Type Of Lymphedema Research Articles

Prevention and Treatment of Posttraumatic Lymphedema by Soft Tissue Reconstruction With Lymphatic Vessels Free Flap: An Observational Study.

Extremities soft tissue damage may increase the risk of presenting posttraumatic lymphedema. This type of lymphedema is often ignored in trauma and reconstructive literature. We propose a microsurgical soft tissue reconstruction approach to prevent and/or treat posttraumatic lymphedema. This is a multicentric retrospective observational study. Primary and secondary end points were to prevent and/or treat posttraumatic lymphedema and to achieve a stable soft tissue coverage, respectively. Patients with posttraumatic lymphedema and functional lymphatic channels in the indocyanine green lymphography, and patients with acute soft tissue trauma with lymphatic damage without lymphedema, either to treat and prevent lymphedema, respectively, were included as candidates for soft tissue reconstruction using a superficial circumflex iliac artery perforator lymphatic vessels free flap (SCIP-LV). Patients with no pitting edema, fibrosis, or nonfunctional lymphatics channels were excluded. The inguinal lymphatic anatomy was studied with indocyanine green lymphography for designing and in-setting the flap. Eleven patients underwent to microsurgical reconstruction with SCIP-LV free flap; minimum follow-up was 12 months. There were no flap failures. In the posttraumatic lymphedema group, the mean reduction of excess volume was 63.01%. Quality of life improved 51.85%. No patients in the acute trauma group developed lymphedema after the preventive microsurgical approach. Soft tissue reconstruction with SCIP-LV free flap is an effective approach to prevent and treat posttraumatic lymphedema.

Is the Effect of Complex Decongestive Therapy the Same for Primary and Secondary Lower Lymphedema?

Background: The aim was to compare edema and quality of life (QOL) after complex decongestive therapy (CDT) in two types of lymphedema: primary lower limb lymphedema (PLL) and secondary lower limb lymphedema (SLL). Methods and Results: Participants with PLL (n = 20) and SLL (n = 20) were recruited in this prospective single-blinded study. Patients in both groups were treated with CDT for 4 weeks 5 days a week. The amount of edema in their lower extremities was assessed by circumference measurement. The QOL for the patients was evaluated by a Lymphedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphedema (Lymph-ICF-LL) before and immediately following the therapy. There was no significant difference in the volume reductions between the two groups (p > 0.05). Overall initial QOL was significantly lower in patients with PLL than in patients with SLL scores. Post-CDT differed significantly between PLL and SLL groups, QOL was significantly lower for patients with PLL than for patients with SLL scores (p < 0.05). When the changes in both groups were examined, it was found that their QOL increased after the treatment (p < 0.05). Conclusions: While there was no difference in the amount of edema in both groups, the results of patients with SLL were more positive than patients with PLL in terms of QOL. Lymphedema therapists should approach patients with different therapeutic considerations specific to each type of lymphedema before using CDT in clinical practice.

Study of 700 Referrals to a Lymphedema Program.

Background: Lymphedema results from inadequate lymphatic function due to failure of lymphatic development or injury to a functioning lymphatic system. Patients suffer enlargement of the affected area, psychosocial morbidity, infection, and functional disability. The purpose of this study was to characterize the disease in a cohort of patients referred to a specialized center. Methods and Results: Our Lymphedema Program database was reviewed for all referrals between 2009 and 2019. Diagnosis was determined based on history, physical examination, and lymphoscintigraphy. Lymphedema type (primary, secondary, and obesity-induced), location of swelling, morbidity, previous management, accuracy of referral diagnosis, the geographic origin of the patients, and treatment in our center were analyzed. Seven hundred patients were referred with a diagnosis of "lymphedema"; 71% were female and 38% were children. Lymphedema was confirmed in 71% of the cohort: primary (62%), secondary (22%), and obesity-induced (16%). Twenty-nine percent of individuals labeled with "lymphedema" had another condition. One-half of patients had not received treatment, and 36% resided outside of our local referral area. One-third of subjects with lymphedema had an infection and 30% had >1 visit to the center. Patients with confirmed lymphedema were managed with compression stockings (100%), pneumatic compression (69%), and/or an excisional procedure (6%). Conclusions: Patients with lymphedema typically are adequately managed with conservative compression therapies and rarely require excisional operations. Diagnostic confusion is common and individuals with possible lymphedema are best managed by physicians focused on the disease.

