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

A case in which sarcoma was diagnosed two years after stent placement to treat right iliac vein stenosis that accompanied severe unilateral leg edema.

2012

Shinozaki N, Kawaguchi K.

Source

Department of Cardiology, Naganoken Koseiren Shinonoi General Hospital, Japan. shinori3@grn.janis.or.jp

Abstract

A 70-year-old man complained of right leg swelling due to right iliac vein stenosis. No mass was identified around the stenotic site, and the vessel wall had not become thickened. Self-expandable stents were positioned at the stenotic site. About two years later, chest CT revealed lung nodules. Pathology showed sarcoma. A mass that was considered to be the primary lesion was found around the stent in the right iliac vein. Although sarcoma of the iliac vein is very rare, it should be considered in the differential diagnosis of iliac vein stenosis, even if there are no suspicious findings from image studies.

Internal Medicine

See also: Leg Swelling

Pramipexole-related chronic lower limb oedema in a patient with Parkinson's disease.

Sept 2012

Zavala JA, Munhoz RP, Teive HA.

Source

Department of Neurology, Austin Health, 6 North, Austin Tower, 145 Studley Road, Heidelberg, Victoria 3084, Australia. zavala.md@gmail.com

Abstract

Pramipexole is a non-ergot dopamine agonist that is used frequently as a single therapy or in combination for the management of Parkinson's disease. Common side effects are daytime drowsiness, hypotension, hallucinations and compulsive behaviour. We describe a patient who developed severe chronic and extensive lymphoedema after pramipexole was introduced and that resolved after its cessation.

SciVerse