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

The contralateral rectus abdominis musculocutaneous flap for treatment of lower extremity lymphedema.

One of my desires is to bring all types of information relating to leg lymphedema to the readers. I must admit,

I really had to grit my teeth on this article.

The authors speak of a long term follow up time frame as 31 months. This is hardly adequate when you are

investigating long term possible complications. Indeed, I had the Thompson'sprocedure done in three surgeries

from 1971 through 1973. The first 31 months did see a reduction in leg size and a slight reduction in cellulitis

episodes.

However, long term should mean a 10, 20 or even longer time frame. After twenty years, I experienced horrific

complications from the surgery, not the least of all was mixed b-cell lymphoma.

Also, if the research proves to be correct about the possibilities that secondary lymphedema patients

are people who are already "at risk" for lymphedema, then the introduction of yet another area of surgery (abdomen)

could prove to be disasterous as well. Any type of surgery that would injury, damage or adversly effect the lymph

system in the abdomen can (as has been well documented) cause abdominal lymphedema.

Please do not consider the posting of this article as an endorsement of any kind and I would further discourage

lymphedema patients from having it.

Pat

The contralateral rectus abdominis musculocutaneous flap for treatment of lower extremity lymphedema.

Ann Plast Surg. 2009 Jan

Parrett BM, Sepic J., Pribaz JJ

Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115

Lymphedema is common after inguinal lymphadenectomy or resection of groin tumors. Animal studies have shown success using the rectus abdominis musculocutaneous (RAM) flap as a treatment for lymphedema. Four patients with acquired lower extremity lymphedema were treated with a contralateral RAM flap with an inferior cutaneous pedicle left intact to facilitate lymphatic drainage into the unaffected groin. One patient also had lymphaticovenous anastomoses performed during flap transfer. All flaps survived with no postoperative complications. With a mean follow-up of 31 months, the mean reduction in limb circumference from the preoperative excess was 81% at the thigh, 70% at the calf, and 71% at the ankle. None of the patients with recurrent cellulitis had further incidences of groin cellulitis. Two patients required future flap debulking. Lymphoscintigraphy was performed in 1 patient and demonstrated reconstitution of lymphatic flow from the affected leg through the flap. According to this preliminary study, transfer of a contralateral RAM flap to the groin of a lymphedematous leg improves lymphedema and decreases the incidence of cellulitis.

PubMed

For further information on surgeries used for the treatment of lymphedema, please see:

Surgery for Lymphedema

and

The Thompson's Procedure

Interventions for varicose veins and leg lymphedema in pregnancy.

Interventions for varicose veins and leg lymphedema in pregnancy.
Cochrane Database Syst Rev. 2007 Jan

Bamigboye AA, Smyth R.
Mediclinic Private Hospital and Department of Obstetrics and Gynaecology, University of Witwatersra, PO Box 15184, Nelspruit, Mpumalanga, South Africa, 1200. bami@medinet.co.za

BACKGROUND: Pregnancy is presumed to be a major contributory factor in the increased incidence of varicose veins in women, which can in turn lead to venous insufficiency and leg oedema. The most common symptom of varicose veins and oedema is the substantial pain experienced, as well as night cramps, numbness, tingling, the legs may feel heavy, achy, and possibly be unsightly. Treatment of varicose veins are usually divided into three main groups: surgery, pharmacological and non-pharmacological treatments. Treatments of leg oedema comprise mostly of symptom reduction rather than cure and use pharmacological and non-pharmacological approaches.

OBJECTIVES: To assess any form of intervention used to relieve the symptoms associated with varicose veins and leg oedema in pregnancy.

SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2006).

SELECTION CRITERIA: Randomised trials of treatments for varicose veins or leg oedema, or both, in pregnancy.

DATA COLLECTION AND ANALYSIS: Both review authors independently assessed trials for eligibility, methodological quality and extracted all data.

MAIN RESULTS: Three trials, involving 159 women, were included.

VARICOSE VEINS: One trial, involving 69 women, reported that rutoside significantly reduced the symptoms associated with varicose veins (relative risk (RR) 1.89, 95% confidence interval (CI) 1.11 to 3.22). There were no significant differences in side-effects (RR 0.86, 95% CI 0.13 to 5.79) or incidence of deep vein thrombosis (RR 0.17, 95% CI 0.01 to 3.49).

EDEMA: One trial, involving 35 women, reported no significant difference in lower leg volume when compression stockings were compared against rest (weighted mean difference -258.80, 95% CI -566.91 to 49.31). Another trial, involving 55 women, compared reflexology with rest. Reflexology significantly reduced the symptoms associated with oedema (reduction in symptoms: RR 9.09, 95% CI 1.41 to 58.54). There was no evidence of significant difference in the women's satisfaction and acceptability with either intervention (RR 6.00, 95% CI 0.92 to 39.11).

AUTHORS' CONCLUSIONS: Rutosides appear to help relieve the symptoms of varicose veins in late pregnancy. However, this finding is based on one small study (69 women) and there are not enough data presented in the study to assess its safety in pregnancy. It therefore cannot be routinely recommended. Reflexology appears to help improve symptoms for women with leg oedema, but again this is based on one small study (43 women). External compression stockings do not appear to have any advantages in reducing oedema.

Plain language summary

Not enough evidence on treatments for varicose veins and leg oedema in pregnancyVaricose veins, sometimes called varicosity, occur when a valve in the blood vessel walls weakens and the blood stagnates. This in turn leads to problems with the circulation in the veins and to oedema or swelling. The vein then becomes distended, its walls stretch and sag, allowing the vein to swell into a tiny balloon near the surface of the skin. The veins in the legs are most commonly affected as they are working against gravity, but the vulva (vaginal opening) or rectum, resulting in haemorrhoids (piles), can be affected too. Pregnancy seems to increase the risk of varicose veins and they cause considerable pain, night cramps, numbness, tingling, the legs may feel heavy, achy, and they are rather ugly. Treatments for varicose veins are usually divided into three main groups: surgery, pharmacological treatments and non-pharmacological. The review identified three trials involving 159 women. Although the drug rutoside seemed to be effective in reducing symptoms, the study was too small to be able to say this with real confidence. Similarly, with compression stockings and reflexology, there were insufficient data to be able to assess benefits and harms, but they looked promising. More research is needed.

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