Primary lower limb lymphedema: a focus on its functional, social and emotional impact

**This is actually an older article that has recently become available through PubMed.  It was written in 2010 and after you read this, you will be thinking "three years later and almost no progress has been made!. It speaks of quality of life. Sad and very frustrating.  Pat**

Int J Med Sci. 2010; 7(6): 353–357.

Published online 2010 October 22.

Emmanouil K Symvoulakis, Dimitrios I Anyfantakis, and Christos Lionis

Author information ► Article notes ► Copyright and License information ►

Abstract

Primary lymphedema is a rare, chronic and distressing condition with negative effects on physical, social and emotional level. The purpose of these reports was to present and discuss two different cases of primary lower limb lymphedema with a focus on its physical and mental impact and on some qualitative aspects of patients' self-reported experiences. The patients were recruited as they used occasional services within the University Hospital of Heraklion (Crete, Greece). The functional and mental impact of primary lymphedema was measured using the generic Medical Outcome Study short form-36 questionnaire and open-ended questions led to give more emphasis to patients' experiences. The analysis of short form-36 results in the first patient disclosed a significant functional impairment with a minor impact of the condition on emotional and social domains. For the second patient quality of life scores in the emotional and social domains were affected. Our findings support further the statement that physicians should pay full attention to appraise the patient's physical and emotional condition. General practitioners have the opportunity to monitor the long-term impact of chronic disorders. Posing simple open-ended questions and assessing the level of physical and mental deficits in terms of well-being through the use of specific metric tools can effectively follow-up rare conditions in the community.

Full text article:

NIH-International Journal of Medical Sciences

A prospective study in detection of lower-limb lymphedema and evaluation of quality of life after vulvar cancer surgery.

Jul 2012

Novackova M, Halaska MJ, Robova H, Mala I, Pluta M, Chmel R, Rob L.

Source

Department of Obstetrics and Gynaecology, 2nd Medical Faculty of Charles University in Prague, Czech Republic. marta.novackova@seznam.cz

Abstract

BACKGROUND:

Lower-limb lymphedema is one of the most disabling adverse effects of vulvar cancer surgery. Multifrequency Bioelectrical Impedance Analysis (MFBIA) is a modern noninvasive method to detect lymphedema. The first aim of this study was to prospectively determine the prevalence of secondary lower-limb lymphedema after surgical treatment for vulvar cancer using objective methods, circumference measurements and MFBIA technique. The second aim was to compare quality of life (QoL) before and 6 months after vulvar surgery.

METHODS:

Twenty-nine patients underwent vulvar cancer surgery in our study: 17 underwent inguinofemoral lymphadenectomy (RAD), and 12 underwent sentinel lymph node biopsy (CONS). Patients were examined before and 6 months after vulvar surgery by measuring the circumference of the lower limbs and with MFBIA. A control group of 27 healthy women was also measured. To evaluate QoL, the European Organisation for Research and Treatment of Cancer (EORTC) QoL questionnaires (QLQ-C30 and QLQ-CX24) were administered to patients before and 6 months after surgery.

RESULTS:

Using circumference measurement, 9 lymphedemas (31%) were diagnosed: 3 (25%) in the CONS and 6 (37.5%) in the RAD group (P = 0.69). After vulvar surgery, patients in the RAD group reported more fatigue and worsening of physical and role functioning. When comparing both groups, the RAD group had significantly worse parameters in social functioning, fatigue, and dyspnea.

CONCLUSIONS:

Lower radicality in inguinofemoral lymphadenectomy shows a trend toward lower morbidity and significantly improves QoL. Multifrequency Bioelectrical Impedance Analysis was tested in these patients as a noninvasive, objective method for lymphedema detection. Detection of lymphedema based on subjective evaluations proved to have an unsatisfactory sensitivity. Less radical surgery showed objectively better results in QoL.

