Lymphedema Volume Research Articles

Les lymphœdèmes primaires de l’enfant

Lymphedema results from impaired lymphatic transport with increased limb volume and is divided into primary and secondary forms. In children, primary lymphedema is the most frequent, with a sporadic, rarely familial form or associated with complex malformative or genetic disorders. Diagnosis of lymphedema is mainly clinical and lymphoscintigraphy is useful to assess the lymphatic function of both limbs precisely. The main differential diagnosis is overgrowth syndrome. Erysipelas (cellulitis) is the main complication, but psychological or functional discomfort may occur throughout the course of lymphedema. Lymphedema management is based on multilayer low-stretch bandage, skin care, and eventually manual lymph drainage. The objective of treatment is to reduce lymphedema volume and then stabilize it. Multilayer low-stretch bandage and elastic compression are the cornerstone of treatment. Parent's motivation, including self-management, is required to ensure the child's compliance and improve quality of life.

Sulfuretin has therapeutic activity against acquired lymphedema by reducing adipogenesis

Acquired lymphedema is a pathological condition associated with lymphatic dysfunction caused by surgical treatments for cancer. Although global estimates of the prevalence of acquired lymphedema have been rising, there are currently no effective therapeutics available. Since adipose tissue accumulation is a clinical hallmark of lymphedema, we hypothesized that regulation of adipogenesis in lymphedematous tissue could be used as a therapeutic intervention against lymphedema. Toward this, we investigated the possibility of anti-adipogenic 30% ethanol Rhus verniciflua Stokes (RVS) extract as a potential lymphedema treatment. Oral administration of RVS extract ameliorated volumetric symptoms of lymphedema in a mouse model. RVS administration also reduced adipose tissue accumulation in lymphedematous tissue and downregulated expression of adipocyte markers, including Pparγ and Fabp4. Sulfuretin was identified as a major bioactive compound in the 30% ethanol RVS extract in liquid chromatography-mass spectrometry analysis. Similar to the activities of RVS, sulfuretin inhibited adipocyte differentiation in 3T3-L1 preadipocytes. Moreover, treatment with sulfuretin on lymphedema-induced mice reduced lymphedema volume, decreased the expression of adipogenic markers, but induced the expression of markers associated with lymphangiogenesis. Taken together, our data raise the possibility that sulfuretin might be used in therapeutic interventions against acquired lymphedema.

Correlation Between Upper Limb Volume and Arterial and Venous Blood Flow Velocity in Lymphedema Secondary to Breast Cancer Treatment

ObjectiveThe purpose of this study was to correlate upper limb volume and arterial and venous blood flow velocity in breast cancer survivors. MethodsA cross-sectional study was conducted on 30 women with lymphedema and a mean age of 55.60 years (standard deviation = 8.12). For the assessment of upper limb volume, perimetry was performed with measures at 6 points on the limb, which were mathematically calculated as volume. The blood flow velocity of the axillary and brachial arteries and veins were assessed by Doppler ultrasound with a probe at 4 MHz. In the statistical analysis, a Shapiro-Wilk test determined a non-normal data distribution. Spearman correlation coefficients (ρ) were calculated to determine the association between the variables blood flow velocity and lymphedema volume. ResultsWe identified significant and positive associations between all variables correlated with limb volume: blood flow velocity of the axillary artery (ρ = 0.381, P = .041), axillary vein (ρ = 0.383, P = .039), brachial artery (ρ = 0.375, P = .044), and the brachial vein (ρ = 0.373, P = .045). ConclusionThere is a positive association between limb volume and blood flow velocity in the upper limbs of women with lymphedema secondary to breast cancer treatment.

