Lymphangiogenesis: Molecular Mechanisms and Future Promise

The proportion of women who had an increase of 5% or more in limb swelling was similar in the weight-lifting group (11%) and the control group (12%) (cumulative incidence ratio, 1.00; 95% confidence interval, 0.88 to 1.13). As compared with the control group, the weight-lifting group had greater improvements in self-reported severity of lymphedema symptoms (P = 0.03) and upper- and lower-body strength (P<0.001 for both comparisons) and a lower incidence of lymphedema exacerbations as assessed by a certified lymphedema specialist (14% vs. 29%, P = 0.04). There were no serious adverse events related to the intervention. Conclusions In breast-cancer survivors with lymphedema, slowly progressive weight lifting had no significant effect on limb swelling and resulted in a decreased incidence of exacerbations of lymphedema, reduced symptoms, and increased strength. (ClinicalTrials.gov number, NCT00194363.)

https://www.nejm.org/doi/pdf/10.1056/NEJMoa0810118

Weight Lifting in Women with Breast-Cancer–Related Lymphedema

Purpose This study estimated the economic burden of breast cancer–related lymphedema (BCRL) among working-age women, the incidence of lymphedema, and associated risk factors. Methods We used claims data to study an incident cohort of breast cancer patients for the 2 years after the initiation of cancer treatment. A logistic regression model was used to ascertain factors associated with lymphedema. We compared the medical costs and rate of infections likely associated with lymphedema between a woman with BCRL and a matched control. We performed nonparametric bootstrapping to compare the unadjusted cost differences and estimated the adjusted cost differences in regression analysis. Results Approximately 10% of the 1,877 patients had claims indicating treatment of lymphedema. Predictors included treatment with full axillary node dissection (odds ratio [OR] = 6.3, P < .001) and chemotherapy (OR = 1.6, P = .01). A geographic variation was observed; women who resided in the West were more likely to have lymphed...

Incidence, Treatment Costs, and Complications of Lymphedema After Breast Cancer Among Women of Working Age: A 2-Year Follow-Up Study

The primary goals of oncologic therapy are the compassionate care of cancer patients, eradication of disease, and palliation of symptoms. Advances in various targeted therapies such as highly conformal and image-guided radiotherapy techniques, sentinel lymph node dissection, and molecularly targeted agents hold the promise of allowing those goals to be reached with fewer treatment-related complications. Unfortunately, certain side effects remain problematic due to the inability to completely avoid injuring normal tissues. Lymphedema, a chronic condition that occurs as a result of the body's inability to drain lymph fluid from the tissues, is a common treatment-related side effect experienced by cancer patients. In this review, many of the important aspects of lymphedema with which clinicians who treat cancer patients should be familiar are outlined, including the anatomy, pathophysiology, diagnosis, and management of this condition. The authors also identify some of the resources available both to cancer patients with lymphedema and to the clinicians who treat them. It is hoped that this review will convey the importance of the early identification and management of this incurable disorder because this is essential to minimizing its complications.

https://www.onlinelibrary.wiley.com/doi/pdf/10.3322/caac.20001

Lymphedema: A primer on the identification and management of a chronic condition in oncologic treatment

Background:Management of arm lymphedema following breast cancer treatment is challenging, and emphasis should be put on early diagnosis and prevention of secondary lymphedema. Indocyanine green lymphography is becoming a method of choice for evaluation of lymphedema.Methods:Twenty patients with seco

Indocyanine Green–Enhanced Lymphography for Upper Extremity Lymphedema: A Novel Severity Staging System Using Dermal Backflow Patterns

