Secondary Leg Lymphedema

Secondary Leg Lymphedema

Related terms: leg swelling, leg edema, leg lymphoedema

Introduction

If you ask most people that are familiar with lymphedema the question, “Are you aware of secondary lymphedema,” most would reply that “yes, it is where the arm swells after the lymph system has been damaged by breast cancerbiopsy and treatment.” This is called arm lymphedema.

Even if they are aware that such a condition as secondary leg lymphedema exists, their response might well be that it is a small group of afflicted men who have prostate cancer.

Thus shows how little awareness there is about this particular form of lymphedema. Even in the lymphedema world it is a poor step-child.

However, if the membership of Lymphedema People and the posts in the online lymphedema support groups are an indication, this condition is increasing dramatically.

The reasons for this increase are multiple. They include:

1. increased survival rates of cancer 2. improved treatment of trauma injuries that previously would have been terminal 3. increase in antibiotics for infections and treatment for other conditions that previously might have resulted in death.

It is also important to note that secondary leg lymphedema does not necessarily start immediately after the injury or trauma. It may not start for years.

What is secondary leg lymphedema?

Secondary lymphedema is a condition where the lymphatic system has been damaged. The main job of this system is to move excess through and out of our bodies. When it becomes damaged or impaired, it is no longer able to accomplish this function and these fluids (lymph fluids) collect in the interstitial tissues of our legs. This causes leg swelling.

Another important function of the lymph system is to help our bodies fight infections. With lymphedema, this ability is also weakened and the patient becomes more susceptible to infections.

What causes secondary leg lymphedema?

Secondary leg lymphedema (also referred to as acquired lymphedema) is caused by or can develop as a results of:

1.) Surgeries involving the abdomen or legs where the lymph system has been damaged. This includes any intrusive surgery.

Examples are

vein stripping surgery for peripheral vascular disease hip replacement knee replaement insertion of bolts, screws and other devices in orthopaedic repair lipectomy

2.) Removal of lymph nodes for cancer biopsy. These cancers include, but are not limited to

prostate cancer testicular cancer ovarian cancer uteran cancer vulva cancer bladder lymphoma - both hodgkins and non hodgkinsmelanoma colon Kaposi Sarcoma

3.) Radiation treatment of these cancers that scars the lymph system and lymph nodes

4. Some types of chemo therapy. For example, tamoxifen has been linked to secondary lymphedema and blood clots.

5.) Severe infections/sepsis. Generally referred to as lymphangitis, this is a serious life-threatening infection of the lymph system/nodes.

6.) Trauma injuries such as those experienced in an automobile accident that severly injures the leg and the lymph system.

7.) Burns - this even includes severe sunburn. We have a member that acquired secondary leg lymphedema from this.

8.) Bone breaks and fractures.

9.) Morbid obesity - the lymphatics are eventually crushed by the excessive weight. When that occurs, the damage is permanent and chronic secondary leg lymphedema begins.

10.)Insect bites

11.)Parasitic infections

What are some of the symptoms of secondary leg lymphedema?

These symptoms may include:

1.) Unexplained swelling of either part of or the entire leg. In early stage lymphedema, this swelling will actually do down during the night and/or periods of rest, causing the patient to think it is just a passing thing and ignore it.

2.) A feeling of heaviness or tightness in the leg

3.) Increaseing restriction on the range of motion for the leg.

4.) Unsual or unexplained aching or discomfort in the leg.

5.) Any change involving hardening and/or thickening of the skin or areas of skin on the leg.

Congenital Lymphedema : Another Unique and Gender Specific Stigmata of Tuberous Sclerosis?

Congenital lymphedema : another unique and gender specific stigmata of tuberous sclerosis?

Nov 2012

Sukulal K, Namboodiri N.

Source

Department of Cardiology, SCTIMST, Thiruvananthapuram, Kerala, India.

We report a child of tuberous sclerosis with a rare association of congenital lymphedema and cardiac rhabdomyoma since birth.

A 3-month-old female child, born of non-consanguineous marriage , was detected soon after birth to have nonpitting edema of left lower limb extending from thigh to foot. Neurosonogram and USG abdomen were normal. Echocardiography revealed a 9 x 9 mm rounded pedunculated mass in LV outflow tract, attached to aorto-mitral continuity junction. Physical examination revealed multiple hypopigmented macules in right upper limb and trunk suggestive of ash leaf macules. X-ray chest and ECG was normal for age. Blood investigations were normal. The child’s father had a history of seizure disorder and was on antiepileptic drugs. His physical examination revealed hypopigmented to depigmented macules in both upper limbs and trunk, skin colored plaques with irregular border in lumbosacral region and multiple hyperpigmented to erythematous papules and small plaques over face suggestive of ash leaf macules, shagreen patches, and angiofibromas respectively.

