Showing papers in "Lymphology in 1998"

A randomized study comparing manual lymph drainage with sequential pneumatic compression for treatment of postoperative arm lymphedema.

Abstract: We compared manual lymph drainage (MLD) with sequential pneumatic compression (SPC) for treatment of unilateral arm lymphedema in 28 women previously treated for breast cancer. After 2 weeks of therapy with a standard compression sleeve (Part I) with maintenance of a steady arm volume, each patient was randomly assigned to either one of two treatment regimens (Part II). MLD was performed according to the Vodder technique for 45 min/day and SPC was performed with a pressure of 40-60 mmHg for 2 hours/day. Both treatments were carried out for 2 weeks. Arm volume was measured by water displacement. Arm mobility, strength, and subjective assessments were also determined. Lymphedema was reduced by 49 ml (7% reduction) (p = 0.01) in the total group during Part I. During Part II, the MLD group decreased by 75 ml (15% reduction) (p < 0.001) and the SPC group by 28 ml (7% reduction) (p = 0.03). The total group reported a decrease of tension (p = 0.004) and heaviness (p = 0.01) during Part I. During Part II, only the MLD group reported a further decrease of tension (p = 0.01) and heaviness (p = 0.008). MLD and SPC each significantly decreased arm volume but no significant difference was detected between the two treatment methods.

Liposuction reduces arm lymphedema without significantly altering the already impaired lymph transport

Abstract: In a prospective study, 20 patients with arm lymphedema after breast cancer treatment underwent liposuction combined with Controlled Compression Therapy (CCT) or CCT alone. Indirect lymphoscintigraphy (ILS) was used to study lymph kinetics before and after intervention. Lymphoscintigrams from the contralateral, non-edematous arm were characterized by prompt transit of the radiotracer (99mTc-albumin nanocolloid) to the axillary nodes, whereas tracer accumulation as dermal backflow characterized tracer transport in the lymphedematous arm. Neither liposuction with CCT nor CCT alone, changed this ILS profile. Liposuction combined with CCT reduced arm edema volume by (median) 115% (range 92-179%), whereas CCT alone decreased arm edema volume by only 54% (range 7-81%) (p = 0.008). Because liposuction in conjunction with CCT was not associated with further impairment to an already restricted lymph transport, we recommend this therapy (liposuction with external compression) for chronic arm lymphedema, as it reduces edema volume safely, rapidly, and more efficiently than external compression alone. Moreover, it does not worsen an already impaired lymph transport in the lymphedematous upper extremity.

Phenotypic and genotypic heterogeneity in familial milroy lymphedema

Abstract: Familial Milroy lymphedema (ML) is classified as an autosomal dominant disorder characterized by peripheral edema of the lower extremities at birth or in early childhood. The variety of phenotypes are not well described, and the genomic location and functional expression of the gene or genes underlying this and related familial lymphedema syndromes remain largely unknown. In this collaborative study between the University of Arizona and the University of Sao Paulo, we collected clinical pedigrees on 6 ML families, carried out clinical examination of affected and unaffected individuals, and, in representative affected members of two of the families performed dynamic lymphangioscintigraphy (LAS) of the lower and upper limbs to delineate further the ML lymphangiodysplastic phenotype. To localize the gene for ML, we conducted a genome-wide search in 4 of the families using 387 polymorphic dinucleotide-repeat markers at approximate 10 cM spacing in 54 subjects (affected, unaffected bloodline relatives, and spouses). In all 6 families (86 subjects), we specifically examined the suggested linkage to the vascular endothelial growth factor (VEGF)-C receptor (Flt4) gene localized to the chromosome region 5q34-q35. The findings provide evidence for a spectrum of ML clinical and LAS phenotypes and also suggest ML locus heterogeneity.

Treatment of chronic postmastectomy lymphedema with low level laser therapy: a 2.5 year follow-up.

Abstract: Ten women with unilateral arm lymphedema after axillary clearance (radical mastectomy) and radiotherapy for breast cancer received 16 treatment sessions with Low Level Laser Therapy (LLLT) over 10 weeks and seven patients were followed for 36 months The effect of LLLT was monitored by arm circumference, plethysmography, tonometry, bioimpedance and a questionnaire dealing with subjective symptoms After treatment, edema volume (both extracellular and intracellular) was decreased, the tissue (except for the upper arm) progressively softened or approached a normal texture, and the patients reported improvement in aches/pains, tightness, heaviness, cramps, pins/needles, and mobility of the arm Skin integrity was also improved and the index for risk of infection decreased Follow-up assessment at 1, 3, 6, and 30-36 months showed varying trends although at 30-36 months most subjective parameters and bioimpedance derived data on ECF and ICF tended to return toward pre-treatment levels Arm circumference continued to show overall improvement, however, with a volume reduction of the affected arm reaching 29% Tonometry also showed maintenance of near normal values for the involved forearm and anterior and posterior chest; however, the upper arm showed progressive induration The data suggest that laser treatment, at least initially, improved most objective and subjective parameters of arm lymphedema