Interest of an auto-adjustable nighttime compression sleeve (MOBIDERM\xae Autofit) in maintenance phase of upper limb lymphedema: the MARILYN pilot RCT

PurposeBreast cancer-related lymphedema (BCRL) is a debilitating condition. The recommended treatment is based on decongestive lymphedema therapy (DLT) with two separate phases: a short-term intensive phase to reduce lymphedema volume and a long-term maintenance phase to stabilize it. Optimizing compression therapy and compliance during maintenance phase are key factors for long-term control of lymphedema. The primary objective of this pilot prospective open-label randomized study was to assess the benefit of a new auto-adjustable nighttime arm sleeve (MOBIDERM® Autofit) on lymphedema volume during the maintenance phase after the intensive phase.MethodsForty women with BRCL were consecutively enrolled and randomized (D0) for 1 month in 1:1 ratio either in night-use group: with MOBIDERM® Autofit (on top of a daytime compression hosiery), or in no night-use group: without MOBIDERM® Autofit (daytime hosiery alone). From Day 31 to Day 90, all patients were fitted with MOBIDERM® Autofit. Primary endpoint was lymphedema volume variation between Day 0 and Day 30. Secondary endpoints were compliance, quality of life (LYMQOL arm questionnaire), functional symptoms (heaviness, limb use limitation, pain), sleep quality, and safety.ResultsIn ITT population, between Day 0 and Day 30, mean lymphedema volume increase was higher in no night-use group with 92.9 mL (i.e., 3.2%) than in night-use group with 46.7 mL (i.e., 1.80%), p = 0.757. Between Day 30 and Day 90, all patients fitted with MOBIDERM® Autofit, lymphedema volume remained stable in both groups. The device improved functional symptoms and function domain of the LYMQOL arm questionnaire. MOBIDERM® Autofit was worn overnight almost 85% of the nights. It was well accepted by the patients and no adverse reaction leading to permanent device discontinuation occurred.ConclusionsOur results suggest that MOBIDERM® Autofit offers clinical benefits during maintenance phase of lymphedema treatment and enhances patient’s self-management.

Hydrolysis of Hyaluronic Acid in Lymphedematous Tissue Alleviates Fibrogenesis via TH1 Cell-Mediated Cytokine Expression

Although surgery and radiation are beneficial for treating cancer, they can also lead to malfunctions of the lymphatic system such as secondary lymphedema. This abnormality of the lymphatic system is characterized by severe swelling, adipogenesis, inflammation, and fibrosis in the lymphedematous region. Moreover, the proliferation of fibrotic tissue in the lymphedematous region generates edema that is no longer spontaneously reversible. No treatment for fibrosis has been validated in patients with lymphedema. In our efforts to develop a therapeutic agent for lymphedema fibrosis, we used a newly established mouse hind limb model. Previous studies have demonstrated that hyaluronic acid accumulates in the lymphedematous region. Thus, we challenged mice with of hyaluronidase (HYAL), with the aim of reducing fibrogenesis. After subcutaneous injections in the lymphedematous mouse leg every two days, the volume of lymphedema had reduced significantly by 7 days post-operation. Histochemical analysis indicated that collagen accumulation and myofibroblast differentiation were decreased in epidermal tissues after HYAL injection. Moreover, it was associated with upregulation of interferon-gamma, increased numbers of Th1 cells, and downregulation of interleukin-4 and interleukin-6 in the lymphedematous region and spleen. These results indicate that hydrolysis of hyaluronic acid can boost an anti-fibrotic immune response in the mouse lymphedema model.

Therapeutic effects of hyaluronidase on acquired lymphedema using a newly developed mouse limb model

