic venous anastomosis (LVA) for treatment of secondary arm lymphedema.

Lymphatic venous anastomosis (LVA) for treatment of secondary arm lymphedema. A prospective study of 11 LVA procedures in 10 patients with breast cancer related lymphedema and a critical review of the literature.
Breast Cancer Res Treat. 2008 Feb 13
Damstra RJ, Voesten HG, van Schelven WD, van der Lei B.
Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital, Compagnonsplein 1, 9202 NN, Drachten, The Netherlands, r.damstra@nijsmellinghe.nl.

Keywords

Lympho-venous anastomosis (LVA) - Microsurgery - Evidence-based medicine - Lymphoscintigraphy - Inverse water volumetry - Review - Breast cancer related lymphedema

Objective

The incidence of breast cancer related lymphedema (BCRL) varies between 7-35% depending on the combination of treatment modalities. Early detection of BCRL is crucial in order to start an effective non-operative treatment program. Because of the lack of prospective research on this topic, this study was undertaken to prospectively determine the effect of Lympho Venous Anastomosis (LVA) on BCRL and to review the current literature.

Study design and methods

Ten patients who were previously treated for breast cancer by surgery, radiotherapy, and chemotherapy, and were unresponsive to 12-weeks of non-operative treatment, underwent an LVA procedure (Degni-Cordeiro).

Objective measurements were gathered for circumferential measurement and water volumetry, and quality of life. Various types of lymphoscintigraphy were carried out pre-operatively and post-operatively at 3 and 12 months. Treatment was embedded in a multidisciplinary setting. Results Post-operative volume measurements initially showed a 4.8% reduction of lymphedema at 3 months and a 2% reduction after one year. Various scintigraphic parameters showed some improvement. Quality of life questionnaires reported minimal improvement. Reviewing the literature, only retrospective studies were found; these reported varying results for LVA procedures.

The selection of patients, classification of lymphedema, indications and types of LVA, and additional therapeutic options were heterogeneous, not comparable, and lacked a validated method of effect-assessment.

Conclusions

Our results showed a minimal reduction in volume of lymphedema following LVA; in the literature, there was no convincing evidence of the success of LVA. Non-operative treatment and elastic stockings are still preferred by most patients with lymphedema, especially in early stages with few irreversible changes.

Springer Link

Lymphedema in the morbidly obese patient: unique challenges in a unique population.

Lymphedema in the morbidly obese patient: unique challenges in a unique population.

Ostomy Wound Manage. 2008 Jan

Fife CE, Carter MJ.
Department of Anesthesiology, University of Texas Health Science Center, Houston, Texas, USA. Caroline.E.Fife@uth.tmc.edu

The population of morbidly obese patients, along with the incidence of lymphedema and massive localized lymphedema associated with this condition, is increasing. A 5-year retrospective review of data (2000-2005) shows that the percentage of patients >350 lb in the authors' clinic population increased from approximately 7% to 11% and 75% of their morbidly obese patients (body mass index >40) had or have lymphedema. After a differential diagnosis between lipedema and lymphedema (primary or secondary) has been made, lymphedema management options include compression bandaging, manual lymphatic drainage, and localized surgeries. The treatment of morbidly obese lymphedema patients requires additional staff time and specialized equipment to move or position them and may be confounded by other conditions (eg, heart failure and venous insufficiency) that contribute to edema. Lymphedema treatments have been found to be useful, providing patients are able to follow treatment guidelines, especially with regard to weight control. In the authors' experience, massive localized lymphedema will recur unless the primary issue of obesity is addressed. Establishing clear criteria and patient participation guidelines before initiating a comprehensive localized lymphedema program will improve outcomes.

PMID: 18250486 [PubMed - in process]

See also:

Obesity and Lymphedema

The Lymphedema Diet

The prognostic significance of facial lymphedema in HIV-seropositive subjects with Kaposi sarcoma.

The prognostic significance of facial lymphoedema in HIV-seropositive subjects with Kaposi sarcoma.

Jan 2008

Feller L, Masipa JN, Wood NH, Raubenheimer EJ, Lemmer J.

