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

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

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

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

Feb 2013

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

Source

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

Abstract

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

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

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

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

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Diagnostic, IV.

Pub Med

Lymphatic Drainage of the Neck

Lymphatic Drainage of the Neck

The lymphatic drainage of the head and neck.

dartmouth.edu

The lymphatic system drainage of the head and neck

A Closer Look at Lipedema and the Effects on the Lymphatic System

**Editor's note:  There is presently an article being published that frankly, has me very outraged.  When I can get the facts straight, I will be writing publicly about it.  In the meantime, because lipedema is mentioned in this article, I wanted to post some solid info on this condition.  The following is by Joachm Zuther, founder and director of the American Academy of Lymphatic Studies (ACOLS) and from his Lymphedema Blog.  I highly recommend both, the article and the blog. Pat**

BY JOACHIM ZUTHER, ON DECEMBER 13TH, 2012

Lipedema is characterized by symmetric enlargement of the limbs, generally affecting the lower extremities extending from the hips to the ankles secondary to the deposition of fat; upper extremities are affected in 30% (1) of the cases.  

Lipedema is not rare and not caused by a disorder of the lymphatic system, but is commonly misdiagnosed as bilateral lymphedema, extreme cellulitis, or morbid obesity.

Most commonly used synonyms for lipedema include:

• Adiposalgia/Adipoalgesia
• Adiposis dolorosa
• Lipalgia
• Lipomatosis dolorosa of the legs
• Lipodystrophia dolorosa
• Painful column leg
• 
  IMPORTANT: see remainder of article with diagnostic images:

A Closer Look at Lipedema and the Effects on the Lymphatic System

See also:

Lipedema

Lipedema Xanga

Support Group

Lipedema, Lipodema, Lipoedema

Complications of Autologous Lymph-node Transplantation for Limb Lymphoedema

Complications of Autologous Lymph-node Transplantation for Limb Lymphoedema


European Journal of Vascular and Endovascular Surgery
Available online 8 January 2013

·S. Vignes, , M. Blanchard, A. Yannoutsos, M. Arrault
Department of Lymphology, Centre National de Référence des Maladies Vasculaires 
Rares (lymphœdèmes primaires), Hôpital Cognacq-Jay, 15, rue Eugène Millon, 75015 
Paris, France

Objective

This study aims to assess potential complications of autologous lymph-node transplantation (ALNT) to treat limb lymphoedema.

Design

Prospective, observational study.

Method

All limb-lymphoedema patients, followed up in a single lymphology department, who decided to undergo ALNT (January 2004–June 2012) independently of our medical team, were included.

Results

Among the 26 patients (22 females, four males) included, 14 had secondary upper-limb lymphoedema after breast-cancer treatment and seven had secondary and five primary lower-limb lymphoedema. Median (interquartile range, IQR) ages at primary lower-limb lymphoedema and secondary lymphoedema onset were 18.5 (13–30) and 47.4 (35–58) years, respectively. Median body mass index (BMI) was 25.9 (22.9–29.3) kg m−2. For all patients, median pre-surgery lymphoedema duration was 37 (24–90) months. Thirty-four ALNs were transplanted into the 26  patients, combined with liposuction in four lower-limb-lymphoedema patients. Ten (38%) patients developed 15 complications: six, chronic lymphoedema (four upper limb, two lower limb), defined as ≥2-cm difference versus the contralateral side, in the limb on the donor lymph-node-site territory, persisting for a median of 40 months post-ALNT; four, post-surgical lymphocoeles; one testicular hydrocoele requiring  surgery; and four with persistent donor-site pain. Median (IQR)pre- and post-surgical lymphoedema volumes, calculated using the formula for a truncated cone, were, respectively, 1023 (633–1375) ml (median: 3 (1–6) months) and 1058 (666–1506) ml (median: 40 (14–72) months; P = 0.73).

Conclusion

ALNT may engender severe, chronic complications, particularly persistent iatrogenic lymphoedema. Further investigations are required to evaluate and clearly determine its indications.

Keywords
* Complication; 
* Lymphoedema; 
* Autologous lymph-node transplantation; 
* Surgery

*Link not available yet

Trends in Risk Reduction Practices for the Prevention of Lymphedema in the First 12 Months after Breast Cancer Surgery.

Dec 2012

McLaughlin SA, Bagaria S, Gibson T, Arnold M, Diehl N, Crook J, Parker A, Nguyen J.