Acquired lymphedema is one of the most dreaded side effects of cancer treatment, such as surgical treatment or irradiation. However, due to the lack of appropriate animal models, there is no effective therapeutic method to cure acquired lymphedema. To develop a reproducible acquired lymphedema animal model, we devised a mouse hind limb model by removing a superficial inguinal lymph node, a popliteal lymph node, a deep inguinal lymph node, and the femoral lymphatic vessel. We measured the volume of lymphedematous leg and observed the change in level of hyaluronic acid (HA) and lymphangiogenic factors after injecting hyaluronidase. Our model showed the distinguishable swelling and the reliable symptoms compared to previously reported models. In the lymphedematous regions of our model, we confirmed that HA, a major component of extracellular matrix, accumulated to higher levels than in a normal mouse. This lymphedema volume was rapidly reduced by treating hyaluronidase. Following hyaluronidase injection, the lymphedematous region of our model resembled a normal hind limb. Our findings indicated that hyaluronidase promoted lymphangiogenesis on the lymphedematous limb. Based on hyaluronidase treatment in the lymphedematous region, this could potentially be a new therapeutic approach for acquired lymphedema mediated through the modification of the size of HA fragments. Impact statement In this manuscript, the essence of the work described in this manuscript involves the development of (1) a mouse limb model showing acquired lymphedema and (2) a potent therapeutic treatment using hyaluronidase to remedy acquired lymphedema in our model. In order to develop a reproducible acquired lymphedema animal model that reflects the most common symptoms experienced by lymphedema patients, we devised a mouse hind limb model by removing lymph nodes and lymphatics. Our model showed the distinguishable swelling and the reliable symptoms compared to previously reported models. In the lymphedematous regions of our model, we confirmed that hyaluronic acid (HA) accumulated to higher levels than in a normal mouse. This lymphedema volume was rapidly reduced by treating the lymphedematous leg with hyaluronidase, which also degraded high molecular weight HA to low molecular weight HA. Immunohistochemical analysis, quantitative real-time PCR analysis and lymphangioscintigraphy showed that hyaluronidase enhanced lymphangiogenesis in the lymphedematous limb.

Effectiveness of hydrotherapy as an adjunct treatment for the management of breast cancer related lymphoedema in women following breast cancer surgery: a systematic review

Cancer is a leading cause of death and disability around the world. Of all cancers, breast cancer commonly ranks amongst the top three. Surgical intervention for breast cancer is common and a possible side effect of this is breast cancer related lymphoedema (BCRL). Women with breast cancer related lymphoedema commonly have regional limb swelling and pain, which can negatively impact mental and social well-being as well as upper limb function. Hydrotherapy is therapeutic modality which may be used as an adjunct to self-management strategies after the intensive phase of lymphoedema management. Yet despite its popularity, recent research has questioned its effectiveness in clinical practice. Purpose: To determine the effectiveness of hydrotherapy as an adjunct treatment to usual care on arm volume and pain when compared with usual care alone for women with breast cancer related lymphoedema. Method: A comprehensive search of eight electronic databases, including Medline, Embase, CINAHL, Scopus, Web of Science, AMED, The Cochrane Library and PEDro was completed. Studies of adult women with secondary upper limb lymphoedema following breast cancer surgery, which measured lymphoedema volume, pain, upper limb and QOL outcomes were included. Methodological quality was assessed using a modified CASP tool for randomised controlled trials. The NHMRC FORM methodology was utilised to synthesise the evidence and provide an overall grade of recommendation. Results: Four randomised controlled trials and one controlled clinical trial were included in this systematic review. Critical appraisal of the included studies revealed overall methodological quality to be moderate. Hydrotherapy interventions duration varied between 8 to 12 weeks with some similarities between outcome measures assessed. Collectively, there is mixed evidence to support the positive impact of hydrotherapy as an adjunct treatment on reducing lymphoedema volume in the short-term and emerging evidence for upper limb function, pain and QOL. Conclusion: A small number of studies have investigated the effect of hydrotherapy as an adjunct treatment in the breast cancer related lymphoedema population. Hydrotherapy could be considered as an adjunct treatment for women with breast cancer related lymphoedema, although the evidence base is mixed. Hydrotherapy may have positive physiological as well psychosocial impacts, as it is delivered in a group setting. However, the current literature base is limited by small sample size, lack of standardised exercise parameters, inadequate baseline characteristic assessment and limited long-term follow-up.

Vulvar non-filarial elephantiasis associated with scabies

Vulvar elephantiasis is a very rare condition often caused by filariasis infection. Other causes like general inflammatory disease, cancer treatment, traumatic causes or other infections can also explain the occurrence of this condition . In some cases it is due to unknown causes. In this study, we present the clinical case of a Moroccan youth female patient with no significant history, who presented vulvar elephantiasis associated with scabies with no evidence of filariasis infection, general inflammatory disease, malignancy, or other infection. This clinical case is interesting because of the large volume of lymphedema, its atypical localization, its association with generalized scabies, and the absence of a well-defined etiology, which may explain its occurrence.