Preliminary Report: The Relevance of Tumor Necrosis Factor-α in Acquired Primary Lymphedema-A Histopathological Investigation.

Background: Lymphedema includes primary lymphedema (P-LE) and secondary lymphedema (S-LE), which is a chronic progressive disease. The former group is further classified as congenital and acquired P-LE (AP-LE); its etiology is unclear, and only a few studies on its pathophysiology exist. We hypothesized that an autoimmune disease or self-inflammatory mechanism occurs in lymphatic vessels, leading to obstruction. Methods and Results: We enrolled 46 patients with lymphedema who underwent lymphaticovenous anastomosis (LVA) from January to October 2015. Collecting lymph ducts were obtained during LVA. We performed hematoxylin/eosin staining and immunostaining for LYVE-1, IL-1β, IL-6, and TNF-α. There were no substantial histological differences between the two types of lymphedema, whereas some differences in expression of inflammatory cytokines, including interleukin (IL)-1β and tumor necrosis factor (TNF)-α, were observed. Only a few inflammatory cells could be seen around the vessels. Although no significant differences in expression of IL-1β were found between AP-LE and S-LE, TNF-α was more highly expressed in the smooth muscle layer in AP-LE patients than in S-LE patients. There were no significant morphological differences in the collecting ducts of lymphatic vessels between S-LE and P-LE. Nevertheless, higher levels of TNF-α accumulation were found in the thick smooth muscle layer of P-LE patients than in that of S-LE patients. Conclusion: TNF-α-related inflammation in collecting ducts of lymphatic vessels is an important characteristic of the pathology of P-LE. TNF-α inhibitors might improve symptoms of AP-LE.

Flat knit hosiery and compression wraps: managing lower limb lymphoedema

This article will give an overview of the causes and different types of lymphoedema of the lower limbs, together with the options available to manage the condition. Compression therapy is one of the main treatments for managing lymphoedema and the difference between circular knit and flat knit hosiery will be explained. More recently, compression wraps have been introduced as an alternative to hosiery and these may encourage patients to self-care for their condition and increase adherence to treatment. The need for a good skin regime in order to prevent cellulitis will be discussed, together with some useful resources, which will assist health professionals in caring for patients with lymphoedema.

Sensitivity and Specificity of the Stemmer Sign for Lymphedema: A Clinical-Lymphoscintigraphic Study

Background The Stemmer sign is a physical examination finding used to diagnose lymphedema. If the examiner cannot pinch the skin of the dorsum of the foot or hand then this positive finding is associated with lymphedema. The purpose of the study was to determine the accuracy of the Stemmer sign to predict lymphedema. Methods All patients referred to our Lymphedema Program between 2016 and 2018 were tested for the Stemmer sign and underwent lymphoscintigraphy to define the patient's lymphatic function. Patient age, lymphedema type (primary and secondary), disease location (arm and leg), lymphoscintigraphy findings, stage, severity, and body mass index were recorded. Comparison of predictive variables and Stemmer sign result was performed using Fisher's exact test and Student's t test. Results One hundred ten patients were studied: patients with a positive Stemmer sign (n = 87) exhibited abnormal (n = 80) or normal (n = 7) lymphatic function by lymphoscintigraphy (sensitivity = 92%). False-positive Stemmer signs included individuals with obesity (n = 6) or spinal muscle atrophy (n = 1). Subjects with a negative Stemmer sign (n = 23) had normal (n = 13) or abnormal (n = 10) lymphatic function by imaging (specificity = 57%). Patients with a false-negative Stemmer sign were more likely to have a normal body mass index (P = 0.02) and Stage 1 disease (P = 0.01). Conclusions A positive Stemmer sign is a sensitive predictor for primary and secondary lymphedema of the arms or legs and, thus, is a useful part of the physical examination. Because the test exhibits moderate specificity, lymphoscintigraphy should be considered for patients with a high suspicion of lymphedema that have a negative Stemmer sign.