Lymphedema is a chronic tissue swelling that is most commonly manifested in a limb. This condition results from impaired lymph drainage in the presence of normal capillary filtration. The three main consequences of lymphatic failure are lymphedema, infection and, very rarely, cancer [1]. Most forms of primary lymphedema are thought to be caused by a congenital abnormality of the lymphatic system and present at or soon after birth. Cardiac rhabdomyomas are intracavitary or intramural tumors that are present in nearly 50 to 70% of infants with tuberous sclerosis (TSC). Most children are asymptomatic. Symptoms are attributed to the presence of intracardiac obstruction, myocardial involvement, and rhythm disturbances [2].

Congenital lymphedema is a rare association with tuberous sclerosis with only few cases reported earlier [3,4]. The previous reported patients were females but unlike our child, they presented with history of multiple seizures while our child had no seizures but instead had a cardiac rhabdomyoma detected incidentally. It is interesting to note that pulmonary lymphangio-myomatosis seen in tuberous sclerosis similarly occurs only in women which is hypothesized to be due to the fact that estrogen regulates TSC gene signalling and, perhaps, also the migration of TSC2-deficient cells [3].

The pathophysiology of congenital lymphedema in tuberous sclerosis is yet unclear. Previous authors have suggested that it could be due to the dysplastic development of lymphatic system in the affected limb as part of TSC gene mutation as this gene regulates cell growth, proliferation and migration. Congenital lymphedema may also be due to the abnormal smooth cell hypertrophy in subcutaneous tissue which externally compresses the superficial lymphatics. An increased awareness of this association may help pediatricians suspect tuberous sclerosis in a female child when congenital lymphedema is the sole external manifestation.

Indian Pediatrics

A newly designed SIPC device for management of lymphoedema.

WARNING TO ALL LYMPHEDEMA PATIENTS

This abstract is a prime example of just how bad information can be that is presented even through PubMed.

Lymphology 101 clearly shows that high pressure pneumatic devices can cause serious damage to the good lymphatics, making lymphedema even worse.

Read this for education, but please, please, please, what ever you do never ever ever set the compression level on high if you use a pneumatic device.

A newly designed SIPC device for management of lymphoedema.

PubMed

Pat

Lambda-shaped anastomosis with intravascular stenting method for safe and effective lymphaticovenular anastomosis.

2011

Yamamoto T, Narushima M, Kikuchi K, Yoshimatsu H, Todokoro T, Mihara M, Koshima I.

Source

Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan. tyamamoto-tky@umin.ac.jp

Abstract

BACKGROUND:

Lymphaticovenular anastomosis has become an increasingly common treatment for lymphedema. Supermicrosurgical techniques are essential for the successful performance of lymphaticovenular anastomosis. A positive correlation between the number of lymphaticovenular anastomoses performed and therapeutic efficacy has been reported, and in performing these anastomoses, the establishment of as many bypasses as possible is important.

METHODS: Forty limbs of 20 patients with lower extremity lymphedema who underwent lymphaticovenular anastomosis in our department were assessed. All cases were performed under local anesthesia using two to four surgical microscopes. A new method of anastomosis, lambda-shaped anastomosis assisted by intravascular stenting, was chosen in required cases.

RESULTS: Lymphaticovenular anastomoses resulted in 186 anastomoses on 20 patients with lower extremity lymphedema; the average number of anastomoses per case was 9.3 (range, five to 18). The number of surgical microscopes used ranged from two to four (average, 3.3), and the duration of the operation ranged from 3 to 5 hours (average, 4.1). In the cases of lambda-shaped anastomosis (n = 11), the number of anastomoses was significantly greater than in the cases without lambda-shaped anastomosis (n = 9; 10.2 ± 2.3 versus 8.2 ± 1.4; p < 0.05).

CONCLUSIONS:

Lambda-shaped anastomosis assisted by intravascular stenting is a safe and relatively easy method that can be performed by surgeons with less than 1 year of experience in microsurgery. This in turn allows efficient lymphaticovenular anastomoses to be performed simultaneously by a team of surgeons, resulting in an increased number of bypasses.