Background

Kaposi Sarcoma (KS) is a multifocal angioproliferative neoplasm characterized by inflammation, oedema, neoangiogenesis and spindle cell proliferation. The pathogenesis of human immunodeficiency virus (HIV)-associated KS (HIV-KS) is multifactorial and is influenced by HIV, by human herpesvirus-8 (HHV-8), and by increased production of cytokines and growth factors. Whether HIV-KS is a true malignancy or a reactive hyperplastic inflammatory condition is debatable.

Results and conclusions

Oedema of the face, legs and hands is a prominent feature of HIV-KS and is probably caused by lymphoedema related to the HIV-KS lesions. The cases of two HIV-seropositive subjects with KS-associated facial lymphoedema are reported. Extensive oral HIV-KS in association with facial oedema in the absence of anti-retroviral treatment appears to be an indication of a poor prognosis.

Aids Research and Therapy

Primary non-syndromic lymphedema (Meige disease) is not caused by mutations in FOXC2.

Primary non-syndromic lymphedema (Meige disease) is not caused by mutations in FOXC2.

Eur J Hum Genet. 2008 Jan 16

Rezaie T, Ghoroghchian R, Bell R, Brice G, Hasan A, Burnand K, Vernon S, Mansour S, Mortimer P, Jeffery S, Child A, Sarfarazi M. 1Molecular Ophthalmic Genetics Laboratory, Department of Surgery, University of Connecticut Health Center, Farmington, CT, USA.

Primary lymphoedema is a genetic disorder with numerous phenotypic subgroups. The most common form is the non-syndromic Meige disease, which is primarily of pubertal or later onset, with oedema clinically indistinguishable from that found in the lymphoedema-distichiasis syndrome. There are also other very rare forms of lymphoedema such as yellow nail syndrome and lymphoedema with ptosis, which are clinically similar to Meige disease.

The only causative genes so far identified for the non-congenital primary lymphoedemas are the transcription factor FOXC2, where mutations are known to produce lymphoedema with distichiasis, and SOX18 in the very rare condition hypotrichosis- lymphoedema-telangiectasia.

This study has examined FOXC2 gene by sequence analysis in 23 affected individuals with Meige disease. A novel truncating mutation (c.563-584del) was identified in one family and found to segregate with the disease in eight affected relatives over three generations. This deletion creates a frameshift that predicts a premature stop at nucleotide 599 and truncating the normal protein by 38%.

Although the affected patient initially selected for mutation screening from this family had lymphoedema without distichiasis, all but one of his affected relatives who carried the FOXC2 mutation did have accessory eyelashes originating from their meibomian glands. This is further confirmation that of the primary lymphoedemas, only lymphoedema with distichiasis is caused by FOXC2 mutations.

All forms of post-pubertal lymphoedema need careful phenotyping for distichiasis, which may prove difficult to confirm unless several family members are examined, and cannot ever be assumed to be absent from self-report.European Journal of Human Genetics advance online publication, 16 January 2008;doi:10.1038/sj.ejhg. 5201982.

Nature

Manipulative therapy of secondary lymphedema in the presence of locoregional tumors

Manipulative therapy of secondary lymphedema in the presence of locoregional tumors

Cancer. 2007 Dec 17

Pinell XA, Kirkpatrick SH, Hawkins K, Mondry TE, Johnstone PA.
Radiation Oncology Department, Emory University School of Medicine, Atlanta, Georgia.

BACKGROUND: Complete decongestive therapy (CDT), including manual lymphatic drainage (MLD) is a manipulative intervention of documented benefit to patients with lymphedema (LE). Although the role of CDT for LE is well described, to the authors' knowledge there are no data regarding its efficacy for patients with LE due to tumor masses in the draining anatomic bed. Traditionally, LE therapists are wary of providing therapy to such patients with 'malignant' LE for fear of exacerbating the underlying cancer, and that the obstruction will render therapy less effective. In the current study, the authors' experience providing CDT for such patients is discussed.