Analysis of lymphatic drainage in various forms of leg edema using two compartment lymphoscintigraphy

Abstract: The anatomical and functional status of the epifascial and subfascial lymphatic compartments was analyzed using two compartment lymphoscintigraphy in five groups of patients (total 55) with various forms of edema of the lower extremities. Digital whole body scintigraphy enabled semiquantitative estimation of radiotracer transport with comparison of lymphatic drainage between those individuals without (normal) and those with leg edema by calculating the uptake of the radiopharmaceutical transported to regional lymph nodes. A visual assessment of the lymphatic drainage pathways of the legs was also performed. In patients with cyclic idiopathic edema, an accelerated rate of lymphatic transport was detected (high lymph volume overload or dynamic insufficiency). In those with venous (phlebo) edemas, high volume lymphatic overload (dynamic insufficiency) of the epifascial compartment was scintigraphically detected by increased tracer uptake in regional nodes. In patients with deep femoral venous occlusion (post-thrombotic syndrome). subfascial lymphatic transport was uniformly markedly reduced (safety valve lymphatic insufficiency). On the other hand, in the epifascial compartment, lymph transport was accelerated. In those patients with recurrent or extensive skin ulceration, lymph transport was reduced. Patients with lipedema (obesity) scintigraphically showed no alteration in lymphatic transport. This study demonstrates that lymphatic drainage is notably affected (except in obesity termed lipedema) in various edemas of the leg. Lymphatic drainage varied depending on the specific compartment and the pathophysiologic mechanism accounting for the edema. Two compartment lymphoscintigraphy is a valuable diagnostic tool for accurate assessment of leg edema of known and unknown origin.

The Risk of Genital Edema After External Pump Compression for Lower Limb Lymphedema

Abstract: In a single lymphedema treatment facility, 128 consecutive patients with lower limblymphedema were retrospectively analyzed for the development of genital edema. The patientswere separated for analysis on the basis of who used or did not use compressive pump therapy.Of the 128 patients with lower limb lymphedema, 75 received no pump therapy, and 53 usedpumps. Of the 75 who did not use pump compression, only 2 had genital edema. Of the 53patients who used pump compression, 23 patients developed genital edema after pump therapy(p<.0001). The incidence of genital edema was unaffected by age, sex, grade or duration oflymphedema, whether lymphedema was primary or secondary, whether a single or sequentialpump was used, the pressure level applied, or duration or hours per day of pump therapy.Compressive pump therapy for lower limb lymphedema produces an unacceptably highincidence of genital edema.

Transaxial computer tomography of lower extremity lymphedema

Abstract: We examined retrospectively 11 patients with isolated unilateral lower limb lymphedema(clinical criteria confirmed by isotope lymphography) using computer tomography. Inconjunction with earlier observations, the findings of soft tissue stranding, skin thickening, fatdeposition in the epifascial compartment and perimuscular fascial thickening and edema relateto lymph stasis. This noninvasive and relatively simple imaging technique allows analysis of softtissue changes in leg lymphedema and can be used to evaluate lymphatic insufficiency and itsextent as well as document the response to treatment.

The role of magnetic resonance imaging in diagnosis of peripheral lymphatic disorders

Abstract: Magnetic resonance imaging (MRI) was used in 13 patients with peripheral lymphedema and 2 patients with extensive cavernous lymphangioma of the limb for the purpose of evaluating its role in diagnosis of lymphatic disorders. In chronic lymphedema, MRI showed deformity of lymphatics at different tissue levels. In the subcutis, MRI characteristically displayed diffuse edema or a honeycombed pattern consistent with reticular lymphangiectasis and "lakes" with a marked increase in signal intensity with T2-weighted imaging. In lymphedema hyperplasia and chylous reflux, MRI depicted dilated retroperitoneal lymphatic collectors and lumbar trunks. In cavernous lymphangiomatosis, MRI demonstrated a prominent lattice-like pattern which had lower signal intensity on T1-weighted imaging and higher intensity on T2-weighted imaging. The findings of MRI are valuable not only for accurate assessment of lymphatic dysplasia syndromes but also provide a blueprint for treatment options.

Excision of subcutaneous tissue and deep muscle fascia for advanced lymphedema.

