Intensive treatment of leg lymphedema.

Apr 2010

Pereira de Godoy JM, Azoubel LM, de Fátima Guerreiro de Godoy M.

Source

Department of Cardiology and Cardiovascular Surgery and professor of the post graduation course of Medicine School of São Jose do Rio Preto-FAMERP-Brazil.

Abstract

BACKGROUND:

Despite of all the problems caused by lymphedema, this disease continues to affect millions of people worldwide. Thus, the identification of the most efficacious forms of treatment is necessary.

AIM:

The aim of this study was to evaluate a novel intensive outpatient treatment for leg lymphedema.

METHODS:

Twenty-three legs of 19 patients were evaluated in a prospective randomized study. The inclusion criteria were patients with Grade II and III lymphedema, where the difference, measured by volumetry, between the affected limb below the knee and the healthy limb was greater than 1.5 kg. Intensive treatment was carried out for 6- to 8-h sessions in the outpatient clinic. Analysis of variance was utilized for statistical analysis with an alpha error of 5% (P-value <0.05) being considered significant.

RESULTS:

All limbs had significant reductions in size with the final mean loss being 81.1% of the volume of edema. The greatest losses occurred in the first week (P-value <0.001). Losses of more than 90% of the lymphedema occurred in 9 (39.13%) patients; losses of more than 80% in 13 (56.52%), losses of more than 70% in 17 (73.91%) and losses of more than 50% were rec

CONCLUSION:

The intensive treatment of lymphedema in the outpatient clinic can produce significant reductions in the volume of edema over a short period of time and can be recommended for any grade of lymphedema, in particular the more advanced degrees.

NIH

Unilateral leg swelling: deep vein thrombosis?

Feb 2011

Bekou V, Galis D, Traber J.

Source

Venenklinik Bellevue, Kreuzlingen, Kreuzlingen, Switzerland.

Abstract

OBJECTIVE:

We present two cases of a unilateral leg swelling of unusual aetiology as a reminder to the physician to consider causes of unilateral leg swelling other than deep vein thrombosis, lymphoedema and infectious diseases.

CASE REPORTS:

Both of our patients developed progressive leg swelling. Subsequent investigation revealed a lesion compressing the femoral vein. At exploration this was found to be a ganglion cyst. In one patient surgical removal of the cyst and in the other puncture of the cyst and instillation of steroid resulted in prompt resolution of the swelling.

CONCLUSION:

Venous compression due to external cystic lesions, although rare, is recognized. In strange cases this differential diagnosis should also be taken into account. Therapeutic options are the surgical removal or puncture of the cyst.

Phlebology

Please click on the following links for a comparison of leg edema from a deep venous thrombosis (DVT) versus Leg Lymphedema - also Post-Thrombotic Syndrome

High resolution unenhanced computed tomography in patients with swollen legs.

An older abstract from 2002, laying the basic info foundation for understanding CT scans of leg lymphedema. Also mentioned in the article are DVTs and lipedema, and the use of the ultrasound.

The study:

High resolution unenhanced computed tomography in patients with swollen legs.

Sept 2002

Monnin-Delhom ED, Gallix BP, Achard C, Bruel JM, Janbon C.

Source

Service d'Imagerie Medicale, Saint Eloi Hospital, Montpellier, France. e-monnin@chu-montpellier.fr

Abstract

PURPOSE:

To evaluate the accuracy of computed tomography (CT) scan imaging in distinguishing lymphedema from deep venous thrombosis (DVT) and lipodystrophy (lipedema) in patients with swollen legs.

MATERIAL AND METHODS:

CT scans of the lower limbs were performed in 55 patients with 76 swollen legs (44 lymphedemas, 12 DVT and 20 lipedemas). Thirty-four normal contralateral legs were also similarly evaluated. Primarylymphedema was verified by lymphography or lymphoscintigraphy, whereas secondary lymphedema was documented by a typical clinical history. DVT was established by ultrasound Doppler imaging. The diagnosis of lipedema was made with bilateral swollen legs where lymphoscintigraphy and Doppler examination were both unremarkable. Qualitative CT analysis was based on skin thickening, subcutaneous edema accumulation with a honeycombed pattern, and muscle compartment enlargement.