Lippincott, Wilkins, Williams

Distichiasis-lymphedema syndrome with optic disc pit

Leg Lymphedema

Jan-Feb 2011

Indian J Ophthalmol. 2011 Jan-Feb; 59(1): 71–72.

doi:  10.4103/0301-4738.73703

K Kaarthigeyan, M Ramprakash,¹ and G Kalpana²

Author information ► Copyright and License information

Dear Editor,

An eight-year old boy, first born to third degree consanguineous parents, presented with right leg swelling for three months, with gradual onset, which progressed up to knee. There was no history of fever, injury, abdominal pain or contact with tuberculosis. He was treated with anti-filarial drugs elsewhere. At two years of age, he had frequent episodes of redness and constant rubbing of eyes and was then diagnosed to have double-rowed eye lashes involving all four eyelids and the extra rows of lashes were cauterized and removed elsewhere. The boy still continued to be symptomatic. None of the other family members had similar complaints.

On examination, he had right lower limb edema, which was from the knee downward.  There were no bony deformities or vertebral anomalies. Systemic examination was normal. He had mild congestion of both eyes. His visual acuity was 20/20; N6 in both eyes, and had no refractory error. Slit-lamp examination revealed distichiasis.  focal area of loss of eyelashes and depigmentation of skin was noted in the left upper eyelid. Fundus examination revealed an optic disc pit in the left eye and the macula was normal

Blood parameters were normal. Night smears for microfilaria were negative. Ultrasonography (USG) abdomen, echocardiogram, magnetic resonance imaging (MRI) spine, and vascular Doppler studies of both limbs were normal. Isotope lymphoscintigraphy confirmed the lymphedema. The parents were also screened and found to be normal. A clinical diagnosis of distichiasis-lymphedema syndrome (DLS) was made. Conservative management for symptomatic distichiasis, with lubrication and epilation was carried out, advice for Amsler test at home periodically and stockings for lymphedema were given. The parents were genetically counseled for prevention of secondary complications such as, cellulitis, foot infections, and varicose veins.

Full Text Article:

Indian Journal of Opthalmology

Leg and Inguinal Lymph Nodes

The inguinal nodes - groin area.  I had a lymphangiogram done in 1966 and a lymphoscintigraphy done in 2006 - and they showed me missing significant numbers of inguinal nodes.  In 1962, when I was nine years old, I had an inguinal node removed due to necrosis from cellulitis - in left leg.

In 2000, I had a small needle biopsy on an inguinal node in the right leg.  Yep....it was positive.

In 1995, I was diagnosed with mixed b-cell lymphoma.







Wellsphere




Plymouth Hospitals



Lymphedema People

Lymph nodes - female. Though the abdominal nodes will be different due to different organs, the inguinal nodes remain the same.



Healthtap



Hopkins

Lymphoscintigraphy in unilateral lower limb and scrotal lymphedema caused by filariasis.

Dec 2012

Subramanyam P, Palaniswamy SS.

Source

Department of Nuclear Medicine and PETCT, Amrita Institute of Medical Sciences, Cochin, Kerala, India.

Abstract

Lymphedema is the edema that results from chronic lymphatic insufficiency. Lymphatic filariasis is caused by the filarial nematodes Wuchereria bancrofti, Brugia malayi, and Brugia timori. Lymphatic filariasis is common in tropical and subtropical regions. Early diagnosis and prompt therapy can be implemented using lymphoscintigraphy. Our patient is a 15-year-old boy presenting with a 3-month history of hydrocele. The patient was referred to us to rule out any lower limb lymphatic obstruction as the patient is from an endemic area. Tc Sulfur colloid (filtered) lymphoscintigraphy showed abnormal tracer collection in the scrotum and penis. There is associated dermal backflow or stasis in the left thigh region extending just above the knee, suggesting partial obstruction of left inguinal lymphatic channels.

AJTMH

See also:

Leg Lymphedema

Lymphoscintigraphy

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

Traveling and Leg Lymphedema

Traveling and Leg Lymphedema

A lot of people with leg lymphedema have questions regarding travel and leg lymphedema.  More particular, the questions often involve leg lymphedema and airplane flights.  This info is from one of my pages in the forum section of Lymphedema People:


The longest flight I ever took was only ten hours and that was way back in the mid-seventies when I was (ugh) so much younger and my lymphedema was no where near as bad as it is now.

My leg lymphedema has never had a problem due to air travel, whether it was a long or short flight. The great thing about longer flights like that is that the larger jets are generally used. In them you are much more able to stretch, move around and even take a short walk down the aisle.

There are a few pointers I would mention:

1.) Don't keep your legs at a 45 degree angle - try to stretch them out in front of you as much as possible.