METHODS: Cancer survivors with LE were referred to therapists at 2 Atlanta-area clinics. CDT consists of treatment (Phase 1) and maintenance phases (Phase 2). During Phase 1, the patient undergoes manipulative therapy and bandaging daily until the LE reduction plateaus; at that point, Phase 2 (self-care) begins. At the beginning and end of Phase 1, LE is quantified and differences in girth volume calculated. The results for patients completing Phase 1 therapy for LE in the presence of locoregional masses were compared with results for patients with LE in the absence of such disease. Both volume reduction of the affected limb and number of treatments to plateau were analyzed.

RESULTS: Between January 2004, and March 2007, LE of 82 limbs in 72 patients was treated with CDT and Phase 1 was completed. The median number of treatments to plateau was 12 (range, 4-23 treatments); the median limb volume reduction was 22% (range, -23 to 164%). Nineteen limbs (16 patients) with associated chest wall/axillary or pelvic/inguinal tumors had nonsignificant difference in LE reduction (P = .75) in the presence of significantly more sessions to attain plateau (P = .0016) compared with 63 limbs in 56 patients without such masses.

CONCLUSIONS: Patients with LE may obtain relief with CDT regardless of whether they have locoregional disease contributing to their symptoms. However, it will likely take longer to achieve that effect. Manipulative therapy of LE should not be withheld because of persistent or recurrent disease in the draining anatomic bed. Cancer 2008. (c) 2007 American Cancer Society.

Wiley InterScience

Adrenomedullin - hormone for possible treatment of lymphedema?

Hormone Could Ease Painful Lymphedema

12/20/07

THURSDAY, Dec. 20 (HealthDay News) -- A hormone called adrenomedullin may prove an effective drug target for treating lymphedema, a painful swelling of the limbs that can follow breast cancer or other cancer treatment, U.S. researchers say.

It may also help prevent the spread of cancer, according to a team from the University of North Carolina at Chapel Hill School of Medicine.

Adrenomedullin, which is secreted by cells throughout the body, is known to play a role in cardiovascular disease and other cell functions. In a new study, the UNC group found that adrenomedullin also plays an important role in the formation of the lymphatic system in mice.

They said it may be possible to develop drugs that target this hormone in order to help the more than 100 million people worldwide who suffer from lymphedema. The condition occurs when the lymphatic system fails to work properly. In rare cases, it is genetic, but millions suffer lymphedema due to parasitic infections or as the aftermath of cancer therapies.
Currently, the only treatments for lymphedema include massage and the use of low-compression stockings and other garments. But these aren't much help, the UNC researchers said.

"Our research also may lead to therapies to prevent cancer cells from traveling through these lymphatic vessels to infiltrate other parts of the body," senior study author Kathleen M. Caron, assistant professor of cell and molecular physiology and genetics, said in a prepared statement.
The study is published in the Dec. 20 issue of the Journal of Clinical Investigation.

Health News

Hormone May be New Drug Target for Preventing Lymphedema, Tumor Spread

Keywords: HORMAN - LYMPH SYSTEM - ADRENOMEDULLIN - TUMOR SPREAD

Description

A hormone secreted by cells throughout the body and known to play a role in cardiovascular disease and other cell functions is also critical for proper formation of the lymphatic system in mice, according to research from the University of North Carolina at Chapel Hill School of Medicine.

Newswise -- A hormone secreted by cells throughout the body and known to play a role in cardiovascular disease and other cell functions is also critical for proper formation of the lymphatic system in mice, according to research from the University of North Carolina at Chapel Hill School of Medicine.

By targeting this hormone, called adrenomedullin, researchers may be able to treat the more than 100 million people worldwide affected by lymphedema, a condition that causes painful swelling in arms and legs.

"Our research also may lead to therapies to prevent cancer cells from traveling through these lymphatic vessels to infiltrate other parts of the body," said Kathleen M. Caron, senior study author and assistant professor of cell and molecular physiology and genetics at UNC.

Adrenomedullin is a powerful vascular peptide that can widen existing blood vessels and even promote the growth of new ones. But it also has many more functions, such as helping control metabolism, heart rate, thirst and appetite, stress response, antibacterial activity and nerve signal transmission.