Sensitivity and Specificity of the Stemmer Sign for Lymphedema: A Clinical Lymphoscintigraphic Study.

Background:The Stemmer sign is a physical examination finding used to diagnose lymphedema. If the examiner cannot pinch the skin of the dorsum of the foot or hand then this positive finding is associated with lymphedema. The purpose of the study was to determine the accuracy of the Stemmer sign to predict lymphedema.Methods:All patients referred to our Lymphedema Program between 2016 and 2018 were tested for the Stemmer sign and underwent lymphoscintigraphy to define the patient’s lymphatic function. Patient age, lymphedema type (primary and secondary), disease location (arm and leg), lymphoscintigraphy findings, stage, severity, and body mass index were recorded. Comparison of predictive variables and Stemmer sign result was performed using Fisher’s exact test and Student’s t test.Results:One hundred ten patients were studied: patients with a positive Stemmer sign (n = 87) exhibited abnormal (n = 80) or normal (n = 7) lymphatic function by lymphoscintigraphy (sensitivity = 92%). False-positive Stemmer signs included individuals with obesity (n = 6) or spinal muscle atrophy (n = 1). Subjects with a negative Stemmer sign (n = 23) had normal (n = 13) or abnormal (n = 10) lymphatic function by imaging (specificity = 57%). Patients with a false-negative Stemmer sign were more likely to have a normal body mass index (P = 0.02) and Stage 1 disease (P = 0.01).Conclusions:A positive Stemmer sign is a sensitive predictor for primary and secondary lymphedema of the arms or legs and, thus, is a useful part of the physical examination. Because the test exhibits moderate specificity, lymphoscintigraphy should be considered for patients with a high suspicion of lymphedema that have a negative Stemmer sign.

LIMPRINT in Specialist Lymphedema Services in United Kingdom, France, Italy, and Turkey.

Background: There is no standardized international model for specialist lymphedema services, which covers the types of lymphedema treated and the treatments provided. The aim of this study was to provide a profile of patients attending specialist lymphedema services in different countries to explore similarities and differences.Methods and Results: The LIMPRINT core tool was used in specialist lymphedema services in the United Kingdom, France, Italy, and Turkey. Services in Turkey saw a slightly younger age group, with a higher proportion of female patients reflecting a particular focus on breast cancer-related lymphedema. There were higher levels of obesity and restricted mobility in patients in the United Kingdom compared with other countries. Italy and France saw the highest percentage of patients with primary lymphedema. Diabetes was a common comorbidity in the United Kingdom and Turkey. The United Kingdom saw the largest number of patients with lower limb lymphedema.Conclusions: The results show a wide range of complexity of patients treated in specialist lymphedema services. Some of the differences between countries may reflect different stages in the evolution of specialist lymphedema services, rather than a true difference in prevalence, with those with “younger” services treating a high proportion of patients with cancer and those with more established services treating a wider range of different types of lymphedema, including more elderly people with multiple comorbidities.

Factors associated with depression symptoms in women after breast cancer.