Abstract: In advanced peripheral lymphedema particularly involving the legs, complex physical therapy (massage/bandage-wrapping compression, remedial exercises, and maintenance use of a low stretch elastic compression garment), is not uniformly successful. In six patients with morbid lymphedema of the legs, we described our positive experience using a modified Auchincloss/Homans excisional operation.

Changes of tissue fluid hyaluronan (hyaluronic acid) in peripheral lymphedema.

Abstract: Hyaluronan (hyaluronic acid or HA) is an important component of the extracellular matrix which is synthesized in the tissue, transported in lymph and catabolized mainly in lymph nodes and the liver. In 39 patients with chronic peripheral lymphedema, the HA content in lymphedematous interstitial fluid was measured using radioimmunoassay. For comparison, the concentration of HA in serum and normal tissue fluid were also determined. These samples were also tested for protein concentration. The results showed that the HA concentration in interstitial fluid of a lymphedema limb was 22 x 10(3) +/- 10(3) (aspiration) and 30 x 10(3) +/- 4 x 10(3) (wick) ng/ml which were significantly higher than that in interstitial fluid, serum and lymph of normal limbs (control) and interstitial fluid of limbs with venous edema (p < 0.001). The protein concentration in these fluids did not show significant differences between lymphedema and those with normal limbs. The findings suggest that HA stagnates in the limb with impaired lymph drainage which may exert a deleterious effect on the interstitium.

Lymphatic drainage reduces intestinal edema and fluid loss.

Abstract: Lymphatic vessels are important in removing excess fluid from the intestine and transporting the fluid to veins in the neck. However, in some diseases, neck vein pressure is increased and the high pressure may slow lymph flow. This study was to test the hypothesis that lymphatic clearance of fluid from the intestine may be increased by draining the lymphatics. Inflatable cuffs were used to increase neck vein pressure and portal venous pressure in anesthetized sheep. The lymphatic vessel from one segment of small intestine was cannulated and drained. The lymphatic vessel to a control segment of intestine was left intact. After 90 min. we found significantly less fluid in the lumen of the drained vs. control segments (7.4 +/- 3.1 (SD) ml vs 11.5 +/- 4.7 ml per gram dry tissue, respectively). Also we found significantly less tissue fluid in the drained vs control segments (5.3 +/- 0.3 ml/g vs 6.0 +/- 0.4 ml/g). The findings support the hypothesis that external diversion of lymph in the presence of an elevated central venous pressure reduces edema formation.

Functional microanatomy of initial lymphatics with special consideration of the extracellular matrix

Abstract: In current conceptions on the functional morphology of initial lymphatics, the extracellular matrix (ECM) as an integral part of the lymphatic vascular wall has not been duly considered. In the present study based on scanning electron microscopy (SEM) and confocal laser scanning microscopy (CLSM) of tongue tissue in rats, new insights were obtained into both the architecture of the fibrous network of the ECM and its functional features. A digestion technique was applied, by which the endothelium of initial lymphatics was detached thereby allowing a direct view of the ECM from both sides. Fluorescent latex particles and liposomes were used as indicators of transmural permeability, whereas labeled macrophages served as a model for penetrating cells. The two layers of the lymph vascular wall were also examined under experimental edema conditions with tissue pressures ranging from 10 to 150 mmHg. A concept is proposed which considers the histomechanics of the initial lymphatics with the surrounding connective fiber tissue including the structural basis for the permeability of the lymphatic vascular wall. The role of the ECM as a supporting element and prefilter for the lymphatic endothelium is emphasized.

Levels of eicosanoids (6-oxo-PGF1 alpha and 8-epi-PGF2 alpha) in human and porcine lymphatics and lymph.

Abstract: Prostaglandin (PG)I2 is the primaryeicosanoid synthesized by human lymphaticsand 8-epi-PGF2", an isoprostane formedduring free radical catalyzed peroxidation,is the most potent stimulator of lymphaticcontraction tested thus far. We now examinethe respective concentrations in thelymphatic wall of both human and porcinelymphatics and lymph fluid using specificimmunoassays. Although both compoundsare detectable in the lymphatic wall andlymph fluid, PGI2- (via its main metabolite6-oxo-PGF1") is greater in the lymphaticwall whereas 8-epi-PGF2" dominates inlymph fluid. Because inflammation isassociated with oxidative injury, which inturn stimulates release of isoprostane,eicosanoid derivatives may modulatelymphatic tone during acute tissue reaction.