The study, published Dec. 20, 2007, in the Journal of Clinical Investigation, demonstrates that this peptide is necessary for yet another function in our bodies: without it, our lymphatic system - an important part of the body's immune system - does not form normally. The lymphatic system includes lymph nodes and a network of thin tubes that transport fluid and immune cells that have leached out of tissues back into the circulatory system. These tubes branch, like blood vessels, into all the tissues of the body. Between two and three liters of the almost colorless fluid called lymph go through the lymphatic system in a day.

If this system fails to function properly, excess fluid collects and swells in tissue, causing lymphedema. In rare instances, the condition is inherited through genetic mutations. For two to three million cancer survivors, it comes as a consequence of early treatment, as the surgical removal of lymph nodes and radiation therapy creates damage to the lymphatic system that lasts a lifetime. But the most common cause, affecting up to 120 million people worldwide, is a parasitic infection.

"Lymphedema is a very serious problem," Caron said. "Not only does it limit your mobility, but it can be quite painful and disfiguring."

The only current treatments for the condition - using low-compression stockings and other garments, and massage - are not much help, Caron says. Before now, only a dozen or so genes had been implicated in the formation of lymphatic vessels, or lymphangiogenesis, and none of them have yet yielded an effective therapy. But through this study, the researchers have described three new targets, adrenomedullin and two of its partners in the cell, which together hold true promise for a pharmaceutical treatment for lymphedema.

Caron and her team of researchers discovered the importance of this hormone in the formation of the lymphatic system after genetically manipulating mice so that they completely lacked either adrenomedullin or its related cell partners. They found that these mice looked a lot like other mice with impaired lymphangiogenesis. Careful examination showed that the lymph sacs that normally take up excess fluid from the tissues were much smaller than they should be, and the sacs without adrenomedullin were made up of fewer cells than normal.

By increasing adrenomedullin within the cells of the lymphatic system, the researchers believe that they can encourage the lymph sacs to proliferate and take up more fluid. Not only could this approach provide a new treatment for lymphedema, but it may also prove useful in preventing the spread of cancer because invasive cancers sometimes penetrate the lymphatic vessels and metastasize to distant sites.

"In cancer treatments of the future, patients suffering from these aggressive cancers could be identified early and could be treated with a drug to inhibit the growth of the lymph vessels that transport the cancerous cells, thus keeping the cancer in check," Caron said.

The research was funded in part by The Burroughs Wellcome Fund, the National Institutes of Health and the American Heart Association.

Study co-authors are Kimberly L. Fritz-Six, William P. Dunworth and Manyu Li, all of the UNC School of Medicine.

Newswise

Effectiveness of the treatment-phase of two-phase complex decongestive physiotherapy for the treatment of extremity lymphedema.

Effectiveness of the treatment-phase of two-phase complex decongestive physiotherapy for the treatment of extremity lymphedema.

Int J Clin Oncol. 2007 Dec

Yamamoto R, Yamamoto T.
Rhythmic Obstetrics and Gynecology Clinic, 4F-1, No. 26 Keiwa bldg., Kita 24, Nishi 4, Kita-Ku, Sapporo, 001-0024, Japan, rhythmic@minos.ocn.ne.jp.

BACKGROUND: Complex decongestive physiotherapy (CDP) consists of a two-phase treatment program and is the international standard therapy for lymphedema. However, this therapy is not performed at most hospitals in Japan.

METHODS: The subjects of the present study were 82 Japanese women with lymphedema of an extremity (median age, 64 years; range, 40-86 years). The volume of the affected extremity was compared before and after therapy, and the duration of the CDP treatment phase and rate of edema reduction were ascertained. The associations between the effect of CDP and duration of lymphedema, operative procedure, and radiotherapy were also investigated.

RESULTS: For patients with upper-extremity lymphedema, the median duration of the CDP treatment phase was 6 treatment days (range, 3-26 days), median reduction of edema volume was 328.7 ml (range, 76.6-1258.0 ml; P = 0.0014), and median rate of edema reduction was 58.9% (range, 42.7%-97.1%). For patients with lower-extremity lymphedema, the median duration of the CDP treatment phase was 10 treatment days (range, 2-35 days), median reduction of edema volume was 1573.7 ml (range, 293.9-3471.1 ml; P <>

CONCLUSION: In a study of Japanese women with lymphedema, CDP comprising a two-phase treatment program was clearly effective.