Source

Department of General Surgery, Mayo Clinic, Jacksonville, FL. Electronic address: McLaughlin.Sarah@mayo.edu.

Abstract

BACKGROUND:

 Lymphedema is a feared complication of breast cancer surgery. We evaluated the trends in lymphedemadevelopment, patient worry, and risk reduction behaviors.

STUDY DESIGN:

 We prospectively enrolled 120 women undergoing sentinel node biopsy (SLNB) or axillary node dissection (ALND) for breast cancer and assessed lymphedema by upper extremity volume preoperatively and at 6 and 12 months postoperatively. We defined lymphedema as a >10% volume change from baseline relative to the contralateral upper extremity. Patients completed a validated instrument evaluating lymphedema worry and risk reducing behaviors. Associations were determined by Fisher's exact and signed rank tests.

RESULTS:

 At 6 months, lymphedema was similar between ALND and SLNB patients (p = 0.22), but was higher in ALND women at 12 months (19% vs 3%, p = 0.005). A clear relationship exists between relative change in upper extremity volume at 6 and 12 months (Kendall tau coefficient 0.504. Among the women with 0 to 9% volume change at 6 months, 22% had progressive swelling, and 18% resolved their volume changes at 12 months. Overall, 75% of ALND and 50% of SLNB patients had persistent worry about lymphedema at follow-up, and no difference existed in the number of risk reducing behaviors practiced among the 2 groups.

CONCLUSIONS:

 Upper extremity volumes fluctuate, and there is a period of latency before development of lymphedema. Despite the low risk of lymphedema after SLNB, most women worry about lymphedema and practice risk reducing behaviors. Additional study into early upper extremity volume changes is warranted to allay the fears of most women and better predict which women will progress to lymphedema.

Elsevier

Increased Interstitial Protein Because of Impaired Lymph Drainage Does Not Induce Fibrosis and Inflammation in Lymphedema.

Jan 2103

Markhus CE, Karlsen TV, Wagner M, Svendsen OS, Tenstad O, Alitalo K, Wiig H.

Source

Department of Biomedicine, University of Bergen, Norway.

Abstract

OBJECTIVE:

The pathophysiology of lymphedema is incompletely understood. We asked how transcapillary fluid balance parameters and lymph flow are affected in a transgenic mouse model of primary lymphedema, which due to an inhibition of VEGFR-3-Ig signaling lacks dermal lymphatics, and whether protein accumulation in the interstitium occurring inlymphedema results in inflammation.

METHODS AND RESULTS:

As estimated using a new optical-imaging technique, we found that this signaling defect resulted in lymph drainage in hind limb skin of K14-VEGFR-3-Ig mice that was 34% of the corresponding value in wild-type. The interstitial fluid pressure and tissue fluid volumes were significantly increased in the areas of visible swelling only, whereas the colloid osmotic pressure in plasma, and thus the colloid osmotic pressure gradient, was reduced compared to wild-type mice. An acute volume load resulted in an exaggerated interstitial fluid pressure response in transgenic mice. There was no accumulation of collagen or lipid in skin, suggesting that chronic edema presented in the K14-VEGFR-3-Ig mouse was not sufficient to induce changes in tissue composition. Proinflammatory cytokines (interleukin-2, interleukin-6, interleukin-12) in subcutaneous interstitial fluid and macrophage infiltration in skin of the paw were lower, whereas the monocyte/macrophage cell fraction in blood and spleen was higher in transgenic compared with wild-type mice.

CONCLUSIONS:

Our data suggest that a high interstitial protein concentration and longstanding edema is not sufficient to induce fibrosis and inflammation characteristic for the human condition and may have implications for our understanding of the pathophysiology of this condition.

A M A

Two cases of cutaneous angiosarcoma developed after breast cancer surgery.

2012

Iga N, Endo Y, Fujisawa A, Matsumura Y, Kabashima K, Tanioka M, Miyachi Y.

Source

Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan.

