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

Sept 24, 2012

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

Source

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

Abstract

PURPOSE: 

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

METHODS: 

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

RESULTS: 

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

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

CONCLUSION

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

PubMed

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

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

Sept 2012

Lee S, Han JS, Ross HM, Epstein JI.

Source

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

Abstract

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

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

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

PubMed

see also: Male Genital Lymphedema

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

Sept 2012

Pereira de Godoy JM, Guerreiro Godoy MD.

Abstract

PURPOSE:

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

METHODS:

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

RESULTS:

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

CONCLUSION:

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

PubMed

Management of lymphedema.

Jul 2012

Vojáčková N, Fialová J, Hercogová J.

Source

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

Abstract

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

Wiley OnLine

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

Sept 2012

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

Source

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

Abstract

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

PubMed

For further information on Lymphoscintigraphy

Primary upper-limb lymphedema.

Primary upper-limb lymphedema.

August 2012

Vignes S, Arrault M, Yannoutsos A, Blanchard M.
Source

Department of Lymphology, Centre National de Référence des Maladies Vasculaires
Rares (lymphœdèmes primaires), Hôpital Cognacq-Jay, 75015 Paris, France.

Abstract

Background: Lymphedema is a general term applied to designate pathological regional accumulation of protein-rich fluid. It can be either primary or secondary, mainly after cancer treatment.

Objective: To analyze clinical and lymphoscintigraphic characteristics of  primary upper-limb lymphedema. 

Method: All patients with upper-limb lymphedema (January 2007-December 2011) recruited in a single Department of Lymphology were included.

Results: Sixty patients (33 females, 27 males) were enrolled. For the 54 noncongenital lymphedemas, mean age at onset was 38.5 (3-82) years. Lymphedema was unilateral in 51 (85%) patients. It always affected the hand, but less often the forearm (55%) or upper arm (23%). Eleven (18%) patients developed cellulitis after lymphedema onset. Twenty-one (35%) patients had associated lower-limb lymphedema. Forty-six patients (with 49 lymphedematous limbs) underwent
lymphoscintigraphy: axillary lymph-node uptake was diminished in 18 (37%), absent in 24 (49%) and normal in 7 limbs (14%). Among the 43 patients with unilateral lymphedema and lymphoscintigraphy, 28 had epitrochlear node visualization, suggesting a re-routing through the deep lymphatic system, 15 only on the lymphedematous limb and 22 on the contralateral nonlymphedematous limb. Median follow-up was 103 months and 57/60 (95%) patients considered their lymphedema stable.

Conclusion: Primary upper-limb lymphedema appears later in life than lower-limb lymphedema without sex predominance. Infectious complications are rare and patients considered the lymphedema volume stable throughout life.

PubMed

IMPORTANT NOTICE WHICH MAY CHANGE YOUR ACCESS TO LYMPHEDEMA SERVICES IN 2014

IMPORTANT NOTICE WHICH MAY CHANGE YOUR ACCESS TO LYMPHEDEMA SERVICES IN 2014

WE HAVE ONLY UNTIL SEPT 4, 2012, TO RESPOND TO THIS!!  It is up to us to have our voices heard VERY loudly on this. 

Medicare Part B

CLAIMS-BASED DATA COLLECTION STRATEGY FOR THERAPY SERVICES PROPOSED

CMS issued proposed rule, CMS1590P, on July 6 that includes a proposal to collect data on patient function related to physical and occupational therapy, and speech language pathology services. Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) requires CMS to implement, beginning on January 1, 2013, ". . . a claims based data collection strategy that is designed
to assist in reforming the Medicare payment system for outpatient therapy services subject to the limitations of section 1833(g) of the Act.

Such strategy shall be designed to provide for the collection of data on patient function during the course of therapy services in order to better understand patient condition and outcomes."

The proposed appeared in the July 30, 2012 Federal Register. CMS will accept comments on the proposed rule until September 04, 2012, and will respond to them in a final rule with comment period to be issued by November 1, 2012.

The Problem:
1. New non-payable data collection codes for reporting functional limitations for each claim;
2. Goal is new therapist reimbursement based on improvement of function and complexity of services;
3. Proposed criteria for evaluating improvement of functional limitations are all physical measures There are no measures proposed that would measure
lymphedema severity or improvement of lymphatic function;

Action:

Write a letter to CMS pointing out the impact the new rule will have to you, as a lymphedema patient, if there are no quality measures appropriate to describe the severity/complexity of the “functional limitation” of lymphedema, and
therefore neither the severity/complexity of the functional limitation, nor the progress attained by the therapist. This lack of means of describing and
evaluating the improvement achieved by lymphedema therapy could result in the
incorrect conclusion that the therapy is of no medical value and disapproved.

To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on September 4, 2012.

ADDRESSES: In commenting, please refer to file code CMS–1590–P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission. You may submit comments in one of four ways (please choose only
one of the ways listed):

1. Electronically. You may submit electronic comments on this regulation to regulations
http://www.regulations.gov. Follow the instructions for ``submitting a comment.''