Lippincott, Williams & Wilkins


*Editor's Note: Article is for information only and is NOT to be construed as an endorsement of the procedure, nor as a position of opposing the procedure.

Lower limb lymphedema treated with lymphatico-venous anastomosis based on pre- and intraoperative icg lymphography and non-contact vein visualization: A case report.

Mar 2012

Mihara M, Hara H, Narushima M, Hayashi Y, Yamamoto T, Oshima A, Kikuchi K, Murai N, Koshima I.

Source

Department of Plastic and Reconstructive Surgery, University of Tokyo, Japan. mihara@keiseigeka.name

Abstract 

Lymphatico-venous anastomosis (LVA) is used to resolve lymph retention in lymphedema. However, the postoperative outcome of lower limb lymphedema is poorer than that for upper limb lymphedema, because of the location lower than the heart level. Improvement of the therapeutic outcome requires application of as many anastomoses as possible in a limited operation time, particularly since there is a positive correlation between the number of anastomoses and the therapeutic effect of LVA. In this case, we described a method to increase the efficiency of lymphatico-venous anastomosis for bilateral severe lower limb lymphedema through efficient identification of lymph vessels and veins suitable for anastomosis using indocyanine green (ICG) contrast imaging and AccuVein, a noncontact vein visualization system, respectively. Ten LVAs were succeeded at seven incisions, and the operation time was 3 hours and 5 minutes. Accuvein can be used for identification of subcutaneous venules with a diameter of about 0.5-1.0 mm. We used this approach in surgery for a case of bilateral lower limb lymphedema, with a resultant improvement in the surgical outcome.

*Editor's Note: Article is for information only and is NOT to be construed as an endorsement of the procedure, nor as a position of opposing the procedure.

Wiley OnLine

Is selective lymphadenectomy more cost-effective than routine lymphadenectomy in patients with endometrial cancer?

Oct 2012

Clements AE, Tierney BJ, Cohn DE, Straughn JM Jr.

Source

Divisions of Gynecologic Oncology, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA. Electronic address: aine.clements@osumc.edu.

Abstract

OBJECTIVE:

The objective of this study is to determine the cost-effectiveness of two strategies in women undergoing surgery for newly diagnosed endometrial cancer.

METHODS:

A decision analysis model compared two surgical strategies: 1) routine lymphadenectomy independent of intraoperative risk factors or 2) selective lymphadenectomy for women with high or intermediate risk tumors based on intraoperative assessment including tumor grade, depth of invasion, and tumor size. Published data were used to estimate the outcomes of stage, adjuvant therapy, and recurrence. Costs of surgery, radiation, and chemotherapy were estimated using Medicare Current Procedural Technology codes and Physician Fee Schedule. Cost-effectiveness ratios were estimated for each strategy. Sensitivity analyses were performed including an estimate for lymphedema (10%) for patients that underwent a lymphadenectomy.

RESULTS:

For 40,000 women diagnosed annually with endometrial cancer in the United States, the annual cost of selective lymphadenectomy is $1.14billion compared to $1.02billion for routine lymphadenectomy. The selective lymphadenectomy strategy was $123.3million more expensive. Five-year progression-free survival was 85.9% with routine compared to 79.3% with selective. Treatment cost $6349 more per survivor in the selective strategy compared to routine strategy ($36,078 vs. $29,729). These results held up under a variety of sensitivity analyses including costs due to lymphedema which were higher in the routine lymphadenectomy strategy compared to the selective lymphadenectomy strategy ($10million vs. $7.75million).

CONCLUSIONS:

A strategy of selective lymphadenectomy based on intraoperative risk factors for patients with endometrial cancer was less effective and more costly than routine lymphadenectomy even when the impact of lymphedema was considered.

Elsevier

see also: PubMed

Complications of lymphadenectomy for gynecologic cancer.

Oct 2012

Achouri A, Huchon C, Bats AS, Bensaid C, Nos C, Lécuru F.

Source

Service de Chirurgie Cancérologique Gynécologique et du Sein, Hôpital Européen Georges Pompidou, AP-HP, Paris, France; Faculté de médecine, Université Paris-Descartes, Paris, France. Electronic address: abdellaziz.achouri@egp.aphp.fr.