Springer Link

Secondary scrotal lymphedema: A novel microsurgical approach

Secondary scrotal lymphedema: A novel microsurgical approach
Sylvain Mukenge, M.D. 1 *, Carlo Pulitanò, M.D. 1, Renzo Colombo, M.D. 2, Daniela Negrini, B.D. 3, Gianfranco Ferla, M.D. 1
1Department of Surgery, Scientific Institute San Raffaele, Vita-Salute San Raffaele University, Milan, Italy2Department of Urology, Scientific Institute San Raffaele, Vita-Salute San Raffaele University, Milan, Italy3Department of Experimental and Clinical Biomedical Sciences, University of Insubria, Varese, Italy
email: Sylvain Mukenge (mukenge.mvunde@hsr.it)

*Correspondence to Sylvain Mukenge, Department of Surgery, Scientific Instistute H San Raffaele, Via Olgettina 60, 20132 Milan, Italy
setDOI("ADOI=10.1002/micr.20426")

Abstract

Secondary scrotal lymphedema is an infrequent complication of radical cystectomy assiociated with pelvic lymphadenectomy. We report a case of secondary lymphedema of male genitalia presenting more than 4 years after a radical cystectomy with extended pelvic lymphadenectomy for adenocarcinoma of the bladder. Microsurgical lymphovenous anastomoses are usually performed using only the scrotal lymphatics excluding the testicular lymphatics drainage. We have experimented a new microsurgical technique based on lymphovenous anastomosis between the collectors of the spermatic funiculus and the veins of the pampiniform plexus, allowing the testicular lymphatic drainage.

Wiley InterScience

Infectious Disease Doctor for Lymphedema

Infectious Disease Doctor

I am a firm believer in the concept of a “team” approach to the management and treatment of lymphedema and its associated complications.

What is a Team Approach?

The team approach is a group of medical providers working together for the well being and health of the lymphedema patient.

In my situation, my team consists of

Primary Care Doctor
Oncologist
Pulmonary Doctor
Infectious Diease Doctor

Why Do I Need an Infectious Disease Doctor?

Until I acquired lymphoma, the most pressing complication that I experienced with my leg lymphedema was recurrent and severe cellulitiis. It was apparent long ago that we desperately needed a way to control it (try to prevent) and if it did occur to promptly and successfully treat the infection.

The result is that I have been under the care of an ID doctor now for over twenty years.
Because of our susceptibility to infections and because our lymphedema arm or leg is immunocompromised, it is essential that any lymphedema patient with recurrent infections enlist the aide of an “ID” doctor. They are specially trained in infections and are far more qualified to treat them then any other type of doctor.

My ID doc, Dr. Elliott Raizes has been a life saver and a God send in my own battle with lymphedema. Not only does he has that “old fashioned” and rapidly disappearing concern for his patients, but his knowledge of bacterial infections is unbelievable.

How Do I Find an Infectious Disease Doctor?

The easiest way is to simply ask or if need be insist on a referral to one in your area from your PCP. They may already know of a good doctor within your community.

You can also find participating ID doctors in your insurance plan through their “Find a Doctor” service or you can locate one through the internet.

Pat

What is an ID Specialist?

Infectious Disease Specialists are like medical detectives. They examine difficult cases, looking for clues to identify the culprit and solve the problem.

Your ID Physician Has 9-10 Years of Specialized Education & Training

4 years of medical school
3 years training as a doctor of internal medicine
2-3 years specialized training in infectious diseases

Most ID specialists who treat patients also are board certified. They have passed a difficult certification examination by the American Board of Internal Medicine in both internal medicine and infectious diseases.

Reducing Risk of Infectious Disease

One of the best strategies for preventing infectious diseases is immunization. Make sure you and your children receive all recommended vaccinations.

Ask your doctor for advice about other things you and your family can do to prevent infectious diseases.