2. By regular mail. You may mail written comments to the following address ONLY:
Centers for Medicare & Medicaid Services, Department of Health and Human
Services, Attention: CMS–1590–P, P.O. Box 8013, Baltimore, MD 21244–8013.

Please allow sufficient time for mailed comments to be received before the close
of the comment period.

3. By express or overnight mail. You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–1590–P, Mail Stop C4–26–05, 7500 Security Boulevard, Baltimore, MD 21244–1850.

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments before the close of the comment period to either of the
following addresses:

a. For delivery in Washington, DC— Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Room 445–G, Hubert H. Humphrey
Building, 200 Independence Avenue SW., Washington, DC 20201. (Because access to
the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)

b. For delivery in Baltimore, MD— Centers for Medicare & Medicaid Services,
Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD
21244–1850. If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786– 7195 in advance to schedule your arrival with one of our staff members. Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

Robert Weiss, M.S.
Lymphedema Patient Advocate
National Lymphedema Network

Patient awareness and knowledge of breast cancer-related lymphedema in a large, integrated health care delivery system.

Sept 2012

Marilyn L. Kwan, Ling Shen, Julie R. Munneke, Emily K. Tam, Paula N. Partee, Mary André,Susan E. Kutner, Carol P. Somkin, Lynn M. Ackerson and Saskia R. J. Thiadens

Source

Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA, marilyn.l.kwan@kp.org.

Abstract

Breast cancer patients have voiced dissatisfaction regarding their education on breast cancer-related lymphedema risk and risk reduction strategies from their clinicians. Informing patients about lymphedema can contribute to decrease their risk of developing the condition, or among those already affected, prevent it from progressing further. In this cross-sectional study, a lymphedema awareness score was calculated based on responses to a brief telephone interview conducted among 389 women diagnosed with invasive breast cancer at Kaiser Permanente Northern California from 2000 to 2008 and had a previous record of a lymphedema-related diagnosis or procedure in their electronic medical record. 

During the telephone interview, women self-reported a lymphedema clinical diagnosis, lymphedema symptoms but nolymphedema diagnosis, or neither a diagnosis nor symptoms, and responded to questions on lymphedema education and support services as well as health knowledge. Multivariable logistic regression [odds ratio (OR) and 95 % confidence interval (CI)] was used to determine the associations of selected sociodemographic and clinical factors with the odds of having lymphedema awareness (adequate vs. inadequate). 

These results can help inform educational interventions to strengthen patient knowledge of lymphedema risk and risk reduction practices, particularly in an integrated health care delivery setting. With the growing population of breast cancer survivors, increasing patient awareness and education about lymphedema risk reduction and care after cancer diagnosis is warranted.

View the full report:

Springerlink-PubMed

Flow control in our vessels: vascular valves make sure there is no way back.

Aug 2012

Bazigou E, Makinen T.

Source

Lymphatic Development Laboratory, Cancer Research UK London Research Institute, 44 Lincoln's Inn Fields, London, WC2A 3LY, UK, e.bazigou@imperial.ac.uk.

Abstract

The efficient transport of blood and lymph relies on competent intraluminal valves that ensure unidirectional fluid flow through the vessels. In the lymphatic vessels, lack of luminal valves causes reflux of lymph and can lead to lymphedema, while dysfunction of venous valves is associated with venous hypertension, varicose veins, and thrombosis that can lead to edema and ulcerations. Despite their clinical importance, the mechanisms that regulate valve formation are poorly understood and have only recently begun to be characterized. Here, we discuss new findings regarding the development of venous and lymphatic valves that indicate the involvement of common molecular mechanisms in regulating valve formation in different vascular beds.

Full Text Article available through Springerlink.  URL will not work when placed in this article.

http://www.springerlink.com/content/k784vh15p7040q7n/

Lymphedema People FACEBOOK

A very special announcement

We are now in Facebook....come join us!!!!!!!!!

LYMPHEDEMA PEOPLE FACEBOOK.

Amazing amount of discussions, great people, good comradery, solid info!

Pat

Lymphedema treatment in palliative care: a case study.

Lymphoedema treatment in palliative care: a case study.

August 2012

Cooper G.

Abstract

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

Internurse

The Puzzle Lymphedema Book

The Puzzle Lymphedema Book

JUST A WEE REMINDER


Here's our new book on lymphedema. I also have a chapter with several articles.....

(including my own story). Pat

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

The book is compiled so that people who have been touched by lymphedema can share their stories; their trials and tribulations, their sadness and disappointments, their strength and hopes. It is intended to encourage, educate and inspire patients and loved ones, who can often feel isolated and uninformed.
We hope to increase awareness and general knowledge of a condition that is often overlooked and misdiagnosed, yet which can have monumental physical and emotional impact on the lives that it affects.

Not every story has a happy ending, yet there is hope. By sharing these stories with one another, we can learn from the struggles and successes that others have
experienced, and can help each other to live well with lymphedema.

How do I get this book ???

