Unilateral Lower Extremity Lymphedema Research Articles

Postural stability, spinal alignment, mobility, and postural competency in women with unilateral lower extremity lymphedema after radical hysterectomy following gynecologic cancer: A case-control study

PurposeTo compare postural stability, spinal alignment, mobility, and postural competency in women with unilateral lower extremity lymphedema after radical hysterectomy following gynecologic cancer with a matched control group. MethodsTwenty-seven women with unilateral lower extremity lymphedema (lymphedema group, age: 54.14 ± 5.80 years) and 30 healthy women (control group, age: 51.90 ± 6.54 years) were included. The lymphedema severity was evaluated with circumferential measurements. Postural stability with the Biodex Balance System SD and the spinal alignment, mobility, and postural competency with the Spinal Mouse device were assessed. ResultsIn the lymphedema group, it was found that 3.7% of the women had mild lymphedema, 7.4% had moderate lymphedema, and 88.9% had severe lymphedema. Static eyes open (EO) (overall, medio-lateral and antero-posterior) and eyes closed (EC) (antero-posterior) stability scores and dynamic EO and EC stability scores (overall and antero-posterior) were detected to be higher in the lymphedema group than in the controls (p < 0.05). Spinal mobility and postural competency scores were lower in the lymphedema group than in the control group (p < 0.05). In other parameters, there were no significant differences between the groups (p > 0.05). ConclusionDecreased postural stability, spinal mobility, and postural competency were detected in women with unilateral lower extremity lymphedema; however, no difference was seen in spinal alignment. These changes should be taken into account in the assessment and the treatment of unilateral lower extremity lymphedema.

Unilateral lower extremity lymphedema as a first symptom of primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBCL-LT)

Unilateral lower extremity lymphedema as a first symptom of primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBCL-LT)

A non-randomized, open-label study of the safety and effectiveness of a novel non-pneumatic compression device (NPCD) for lower limb lymphedema

Lower extremity lymphedema (LEL) can result in detriments to quality of life (QOL) and impose a significant economic burden on patients and payers. A common component of treatment is pneumatic compression, which requires patients to remain immobile. We investigated a novel non-pneumatic compression device (NPCD) that allows patients to remain active during compression treatment, to see if it reduces swelling and improves QOL. We conducted a non-randomized, open-label, 12-week pilot study of adult patients with primary or secondary unilateral LEL, and measured changes in limb edema and QOL using the Lymphedema Quality of Life Questionnaire (LYMQOL). Twenty-four subjects were enrolled; the majority were female (17) with secondary lymphedema (21). Eighteen completed the study. Statistically significant improvements were observed in overall QOL, aggregated LYMQOL total score, and three of four LYMQOL subscales (Function, Appearance, Mood). The fourth (Symptoms) trended toward significant improvement (p = 0.06). The average reduction in affected limb edema was 39.4%. The novel NPCD produced statistically significant improvements in QOL, functioning, and edema volume of patients with LEL. Innovations in devices to manage LEL can be effective while allowing patients to maintain mobility and physical activity during treatment.

Clinical Utility of Bioelectrical Impedance Analysis Parameters for Evaluating Patients with Lower Limb Lymphedema after Lymphovenous Anastomosis.

In lymphedema, lymphatic fluid accumulates in the interstitial space, and localized swelling appears. Lymphovenous anastomosis (LVA) is the most widely used surgery to rebuild a damaged lymphatic system; however, assessing outcome of LVA involves performing volume measurements, which provides limited information on body composition changes. Therefore, we analyzed the bioelectrical impedance analysis (BIA) parameters that can reflect the status of lymphedema patients who underwent LVA. We retrospectively reviewed records of 42 patients with unilateral lower extremity lymphedema who had LVA. We measured the perioperative BIA parameters such as extracellular water (ECW) ratio and volume as defined by the percentage of excess volume (PEV). We evaluated the relationship between the amount of change in PEV and in BIA parameters before and after surgery. We confirmed the correlation between ΔPEV and BIA parameters using Spearman's correlation. Most patients included had secondary lymphedema due to cancer. Average age was 51.76 years and average body mass index was 23.27. PEV and all BIA parameters after surgery showed a significant difference (p < 0.01) compared with preoperative measurements. The ECW ratio aff/unaff showed the strongest correlation with PEV with a correlation coefficient of 0.473 (p < 0.01). Our findings suggest that BIA parameters, especially ECW ratio aff/unaff could reflect the status of patients with lower limb lymphedema after LVA. Appropriate use of BIA parameters may be useful in the postoperative surveillance of patients.