Les lymphœdèmes : du diagnostic au traitement

Lymphedema results from impaired lymphatic transport with increased limb volume. Lymphedema are divided in primary and secondary forms. Upper-limb lymphedema secondary to breast cancer treatment is the most frequent in France. Primary lymphedema is sporadic, rarely familial or associated with complex malformative or genetic disorders. Diagnosis of lymphedema is mainly clinical and lymphoscintigraphy is useful in primary form to assess precisely the lymphatic function of the two limbs. Erysipelas (cellulitis) is the main complication, but psychological or functional discomfort may occur throughout the course of lymphedema. Lipedema is the main differential diagnosis, defined as an abnormal accumulation of fat from hip to ankle. Lymphedema management is based on complete decongestive physiotherapy (multilayer low-stretch bandage, manual lymph drainage, skin care, exercises). The first phase of treatment leads to a reduction of lymphedema volume and the second phase stabilizes the volume. Multilayer low-stretch bandage and elastic compression is the cornerstone of the complete decongestive physiotherapy. Patient-education programs, including self-management, aim to improve patient autonomy.

Efficacy of night-time compression for breast cancer related lymphedema (LYNC): protocol for a multi-centre, randomized controlled efficacy trial.

BackgroundLymphedema is a prevalent long-term effect of breast cancer treatment that is associated with reduced quality of life. More recent observational data suggest that the addition of night-time compression to day-time use of a compression garment results in better long-term control of arm lymphedema. The primary objectives of the randomized controlled phase of the trial are to determine the efficacy of night-time compression on arm lymphedema volume maintenance and quality of life in breast cancer survivors who have completed intensive reduction treatment for their lymphedema.Methods/DesignThe study will be a parallel 3-arm, multi-centre randomized fast-track trial. A total of 120 women with breast cancer related lymphedema will be recruited from 3 centres in Canada and randomized to group 1: Day-time compression garment alone or Group 2: Day-time compression garment + night-time compression bandaging or Group 3: Day-time compression garment + use of a night-time compression system garment. The duration of the primary intervention period will be 12 weeks. The follow-up period after the intervention (weeks 13 to 24) will follow a longitudinal observational design. The primary outcome variables: differences from baseline to week 12 in arm volume and quality of life (Lymphoedema Functioning, Disability and Health Questionnaire: Lymph-ICF). Secondary outcomes include bioimpedance analysis, sleep disturbance and self-efficacy. All measurements are standardized and will be performed prior to randomization, and at weeks 6, 12, 18 and 24.DiscussionThe use of night-time compression as a self-management strategy for chronic breast cancer related lymphedema is seen as an innovative approach to improve long-term control over the condition. This trial aims to advance the knowledge on self-management strategies for lymphedema.Trial registrationThis trial was registered at clinicaltrials.gov on July 9th, 2014 (NCT02187289)

The Effect of Complete Decongestive Therapy on Edema Volume Reduction and Pain in Women With Post Breast Surgery Lymph Edema.

BackgroundUpper extremity lymph edema is the most common side effect of breast cancer treatment that may produce significant physical and psychological morbidity. Pain is the frequent symptom of lymph edema that causes impairment of activities in daily life.ObjectivesThe aim of this study was assessment of the effect of complex decongestive therapy (CDT) on upper extremity lymph edema and pain in women with post breast surgery lymph edema.Patients and MethodsIn this quasi- experimental research with before- after design, 36 women with moderate lymph edema after breast surgery participated in the program. Edema volume was measured by water displacement method; pain values were evaluated by visual analog scale (VAS). Data were recorded before intervention and 2 and 4 weeks after it. CDT included the first phase (intensive phase) and the second phase (maintenance phase). Each phase lasted 2 weeks. After use of Shapiro Wilk test for normality, analysis of variances with GEE and repeated measurements were used to analyze the data.ResultsAfter one month doing CDT program, significant decrease of edema was noticed (P < 0.0001), also pain decreased during 2 and 4 weeks after intervention (P < 0.0001).ConclusionsThis study indicated that CDT program is effective in reducing lymph edema volume and pain in women with moderate post breast surgery lymph edema. It seems that raising patients’ awareness and training healthcare professionals regarding lymph edema preventive strategies have an important role in earlier and better combating this complication.