2.) One thing I do periodically is to do stretch and flex exercises right there in the seat. You can flex the thigh muscle, lower leg muscles - even foot muscles while sitting. This is really helpful.

3.) Do try and get up for that short jaunt down the aisle (not like that aother really really long walk down the aisle)  

4.) Some may not have to, but I do wear compression while on the flight too. The leg swelling, for me, just starts going up the second it is unwrapped or bandaged. This should help and should not interfere with circulation.

5.)My biggest nemisis is cellulitis, so whenever I take a trip, I make certain I take a prescription bottle of antibiotics with me. that way, if there is an emergency with infection, you can start on treatment while you find where to go to get medical help.

Relax now, and enjoy the trip    

Reference page: Air Travel and Leg Lymphedema

Also:

Traveling and Lymphedema

Would complex decongestive therapy reveal long term effect and lymphoscintigraphy predict the outcome of lower-limb lymphedema related to gynecologic cancer treatment?

Sept 2012

Kim YB, Hwang JH, Kim TW, Chang HJ, Lee SG.

Source

Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Pusan, 626-770, Republic of Korea.

Abstract

OBJECTIVE:

The aims of this study were to investigate the long-term effect of complex decongestive therapy (CDT) onlymphedema volume reduction, especially considering the proximal and distal parts of the leg, and to evaluate the utility of pre-therapy lymphoscintigraphy in predicting the response to CDT in patients with lower-limb lymphedema after surgery for gynecologic cancer.

METHODS:

Medical records of 158 patients with secondary lymphedema of unilateral leg after surgery for gynecological cancer were reviewed retrospectively. They were treated with two weeks of CDT along with self-administered home therapy and were followed up for 24months. Whole, proximal and distal leg volume was serially measured by using an optoelectric volumeter prior to and immediately after therapy, and follow-up visits at months 3, 6, 12 and 24. Lymphoscintigraphy was performed prior to therapy.

RESULTS:

The percent volume reduction was 22.1% in the whole leg, 30.9% in the distal leg and 18.4% in the proximal legimmediately after CDT. The volume reduction was maintained for 24months, but the distal leg was significantly well maintained better than the proximal leg. Extremity radioisotope uptake ratio (EUR) among lymphoscintigraphic findings could predict the improvement of lymphedema volume in the distal, proximal and whole leg.

CONCLUSION:This study suggests that the long-term edema reducing effects of CDT are better maintained in the distalleg than in the proximal part, and initial lymphoscintigraphic quantitative finding may usefully predict the short and long-term response to CDT.

SciVerse

How to Wrap Legs for Lymphedema

Instructions

1 Arrange all of your necessary supplies nearby. Pre-cut the tape strips to keep one layer of wrapping in place while you are applying the next. Preparation, patience and allowing yourself ample time to perform the wrap are crucial to successfully finishing the procedure.

2 Apply moisturizing body lotion to the skin of your affected leg. This will maintain good skin condition by hydrating the skin and preventing cracking which would enable bacteria to invade your leg, causing infection. It will also help to alleviate potential skin irritation from using the layers of bandages.

3 Apply a tubular stockinette to protect your skin. Depending on your individual condition, you may (or may not) also use flexible gauze over the stockinette.

4 Use the thin foam-like fabric that your therapist gave you. Wrap a layer of padding around your leg. This will help to distribute the compression evenly.

5 Apply the lymphedema bandages, which are also known as short-stretch bandages. Apply more pressure at your foot, gradually decreasing the pressure as you move upward. The narrower bandages can go around your foot with the wider bandages spiraling up your leg. The exact number of bandages necessary will largely depend on the length and size of your leg as well as the amount of compression that you need.

Tips & Warnings

• Other potential treatments all aim to encourage lymph fluids to flow out of the affected leg and include light exercising of the affected leg, massage, pneumatic compression (a special sleeve which connects to a pump to place pressure on the affected leg) and compression garments. Some of the treatments can be combined for CDT (complete decongestant therapy).
• Severe lymphedema may require surgical removal of excess leg tissue to help reduce swelling.
• Avoid wearing socks that constrict your legs and avoid long periods of standing. If you must be on your feet for work, your doctor may recommend wearing compression stockings.
• Do not use ACE bandages as lymphedema wraps. Lymphedema bandages have limited stretching capacity and offer proper skin pressure for aiding the flow of lymph fluid. These special bandages also prevent constriction which can occur with ACE bandages.
• Contact your doctor immediately if you see a rash, redness or have any signs of infection in the affected leg. Do not apply compression or bandaging.
• This article does not take the place of your doctor's guidance or teaching by an experienced therapist. Individualized lessons and supervision are crucial for learning proper technique.