This book will be available at:

15th State of Georgia Lymphedema Education And; Awareness Program 

15th State of Georgia Lymphedema Education & Awareness Conference

Saturday, October 27, 2012

Emory University Hospital Midtown, 550 Peachtree Street, Atlanta, GA 30308

7:30am-4:30pm 

Speakers include: Jane Armer, PhD, Richard Mistretta, DPM,

 Joseph Feldman, MD, and  David W. Chang, MD

The Conference Brochure may be viewed by clicking here

  You may register online by clicking here.  To register by mail simply print the conference brochure and fill in the required information.  Print the Conference Brochure here.

Lighthouse Lymphedema Network Store

Book descrption

ALSO: We have a cookbook with recipes from members and friends:

LLN Favorite Recipes

Please mail your completed order form and donation to:

Lighthouse Lymphedema Network Book
10240 Crescent Ridge Drive
Roswell, GA 30076

Please send a donation of :
$19.95 per copy
Plus $5.00 per copy for Shipping Costs

Order Form

Name: Last First___________________________________________________

Mailing Address____________________________________________________

City State ZIP Code_________________________________________________

Home Telephone Number Cell Telephone Number________________________

Email Address_____________________________________________________

Number of Copies you would like to order______________________________

$_______________________________________________________________

Amount Enclosed________________________

Discovery of a yellow nail syndrome with major hypothyroidism.

Aug 7 2012

Noël-Savina E, Paleiron N, Leroyer C, Descourt R.

Source

Service de pneumologie, hôpital de la Cavale-Blanche, CHU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France.

Abstract

The yellow nail syndrome is rare. It associates the triad: yellow nails, lymphedema and thoracic events. We report two cases of this syndrome with major hypothyroidism. These observations suggest an association between these two diseases.

EMconsulte 2012

Full Text Article: EMconsulte

Children with Lymphedema Yahoo Group

Children with Lymphedema Yahoo Group

If you have a child with lymphedema, care for a child with lymphedema or am a family member of a child with lymphedema I wanted to be sure you knew about our very special children's group.

It is called Children with Lymphedema.

If you have ever felt alone, confused or overwhelmed with this, please do join us.

The camaraderie, information, encouragement and help is incredible within the group.  Members are from all over the world too.

See You There

Angiosarcoma in Chronic Lymphedema

Angiosarcoma in Chronic Lymphedema

(Stewart-Treves Syndrome

To the Editor:

Angiosarcoma is a malignant endothelial tumor that can
form in any part of the body, including the skin. It is known as hemangiosarcoma or lymphangiosarcoma, depending on whether it derives from the endothelium of the blood vessels or the lymph vessels, respectively.

It was first described in 1948 by Stewart and Treves in a
series of 6 cases of lymphangiosarcoma after chronic postmastectomy lymphedema; since then, more than 400 cases have been reported of angiosarcoma associated with chronic lymphedema at different sites.

We report the case of a patient with angiosarcoma of
the right arm, associated with chronic lymphedema due to non-Hodgkin lymphoma.

The only relevant history reported by the 84-year-old
woman was a nodule in the lower right cervical region;
results of a fine-needle aspiration biopsy of the nodule were negative for malignancy. Because of the growth of the nodule, a new fine-needle aspiration procedure was performed a year later and cytology results indicated suspected lymphoma; resection and biopsy were performed and a diagnosis of non-Hodgkin large B cell (CD20) lymphoma was established.

Computed tomography (CT) revealed several bilateral
enlarged axillary lymph nodes; the largest of these, measuring 2.5-3 cm, was on the right side and in contact with the rib. The CT scan also revealed multiple enlarged hilar, mediastinal, para-aortic, and retroesophageal lymph nodes, and a 4.3-cm solid mass in the anterior segment of the right upper lobe of the lung.

SEE FULL TEXT WITH DIAGNOSTIC IMAGES:

ELSEVIER

Also:

Lymphangiosarcoma

Stewart Treves Syndrome

The genetics of vascular anomalies.

The genetics of vascular anomalies. 

August 21, 2012

Frigerio A, Stevenson DA, Grimmer JF.

Source

aDepartment of Human Physiology, University of Milan, Milan, Italy bDivision of Medical Genetics, Department of Pediatrics cDivision of Otolaryngology, University of Utah, Salt Lake City, Utah, USA.

Abstract

PURPOSE OF REVIEW:

To summarize clinically relevant findings in the genetic cause and gene expression of vascular anomalies.

RECENT FINDINGS:

Infantile hemangioma demonstrates familial clustering and is associated with atopic disease. Variable gene expression is seen in infantile hemangioma during proliferation and involution. Capillary malformation may be sporadic or inherited in an autosomal dominant pattern. Capillary malformation-arteriovenous malformation is caused by mutation in RASA1. Some inherited forms of lymphedema are due to mutation in VEGFR3. Venous malformation may be sporadic, paradominant, or autosomal dominant inheritance. Autosomal dominantly inherited forms of venous malformation are due to mutations in TIE2/TEK. Additionally, TIE2 somatic mutations have been identified in about half of sporadic venous malformations.

SUMMARY:

Multiple genes have been identified causing inherited forms of vascular anomalies including capillary malformations, venous malformations and lymphedema. Variable gene expression of infantile hemangioma during proliferation and involution may offer new therapeutic targets for treatment.

Otolaryngology and Head and Neck Surgery