The Reduction in Upper Extremity Volume and Improved Quality of Life in Women With Post-Mastectomy Lymphedema by Complex Decongestive Therapy

Background: Breast cancer is one of the most common malignancies all over the world. The rate of survival of the patients with cancer has increased due to developing diverse treatment methods, as a result of which the treatment-related side effects have become the focus of attention more than before. Lymphedema related to breast cancer is one of the frequent side effects which has significantly affected the patient’s quality of life. Objectives: The purpose of this research was to assess the effect of complete or complex decongestive therapy on breast cancer-related lymphedema and the patients’ quality of life. Patients and Methods: The present study was conducted from January 2013 to January 2014 and comprised 119 patients with breast cancer, related lymphedema, who had undergone complete or complex decongestive therapy (CDT). The patients’ volume and grade of lymphedema were measured and determined before and after treatment, using the direct volumeter device to measure the lymphedema volume. To determine the quality of life, the European organization for research and treatment of cancer quality of life questionnaire (EQRTC BR-23) was completed before and after the treatment. Result: The volume of lymphedema was significantly reduced after CDT (P < 0.001). The scores of quality of life were significantly increased regarding body image (BI) (P < 0.001), future prospective (FP) (P = 0.008), sexual functioning (SF) (P = 0.006), systemic therapy side effect (STSE) (P = 0.008) and arm symptoms (AS) (P < 0.001) which was clear indication of improved quality of life. Conclusions: It is concluded that not only CDT causes reduction in lymph edema volume but also it improves the life quality of patients with breast cancer-related lymphedema

Current Treatments for Breast Cancer-Related Lymphoedema: A Systematic Review

Background and objective:Breast cancer-related lymphoedema (BCRL) is a disabling complication with long term impact on quality on life after breast cancer treatment. Its management remains a major challenge for patients and health care professionals; the goal of this overview was to summarize effects of different treatment strategies for patients with BCRL.Methods:A thorough search was undertaken to allow a systematic review or meta-analysis of treatments for BCRL. Two investigators independently selected studies and abstracted the data.Results:Combined physical therapy (CPT) with different combinations of surgery, oral pharmaceuticals, low-level laser therapy, weight reduction, mesenchymal stem cell therapy, kinesio tex taping, and acupuncture might be effective in reducing lymphoedema, but exercise demonstrated no obvious benefit. The results of direct comparisons showed CPT might be more effective than standard physiotherapy (ST). Manual lymphatic drainage (MLD) may not offer additional benefits to ST for swelling reduction, but could facilitate compression bandaging. MLD seemed to have similar effects with self-administered simple lymphatic drainage (SLD) or using an intermittent pneumatic compression pump (IPC). IPC might also not be associated with additional effectiveness for CPT. Efficacy of stem cell therapy vs. compression sleeve or CPT, as well as the effects of daflon and coumarin could not be established.Conclusion:Although many treatments for BCRL might reduce lymphoedema volume, their effects were not well established. The quality of many of the original studies in the included reviews was not optimal, so that in future randomized control trials are a high priority.