When You Need an ID Specialist

Many common infections can be treated by your personal physician. Your doctor might refer you to an ID specialist in cases where an infection is difficult to diagnose, is accompanied by a high fever, or does not respond to treatment. ID specialists also see healthy people who plan to travel to foreign countries or locations where infection risk is higher. In these cases, ID specialists can help determine whether special immunizations or other preventive measures are necessary to protect travelers from disease.

Typical Procedures

ID specialists review your medical data, including X-rays and laboratory reports such as blood work and culture data. They also may perform a physical exam to help determine the cause of the problem.

Tests

ID specialists often order laboratory tests to examine samples of blood or other body f luids or cultures from wounds. A blood serum analysis can help the ID specialist detect antibodies that indicate what type of infection you have. These advanced tests can further explain the results of earlier tests, helping to pinpoint the problem.

Treatments

Treatments consist of medicines—usually antibiotics—to help battle the infection and prevent it from returning. These medicines may be given to you orally (in the form of pills or liquids) or administered directly into your veins, via an IV tube. Many ID specialists have IV antibiotic therapy available in their offices, which decreases the likelihood that you will need to be hospitalized.

What Information Should You Give Your ID Specialist?

All medical records related to your condition

X-rays, laboratory reports and immunization records. Often your personal physician will forward this information to the specialist before your scheduled appointment.
A list of all medications you take

This list should include over-the-counter and prescription medications

A list of any allergies you have.

Let the ID specialist know if you are taking birth control pills.

Some antibiotics may interfere with the effectiveness of oral contraceptives.

How Does My ID Specialist Work With Other Medical Professionals?

The ID specialist works with your personal physician to determine which diagnostic tests are appropriate. If treatment is necessary, your doctor and the ID specialist will work together to develop a treatment plan best suited to your needs. Often you will be asked to return to the ID specialist for a follow-up visit. This allows the specialist to check on your progress, confirm that the infection is gone and help prevent it from coming back. If you acquire an infection while in the hospital, the ID specialist will work with other hospital physicians to help direct your care.

The specialist also might provide follow-up care after you go home.

If your ID specialist is also your personal physician, he or she will coordinate your care, referring you to other specialists when necessary.

ID Specialists Are Experts in the Diagnosis and Treatment of Illnesses Caused by Microorganisms.

ID specialists see patients to determine whether their symptoms are due to an infection.

Patients often see ID specialists due to a fever.

Some ID specialists serve as primary care physicians, for example, for people with HIV/AIDS, treating most illnesses and coordinating their patients’ overall care.

In all of these cases, the specialized training and diagnostic tools of the ID specialist can help determine the cause of your infection and the best approach to treatment.

Where Can I Get More Information About the Prevention and Treatment of Infectious Diseases?

Your doctor is your best source of information. In addition, the Infectious Diseases Society of America (IDSA), a professional organization of nearly 8,000 ID physicians, scientists, and other infectious diseases experts, can help point you in the direction of resources and additional information.

Visit IDSA’s website

Infectious Disease

Infectious Disease Internal Medicine Subspecialty

An infectious disease (ID) specialist is a doctor of internal medicine (or, in some cases, pediatrics) who is qualified as an expert in the diagnosis and treatment of infectious diseases. After seven or more years of medical school and postgraduate training, ID specialists complete two to three years of additional training in infectious diseases.

ID specialists have expertise in infections of the sinuses, heart, brain, lungs, urinary tract, bowel, bones and pelvic organs. Their extensive training focuses on all kinds of infections, including those caused by bacteria, viruses, fungi and parasites. Many ID physicians specialize in treating patients with infections due to human immunodeficiency virus (HIV), the cause of AIDS.
Along with their specialized knowledge comes a particular insight into the use of antibiotics and their potential adverse effects. ID specialists also have additional training in immunology (how the body fights infection), epidemiology (how infections spread) and infection control.

What an infectious disease specialist does

The role of an infectious disease specialist is to review a patient's medical data, including records, X-rays and laboratory reports. They may perform a physical examination, depending on the type of problem. They also counsel healthy people who plan to travel to countries where there is an increased risk of infection.

Laboratory studies are often necessary and may include blood studies and cultures of wounds or body fluids. They may order blood serum studies for antibodies indicating the presence of unusual or uncommon diseases. These studies may help explain the results of studies that a general internist may already have done.