Background: Lymphedema is a chronic, debilitating condition that has traditionally been seen as refractory or incurable. Recent years have brought new advances in the study of lymphedema pathophysiology. as well as diagnostic and therapeutic tools that are changing this perspective. Objective: To provide a systematic approach to evaluating and managing patients with lymphedema. Methods: We performed MEDLINE searches of the English-language literature (1966 to March 2006) using the terms lymphedema, breast cancer-associated lymphedema, lymphatic complications, lymphatic imaging, decongestive therapy, and surgical treatment of lymphedema. Relevant bibliographies and International Society of Lymphology guidelines were also reviewed. Results: In the United States, the populations primarily affected by lymphedema are patients undergoing treatment of malignancy, particularly women treated for breast cancer. A thorough evaluation of patients presenting with extremity swelling should include identification of prior surgical or radiation therapy for malignancy, as well as documentation of other risk factors for lymphedema, such as prior trauma to or infection of the affected limb. Physical examination should focus on differentiating signs of lymphedema from other causes of systemic or localized swelling. Lymphatic dysfunction can be visualized through lymphoscintigraphy; the diagnosis of lymphedema can also be confirmed through other imaging modalities, including CT or MRI. The mainstay of therapy in diagnosed cases of lymphedema involves compression garment use, as well as intensive bandaging and lymphatic massage. For patients who are unresponsive to conservative therapy; several surgical options with varied proven efficacies have been used in appropriate candidates, including excisional approaches, microsurgical lymphatic anastomoses, and circumferential suction-assisted lipectomy, an approach that has shown promise for long-term relief of symptoms. Conclusions: The diagnosis of lymphedema requires careful attention to patient risk factors and specific findings on physical examination. Noninvasive diagnostic tools and lymphatic imaging can be helpful to confirm the diagnosis of lymphedema or to address a challenging clinical presentation. Initial treatment with decongestive lymphatic therapy can provide significant improvement in patient symptoms and volume reduction of edematous extremities. Selected patients who are unresponsive to conservative therapy can achieve similar outcomes with surgical intervention, most promisingly suction-assisted lipectomy. (Less)

Lymphedema: a comprehensive review.

Background Lymphedema, a chronic disfiguring condition resulting from lymphatic dysfunction or disruption, can be difficult to accurately diagnose and manage. Of particular challenge is identifying the presence of clinically significant limb swelling through simple and noninvasive methods. Many historical and currently used techniques for documenting differences in limb volume, including volume displacement and circumferential measurements, have proven difficult and unreliable. Bioimpedance spectroscopy analysis, a technology that uses resistance to electrical current in comparing the composition of fluid compartments within the body, has been considered as a cost-effective and reproducible alternative for evaluating patients with suspected lymphedema. Patients and methods All patients were recruited through the Beth Israel Deaconess Medical Center Lymphedema Clinic. A total of 15 patients (mean age: 55.2 years) with upper-extremity or lower-extremity lymphedema as documented by lymphoscintigraphy underwent bioimpedance spectroscopy analysis using an Impedimed SFB7 device. Seven healthy medical students and surgical residents (mean age: 26.9 years) were selected to serve as normal controls. All study participants underwent analysis of both limbs, which allowed participants to act as their own controls. The multifrequency bioimpedance device documented impedance values for each limb, with lower values correlating with higher levels of accumulated protein-rich edematous fluid. Results The average ratio of impedance to current flow of the affected limb to the unaffected limb in lymphedema patients was 0.9 (range: 0.67 to 1.01). In the control group, the average impedance ratio of the participant's dominant limb to their nondominant limb was 0.99 (range: 0.95 to 1.02) (P = 0.01). Conclusions Bioimpedance spectroscopy can be used as a reliable and accurate tool for documenting the presence of lymphedema in patients with either upper- or lower-extremity swelling. Measurement with the device is quick and simple and results are reproducible among patients. Given significant limitations with other methods of evaluating lymphedema, the use of bioimpedance analysis may aid in the diagnosis of lymphedema and allow for tracking patients over time as they proceed with treatment of their disease.

The use of bioimpedance analysis to evaluate lymphedema.

Learning Objectives: After studying this article, the participant should be able to: 1. Discuss the initial evaluation of a patient presenting with lower extremity enlargement. 2. Distinguish underlying medical conditions causing lower extremity enlargement, including lymphedema and lipedema. 3. Discuss appropriate management and treatment for patients presenting with these conditions. Background: Given the epidemic of obesity in the United States, many patients will consult the plastic surgeon with complaints of lower extremity enlargement secondary to “fat legs.” In addition to cosmetic disfigurement, some patients may suffer from underlying medical conditions that are responsible for their symptoms. Knowledge of these other causes, including lymphedema and a disorder of abnormal fat deposition known as lipedema, ensures appropriate management and/or surgical treatment for affected patients. Methods: Initial evaluation for lower extremity enlargement should include a discussion of pertinent medical history and a focused physical examination for findings that might indicate a pathologic underlying cause. When indicated, patients should undergo additional testing, including radiologic studies, to confirm their diagnoses. Results: For those patients found to have lymphatic dysfunction, conservative management, such as massage therapy, use of compression garments, and limb elevation, should be initially recommended. Excisional or suction-assisted lipectomy may be considered in patients who fail conservative therapy. More extensive consultation with the plastic surgeon is recommended for patients seeking aesthetic improvement in contour and shape of large legs without a specified underlying abnormality. Conclusions: Patients with lower extremity enlargement may present to the plastic surgeon unsure of the specific cause of their deformity. A broad differential diagnosis exists for their presentation, which can be narrowed by using the common features and unique manifestations of the conditions.