Impact of carpal tunnel syndrome surgery on women with breast cancer-related lymphedema

Carpal tunnel syndrome may occur in women with ipsilateral lymphedema after breast cancer treatment. Surgery on the lymphedematous arm is classically feared. Thirty-two consecutive women (mean age at cancer treatment 49 years, interquartile range (Q1;Q3) 43;56) with upper limb lymphedema after breast cancer treatment, followed in a single lymphology unit, and symptomatic carpal tunnel syndrome (electromyographically confirmed) requiring surgery were included. Lymphedema volume was calculated using the truncated cone formula, recorded before and after carpal tunnel syndrome surgery, and at each follow-up visit. Median time to lymphedema onset after cancer treatment was 19 (interquartile range (Q1;Q3) 5;73) months. Median lymphedema volume was 497 (Q1;Q3 355;793) mL before (median 4 months) and 582 (Q1;Q3 388;930) mL after carpal tunnel syndrome surgery (median 5 months) (P = 0.004). At the last follow-up post-carpal tunnel syndrome surgery (median 33 months), lymphedema volume was 447 (Q1;Q3 260;733) mL (non-significant, compared to pre-surgery volume). Regular lymphedema treatment included elastic sleeve (n = 31), low-stretch bandage (n = 20), and/or manual lymph drainage (n = 20), with no change before and after carpal tunnel syndrome surgery. All carpal tunnel syndrome clinical manifestations disappeared after surgery and none of the patients experienced local complications. Carpal tunnel syndrome may be treated surgically in women with ipsilateral upper limb lymphedema after breast cancer treatment. Although lymphedema volume increased transiently, it remained stable over long-term follow-up, with no local complications.

Manual lymphatic drainage for lymphedema following breast cancer treatment.

Manual lymphatic drainage for lymphedema following breast cancer treatment.

Lymphedema Characteristics and the Efficacy of Complex Decongestive Physiotherapy in Malignant Lymphedema.

The aim of this study is to identify the lymphedema characteristics and the efficacy of complex decongestive physiotherapy (CDP) in 29 patients with malignant lymphedema. After CDP, total decreased volume of lymphedema was 306 mL, percentage of excess volume (PEV) changed from 43.4% to 22.7%, and lymphedema severity improved from severe to moderate status. The CDP efficacy-percentage reduction in excess volume (PREV) was 46.6%. The stage of lymphedema (P = .004), range of motion (P < .001), pain, heaviness, and tension scores (P < .001) were significantly improved after CDP. This shows that CDP is efficacious and useful in malignant lymphedema.

Limb Differences in the Therapeutic Effects of Complex Decongestive Therapy on Edema, Quality of Life, and Satisfaction in Lymphedema Patients.

ObjectiveTo investigate the changing patterns of edema, quality of life (QOL), and patient-satisfaction after complex decongestive therapy (CDT) in three trajectories: arm lymphedema (AL), secondary leg lymphedema (LL) and primary leg lymphedema (PL).MethodsCandidates for AL (n=35), LL (n=35) and PL (n=14) were identified from prospective databases. The patients were treated with CDT for 2 weeks, and lymphedema volume was measured before and immediately following the therapy. Patients then self-administered home therapy for 3 months and presented for a follow-up visit. The Korean version of Short Form-36 (SF-36) was used to assess QOL, and we administered a study-specific satisfaction survey.ResultsThere was no significant difference in the volume reductions between the 3 groups. There were no significant differences in all of the measures between PL and LL. Overall initial QOL was significantly lower in patients with LL than in patients with AL. SF-36 scores post-CDT did not differ significantly between AL and LL. Clinically significant differences were noted between AL and LL in the mean values of the satisfaction survey.ConclusionAL, LL, and PL may have different longitudinal courses. We suggest that lower extremity lymphedema patients present more favorable outcomes after CDT with respect to QOL and satisfaction than upper extremity lymphedema patients. Clinicians should approach patients with different therapeutic considerations specific to each type or region of lymphedema before using CDT in clinical practice.

Breast cancer-related lymphedema: a randomized controlled pilot and feasibility study.