Read more: How to Wrap Legs for Lymphedema | eHow.com 

The efficacy of complex decongestive physiotherapy (CDP) and predictive factors of response to CDP in lower limb lymphedema (LLL) after pelvic cancer treatment.

June 2012

Liao SF, Li SH, Huang HY.

Source

Department of Physical Medicine and Rehabilitation, Changhua Christian Hospital, 135 Nanxiao Street, Changhua 500, Taiwan. sueliao3@gmail.com

Abstract

OBJECTIVE:

The aim of this study was to estimate the efficacy of an intensive CDP program, as well as to identify the predictors associated with lymphedema severity and response to CDP in lower limb lymphedema (LLL) after pelvic cancer therapy.

METHODS:

We performed a retrospective review of post-pelvic cancer LLL patients that were treated with a CDP program between January 2004 and March 2011.

RESULTS:

Twenty-seven (61.4%) of the total 44 patients had cervical cancer, 9 (20.5%) had endometrial cancer, and 8 (18.2%) had ovarian cancer. The mean age was 62.2 years, 18 (40.9%) patients received radiotherapy and a mean of 12.6 sessions of daily CDP, and mean lymphedema duration was 34.8 months. The interval from pelvic cancer treatment to LLL development was 63.4 months. Lymphedema severity, baseline and post-CDP percentage of excess volume (PEV) were 32.9% ± 18.4% and 18.8%± 16.7%. Baseline PEV was not correlated with duration of lymphedema, number of CDP sessions, age or radiotherapy, and was significantly different to post-CDP PEV, CDP efficacy, percentage reduction of excess volume, was minus fifty-five percent and was correlated with baseline PEV, but not with the number of CDP sessions, duration of lympheema, or age.  PEV was the only predictive factor for CDP efficacy.

CONCLUSIONS:

The key to predicting successful lymphedema treatment of LLL is the initial PEV. The intensive CDP program was effective and successful. We should encourage and refer patients to undergo treatment for LLL, even when the LLL is mild.

Elsevier

Stewart-Treves syndrome arising in patients with lymphaticovenular anastomosis for chronic lymphedema of the leg.

Stewart-Treves syndrome arising in patients with lymphaticovenular anastomosis for chronic lymphedema of the leg.

Eur J Dermatology 2012

Case 1. A 51-year-old woman presented with lymphedema of the left leg in 2000, without past history of surgery or radiation. She underwent lymphaticovenular anastomosis twice for her left lymphedema in 2003 and 2006. The skin incision
was made at the thigh, knee and ankle. However, the surgery was unsuccessful, and conservative pressure therapy was continued. In 2010, she was referred to our department with a one-year history of a purplish lesion on her left lower leg. Examination revealed a slightly indurated, ecchymotic lesion, measuring 8×7 cm on the lymphedematous lower leg. 

A biopsy specimen of the lesion showed some vascular channels lined by atypical endothelial cells with an extravasation of erythrocytes and scattered 
atypical cells in the dermis (figure 1C). Double immunofluorescence analysis showed that tumor cells were positive for podoplanin and negative for von Willebrand factor (figure 1D), indicating the development of lymphangiosarcoma.

FDG PET/CT imaging showed a mottled, abnormal
accumulation in the left lower leg (figure 1B). She was
treated with X-ray at a dose of 60 Gy and eight courses
of monthly docetaxel. There has been no evidence of local recurrence or metastases 13 months after the radiation.

Case 2. A 71-year-old woman, who was treated for cervical carcinoma in 1996, undergoing a hysterectomy and radiotherapy, developed chronic lymphedema of both legs. She underwent lymphaticovenular anastomosis twice in 2000 and 2001. However, the lymphedema gradually progressed, accompanied by hyperkeratotic papules of lymphangiectases.