The Clinical Usefulness of Ultrasonographic Measurement Technique in Patients with Lower Extremity Lymphedema.

Background: A previous study reported a new ultrasonography (US) measurement technique to evaluate the cross-sectional area (ΔCSA) of lymphedema in the upper extremity. This ΔCSA correlated well with parameters, such as the circumference, volumetry, and bioimpedance analysis (BIA) in healthy people and upper extremity lymphedema patients. This study examined whether a US measurement technique is clinically useful in patients with lymphedema in the lower extremity. Methods and Results: Forty patients diagnosed with unilateral lower extremity lymphedema were enrolled in this study. The subjects' leg circumference, BIA, isokinetic strength, and ΔCSA were examined on the same day. The leg circumference was measured at 15 cm above the knee (AK) and below the knee (BK) crease using a tape measure. BIA was performed by a trained physical therapist, and the data of impedance (Z) at 1 and 5 kHz of each side of the lower limbs and extracellular water (ECW) were used. A fully experienced physician measured soft tissue thickness, the distance between the skin and the fascia of the muscle, three times each at the anterior, medial, posterior, and lateral aspects of the bilateral legs by US at 15 cm AK and BK. The amount of soft tissue in the ΔCSA was calculated using the designed formula from the mean values of the thicknesses. Each parameter was calculated as the ratio of the sound side to the lesion side. The Pearson and Spearman correlation coefficients were used to assess the significance of these parameters. The ratio of ΔCSA measured at 15 cm AK and BK showed strong positive correlations with the circumference difference at the same level (rho = 0.790, p = 0.000, and rho = 0.882, p = 0.000, respectively). In addition, it showed moderate or strong correlations with the ratio of Z at 5 and 1 kHz in the BIA of the lower limbs (AK15, r = -0.511, p = 0.001 and r = -0.497, p = 0.001; BK15, r = -0.780, p = 0.000 and r = -0.756, p = 0.000, respectively). Although ECW and body mass index showed weak positive correlations with the ratio of ΔCSA measured at 15 cm BK, there was no significant correlation between the ratio of ΔCSA and the isokinetic muscle strength. Conclusion: The ΔCSA results showed moderate-to-strong correlations with other conveniently used methods except for the isokinetic muscle strength. As the US ΔCSA technique could measure lymphedema status with a structural consideration, it could also be recommended as a conventional measurement method in patients with upper and lower extremity lymphedema.

The efficacy of change in limb volume on functional mobility, health-related quality of life, social appearance anxiety, and depression in patients with lower extremity lymphedema.

This study aims to investigate the impact of change in limb volume on the levels of functional mobility, health-related quality of life, social appearance anxiety, and depression before and after complex decongestive physiotherapy in patients with lower extremity lymphedema. Twenty-seven patients with unilateral lower extremity lymphedema were included. The treatment period was 20 sessions. The outcome measures were the limb volume, the Timed Up and Go test, the Short Form-36, the Social Appearance Anxiety Scale, and the Beck Depression Inventory. A statistically significant decrease in the limb volume (p < 0.001) and statistically significant improvements in the Timed Up and Go test performance (p < 0.001), the Short Form-36 Physical Component Summary score (p < 0.01), the Social Appearance Anxiety Scale score (p < 0.001), and the Beck Depression Inventory score (p < 0.001) were found. No statistically significant difference was found on the Short Form-36 Mental Component Summary score (p > 0.05). The decrease in the limb volume improves the functional mobility, physical health-related quality of life, social appearance anxiety, and depression in patients with lower extremity lymphedema, but not the mental health-related quality of life.