Chronic lymphedema occurs frequently in breast cancer patients and is associated with significant morbidity and reduced quality-of-life. In this pilot study, the authors (1) addressed whether conducting a larger randomized controlled trial of aqua lymphatic therapy (ALT) would be feasible and (2) estimated the extent to which ALT combined with home-based exercise compared with home-based exercise alone would reduce arm disability in patients with breast cancer-related lymphedema. Twenty-five women with breast cancer-related lymphedema were randomized to either ALT in addition to a home land-based exercise program (ALT group; n = 13) or to a home land-based exercise program alone (control group; n = 12). The participants were evaluated before and after a 12-wk intervention period composed of weekly pool exercise sessions. Main outcome measures were arm volume, arm disability, pain, and quality-of-life. At follow-up, there was no statistical difference between the control and ALT groups in any of the outcomes, except for present pain intensity. At the end of the study period, there was no change in the lymphedematous limb volume in either group. Grip strength was improved in both groups. Only the ALT group showed a statistically significant difference with a reduction in pain intensity score and arm disability. Furthermore, quality-of-life significantly improved only in the ALT group. Conducting a larger randomized controlled trial would be feasible. In comparison with the beginning of the intervention, the participants in the ALT group showed significant beneficial changes after 12 wks of treatment, whereas the control group did not improve. ALT did not make the lymphedema volume worse and therefore may serve as a safe alternative to land-based treatments of breast cancer-related lymphedema.

Large-volume sirolimus-induced upper limb lymphedema after renal transplantation ipsilateral to the arteriovenous fistula.

To analyze upper-limb lymphedema characteristics of renal transplant recipients taking sirolimus, an mTOR inhibitor. Cross-sectional study of sirolimus-treated upper-limb lymphedema patients (01/2009-12/2013). Three men and two women, whose mean age at transplantation was 60 (range: 49-76) years, were included. Sirolimus (1-2.5 mg/day) had been taken for 27.5 ± 21 (range: 7-58) months before left (n=4) or right (n=1), whole limb (n=4), or hand and forearm (n=1) upper-limb lymphedema onset, always ipsilateral to the functional arteriovenous fistula. Ultrasonography or fistulography excluded venous thrombosis in all patients. At the time lymphedema appeared, all five arteriovenous fistulas were functional. Mean upper-limb lymphedema volume, calculated with the truncated-cone formula, was 774 ± 162 [range: 594-1035] mL, (i.e. 44%± 11% [range: 36%-64%] excess volume compared to the contralateral limb. One patient also had ipsilateral breast lymphedema. The three lymphoscintigraphies obtained showed total absence of ipsilateral axillary-region tracer uptake. Sirolimus was maintained in all cases. Upper-limb lymphedema treatment included low-stretch bandages (n=4) and elastic sleeve (20-36 mm Hg) (n=5) without fistula complications. Two patients had their fistulas closed without any impact on lymphedema volume. Sirolimus may be implicated in large-volume upper-limb lymphedema in kidney-transplant recipients, ipsilateral to the arteriovenous fistula, and requires compression-based therapy.

Prospective multicentre observational study of lymphedema therapy: POLIT study

Lymphedema treatment is based on Decongestive Lymphedema Therapy (DLT) with an intensive phase followed by a long-term maintenance phase. This study aimed to observe volume variation over the intensive phase and 6 months later. Prospective multicentre observational study of patients with unilateral lymphedema. The primary objective was to assess lymphedema volume variation between baseline, the end of intensive phase and 6 months later. Secondary objectives were to assess the frequency of heaviness limiting limb function and treatments safety predictors for volume reduction. Three hundred and six patients (89.9% women; 59.9±14.3 years old) with upper/lower (n=184/122) limb lymphedema were included. At the end of the intensive phase, median excess lymphedema volume reduction was 31.0% (41.7-19.9) followed by a 16.5% (5.9-42.3) median increase over the 6-month maintenance period phase. Previous intensive treatment was the only significant predictor of this response. As compared to baseline, heaviness limiting limb use was much less frequently reported at the end of the reductive phase (75.5% versus 42.3% respectively), and was more frequent at the end of the maintenance phase (62.6%). The most frequent adverse events reported were skin redness and compression marks (18.4 and 15.7% of patients, respectively). Blisters requiring treatment stoppage were rare (1.4%). Intensive phase decreases lymphedema volume and heaviness limiting limb function. The benefit is partially abolished after the first 6 months of maintenance. There is a need to consider how to provide optimal patient care for the long-term control of lymphedema.