Work in the infectious disease specialty is limited to diagnosis and medical treatment. Infectious diseases specialists do not perform surgery.

When you need an infectious disease specialist

Not everyone who has an infectious disease needs an infectious disease specialist. Your general internist can take care of most infections, but sometimes specialized expertise is needed to either diagnose or manage specific infectious diseases.

When a fever raises the suspicion that you may have an infection, when an infection is potentially serious, or when problems occur with treatment, it may be necessary to consult an infectious diseases specialist. ID specialists can provide special insight into tests that will be helpful in diagnosing and understanding the infection and preventing recurrent infections. They can often help determine what treatment you need, if any, and whether you should receive antibiotics. You may not require any treatment, but if you do, they may confer with your personal physician about which diagnostic testing and forms of treatment are best suited to your needs. If you are hospitalized for an infection or acquire an infection while hospitalized, ID specialists will follow and help direct your hospital care. In some cases, they may continue to see you after you go home from the hospital.

How infectious disease specialists work with other physicians

Although infectious diseases specialists sometimes serve as primary care physicians, in most cases you will still need your regular doctor. Usually you will be asked to return to the ID specialist for a follow-up visit to review test results and to be sure that your infection has been eliminated. ID specialists may wish to follow up with you until we feel confident that the infection will not recur. You will resume care with your regular physician when your condition has stabilized or is cured.

Doctors for Adults

See also: Infectious Disease Doctor

Lymphedema - Medicare - What You Can Do

Lymphedema - Medicare - What You Can Do
I'd like to start everyone off with the following three steps. Take on as much as you all can but don't over-do. I know we all have limited time and energy. The first thing to do is to get your lymphedema under control, then we can start educating and lobbying.

1. If you have recently been denied compression bandages, garments or devices, and you are still within the time period for an appeal, let's get the appeal going. I'll supply the proper forms and help you fill them out. If you have paid for compression materials and have not been formally denied, I'll send you a Medicare claim form. Otherwise I'll help you write a claim letter.

2. I must also know whether you wish to work towards national Medicare legislation or State legislation for the diagnosis and treatment of lymphedema.

Tell me your 9-digit ZIP code and I'll tell you the name and contact info for your legislators with suggestions as to the best ones to contact.

3. When you have some spare time, call your legislators to urge them to support (or introduce) legislation which affects your ability to access quality lymphedema care. Some current bills are as follows:

Stopgap legislation has been introduced in both the Senate and House (S. 543 Nelson/H.R. 1459 Tanner) that would freeze implementation of 75% Rule and prevent additional access problems for individuals requiring lymphedema treatment.

The House recently passed the Children's Health and Medicare Protection (“CHAMP”) Act of 2007, which includes a freeze in the implementation of the 75% Rule at the 60% threshold indefinitely.

The legislation would also allow patients' co-morbidities to continue to be considered for purposes of meeting the 75% Rule quota.

In March 2005 CMS changed their interpretation of the Social Security Act to limit coverage of manual lymph drainage to physical and occupational therapists, thereby eliminating coverage of treatment by specially-qualified nurses, physicians, osteopaths, chiropractors and massage therapists.

This effectively reduced the numberof available trained therapists by some 30 percent. A number of lymphedema treatment clinics around the country have already been forced to close as a result of this policy change. H.R. 1846 Towns attempts to partially rectify this ill-advised policy by restoring physician authority in selecting qualified medical personnel to perform “incident to” services.

Also in March 2006 lymphedema was exempted automatically from therapy caps that were re-imposed on January 1, 2006. But in January 2007 exemption was made dependent on existence of a co-condition. This constitutes another roadblock to access to physician-prescribed treatment for lymphedema patients.

S. 450 Ensign/H.R. 748 Becerra would permanently eliminate therapy caps.

Thanks for helping.