In 2010, she was referred to our department for
further evaluation regarding a two-month history of a hemorrhagic lesion on her right buttock with high uptake of FDG as determined by PET/CT (figure 1E). Physical examination revealed hemorrhagic nodules on the right buttock and lower abdomen (figure 1F). Under a diagnosis of STS, she was treated by electron beams at a total dose of 60 Gy, followed by intravenous injections of interleukin-2 for five weeks. However, she developed several recurrences on her buttock and died of sepsis.

Stewart-Treves syndrome (STS) is a rare form of lymphangiosarcoma that occurs as a complication of lymphedema. The lymphedematous region becomes an immunologically vulnerable area that is predisposed to malignancy. Lymphedema in the extremities is troublesome for patients and conventional therapies are not always satisfactory.

Lymphaticovenular anastomosis is a novel treatment of lymphedema in the extremities [1]. The supermicrosurgical anastomosis of a lymphatic collector and a subdermal venule is performed through two or three incisions. This surgery has good results in most patients with upper extremity lesions and in about half of those with lower extremity lesions [2].

In the present cases, chronic lymph stasis might predispose the onset of the lymphangiosarcoma. The association between lymphangiosarcoma and lymphaticovenular anastomosis is unclear. A history of prior trauma and surgery has been noted in some studies on cutaneous angiosarcoma.

However, Holden et al. [3], found no definitive predisposing factors in any of 72 patients reviewed. We previously reported a case of metastatic angiosarcoma in a skin graft donor site associated with the Koebner phenomenon, and proposed that this phenomenon may be involved in the pathogenesis of angiosarcoma [4].

Furthermore, a fewcases of angiosarcoma have occurred in post-transplant patients with arteriovenous fistula (AVF) [5, 6]. Oscillatory blood flow in AVF causes shear stress at the endothelium, providing a pro-inflammatory stimulus to upregulate growth peptides, and enhances the activity of the DNA transcription regular NFkB by phosphorylation [5]. Similarly, the aberrant flow through lymphaticovenular anastomosis may be one of the factors contributing to the tumorigenesis of
STS. The prognosis is poor despite aggressive treatment.

Therefore, we should be aware of the possible occurrence of this condition during the treatment and follow-up of chronic lymphedema.

Disclosure. Financial support: none. Conflict of interest: None

Pseudosarcoma - massive localized lymphoedema in morbidly obese - a rare entity: Case report.

2012

**Editors note: massive localized lymphedema is generally always in the legs if a morbidly obese patient has it, this is why I wanted to put this piece in our Leg Lymphedema blog. Pat - blog editor

Narayanarao T, Suvarchala A, Krishnababu G.

Source

Andhra Medical College, Chief Surgeon, King George Hospital,Visakhapatnam, Andhra Pradesh, India.

Abstract

INTRODUCTION:

Massive localized lymphoedema (MLL) first described in 1998 by Farshid and Weiss. Usually MLL present like huge pedunculated mass and appear like sarcoma hence called Pseudosarcoma. Morbid obesity is a growing epidemic in our society. Morbid obesity is usually associated with hypertension, Diabetes mellitus, dermatological complications like Acanthosis nigricans, skin tags, leg ulcers, edema, lymphoedema, plantar hyperkeratosis and massive localizedlymphoedema (MLL) is one of the complications of morbid obesity. Pseudosarcoma is due to derangement of lymphatic channels secondary to excessive deposition of adipose tissue.

PRESENTATION OF CASE:

We report a patient afflicted with this unique disorder presented with huge mass arising from monspubis in morbidly obese individual with body mass index (BMI) 55.

DISCUSSION:

Massive localized lymphedema presenting like pseudosarcoma in morbidly obese individuals is rare. Awareness of this disease is essential to avoid misdiagnosis as soft tissue neoplasm. It is a term used to describe a benign over growth of lymhoproliferative tissue in morbidly obese patients. Because of its size patients have difficult to do daily activities. Histopathologically characterized by dilated lymphatic channels with fibrotic and edematous tissue, without evidence of malignancy. Patient seeks treatment only if there is huge swelling causing discomfort, complications like excoriation, wound break down occur. The treatment of choice is complete excision.

CONCLUSION:

Surgical treatment is effective if done along with bariatric surgery. Functional rehabilitation was achieved. No recurrence was observed within the follow up period of twenty months and BMI was reduced to 28.

PMC