Correlation of the changes in physical activity and clinical results following lymphatic microsurgery.

The physical activity (PA) of patients may change after microsurgical treatment for lower extremity lymphedema (LEL). We investigated whether PA changes perioperatively and whether it influences the treatment result. Sixty patients with unilateral LEL (56 secondary and 4 primary) underwent lymphatic microsurgeries. Patients were divided into two groups based on improvement in International Physical Activity Questionnaire Short Form (IPAQ-SF) categories; the outcomes were compared. Fifty-three patients in whom linear pattern could be partially observed in indocyanine green lymphography or lymphoscintigraphy underwent lymphaticovenular anastomosis (LVA); seven patients in whom no linear pattern was observed underwent simultaneous LVA and vascularized lymph node transfer. No surgical complication was observed. The median IPAQ-SF score significantly improved from 990 (interquartile range: 231-2,376) to 1,386 (interquartile range: 940.5-4,158; p < .0001). The IPAQ-SF category improved in 22 patients (33.7%), who were categorized into the IPAQ-improved group. Improvement in excess limb volume was significantly larger in the IPAQ-improved group than that in the unimproved group (8.0 ± 4.2 vs. 3.5 ± 2.4%; p < .0001). The PA of patients may change after surgical treatment for unilateral LEL. Perioperative improvement in PA significantly correlated with the perioperative change in the excess limb volume. The change in PA is an important factor that might affect the outcome of surgical treatment for LEL. In evaluating the results of microsurgery for lymphedema, it may be necessary to consider changes in PA to avoid bias.

Volumetric Differences in the Suprafascial and Subfascial Compartments of Patients with Secondary Unilateral Lower Limb Lymphedema

The subfascial compartment (deep to the deep fascia) in extremity lymphedema has not been evaluated. This study investigated the volumetric differences between the suprafascial and subfascial compartments of patients with unilateral lower extremity lymphedema. Thirty-two female patients with unilateral lower extremity lymphedema were enrolled, with eight patients in each of Cheng lymphedema grades I to IV. The volumes of the suprafascial and subfascial compartments were calculated after manually drawing the region of interest on computed tomographic images. The volumetric differences and their ratios in the suprafascial and subfascial compartments between each patient's bilateral limbs were compared. The volume of the lymphedematous limbs (9647 ml) was significantly greater than the volume of unaffected limbs (6906 ml), with a median volumetric difference of 2097 ml (30.6 percent) (p < 0.01). The median suprafascial compartment volumetric difference was 1887 ml (56.6 percent) and the subfascial compartment volumetric difference was 208 ml (4.7 percent) (p < 0.01). The median volumetric difference ratio of the thigh and lower leg was 24.6 percent and 40.6 percent, respectively. The median volumetric differences in Cheng lymphedema grades I to IV were 1012, 1787, 2434, and 4107 ml, respectively, which were statistically significant among the four Cheng lymphedema grades using the Kruskal-Wallis test (p < 0.01). The volumetric differences in the lymphedematous limb were statistically significantly greater than in the unaffected limb, including both suprafascial and subfascial compartments. The volumetric differences are consistent with the Cheng lymphedema grading system as a reliable indicator of unilateral extremity lymphedema. Diagnostic, IV.

Lymphatic System Transfer for Lymphedema Treatment: Transferring the Lymph Nodes with Their Lymphatic Vessels.