BobRobert Weiss, M.S.Lymphedema Treatment Advocate

Email: LymphActivist@aol.com

Lymphedema - Medicare News (Not Good)

Lymphedema - Medicare News (Not Good)

My proposal to CMS to add over 150 new and revised codes to the HCPCS Codebook for lymphedema treatment supplies was just rejected again by the CMS HCPCS Workgroup in Baltimore. This was very depressing because they never referred to my legal and medical arguments--only stated that "no insurer (i.e. Medicare, Medicaid, Private Insurance Sector) identified a national program operatingneed to establish unique codes to distinguish all the products listed in this application. Existing codes adequately describe the array of products available."

This reiterates my feeling that I have not gotten the required support from providers, suppliers, patients, manufacturers to convince "Medicare, Medicaid and the Private Insurance Sector" that there could be a "program operating need", and that there is a proposed solution to the problem which has a rational legal and medical basis. My record with Medicare Administrative Law Judges recently, since developing my "prosthetic devices" argument, is 4 favorable, 1unfavorable decisions. Two cases have been appealed to the Medicare Appeals Council in Washington. My argument, in brief, is that compression bandages, garment and devices meet the definition in the Social Security Act of "prosthetic devices" when used in the standard treatment of lymphedema, and are covered by Medicare. They are usually denied because they do not meet the policies on surgical dressings benefit category, which is not their medical use or their benefit category.

I am in the process of preparing a formal request for a national coverage analysis on the coverage of the treatment of lymphedema that would lead to a new national coverage determination and policy, but progress is slow. I am also preparing a formal request to SADMERC for a reclassification of compression sleeves and bandages from uncovered S-codes to covered L-codes, and of compression stockings used in treatment of lymphedema from uncovered A-codes to covered L-codes. The request is also to add codes for other compression garments which are not currently described.

Another important reason for reclassifying compression garments from A-codes (Secondary surgical dressings) to L-codes (prosthetic devices) is that the specifications for elastic compression garments are different for the two functions, and the costs can be different. For example, an off-the-shelf elastic compression stocking used to hold a primary dressing on a venous ulcer (A-code) is reimbursed at $43.27. A custom flat-knit stocking used in the treatment of a lymphatic leg (L-code) has far more stringint technical specifications and costs far more than the circular-knit elastic stocking to manufacture.
Differences in use, medical requirements, manufacturing costs, etc warrant two different code groups.

I hope that I can get more support from patients, providers, suppliers and manufacturers this coming year in my efforts to get CMS to change their lymphedema treatment coverage policies. Only by appealing every denial of medical treatment for lymphedema can we impress on CMS that there IS a program operating need for new coverage policies and codes. Denials are based on non-relevantpolicies, HCPCS codes are being used incorrectly, and there are inadequate codes for the medically necessary coverable items used every day by lymphedema patients.

And if CMS does not chose to understand the issue, and in the absence of a lymphedema lobby, we must rely on legislators' constituents (that means YOU) to create the awareness of a need for legislative change.

Robert Weiss, M.S.
Lymphedema Treatment Advocate

Elephantiasis nostras verrucosa complicated with chronic tibial osteomyelitis

Elephantiasis nostras verrucosa complicated with chronic tibial osteomyelitis
Arch Orthop Trauma Surg. 2007 Nov 3

Turhan E, Ege A, Keser S, Bayar A.
School of Medicine, Department of Orthopaedics and Traumatology, Medicine Faculty of Zonguldak Karaelmas University, Kozlu, 67100, Zonguldak, Turkey, dregementurhan@yahoo.com.

Keywords: Elephantiasis nostras verrucosa - Tibial - Osteomyelitis - Amputation

Elephantiasis nostras verrucosa represents an infrequent clinical entity with cutaneous changes characterized by dermal fibrosis, hyperkeratotic verrucous and papillamotous lesions resulting from chronic non-filarial lymphedema secondary to infections, surgeries, tumor obstruction, radiation, congestive heart failure, and obesity. Although recurrent streptococcal lymphangitis is believed to play a critical role in the origin of elephantiasis nostras verrucosa, the exact pathogenesis of the disorder is not yet clear. Therapeutic efforts should aim to reduce lymph stasis, which will also lead to improvement of the cutaneous changes but unfortunately there is no specific treatment for advanced cases. In this report, we present a patient who was treated by below knee amputation as a result of elephantiasis nostras verrucosa complicated with chronic tibial osteomyelitis.

Springer Link