Magnetic resonance imaging of peripheral lymphedema

Abstract: We read with interest the recent report of Insua et al on \"Magnetic Resonance Imaging (MRI) of Peripheral Lymphedema\" (1) and would like to comment on the interpretation of the images. Insua confirms previous MRI findings (2-4) in peripheral lymphedema, especially when longstanding, showing thickening of the skin and subcutaneous tissue, with a characteristic trabecular or honeycombed pattern. In a clinical study of 87 patients with swollen legs, we uniformly found these structures in all patients with lymphedema (n=35) (Fig. 1) but neither in lipedema (n=26) nor in phlebedema (n=12). Although the trabecular pattern in the subcutis is highly sensitive for lymphedema, it is not specific. Fujii, for example, described it in two patients with the nephrotic syndrome (5).

Lingering thoughts on three lymphateers

Abstract: *Based on a presentation at the 16th International Congress of Lymphology, September 27,1997, Madrid, Spain. A fuller obituary on Dr. Grandval will appear in the June 1998 issue of Lymphology. their consuming passion-the lymphatic system. These three charismatic musketeers of lymph, i.e., \"lymphateers\" Mario Degni of Sao Paulo (Brazil), Carlos Grandval of Buenos Aires (Argentina), and John CasleySmith of Adelaide (Australia)came in three different sizes and three different shapes and spoke three different tongues. But their humanity, intellect, and worldliness transcended geographical barriers and hectic

Combined surgical correction of bilateral congenital lower limb lymphedema with associated anomalies.

Abstract: An unusual combination of congenital malformations in a 16-year-old emotionallydisturbed man is described. The anomalies included severe congenital bilateral leg lymphedema,bilateral gynecomastia, unilateral cataract, and malformed external genitalia. Genetic andhormonal investigations were unremarkable. Multiple concomitant operations (vascular andplastic surgeons) to correct the deformities and restore physical well-being and self-esteem wereundertaken.

The lymphatic drainage of the left ventricle in the Yucatan minipig.

Abstract: The gross anatomy of the cardiac lymphatic system draining the left ventricle was studied in 15 Yucatan minipigs and 2 regular swine. The findings confirm that the drainage pathways are similar to those of man and dog. After a coloring marker is injected near the apex of the left ventricle, one or more lymphatics are seen to ascend towards the left atrial appendage. Where there is more than one ascending lymphatic, they typically join before or at the left atrial appendage. This principal lymphatic then passes beneath the appendage and travels behind (dorsal to) the pulmonary artery and aorta to the right side of the mediastinum. From here, the lymphatic passes cephalad along the left border of the superior vena cava to enter the cardiac lymph node between the superior vena cava and the trachea.

Inhibition of mitosis in the guinea pig thymus after ligation of draining efferent lymphatics.

Abstract: Ligature of the cervical lymph duct in guinea pigs resulted in marked dilatation of the lymphatics draining the thymus and marked reduction of mitosis in the thymus. A decrease of about 50% in the number of mitoses was found in the cortex within one day after ligation and in the medulla within five days after ligation. The thickness of the cortex also decreased rapidly and markedly in direct proportion to the decrease in cortical mitosis. Mitosis in the thymus recovered within 10 days after ligation, presumably after regeneration of lymphatics or collateralization. Thickening of the walls and valves of the efferent lymphatics of the thymus after lymph congestion was also demonstrated.

Role of protein kinase c in the regulation of pumping activity in bovine mesenteric lymphatic vessels

Abstract: We investigated the role of protein kinase C (PKC) in regulating the lymphatic myogenicresponse. Bovine mesenteric lymphatics were suspended in an organ bath with inflow andoutflow ends cannulated. Input was provided from a reservoir filled with Krebs solution. ThePKC activator phorbol 12-myristate 13-acetate (PMA) inhibited pumping significantly whethertested at a fixed pressure or as pressures were raised in 2 cm H2O increments (50% inhibitionachieved at 4.6 X 10-8M). The inactive phorbol ester (4-"-PMA) had no effect. The specific PKCinhibitors calphostin (10-9 to 10-7M) or chelerythrine (10-8 to 10-6M) had no significant effect onpumping. However, chelerythrine (10-6M) was capable of reversing the inhibitory effects of PMA(5 X 10-8M). PKC activation is believed to inhibit nitric oxide (NO) production in some bloodvessels, and previous work from our laboratory has demonstrated that NO is important infacilitating pumping activity in bovine lymphatics. We observed that sodium nitroprusside (sNP,10-7M) or L-arginine (10-4M), reversed the depressor effects of PMA. These results suggest thatPKC may not be involved in regulating the vessel's contractile response to pressure-inducedstretch. However, the data with PMA suggest that these ducts contain PKC. PKC activationdepresses lymphatic pumping and this effect may be mediated in part, by inhibition of