Abstract

Several randomized trials have shown that breast-conserving therapy (BCT) is as effective as mastectomy and should be a standard treatment for early-stage breast cancer. Recently, there has been an increase in reports of angiosarcoma (AS) after BCT. Herein, we report a case of AS which developed after BCT and a case of Stewart-Treves syndrome with a focus on lymphedema. Chronic lymphedema is the primary risk factor for AS, which was first described in 1948 by Stewart and Treves [Cancer 1948 pages 1:64-81]. Radiation therapy secondarily tends to induce the development of AS, since radiation therapy induces fibrosis and proliferation of lymphatic vessels via cytokines such as vascular endothelial growth factor, which is followed by subclinical chronic edema. It is suggested that axillary lymph node dissection predisposes patients to the development of AS, since it is closely associated with lymphedema. Breast surgeons and radiologists should be aware of skin changes in order to improve the early detection of AS during the follow-up of patients who have undergone BCT, and especially those treated with axillary lymph node dissection.

PubMed

Experiences of caring for patients with lymphedema and dementia

Experiences of caring for patients with lymphedema and dementia

Dec 2012

[Article in Japanese]

Yokoyama A, Yokoyama K, Matsumoto K, Kubota Y.

Source

The Palliative Care Units, Sanshu Hospital.

Abstract

Recently, the importance of prevention and care of lymphedema patients has been recognized. To improve edema reduction and skin condition, continued care is necessary. However, everyday care requires time and effort, and patients may neglect the required routine. Therefore, it is necessary for patients to recognize the importance of lymphedema and acquire the knowledge and skills to care for their condition. In the case of patients with dementia, it is important to ensure 1) comfortable care for the patients, 2) flexibility of care according to the physical and mental state of the patients, and 3) education of visiting home care staff.

**As more and more lymphers are aging, caring for those of us who have/get dementia will be a significant challenge.**

PubMed

Angiosarcoma in a patient with congenital nonhereditary lymphedema.

Nov 2012

Shon W, Wada DA, Folpe AL, Pittelkow MR.

Source

Divison of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota 55905, USA.

Abstract

Angiosarcoma is an uncommon but aggressive tumor of endothelial origin that may occur in the upper extremities of patients with postmastectomy lymphedema (Stewart-Treves syndrome) as well as in other regions. We present an unusual case of angiosarcoma associated with congenital nonhereditary lymphedema in an 18-year-old man. Our case underscores the need for a careful clinical examination and shows the importance of appropriate sampling and thorough pathologic examination of suspicious areas to exclude the presence of a malignant process.

PubMed

For further information:

Lymphangiosarcoma

Stewart Treves Syndrome

Control of lymphorrhea and treatment of warty excrescences in elephantiasis.

2012

de Godoy JM, Brigídio PA, Buzato E, Godoy Mde F.

Source

Cardiology and Cardiovascular Surgery Department, Faculty of Medicine School of São José do Rio Preto (FAMERP), Avenida Brigadeiro Faria Lima, 5416 Vila São Pedro, 15090-000 São José do Rio Preto, SP, Brazil ; Vascular Laser Center, Clínica Godoy, 1306 Avenida Constituição, 15025-120 São Jose do Rio Preto, SP, Brazil.

Abstract

The aim of this study is to report the control of lymphorrhea in the intensive treatment of elephantiasis, using an Unna boot. The case of a 29-year-old female patient is reported. This young patient evolved with the more serious form of lymphedema, elephantiasis, after surgical treatment of an abdominal neoplasm and radiotherapy. Warty excrescences were present on both legs and genitalia where lymphorrhea was constant. The patient arrived at the Godoy's Clinic for treatment. She was weighed and perimetric evaluations were made at the start of treatment and thereafter every day during an intensive outpatient treatment of eight hours daily for three weeks. Treatment included manual lymph drainage, mechanical lymph drainage using the RA Godoy device, and the continuous use of compression stockings with adjustments made every three hours. An Unna boot was employed as compression at sites of dermal lesions (warty excrescences) with overlapping use of individualized compression stockings that were individually adapted. The Unna boot was renewed every two days during the first week and every 3 days during the second and third weeks. By the end of this course of treatment, most of the warty excrescences had reduced in size or even disappeared and the lymphorrhea was controlled. 

Full Text Article with images:

NIH-NLM

Management of unusual genital lymphedema complication after Fournier's gangrene: a case report.

Management of unusual genital lymphedema complication after Fournier's gangrene: a case report.

**Editor's note:  I am posting this as I just can't believe they did this. Perhaps it was

necessary due to the extent of the gangrene tissue damage. Otherwise, remember
- those of you who are men here - there are other surgical options much lessbrutal and intrusive.  Pat**                 

Management of unusual genital lymphedema complication after Fournier's gangrene: a case report.