Abstract

INTRODUCTION: 

Symptomatic postoperative lymphocysts (SPOLs) and lower-limb lymphedema (LLL) are probably underestimated complications of lymphadenectomy for gynecologic malignancies. Here, our objective was to evaluate the incidence and risk factors of SPOLs and LLL after pelvic and/or aortocaval lymphadenectomy for gynecologic malignancies.

METHODS: Single-center retrospective study of consecutive patients who underwent pelvic and/or aortocaval lymphadenectomy for ovarian cancer, endometrial cancer, or cervical cancer between January 2007 and November 2008. The incidences of SPOL and LLL were computed with their 95% confidence intervals (95%CIs). Multivariate logistic regression was performed to identify independent risk factors for SPOL and LLL.

RESULTS: We identified 88 patients including 36 with ovarian cancer, 35 with endometrial cancer, and 17 with cervical cancer. The overall incidence of SPOL was 34.5% (95%CI, 25-45) and that of LLL was 11.4% (95% confidence interval [95%CI], 5-18). Endometrial cancer was independently associated with a lower risk of SPOL (adjusted odds ratio [aOR], 0.09; 95%CI, 0.02-0.44) and one or more positive pelvic nodes with a higher risk of SPOL (aOR, 4.4; 95%CI, 1.2-16.3). Multivariate logistic regression failed to identify factors significantly associated with LLL.

CONCLUSION:

Complications of lymphadenectomy for gynecologic malignancies are common. This finding supports a more restrictive use of lymphadenectomy or the use of less invasive techniques such as sentinel node biopsy.

PubMed

The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow stage and concept of subclinical lymphedema.

Takumi Yamamoto, Nana Matsuda, Kentaro Doi, Azusa Oshima, Hidehiko Yoshimatsu, Takeshi Todokoro, Fusa Ogata, Makoto Mihara, Mitsunaga Narushima, Takuya Iida, Isao Koshima

Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.

Plastic and reconstructive surgery (impact factor: 2.74). 10/2011; 128(4):314e-321e. DOI:10.1097/PRS.0b013e3182268da8

ABSTRACT

Early diagnosis and treatment are as important for management of secondary lymphedema following cancer treatment as in primary cancer treatment. Indocyanine green lymphography is the modality of choice for routine follow-up evaluation of patients at high risk of developing lymphedema after cancer therapy.

Fifty-six limbs of 28 so-called unilateral secondary lower extremity lymphedema patients who underwent indocyanine green lymphography were compared with dermal backflow patterns of indocyanine green lymphography on 28 asymptomatic limbs and assessed using leg dermal backflow stage.

Of 28 asymptomatic limbs of secondary lower extremity lymphedema patients, the dermal backflow patterns were detected in 19 limbs but were absent in nine limbs. Significant differences were seen between asymptomatic limbs with dermal backflow patterns (n=19) and limbs without them (n=9): age, 51 versus 34, body weight 75 kg versus 34kg, body mass index 23 versus 19, leg dermal bacflow stage of symptomatice limb 3 versus 2.

The splash pattern is the earliest finding on indocyanine green lymphography of asymptomatic limbs of secondary lower extremity lymphedema patients. The leg dermal backflow stage allows early diagnosis of secondary lower extremity lymphedema even in a subclinical stage. The concept of subclinical lymphedema could play an important role in early diagnosis and prevention of lymphedema after cancer treatment.
Diagnostic, V.

Source: PubMed

Lower extremity lymphedema index: a simple method for severity evaluation of lower extremity lymphedema.

Takumi Yamamoto, Nana Matsuda, Takeshi Todokoro, Hidehiko Yoshimatsu, Mitsunaga Narushima, Makoto Mihara, Gentaro Uchida, Isao Koshima

Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan.

Annals of plastic surgery (impact factor: 1.29). 03/2011; 67(6):637-40. DOI:10.1097/SAP.0b013e318208fd75

ABSTRACT

Measurement of the circumference is the most commonly used method for evaluating extremity lymphedema. However, comparison between different patients is difficult with this measurement. To resolve this problem, we have formulated a new index, lower extremity lymphedema (LEL) index, which can be easily obtained from measurements of the body. We evaluated correlation between lower LEL index and clinical stage in patients with LEL. The LEL indices were significantly correlated with clinical stages and could be used as a severity scale. The LEL index makes objective assessment of the severity of lymphedema through a numerical rating, regardless of the body type. This numerical rating makes the index useful for evaluation of lymphedema severities between different cases.

Source: PubMed