ABSTRACTOBJECTIVE:To analyze the factors associated with the presence of depression symptoms in women after breast cancer.METHODS:Cross-sectional study with 181 women with breast cancer, aged 57.0 years (SD = 9.5), who were undergoing treatment or after treatment in the Oncology Research Center in Florianópolis, state of Santa Catarina, Brazil. The questionnaire comprised items addressing general and health information, economic level, anthropometric measures, depression symptoms (Beck Depression Inventory), self-esteem (Rosenberg Self-Esteem Scale), and body image (Body Image After Breast Cancer Questionnaire). Descriptive and inferential statistical analysis were performed by chi-square and Fisher's exact tests to verify association, Mann-Whitney U test to compare the groups and Poisson regression to identify the prevalence ratio of the factors associated with presence of depression symptoms (p < 0.05).RESULTS:We found an association between the presence of depression symptoms and the group of younger women (aged 40–60 years), those who had another disease besides cancer, those who had mastectomy surgery, those who suffered from lymphedema, and those who presented low–medium self-esteem. Less educated women presented more depressive symptoms, as did women with worse body image on the subscales of limitations, transparency, and arm concerns.CONCLUSIONS:Age, educational attainment, diagnosis of other diseases, type of surgery, lymphedema, self-esteem, and body image were factors associated with the presence of depression symptoms in Brazilian women after breast cancer. Health professionals should be aware of these relationships and try to detect depression symptoms earlier and improve the care they provide to these women.

Geographical distribution and prevalence of podoconiosis in Rwanda: a cross-sectional country-wide survey

SummaryBackgroundPodoconiosis is a type of tropical lymphoedema that causes massive swelling of the lower limbs. The disease is associated with both economic insecurity, due to long-term morbidity-related loss of productivity, and intense social stigma. Reliable and detailed data on the prevalence and distribution of podoconiosis are scarce. We aimed to fill this data gap by doing a nationwide community-based study to estimate the number of cases throughout Rwanda.MethodsWe did a population-based cross-sectional survey to determine the national prevalence of podoconiosis. A podoconiosis case was defined as a person with bilateral, asymmetrical lymphoedema of the lower limb present for more than 1 year, who tested negative for Wuchereria bancrofti antigen (determined by Filariasis Test Strip) and specific IgG4 (determined by Wb123 test), and had a history of any of the associated clinical signs and symptoms. All adults (aged ≥15 years) who resided in any of the 30 districts of Rwanda for 10 or more years were invited at the household level to participate. Participants were interviewed and given a physical examination before Filariasis Test Strip and Wb123 testing. We fitted a binomial mixed model combining the site-level podoconiosis prevalence with continuous environmental covariates to estimate prevalence at unsampled locations. We report estimates of cases by district combining our mean predicted prevalence and a contemporary gridded map of estimated population density.FindingsBetween June 12, and July 28, 2017, 1 360 612 individuals—719 730 (53%) women and 640 882 (47%) men—were screened from 80 clusters in 30 districts across Rwanda. 1143 individuals with lymphoedema were identified, of whom 914 (80%) had confirmed podoconiosis, based on the standardised diagnostic algorithm. The overall prevalence of podoconiosis was 68·5 per 100 000 people (95% CI 41·0–109·7). Podoconiosis was found to be widespread in Rwanda. District-level prevalence ranged from 28·3 per 100 000 people (16·8–45·5, Nyarugenge, Kigali province) to 119·2 per 100 000 people (59·9–216·2, Nyamasheke, West province). Prevalence was highest in districts in the North and West provinces: Nyamasheke, Rusizi, Musanze, Nyabihu, Nyaruguru, Burera, and Rubavu. We estimate that 6429 (95% CI 3938–10 088) people live with podoconiosis across Rwanda.InterpretationDespite relatively low prevalence, podoconiosis is widely distributed geographically throughout Rwanda. Many patients are likely to be undiagnosed and morbidity management is scarce. Targeted interventions through a well coordinated health system response are needed to manage those affected. Our findings should inform national level planning, monitoring, and implementation of interventions.FundingWellcome Trust.

Predictive factors of satisfaction and quality of life after immediate breast reconstruction using the BREAST-Q©.