Background:Vascularized lymph node transfer is the most common physiological procedure indicated for severe lymphedema. We describe a new physiological treatment strategy for lymphedema, lymphatic system transfer (LYST), which comprises transfer of the vascularized afferent lymphatic vessels along with their draining lymph nodes.Methods:All patients undergoing LYST for treatment of lymphedema from 2017 to 2018 were identified. Patient demographics, intraoperative factors, and postoperative outcomes were reviewed.Results:Three patients underwent LYST. Average patient age and body mass index were 65.3 years and 23.6 kg/m2, respectively. Indications for LYST were upper extremity lymphedema following mastectomy, radiation, and lymphadenectomy (2) and unilateral lower extremity lymphedema following total hysterectomy and bilateral pelvic lymphadenectomy (1). In all patients, lymphatic vessels could not be visualized by preoperative lymphoscintigraphy. All LYST flaps were procured from the groin region. A superficial circumflex iliac artery perforator flap, including the afferent lymphatic vessels and their draining lymph nodes, was elevated. A large portion of the skin paddle was deepithelialized, and the LYST flap was inset into a subcutaneous tunnel made in the lymphedematous limb. All LYST flaps survived completely. No donor site complications were observed. The average rate of estimated volume decrease in the patients at eighth month follow-up was 21.9%. Average follow-up was 11 months.Conclusions:Because the afferent lymphatic vessels are transferred with the lymph nodes, a presumably lesser degree of lymphangiogenesis is required for a LYST flap to commence its physiological function. Its real-time physiological lymphatic drainage is demonstrated in a video.

Edema Areas of Calves Measured with Magnetic Resonance Imaging as a Novel Indicator for Early Staging of Lower Extremity Lymphedema.

Staging of lower extremity lymphedema (LEL) is difficult in clinical work. The excellent soft tissue contrast of magnetic resonance imaging (MRI) enables soft tissue changes to be feasibly and reproducibly characterized and distinguished. To determine whether cross-section areas of edema calves measured with MRI could be useful for staging of the LEL. We recruited 138 participants who were clinically diagnosed with LEL: 61 unilateral and 77 bilateral LEL. Two legs underwent different stages of LEL. Fourteen characters are diagnosed without LEL; we assumed them as stage 0; age-matched 54, 59, and 54 lower extremities had the LEL, which are classified as stages 1, 2, and 3, respectively. On fat-suppressed T2-weighted mid-axial images of calves, the total area of the soft tissue (TA), muscle area (MA), and the water area (WA) of subcutaneous tissue of the bilateral claves were measured and analyzed statistically for staging of LEL. The difference of TA (DTA) of the unilateral LEL was also analyzed. TA and DTA showed statistical differences among each stage (p < 0.0001), except that it was challenged in making off stages 0 and 1 (p > 0.05). No significant difference was found among four stages of LEL in MA. WA was able to display the perfect sensitivity to lymphedema appearance (p < 0.0001, sensitivity = 100%). The WA of the calves could be suggested as a specific indicator for diagnosis of LEL. TA and DTA are the secondary indicators for staging of LEL.

Complete lymph flow reconstruction: A free vascularized lymph node true perforator flap transfer with efferent lymphaticolymphatic anastomosis

Treatment of primary lower extremity lymphedema (LEL) is challenging, and lymph node transfer (LNT) can be a choice of treatment for progressive LEL. However, LNT has a risk of donor site lymphedema and possible lymph node (LN) sclerosis due to efferent lymphatic vessel (ELV) obstruction. Here, we report the first case of complete lymph flow reconstruction with true perforator LNT with efferent lymphaticolymphatic anastomosis (ELLA) for a patient with primary LEL and severe lymphosclerosis. A 49-year-old female suffered from primary progressive unilateral left LEL refractory to conservative treatments with frequent episodes of cellulitis. A true perforator LN flap was selectively harvested from the left lateral thoracic region under indocyanine green (ICG) lymphography navigation and transferred to the left groin with perforator-to-perforator anastomosis. The ELV of the transplanted LN was supermicrosurgically anastomosed to the contralateral iliac lymphatic vessel that was subcutaneously transferred to the left groin. Postoperatively, the patient experienced no episode of cellulitis with reduced degree of compression treatment, and lymphedematous volume decreased from 306 to 264 in terms of LEL index. Postoperative ICG lymphography showed evidence of reconstructed lymph flow from the left foot to the left groin and to the right inguinal LN through the transplanted LN flap and the ELLA. There were no subjective or objective findings of donor site lymphedema of the left arm or the right back and the lower extremity. True perforator LN flap with ELLA is a safe and effective treatment and has the potential to be a useful therapeutic option for primary unilateral LEL.

