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

Leg Swelling following Inguinal and Ilioinguinal Dissection of Melanoma Metastases

April 2012

Pratsch AL, Kretschmer L.

Source

Georg-August-Universität Göttingen, Abteilung für Dermatologie, Venerologie und Allergologie, Göttingen, Deutschland.

Abstract

Key words: inguinal - iliac - lymph node dissection - melanoma - leg oedema - volumetry

Background: With respect to survival and local disease control, the adequate extent of lymph node dissection for melanoma metastasis to the groin is controversial. Since the methods for accurate quantification of leg oedemas are not well standardised, it remains also unclear whether the iliac part of a radical ilioinguinal lymph node dissection contributes to postoperative lymphoedema. 

Patients and Methods: Using a questionnaire and clinical examinations, we prospectively studied 65 persons for the presence of leg swellings (11 with inguinal lymph node dissection (sCLND), 23 with ilioinguinal dissection (rCLND), and 31 without nodal surgery and without signs of venous insufficiency). Exact volumetry of the legs was performed using the Image 3 D method. 

Results: The mean interval between the lymphadenectomy and the examination for swellings was 24 ± 30 months. Compared with sCLND, the amount of postoperative drainage fluid was significantly higher after rCLND (1960 ± 1390 mL versus (vs.) 898 ± 578 mL). Patients with rCLND perceived more frequently leg swellings (83 % vs. 55 %, p = 0.09), however, also 23 % of the control persons perceived leg swellings. Clinical signs of swelling were found slightly more frequently in the rCLND group (52 % vs. 45 %). After rCLND, the gain in volume of the ipsilateral thigh was significantly higher than after sCLND (7.01 ± 4.83 % vs. 1.29 ± 6.12 %, p = 0.01). Patients with rCLND more frequently needed manual lymph drainage (70 % vs. 45 %). In the control persons, the volumes of the right (mostly dominant) and the left legs did not differ significantly. 

Conclusions: Our results suggest that the iliac part of an ilioinguinal lymph node dissection significantly contributes to lymphoedema. Because of the multitude of reasons for swellings of the lower leg, volumetry of the thigh seems to be most adequate for quantifying the amount of postoperative lymphoedema.

Thieme E-Journal

Primary lymphedema complicated by weeping chylous vesicles in the leg and scrotum: report of a case.

May 2012

Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan, ksuehiro-circ@umin.ac.jp.

Abstract

We report a case of primary lymphedema complicated by leaking chylous vesicles in the toe and scrotum, caused by lymphangiectasia, which was eventually managed with lymphaticovenular anastomoses after conservative treatments proved ineffective. The patient was a 25-year-old man with a 5-year history of massive swelling with chylous weeping of his right legand scrotum. Lymphangioscintigraphy (LAS) showed dilated iliac lymph trunks causing lymph reflux. Although he was instructed in standard methods of complex therapy, it did not alleviate his symptoms. Because of the increasing frequency of cellulitis, lymphatic surgery was finally indicated. The operation consisted of lymphaticovenous anastomoses (LVA) in the ankle and groin, using a super-micro-surgical technique. After surgery, his symptoms resolved and have been controlled by self-care. Thus, early LAS to confirm the dilated iliac lymph trunks causing lymph reflux, followed by LVA might be beneficial for the management of this disease.

Springerlink

Chronic edema of the lower extremities: international consensus recommendations for compression therapy clinical research trials.

August 2012

Stout N, Partsch H, Szolnoky G, Forner-Cordero I, Mosti G, Mortimer P, Flour M, Damstra R, Piller N, Geyer MJ, Benigni JP,Moffat C, Cornu-Thenard A, Schingale F, Clark M, Chauveau M.

Source

Breast Care Department, Walter Reed National Military Medical Center, Bethesda, MD, USA2 Department of Dermatology, Medical University of Vienna, Vienna, Austria3 Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary4 Lymphoedema Unit, University Hospital La Fe Valencia, Spain5 Barbantini-Hospital, Lucca, Italy6 Cardiac anc Vascular Sciences St George's, University of London, London, UK7 Department of Dermatology, University Hospital KU, Leuven, Belgium8 Department of Dermatology, Nij Smellinghe Hospital, Drachten, The Netherlands 9 Department of Surgery, School of Medicine, Flinders Medical Centre, Bedford Park, Australia10 Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, PA, USA11 Hospital Begin, Paris, France12 Thames Valley University, London, UK13 Phlebology Department, Saint Antoine Hospital, Paris, France14 Lympho-Opt Clinic, Pommelsbrunn, Germany15 Wound Healing Research, Cardiff University, UK16 Boucicaut, Fontenay aux Roses, France.

Abstract

Chronic edema is a multifactorial condition affecting patients with various diseases. Although the pathophysiology of edema varies, compression therapy is a basic tenant of treatment, vital to reducing swelling. Clinical trials are disparate or lacking regarding specific protocols and application recommendations for compression materials and methodology to enable optimal efficacy. 

Compression therapy is a basic treatment modality for chronic leg edema; however, the evidence base for the optimal application, duration and intensity of compression therapy is lacking. The aim of this document was to present the proceedings of a day-long international expert consensus group meeting that examined the current state of the science for the use of compression therapy in chronic edema. 

An expert consensus group met in Brighton, UK, in March 2010 to examine the current state of the science for compression therapy in chronic edema of the lower extremities. Panel discussions and open space discussions examined the current literature, clinical practice patterns, common materials and emerging technologies for the management of chronic edema. This document outlines a proposed clinical research agenda focusing on compression therapy in chronic edema. 

Future trials comparing different compression devices, materials, pressures and parameters for application are needed to enhance the evidence base for optimal chronic oedema management. Important outcomes measures and methods of pressure and oedema quantification are outlined. Future trials are encouraged to optimize compression therapy in chronic edema of the lower extremities.

PubMed

15th Annual State of GA Lymphedema Education Program

Winship Cancer Institute of Emory University

and The Lighthouse Lymphedema Network

Cordially invite you to the

15th State of Georgia Lymphedema Education & Awareness Conference

Saturday, October 27, 2012

Emory University Hospital Midtown, 550 Peachtree Street, Atlanta, GA 30308

7:30am-4:30pm

Speakers include: Jane Armer, PhD, Richard Mistretta, DPM,

Joseph Feldman, MD, and David W. Chang, MD

The Conference Brochure may be viewed by clicking here:

http://lighthouselymphedema.org/announcements/15th-annual-state-of-georgia-lymph\
edema-education-and-awareness-program

You may register online by clicking here:

http://lighthouselymphedema.org/get-involved/secureregistration.htm

INFO PAGE:

http://lighthouselymphedema.org/announcements/15th-annual-state-of-georgia-lymph\
edema-education-and-awareness-program