To analyse quality of life and satisfaction after immediate breast reconstruction due to cancer and its determining factors. Studying breast reconstruction is important because of its frequency and variability. In addition to the surgical results, it is necessary to analyse the quality of life and patient satisfaction using a specific tool. An ambispective design was used (n=101; α=0.05; precision=10%), studying anthropometric, sociocultural data, Fagerström test and the BREAST-Q© questionnaire. A logistic regression analysis was performed to identify variables associated with quality of life and satisfaction. Mean age of the patients on diagnosis was 44.87±8.5years. Forty-one of the patients were carried out a skin-sparing mastectomy (42.7%). Immediate reconstruction was performed with implant in 73 (74.5%). The domains on the BREAST-Q© for quality of life with the lowest scores were physical well-being chest (74) and sexual well-being (61.5). The satisfaction domain with the lowest score was with the breast (59). The variables associated with the worst quality of life in the physical well-being chest domain were the skin-sparing mastectomy (OR, 4.2; 95% confidence interval (CI), 1.2-14.1) and lymphedema (OR, 12.9; 95% CI, 1.0-159.9). Antibody treatment was associated with a worse score on the psychosocial well-being domain (OR, 4.25; 95% CI, 1.0-18.0) and sexual well-being domain (OR, 7.34; 95% CI, 0.9-54.6). Satisfaction was associated with nicotine dependence on the breast and outcome scale. The higher the dependence on nicotine, the greater the dissatisfaction with the breasts (OR, 2.41; 95% CI, 1.1-5.3) and with the result (OR, 2.45; 95% CI, 1.0-5.9). The type of treatment and lymphedema modify the patients' quality of life. Nicotine dependence is associated with lower satisfaction with the breast and with the outcome. This study suggests the need for multidisciplinary attention during the first year of adjuvant treatment despite the benefits of immediate reconstruction. It shows the need for preoperative assessment of the level of nicotine dependence, anxiety and depression of smoking patients before preoperative counselling.

Abstract: Correlation Between Lymphedema Disease Severity and Lymphoscintigraphic Findings: A Clinical-Radiological Study

INTRODUCTION: Lymphoscintigraphy is the gold-standard test for diagnosing lymphedema, and is 96% sensitive for detecting the disease. The major abnormal lymphoscintigraphic findings on the test include delayed transit time to the inguinal or axillary lymph nodes (>1 hour) and dermal backflow. A universal protocol for the test does not exist, our protocol obtains images at 1, 2, and 4 hour intervals to confirm diagnosis of the disease and to achieve a measure of the severity of lymphatic dysfunction (e.g., a patient with a transit time of 4 hours to regional lymph nodes would have worse dysfunction compared to a patient with a transit time of 2 hours). The purpose of this project was to determine if lymphoscintigraphy results correlate with clinical presentation. METHODS: Patients treated in our Lymphedema Program between 2009 and 2017 were reviewed. Diagnosis of lymphedema was determined by history, physical examination, and lymphoscintigraphy. Severity was defined by increased volume of the limb: mild (<20%), moderate (20–40%), severe (>40%). Candidate variables included location (arm, leg), age, duration of symptoms, infection history, and lymphedema type (primary, secondary). An association between lymphedema severity and lymphoscintigraphy findings was determined using the Pearson chi-square test and multivariate logistic regression. RESULTS: One hundred thirty-four patients with 181 affected extremities (24 upper, 157 lower) were included. Clinical severity was: 54% mild, 30% moderate, and 16% severe. Delayed tracer transit to the regional nodes was: 45 minutes (34%), 2 hours (18%), and ≥ 4 hours (48%). Thirty-six percent of extremities demonstrated dermal backflow. Abnormal transit time or dermal backflow was identified in 97% of extremities by 45 minutes and in 3% of limbs by 2 hours. Transit time and dermal backflow were not predictive of clinical severity when adjusting for candidate variables (p > 0.1). CONCLUSION: Clinical severity of lymphedema is not associated with lymphoscintigraphy findings. A lymphoscintigram should be interpreted as normal or abnormal, and does not need to exceed 2 hours.