Dec 2012

Ganz OM, Gumener R, Gervaz P, Schwartz J, Pittet-Cuénod B.

Abstract

BACKGROUND: Fournier's gangrene is a bacterial infection characterized by necrotizing fasciitis, skin and soft tissue involvement, and eventually myositis of the perineal region. Aggressive debridement of devitalized tissue and overlying skin is of paramount importance, but often leaves large defects to be reconstructed. The present case reports successful extensive perineal defects coverage following Fournier's gangrene and management of subsequent penile lymphoedema impairing sexual function in a young patient.

CASE PRESENTATION:

Following perianal abscess drainage, a healthy young man presented with scrotal pain. Fournier's gangrene was diagnosed and treated with multiple surgical debridements. Tissue excision extended through the entire perineal area, base of the penile shaft, lower abdominal region, the inner thighs, and gluteal region, corresponding to 12 % of the total body surface area. After serial debridements and negative pressure dressings, the defect was covered by two stages of skin grafting. Graft take was 90 %. Healing was achieved without hypertrophic or retractile scar. However, chronic penile lymphedema remained and was first treated with compressive garments for 2 years. Upon failure of this conservative approach, we performed a circumcision, but only a "penile lift" allowed a satisfactory esthetical and functional result.

CONCLUSION:

Fournier's gangrene can be complicated by a chronic lymphedema of the penis. Conservative treatment is likely to fail in severe cases and can be treated surgically by "penile lift".

PubMed

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

2012

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

Source

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

Abstract

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

PubMed

For further information:

Lymphedema Skin Conditions and Skin Growths

Blood test accurately detects lymphedema, study shows

Dec 18, 2012

Scientists at the Stanford University School of Medicine have identified a set of proteins circulating in blood whose levels accurately flag the presence of lymphedema. The findings, to be reported Dec. 18 in PLoS ONE, spur optimism that this common but relatively neglected condition, which affects an estimated 10 million people in the United States, finally will be amenable to detection (and, eventually, treatment) with 21st-century techniques.

Lymphedema is an often-painful inflammatory condition resulting from the blockage of lymphatic vessels that ordinarily drain fluid from the tissues throughout the body. In the developed world, lymphedema most often arises as an unintended consequence of radiation therapy for cancer. For example, about one in four breast-cancer survivors eventually develops lymphedema, said Stanley Rockson, MD, professor of cardiovascular medicine and the study's senior author. Numerous other factors, including parasitic infections endemic in some developing countries, can cause it as well, he said. 

The blunting of normal immune-cell flow due to lymphatic-vessel blockage helps to trigger the buildup of fluid within the affected area of the body, along with thickening of the skin, profound inflammation, accumulation of fibrous tissue, excessive blood-vessel formation and a marked expansion of the fatty layer beneath the skin. 

By the time the main symptom—swelling of one or more limbs—is detectable, the condition may have gotten such a foothold that it becomes difficult or impossible to reverse, at least given current treatment options, Rockson said. 

The only known way to diagnose lymphedema now is via physical inspection, and all too often it is misdiagnosed or overlooked altogether. But the biological events underpinning this condition may be present five years or more before symptoms become evident, said Rockson. Moreover, there are no effective drugs for combating lymphedema, just costly, time-consuming and annoying physical therapy, which virtually never completely eliminates the symptoms. While physical therapy can arrest progression and reduce swelling by as much as half, the condition typically remains a long-term problem. "Lymphedema virtually never just goes away on its own," said Rockson. Indeed, it tends to progress in severity over time, whether it is treated or not.

The irreversible skin thickening, joint immobility, scarring, increased susceptibility to infection and other consequences of chronic lymphedema can leave patients discomfited for life, all too often resulting in social withdrawal, body-image deterioration and other quality-of-life issues. "This is especially ironic in the case of cancer survivors who have endured difficult life-saving interventions, only to find that now cured, they're unable to enjoy their lives," said Rockson, who is the Allan and Tina Neill Professor of Lymphatic Research and Medicine and chief of consultative cardiology at the medical school. 