RESULTS:

Sensitivity and specificity of CT scan for the diagnosis of lymphedema was 93 and 100%, respectively; for lipedema it was 95 and 100%, respectively; andfor DVT it was 91 and 99%, respectively. Skin thickening was found in 42 lymphedemas (95%), in 9 DVT (75%), and in 2 lipedemas (16%). Subcutaneous edema accumulation was demonstrated in 42 legs (95%) with lymphedema and in 5 (42%) with DVT but in none with lipedema. A honeycombed pattern was present only in lymphedema (18 legs or 41%); muscle enlargement was present in all patients with DVT, in no patient with lipedema, and in 4 (9%) with lymphedema.

CONCLUSION:

Edema accumulation is readily demonstrated with plain CT scan and is not present in lipedema. Specific CT features of the subcutaneous fat and muscle compartments allow accurate differentiation between lymphedema and DVT.

PubMed

Another older article from 2002, that discusses CT staging of leg (lower limb) lymphedema.

Doctors have long maintained that these radiography scans can be valuable in assesing the stages of lymphedema and in understand the physiology of a lymphedematous leg. However, this remain tremendously difficult for several reasons.

First, not many doctors appear to be well trained to interpret these scans in as much as lymphedema is concerned.

Secondly, even if a doctor was able to interpret a CT scan, there really is no specific diagnostic criteria for such a diagnoses or staging.

Notice too, in the study, the comments regarding the difference between the description of a primary lymphedema thigh versus a secondary one.

The abstract follows:

Lymphedema of the lower limbs: CT staging].

[Article in French]

Marotel M, Cluzan RV, Pascot M, Alliot F, Lasry JL.

Source

Hôpital Saint-Michel, 33, rue Olivier-de-Serres, 75015 Paris, France. martine.marotel@hopital-saint-michel.org

Abstract

Routinely performed, CT is useful and reliable for staging lower limb lymphedema. We describe methods we utilized. We found in frequency order: skin thickening, subcutaneous tissues area increase in regard the safe limb, perimuscular aponevrosis thickening, fat infiltration: lines parallel to the skin, edematous areas along perimuscular aponevrosis, lines perpendicular to the skin. The lowest fat density is increased on the pathologic side. Subfascial compartment is slightly fattened. We found huge differences between primary and secondary lymphedema for the thigh. Same images may be generated by old or young lymphedema. Rarely useful for positive diagnosis, CT is indispensable for secondarylymphedema staging (initial staging or after a recent increase). It seems us indispensable for any pretherapeutic staging (whole objectively disorders, exact upper limit, infraclinic bilaterality).

PubMed

Computerized tomography of 150 cases of lymphedema of the leg

This is a very old abstract from 1998. What was fascinating to me personally, is the CT description of the leg tissue with lymphedema. It reminded me of the ones I have had on both legs.

In the early 1970's, I had three Thompsons procedures done on my left leg, and none done on the right. There is a noticeable difference internally for the legs. Strange too was the fact that after a week in the hospital last year, it was the left leg that experienced the greatest decrease in swelling - specifically due to the fact that according to the CT, it has a much smaller amount of subcutaneous tissue then the left.

Does that make the surgery worthwhile? Hardly, the complications, including lymphoma still make it a terrible choice for lymphedema treatment. It is also the only leg that has experienced cellulitis.

The abstract follows:

Computerized tomography of 150 cases of lymphedema of the leg

Nov 1998

[Article in French]

Marotel M, Cluzan R, Pascot M, Ghabboun S, Alliot F, Lasry JL.

Source

Hôpital Saint-Michel, Paris, France.

Abstract

The aim of this work was to evaluate the usefulness of CT imaging to stage lower limb lymphedemas. Between 1992 and 1997, we studied 150 cases of lymphedema, half idiopathic and half secondary. Methods used are described. In decreasing order of frequency, we found: skin thickening, increased subcutaneous tissue surface area compared with the healthy limb, thickening of the perimuscular aponevrosis, fat infiltration: lines parallel to the skin (parallel), edematous areas along the perimuscular aponevrosis, lines perpendicular to the skin (perpendicular). The lowest fat density was increased on the diseased side. The subfascial tissue showed some fat accumulation. These results were compared with findings reported in the literature. There were very major differences between idiopathic lymphedema and secondary lymphedema of the thigh. Similar images were generally generated by new and long-standing lymphedema. Rarely useful for positive diagnosis, CT is indispensable for establishing stage initially or after recent increase and, in our opinion, is essential for pretherapeutic assessment. The CT-scan gives objective evidence of overall disorders, the exact upper limit of the lymphedema, and sometimes reveals infraclinical bilateral involvement.