Diagnostic Accuracy of Lymphoscintigraphy for Lymphedema and Analysis of False-Negative Tests

Background:Lymphedema is the chronic enlargement of tissue due to inadequate lymphatic function. Diagnosis is made by history and physical examination and confirmed with lymphoscintigraphy. The purpose of this study was to assess the accuracy of lymphoscintigraphy for the diagnosis of lymphedema and to determine characteristics of patients with false-negative tests.Methods:Individuals referred to our lymphedema program with “lymphedema” between 2009 and 2016 were analyzed. Subjects were assessed by history, physical examination, and lymphoscintigraphy. Patient age at presentation, duration of lymphedema, location of disease, gender, previous infections, and lymphedema type were analyzed.Results:The study included 227 patients (454 limbs); lymphedema was diagnosed clinically in 169 subjects and confirmed by lymphoscintigraphy in 162 (117 primary, 45 secondary; 96% sensitivity). Fifty-eight patients were thought to have a condition other than lymphedema, and all had negative lymphoscintigrams (100% specificity). A subgroup analysis of the 7 individuals with lymphedema clinically, but normal lymphoscintigrams, showed that all had primary lymphedema; duration of disease and infection history were not different between true-positive and false-negative lymphoscintigram results (P = 0.5). Two patients with a false-negative test underwent repeat lymphoscintigraphy, which then showed lymphatic dysfunction consistent with lymphedema.Conclusion:Lymphoscintigraphy is very sensitive and specific for lymphedema. All patients with false-negative studies had primary lymphedema. A patient with a high clinical suspicion of lymphedema and a normal lymphoscintigram should be treated conservatively for the disease and undergo repeat lymphoscintigraphy.

Abstract 4217: Consumer credit, cancer treatment, and health among women with a history of breast cancer

Abstract Background: Breast cancer treatment may represent an economic shock that may be influenced by, or may influence a cancer survivor’s socio-economic position (SEP). Financial toxicity or economic burden due to cancer treatment and treatment’s adverse effects may be reflected in one’s consumer credit ratings; however, credit’s contribution to individual health for cancer survivors or those managing long-term adverse effects of cancer treatment has not been evaluated. This analysis examined associations between self-rated health outcomes of women with a history of breast cancer, type of cancer treatment, and presence of breast cancer-related lymphedema, a persistent adverse effect of treatment, and consumer credit rating. Methods: From May to September 2015, 129 women from Pennsylvania and New Jersey were enrolled in the PAL Social and Economic Quality of Life cross-sectional study. All participants had a history of breast cancer, and completed a survey of: demographics, SEP, co-morbidities, SF-12 self-rated health, psychosocial stress, adjuvant cancer treatments (chemotherapy, hormone therapy, radiation), breast cancer-related lymphedema symptoms, and credit quality (5-point scale self-reported as poor to excellent). Multivariable linear regression measured the association between credit and health. Results: Mean respondent age was 64, with 38.2% reporting excellent and 37.4% reporting very good/good credit. Participants completed cancer treatment on average 11.5 years ago. After adjusting for demographics and SEP, good credit was associated with a 4.5 (p=0.009) point increase in composite physical health t-score and -1.13 (p=0.02) decrease in psychosocial stress compared to women with poor credit, but was not associated with type of cancer treatment or lymphedema. Conclusion: While credit was associated with self-rated health for women with an average 11.5 year history of breast cancer, current credit quality did not appear to be associated with type of cancer treatment previously received or with the presence of lymphedema, a persistent adverse effect of cancer treatment. It is still possible that cancer treatment may have influenced credit close to time of treatment, and credit was able to rebound since that time. Future work should test causal pathways between credit and health outcomes after cancer diagnosis. Citation Format: Lorraine T. Dean, Kathryn H. Schmitz, Kevin Frick, Lauren Nicholas, Yuehan Zhang, SV Subramanian, Kala Visvanathan. Consumer credit, cancer treatment, and health among women with a history of breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4217. doi:10.1158/1538-7445.AM2017-4217

Correlation Between Lymphedema Disease Severity and Lymphoscintigraphic Findings: A Clinical-Radiologic Study

