Lymphedema results from lymphatic insufficiency leading to a progressive inflammatory process that ultimately manifests as discomfort, recurrent infections, and, at times, secondary malignancy. Collectively, these morbidities contribute to an overall poor quality of life. Although there have been recent advances in microsurgical interventions, a conservative palliative approach remains the mainstay of treatment for this disabling disease. The absence of a cure is due to an incomplete understanding of the pathophysiological changes that result in lymphedema. A histological hallmark of lymphedema is inflammatory cell infiltration and recent studies with animal models and clinical biopsy specimens have suggested that this response plays a key role in the pathology of the disease. The purpose of this report is to provide an overview of the ongoing research in and the current understanding of the inflammatory manifestations of lymphedema.

https://www.mdpi.com/1422-0067/18/1/171/pdf

Inflammatory Manifestations of Lymphedema.

Lymphedema is the clinical manifestation of impaired lymphatic transport. It remains an under-recognized and under-documented clinical condition that still lacks a cure. Despite the substantial advances in the understanding of lymphatic vessel biology and function in the past two decades, there are still unsolved questions regarding the pathophysiology of lymphedema, especially in humans. As a consequence of impaired lymphatic drainage, proteins and lipids accumulate in the interstitial space, causing the regional tissue to undergo extensive and progressive architectural changes, including adipose tissue deposition and fibrosis. These changes are also associated with inflammation. However, the temporal sequence of these events, the relationship between these events, and their interplay during the progression are not clearly understood. Here, we review our current knowledge on the pathophysiology of lymphedema derived from human and animal studies. We also discuss the possible cellular and molecular mechanisms involved in adipose tissue and collagen accumulation during lymphedema. We suggest that more studies should be dedicated to enhancing our understanding of the human pathophysiology of lymphedema to pave the way for new diagnostic and therapeutic avenues for this condition.

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The Unresolved Pathophysiology of Lymphedema.

Lymphedema is an incurable, debilitating and progressive condition, leading to physical and psychosocial consequences for the patients, if left untreated. The Physical Medicine and Rehabilitation (PMR) specialist is responsible for the differential diagnosis and evaluation of the patient to tailor management and rehabilitation strategies. Therefore, the PMR specialist must have knowledge and education on the diagnosis of disease and possible complications as well as evaluation, treatment and follow-up of the patient. In this review, the pathophysiology, epidemiology, and diagnostic and therapeutic approaches of lymphedema as well as preventive strategies and follow-up strategies are discussed in the light of the current literature.

/pdf/lymphedema-diagnosis-treatment-and-follow-up-from-the-view-5bceqoi6cl.pdf

Lymphedema diagnosis, treatment, and follow-up from the view point of physical medicine and rehabilitation specialists.

Lower extremity lymphedema is a chronic, often irreversible condition that affects many patients treated for gynecologic malignancies, with published rates as high as 70% in select populations. It has consistently been shown to affect multiple quality of life metrics. This review focuses on the pathophysiology, incidence, trends, and risk factors associated with lower extremity lymphedema secondary to the treatment of cervical, endometrial, ovarian, and vulvar cancers in the era of sentinel lymph node mapping. We review traditional and contemporary approaches to diagnosis and staging, and discuss new technologies and imaging modalities. Finally, we review the data-based treatment of lower extremity lymphedema and discuss experimental treatments currently being developed. This review highlights the need for more prospective studies and objective metrics, so that we may better evaluate and serve these patients.

https://ijgc.bmj.com/content/ijgc/30/2/252.full.pdf

Lower extremity lymphedema in patients with gynecologic malignancies

British Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice.

Background: Accurate limb volume measurement is key in the assessment of outcomes in lymphedema microsurgery. There are two commonly used methods as follows: manual circumferential measure...

Measuring Limb Volume: Accuracy and Reliability of Tape Measurement Versus Perometer Measurement

Introduction
Recurrent cellulitis is a frequent and challenging complication of lymphoedema. British Lymphology Society cellulitis guidelines state that decongestive lymphatic therapy reduces the frequency of cellulitis attacks, but do not mention the effect of surgical interventions.

This systematic review aims to assess whether surgical interventions for lymphoedema reduce the frequency of attacks of cellulitis.

Materials and methods
Embase, Medline, and the Cochrane database were searched for relevant articles from database inception to January 2016. Four hundred and thirty-six abstracts were retrieved. Studies were included which contained quantitative data on cellulitis incidence before and after a surgical intervention. Two independent reviewers applied selection criteria, selecting 27 papers for full text review. Two were unavailable in the UK from any source.

Results
A variety of surgical techniques were utilized in the 25 papers included: lymphaticovenous anastomosis, superficial-to-deep lymphaticolymphatic anastomosis, lymph node transfer, Charles procedure, muscle flap transfer, Homan's procedure, and subcutaneous tissue excision below skin flaps. Five studies combined techniques. One study compared the intervention to a control group (physical therapy). Cellulitis incidence was decreased following surgical intervention in 24/25 studies included. Eight had quantifiable reductions in cellulitis over a set follow-up period; in the other 16 preoperative incidence was not precisely defined.

Conclusion
Surgery appears effective at reducing cellulitis incidence in lymphoedema. However, high quality evidence from randomized controlled trials is lacking. Future research should concentrate on comparison with control groups, for example compression alone versus compression with surgical intervention, in patients with lymphoedema and greater than two attacks of cellulitis per year.

/pdf/do-surgical-interventions-for-limb-lymphoedema-reduce-4w391rqav2.pdf

Do surgical interventions for limb lymphoedema reduce cellulitis attack frequency

Reduction of last-minute cancellations in elective urology surgery: A quality improvement study.

Peripheral arterial disease (PAD) is a powerful marker of the risk of cardiovascular events such as stroke and myocardial infarction, even in asymptomatic patients. The development of PAD is underpinned by both modifiable risk factors, including smoking, diabetes, dyslipidaemia, hypertension and obesity and non-modifiable risk factors, including male gender and increased age. Optimizing medical management of risk factors, with tight control of diabetes, antiplatelet therapy and exercise, can significantly reduce risk of cardiovascular morbidity and mortality.

Amy R. Sharkey

Papers

Measuring Limb Volume: Accuracy and Reliability of Tape Measurement Versus Perometer Measurement

Do surgical interventions for limb lymphoedema reduce cellulitis attack frequency

Reduction of last-minute cancellations in elective urology surgery: A quality improvement study.

Medical management of risk factors for vascular disease

Building the future: junior doctors as leaders.