Klippel-Trenaunay Syndrome Complicated by Ascites and Vaginal Lymphatic Drainage in Adolescence: A Case Report

BackgroundKlippel-Trenaunay syndrome is a rare disease characterized by capillary malformationsand soft tissue and bony hypertrophy and atypical varicosities. Management of this syndrome is focused primarily on treatment of the complications that arise from these malformations. Ascites and lymphedema are two of the more common complications in these patients. CaseA 15-year-old female with Klippel-Trenaunay syndrome presented with chylous ascites, vaginal drainage, and unilateral lower extremity lymphedema. Treatment included dilation, hysteroscopy and curettage, and laparoscopic evacuation of abdomino-pelvic ascites with resolution of symptoms for 32 months. Repeat laparoscopic drainage was successful and remains symptom free after 12 months. ConclusionVaginal drainage of chylous ascites is a rare complication from Klippel-Trenaunay syndrome and can be successfully managed by techniques to remove abdomino-pelvic ascites.

Lymphedema of the Lower Extremity: Is It Genetic or Nongenetic?

Lymphedema of the lower extremities is a diagnostic challenge. Exclusion of secondary causes of limb swelling and secondary lymphedema is the initial step. Primary lymphedema is classified into idiopathic and familial (hereditary) subgroups. Hereditary lymphedema can be nonsyndromic or associated with congenital anomalies or with abnormal physical findings. A 13-year-old girl presented with unilateral lower extremity lymphedema. Her medical and family history was unremarkable. The physical examination was negative for dysmorphic features and congenital anomalies. Lymphoscintigraphy showed no evidence of lymph flow in the left lower extremity, which persisted at the delayed 2-hour image. A comprehensive clinical and family history that includes a thorough physical examination are the mainstays of the medical assessment of lymphedema in children. Isotopic lymphoscintigraphy is generally considered the gold standard for confirmation of the diagnosis. This article discusses the differential diagnosis, reviews the literature, and suggests a simplified and an updated flowchart for the classification of unilateral limb lymphedema in children.

Lymphedematous Skin and Subcutis: In Vivo High Resolution Magnetic Resonance Imaging Evaluation

Physico-chemical and morphologic parameters of skin layers and subcutaneous tissue in lymphedematous limb were studied in vivo using magnetic resonance imaging. High resolution images were obtained with a depth resolution of about 70 microm, using a specific surface gradient coil specially designed for skin imaging and connected to a standard whole-body imager at 1.5 T. Twenty-one patients with unilateral lower extremity lymphedema (11 primary and 10 secondary) were examined. Skin thickness, relaxation times, and relative proton density were calculated in lymphedematous limbs and in contralateral extremities. In diseased limbs, the average skin thickness (2.17 mm) was significantly larger (p = 1.5 x 10(-4)) than that of contralateral limb (1.14 mm). Major cutaneous alterations due to lymphedema took place in dermis. In lymphedematous dermis, the significant increase of relaxation time values could be due to a shift in the equilibrium of water inside this tissue in relation to the interactions between macromolecules and water molecules. In lymphedematous epidermis our results showed an increase in the number of free water protons. Information about water and fat distribution in lymphedema was also obtained using chemical shift weighted images. Our results demonstrated a water retention diffusely spread over the entire dermis, and an important fluid retention located in the interlobular spacing and beside the superficial fascia. Inside the subcutis, the mean thickness of the superficial fat lobules was increased more than that of the deep fat lobules. From all the various measurements we could not distinguish primary from secondary lymphedema.