Lymphoscintigraphy is used to confirm the diagnosis of lymphedema; pathologic findings are abnormal transit time to regional nodes and dermal backflow. A universal protocol for the test does not exist. The purpose of this study was to determine whether the clinical severity of lymphedema correlates with lymphoscintigraphy findings. Patients treated in our Lymphedema Program between 2009 and 2017 were reviewed. Diagnosis of lymphedema was determined by history, physical examination, and lymphoscintigraphy. Severity was defined by increased volume of the limb as follows: mild (<20%), moderate (20% to 40%), and severe (>40%). Candidate variables included location (arm, leg), age, duration of symptoms, infection history, and lymphedema type (primary, secondary). An association between lymphedema severity and lymphoscintigraphy findings was determined using the Pearson chi-square test and multivariate logistic regression. One hundred and thirty-four patients with 181 affected extremities (24 upper, 157 lower) were included. Clinical severity was as follows: 54% mild, 30% moderate, and 16% severe. Delayed tracer transit to the regional nodes was as follows: 45 minutes (34%), 2 hours (18%), and 4 hours or longer (48%). Thirty-six percent of extremities demonstrated dermal backflow. Abnormal transit time or dermal backflow was identified in 97% of extremities by 45 minutes and in 3% of limbs by 2 hours. Transit time and dermal backflow were not predictive of clinical severity when adjusting for candidate variables (p > 0.1). Clinical severity of lymphedema is not associated with lymphoscintigraphy findings. A lymphoscintigram should be interpreted as normal or abnormal, and does not need to exceed 2 hours.

Lymphedema: From diagnosis to treatment.

Lymphedema is a chronic and progressive disorder resulting from impaired lymphatic system function. In developed countries, upper extremity lymphedema is mainly the consequence of breast cancer surgery in which axillary lymph node dissection and radiation alter upper extremity lymphatic flow. Diagnosis of lymphedema is made clinically. Nevertheless, there are numerous diagnostic tools available for disease staging. Recently, a new technology namely magnetic resonance lymphangiography has emerged in the medical field to assist in both diagnosis and management. There are non-surgical and surgical treatment options available. Non-surgical methods are always the first-line treatment; however, surgical options can be explored in appropriate patients. Recent studies focus on the prevention of lymphedema using surgical techniques utilizing axillary reverse mapping to delineate arm lymphatics from axillary lymphatics. Finding the most suitable technique for each type of lymphedema with variable stages is one of the most complicated decisions for practitioners. More studies are needed to reveal the exact biology of lymphedema to ensure complete understanding of the disease and improve outcomes.

High-resolution 3D volumetry versus conventional measuring techniques for the assessment of experimental lymphedema in the mouse hindlimb.

Secondary lymphedema is a common complication of cancer treatment characterized by chronic limb swelling with interstitial inflammation. The rodent hindlimb is a widely used model for the evaluation of novel lymphedema treatments. However, the assessment of limb volume in small animals is challenging. Recently, high-resolution three-dimensional (3D) imaging modalities have been introduced for rodent limb volumetry. In the present study we evaluated the validity of microcomputed tomography (μCT), magnetic resonance imaging (MRI) and ultrasound in comparison to conventional measuring techniques. For this purpose, acute lymphedema was induced in the mouse hindlimb by a modified popliteal lymphadenectomy. The 4-week course of this type of lymphedema was first assessed in 6 animals. In additional 12 animals, limb volumes were analyzed by μCT, 9.4 T MRI and 30 MHz ultrasound as well as by planimetry, circumferential length and paw thickness measurements. Interobserver correlation was high for all modalities, in particular for μCT analysis (r = 0.975, p < 0.001). Importantly, caliper-measured paw thickness correlated well with μCT (r = 0.861), MRI (r = 0.821) and ultrasound (r = 0.800). Because the assessment of paw thickness represents a time- and cost-effective approach, it may be ideally suited for the quantification of rodent hindlimb lymphedema.