Full text arricle: EM/Consulte

Grades of Lymphedema

Grades of Leg Lymphedema

In establishing a more accurate 'staging" system for lymphedema, a Lymphedema Grades list has been proposed.

In the grading system, lymphedema can (like stages) be categorized by its severity (usually referenced to a healthy extremity)

• Grade 1 (mild edema): Lymphedema involves the distal parts such as a forearm and hand or a lower leg and foot. The difference in circumference is less than 4 centimeters, and other tissue changes are not yet present.

• Grade 2 (moderate edema): Lymphedema involves an entire limb or corresponding quadrant of the trunk. Difference in circumference is more than 4 but less than 6 centimeters. Tissue changes, such as pitting, are apparent. The patient may experience erysipelas.

• Grade 3a (severe edema): Lymphedema is present in one limb and its associated trunk quadrant. The difference in circumference is greater than 6 centimeters. Significant skin alterations, such as cornification or keratosis, cysts and/or fistulae, are present. Additionally, the patient may experience repeated attacks of erysipelas.

• Grade 3b (massive edema): The same symptoms as grade 3a, except two or moreextremities are affected.

• Grade 4 (gigantic edema): Also known as elephantiasis, in this stage of lymphedema, the affected extremities are huge due to almost complete blockage of the lymph channels. Elephantiasis may also affect the head and face.

Stages of Leg Lymphedema

Stages of Leg Lymphedema

There are three basic stages active of lymphedema. The earlier lymphedema is recognized and diagnosed, the easier it is to successful treat it and to avoid many of the complications.

It is important as well to be aware that when you have lymphedema, even in one limb there is always the possibility of another limb being affected at some later time. This “inactive” period referred to as the latency stage. It is associated with hereditary forms of lymphedema.

LATENCY STAGE or STAGE 0

Lymphatic transport capacity is reduced No visible/palpable edema Subjective complaints are possible

STAGE I

(Reversible Lymphedema) Accumulation of protein rich edema fluid Pitting edema Reduces with elevation (no fibrosis)

STAGE II

(Spontaneously Irreversible Lymphedema) Accumulation of protein rich edema fluid Pitting becomes progressively more difficult Connective tissue proliferation (fibrosis)

STAGE III

(Lymphostatic Elephantiasis) Accumulation of protein rich edema fluid Non pitting Fibrosis and sclerosis (severe induration) Skin changes (papillomas, hyperkeratosis, etc.)

STAGE IIII

The limb is so densely fibrotic that it is not possible to make any indentation when pressed. It becomes impossible for ultrasound testing to pick even the blood pulse. The skin becomes brittle and even the slight of bumps causes a serious, extensively weeping wound. Because of the hardness of the tissue, it has become a total septic foci for bacteria and constant cellulitis and systemic infections become the norm. The only treatment for cellulitis is an extended period of IV antibiotics.

There is no treatment option for Stage Four. The complete focus is on management, containment of infections, prevention if at all possible of amputation.

Stage four information is strictly my own thinking as many do not yet recognize as Stage Four, while others have even mentioned a stage Five.

A new staging system has been set forth by Lee, Morgan and Bergan and endorsed by the American Society of Lymphology. This provides a clear technique which can be employed by clinical and laboratory assessments to more accurately diagnose and prescribe therapy for lymphedema. In this improved version, four stages are identified (I-IV). Physicians and researchers can use additional laboratory assessments, such as bioimpedance, MRI, or CT, to build on the findings of a clinical assessment (physical evaluation). From this, results of therapy can be accurately be determined and reported in documentation, as well as research.

Treatment of Leg Lymphedema

The treatment for arm lymphedema is much the same as treatment for leg lymphedema. The preferred treatment is decongestive therapy.