Evaluation and management of the fat leg syndrome.

Background: Few concepts are as fundamental to plastic surgery as scarring, yet swelling within a scar and its adjacent tissues is a common observation which is not well understood. Mechanical forces, scar contracture, fibrosis, and lymph stasis have been considered as possible explanations for these edematous-appearing areas, but conclusive evidence of a cause of swelling has not been established. The purpose of this study was to evaluate the possible role of microlymphatic stasis or disruption as a causal factor. Patients and Methods: Eleven patients (mean age: 43; range: 15 to 70) with localized swelling in conjunction with linear or curvilinear scars were evaluated, 9 with facial scars and 2 with scars of the chest wall and abdomen. Swelling within the scar had been present for an average of 4.5 years (range: 9 months to 13 years). Two patients had undergone previous Z-plasty revisions to the limbs of their curvilinear scars. Radiocolloid lymphoscintigraphy with technetium-99m Sb 2 S 3 was performed on all patients by single or multiple injection technique into the site of the scar corresponding to local edema. Results: Following injection, rapid egress of radiotracer was visualized along lymphatic pathways posterior to the scar, with continuation to locoregional nodes in all patients with U-shaped "trapdoor" or linear scar configuration. However, in 8 cases there was no evidence of lymphatic drainage traversing or bridging the scar. In 2 patients with multiple prior Z-plasty revisions to the limbs of curvilinear scars, no visualization of lymph channels across the Z-plasty flaps was apparent. In total, 8 patients were diagnosed with lymphedema of the area adjacent to or enclosed within the scar. Conclusions: These findings suggest that undrained lymphatic fluid contributes to the pathogenesis of the raised and swollen tissues seen abutting a U-shaped scar. Furthermore, as lymphatic pathways do not reestablish themselves across scars, attempts at improving lymphatic flow with Z-plasty revisions may not succeed in patients with clinical trapdoor scar deformities. Determination of scar lymphedema can assist in the selection of proper management for patients seeking scar revision.

Scar lymphedema: fact or fiction?

Background: Patients with massive weight loss following bariatric surgery are now presenting in large numbers for body contouring. To achieve optimum cosmetic results in these patients, a comprehensive circumferential approach is usually required that includes the lateral thighs and buttocks. For a number of reasons, many patients are not candidates for these comprehensive procedures. Some patients view the circumferential procedures as too extensive or aggressive. Others have large hernias or other medical conditions that necessitate a more limited approach. Still others do not have sufficient resources to treat multiple areas. Methods: A 2-year review of patients presenting with a chief complaint of anterior lower abdominal tissue excess as a consequence of massive weight loss following bariatric procedures was conducted. In 64 cases, patients opted for anterior-only treatment of the lower trunk. Results: Average operative time in patients undergoing modified abdominoplasty alone was 2.5 hours. The mean mass of the excised panniculectomy specimens was 3.8 kg (range, 1.1 to 10.0 kg). The most common complication was wound dehiscence at the T-junction (27 percent), which was treated successfully with local wound care in all cases and did not require reoperation to achieve wound closure. There were no known thromboembolic events. Conclusions: Not all massive weight loss patients are suitable candidates for comprehensive circumferential body contouring procedures, and many patients desire a limited anterior approach to the frontal abdomen. The modified vertical abdominoplasty should be considered as an option in these patients.

Anne G. Warren

Papers

Lymphedema: a comprehensive review.

The use of bioimpedance analysis to evaluate lymphedema.

Evaluation and management of the fat leg syndrome.

Scar lymphedema: fact or fiction?

Modified vertical abdominoplasty in the massive weight loss patient.