Massive limphedema as elephantiasis in the background of an alcoholic chronic liver disease

The cluster of lymph fluid subcutaneously in a specific body region or limb is called lymphedema. Two types of lymphedema exist: primary or hereditary, and secondary or acquired lymphedema. Herein we describe the singular case of a massive lymphedema of lower extremities called elephantiasis. After a complete anamnesis and differential diagnosis, an alcoholic and chronic liver disease as cirrhosis was considered the main etiology of this extreme case of lymphedema. Although lymphedema is one of the symptoms of chronic liver disease, the association between cirrhosis and elephantiasis has not been previously described as described in this clinical case. Through this case report, we discuss and develop all those etiologies of lymphedema, as well as diagnosis and treatment management.

Abstract: Diagnostic Accuracy of Lymphoscintigraphy for Lymphedema

INTRODUCTION: Lymphedema is the chronic enlargement of tissue due to inadequate lymphatic function. Diagnosis is made by history and physical examination and confirmed with lymphoscintigraphy. The purpose of this study was to (1) assess the accuracy of lymphoscintigraphy for the diagnosis of lymphedema and (2) determine characteristics of patients with false-negative tests. METHODS: Patients referred to our lymphedema program with “lymphedema” between 2009–2016 were analyzed. Subjects were assessed by history, physical examination and lymphoscintigraphy. Patient age at presentation, duration of lymphedema, location of disease, gender, previous infections, and lymphedema type were recorded. RESULTS: The study included 228 patients. Lymphedema was diagnosed clinically in 170 subjects and confirmed by lymphoscintigraphy in 162 (117 primary lymphedema, 45 secondary); 58 patients were thought to have a condition other than lymphedema and all had negative lymphoscintigrams (95% sensitivity, 100% specificity). A subgroup analysis of the 8 patients with clinical lymphedema but negative lymphoscintigrams was performed: all had primary lymphedema. Four patients were male, 7 involved the lower extremity, and 3 had prior infections. Mean duration of disease prior to lymphoscintigraphy was 8 years (range 1 month to 32 years). Lymphedema type, duration of disease, and infection history were not different between patients with true positive and false negative lymphoscintigrams (p=0.5). Two patients with a false-negative result underwent repeat lymphoscintigraphy 2.5–3 years later and exhibited a positive study consistent with lymphedema. CONCLUSION: Lymphoscintigraphy is very sensitive and specific for lymphedema. There are no significant predictive factors for false negative studies although all these patients had primary lymphedema. A patient with a high clinical suspicion of lymphedema and a negative lymphoscintigram should be treated for the disease and undergo repeat lymphoscintigraphy over a year later. DISCLOSURES:None

Operative Treatment of Lymphedema Using Suction-Assisted Lipectomy.

Surgical management of lymphedema includes removal of affected tissues (excisional procedures), or operations that create new lymphatic connections (physiologic procedures). The purpose of this study was to determine the efficacy of one type of excisional procedure, suction-assisted lipectomy, for extremity lymphedema. Patients treated in our Lymphedema Program between 2007 and 2015 with liposuction that had postoperative follow-up were reviewed. The diagnosis of lymphedema was made by history/physical examination and confirmed with lymphoscintigraphy. Patient sex, age, type of lymphedema (primary or secondary), location of disease, infection history, volume of lipoaspirate, and reduction of extremity volume were recorded. Fifteen patients were included, mean age was 45 years (range, 17-71). Six patients had secondary upper extremity lymphedema, and 9 patients had lower limb disease. Eight patients had a history of repeated cellulitis involving the lymphedematous extremity. Mean lipoaspirate volume was 1612 mL (range, 1200-2800) for the upper extremity and 2902 mL (range, 2000-4800) for the lower limb. Postoperative follow-up averaged 3.1 years. The mean reduction in excess extremity volume was 73% (range, 48% to 94%), and patients reported improvement in their quality of life. Suction-assisted lipectomy is an effective technique to reduce extremity volume for patients with lymphedema.