For this study, Rockson and his associates obtained skin-biopsy samples from both lymphedematous and normal tissue of 27 patients. Using advanced molecular methods, they compared each patient's diseased tissue with that same patient's healthy tissue to see which genes—the recipes for the myriad proteins produced in our bodies—were more actively engaged in the generation of their respective protein products in diseased versus healthy tissue. Thousands of genes fit the bill. Then the investigators narrowed their search to the overproduced proteins themselves, in particular ones that were already known to circulate throughout the bloodstream of all people, including healthy ones, and for which fast, commercial blood tests already exist. 

Statistical modeling indicated a panel of tests that measured six separate proteins' levels in study subjects' blood was able to distinguish the lymphedematous patients from control subjects who did not have lymphedema. None of these six proteins was predictive by itself. But in aggregate, their presence at certain levels and ratios appeared to serve as a biological fingerprint, or biomarker, for lymphedema. 

Interestingly, all six proteins are well-known, and each is associated with one or another of chronic lymphedema's hallmark biological features: accumulation of fibrous deposits, stimulation of fat-cell activity, inflammation and lymphatic-vessel formation and repair. "These biomarkers may themselves lead us to valuable pharmaceutical targets," said Rockson. 

To determine their six-protein biomarker-panel's validity, Rockson's group collected blood from a new cohort of 36 lymphedematous and 15 healthy adults, extracted blood samples and tested them with the panel. The test distinguished those with lymphedema from healthy subjects with an accuracy approaching 90 percent—good enough for use as a clinical 

diagnostic tool and a vast improvement over current detection methods, said Rockson. 

"This is a significant development," he said. 

Because levels of the six proteins begin to climb early in the course of the disease, such a test should be valuable in determining risk for, or the onset of, lymphedema long before symptoms occur—which in turn would mean earlier, appropriate therapeutic intervention, perhaps in time to spare patients from the condition's most-damaging effects or even reverse its course. "In addition," Rockson said, "a standardized, accurate bioassay for lymphedema could help to pave the road for future human clinical trials of drugs to treat it." Monitoring trial subjects at the molecular level with a lymphedema-detecting blood test could provide early evidence regarding whether an experimental treatment is working. Rockson is involved in conducting clinical trials of pharmaceutical agents for lymphedema, and hopes to use the new test in those trials. Journal reference: PLoS ONE Provided by Stanford University Medical Center 

Medical express

The published study itself:

PLoS One

Lymph Glands or Lymph Nodes

Steady Health



Anatomy for Nurses

Physiotherapeutic stimulation: Early prevention of lymphedema following axillary lymph node dissection for breast cancer treatment

Physiotherapeutic stimulation: Early prevention of lymphedema following axillary lymph node dissection for breast cancer treatment

Authors: Almir J. Sarri, Sonia M. Moriguchi, Rogério Dias, Stela V. Peres, Eduardo T. Da Silva, Kátia H. Koga, Ângelo G.Z. Matthes, Marcelo J. Dos Santos, Euclides T. Da Rocha, Raphael L. Haikel

Affiliations: Department of Physiotherapy, Barretos Cancer Hospital, São Paulo, Brazil. almirsarri@hotmail.com

Doi: 10.3892/etm_00000024

Pages: 147-152

Abstract:

The aim of this study was to confirm the effectiveness of early physiotherapeutic stimulation for lymphatic flow progression in patients with breast cancer undergoing axillary dissection. This was a randomized experimental study on 22 patients who underwent lymphoscintigraphy in their arms on two different occasions, firstly without stimulation and secondly after randomization into two groups: without physiotherapeutic stimulation (WOPS; n=10) and with physiotherapeutic stimulation (WPS; n=12). The lymphoscintigraphy scan was performed with 99mTc-phytate administered into the second interdigital space of the hand, ipsilaterally to the dissected axilla, in three phases: dynamic, static, and delayed whole body imaging. Physiotherapeutic stimulation was carried out using Földi's technique. In both groups, images from the two examinations of each patient were compared. Flow progression was considered positive when, on the second examination, the radiopharmaceutical reached areas more distant from the injection site. Statistical analysis was used to evaluate frequencies, percentages and central trend measurements, and non-parametric tests were conducted. Descriptive analysis showed that the WPS and WOPS groups were similar in terms of mean age, weight, height, body mass index and number of lymph nodes removed. There were statistically significant associations between physiotherapeutic stimulation and radiopharmaceutical progression at all three phases of the study.

Early physiotherapeutic stimulation in breast cancer patients undergoing radical axillary dissection is effective, and can therefore be indicated as a preventive measure against lymphedema. 

Spandidos Publications