Showing papers in "Lymphology in 2001"

Early diagnosis of lymphedema using multiple frequency bioimpedance.

Abstract: Multiple frequency bioelectrical impedance analysis (MFBIA) has previously been shown to provide accurate relative measures of lymphedema in the upper limb of patients (1). This paper reports the results of a three year prospective study to evaluate the efficacy of MFBIA to predict the early onset of lymphedema in patients following treatment for breast cancer. Bioelectrical impedance measurements and circumferential measurements of each upper limb were recorded in healthy control subjects (n=60) to determine the normal range of the ratio (dominant/non-dominant) of extracellular and total limb volumes respectively. Patients undergoing surgery for the treatment of breast cancer were recruited as the study group; MFBIA and circumferential measurements were recorded pre-surgery, one month post-surgery and then at two month intervals for 24 months. One hundred and two patients were recruited into the study. Twenty patients developed lymphedema in the 24 months follow up period of this study. In each of these 20 cases MFBIA predicted the onset of the condition up to 10 months before the condition could be clinically diagnosed. Estimates of the sensitivity and specificity were both approximately 100%. At the time of detection by MFBIA, only one of the patients returned a positive test result from the total limb volumes determined from the circumferential measures. These results confirmed the suitability of the MFBIA technique as a reliable diagnostic procedure for the early detection of lymphedema.

The diagnosis and treatment of peripheral lymphedema: draft revision of the 1995 Consensus Document of the International Society of Lymphology Executive Committee for discussion at the September 3-7, 2001, XVIII International Congress of Lymphology in Genoa, Italy.

Abstract: This proposed revision of the 1995 ISLConsensus Document in the evaluation andmanagement ofperipheral lymphedema (1) isbased upon modifications suggested andpublished following the 1997 XVI InternationalCongress of Lymphology (ICL) inMadrid, Spain (2), discussed at the 1999 XVIIICL in Chennai, India (3), and considered atthe most recent International Society ofLymphology (ISL) Executive Committeemeeting in Hinterzarten, Germany (4). It isdesigned to stimulate and frame debate at theupcoming XVIII ICL (September 2001,Genoa, Italy) and thereby help shape the nextofficial version of the Consensus Document tobe published early next year in the Journaland on the ISL Web site.The document attempts to amalgamatethe broad spectrum ofprotocols advocatedworldwide for the diagnosis and treatment ofperipheral lymphedema into a coordinatedproclamation representing a "Consensus" ofthe international community. The document isnot meant to override individual clinicalconsiderations for problematic patients nor tostifle progress. It is also not meant to be alegal formulation from which variations definemedical malpractice. The Society understandsthat in some clinics the method of treatmentderives from national standards while inothers access to medical equipment andsupplies is limited and therefore the suggestedtreatments are impractical. We continue tostruggle to keep the document concise whilebalancing the need for depth and details. Withthese considerations in mind, we believe thatthe next version of the Consensus shouldrepresent the best judgment of the ISLmembership on how to approach patients withperipheral lymphedema as of2001. Weanticipate that the document will and shouldbe challenged, debated in· the pages ofLymphology (e.g., as Letters to the Editor),and ideally become a continued focal point forrobust discussion at local, national andinternational conferences in lymphology andrelated disciplines. We further anticipate asexperience evolves and new ideas and technologiesemerge that this "living document"will undergo periodic revision and refinement.

Microlymphatic aneurysms in patients with lipedema.

Abstract: "Lipedema," a special form of obesity syndrome, represents swelling of the legs due to an increase of subcutaneous adipose tissue. In 12 patients with lipedema of the legs and in 12 healthy subjects (controls), fluorescence microlymphography was performed to visualize the lymphatic capillary network at the dorsum of the foot, at the medial ankle, and at the thigh. Microaneurysm of a lymphatic capillary was defined as a segment exceeding at least twice the minimal individual diameter of the lymphatic vessel. In patients with lipedema, the propagation of the fluorescent dye into the superficial lymphatic network of the skin was not different from the control group (p > 0.05). In all 8 patients with lipedema of the thigh, microaneurysms were found at this site (7.9 +/- 4.7 aneurysms per depicted network) and in 10 of the 11 patients with excessive fat involvement of the lower leg, multiple microlymphatic aneurysms were found at the ankle region. Two obese patients showed lymphatic microaneurysms in the unaffected thigh and in only 4 patients were microaneurysms found at the foot. None of the healthy controls exhibited microlymphatic aneurysms at the foot and ankle, but in one control subject a single microaneurysm was detected in the thigh. Multiple microlymphatic aneurysms of lymphatic capillaries are a consistent finding in the affected skin regions of patients with lipedema. Its significance remains to be elucidated although its occurrence appears to be unique to these patients.

Physiology of human lymphatic contractility: a historical perspective.

Abstract: The lymphatic system is a transport system that has important roles in fluid/macromoleculehomeostasis, lipid absorption, metastasis and immune function. It accomplishes these roles viathe generation of a regulated lymph circulation which is dependent upon valves and pumps toovercome the normal fluid pressure gradients. Lymphatic contractility plays crucial roles in theregulation and generation of lymph transport. Whereas our understanding of lymphaticcontractility in humans is somewhat limited, a number of studies both in situ and in vitro haveprovided important insights into the presence and modulation of lymphatic contractility. Thesestudies have clearly demonstrated that lymphatic vessels from a number of different humantissues possess both tonic and phasic changes in contractility. These changes in contractility arepresumably involved in the generation and regulation of lymph flow. It has been shown thathuman lymphatic contractility can be influenced by a number of neural and humoral agents as ameans to control lymph transport. However our understanding of the physical and chemicalfactors which regulate both the spontaneous pumping activity and the vessel tone are morelimited. An understanding of the factors which regulate human lymph transport could providevaluable information on human biology that could be of benefit to the treatment and preventionof diseases.

Newly-formed lymph nodes in the submucosa in chronic inflammatory bowel disease.

Abstract: Background and Aims: Routine diagnostic work revealed cell aggregates reminiscent oflymph nodes in the bowel submucosa in occasional cases of chronic inflammatory bowel disease.We therefore investigated whether they fulfill criteria for classification as lymph nodes.Methods: Colon with terminal ileum from a patient with florid Crohn’s disease and acolectomy specimen from a patient with ulcerative colitis were investigated. Sections wereimmunostained with antibodies that recognize endothelial and sinus-lining cells, immuneaccessory cells, and lymphoid cells.Results: Circumscribed collections of cells that fulfill all the major criteria forclassification as lymph nodes were found in the large and small bowel. They had marginal andintermediate sinuses (positive for BMA 120, CD34, CD31, X-11, and von Willebrand’s factor),afferent lymph vessels, T- and B- regions, and a capsule. Small collections composedpredominantly of B cells that had only a marginal sinus were also occasionally observed.Conclusion: Secondary mucosa-associated lymphoid tissue, typically seen as follicularlymphoid hyperplasia, also appears to occur as secondary submucosal lymph nodes. Thisphenomenon seems inconsistent with the notion that lymph nodes do not develop after birth. Wehave also noted secondary development of lymph nodes in lymphangioma andlymphangioleiomyomatosis. It is possible that local lymph vessel proliferation, possibly withchronic lymphedema of the tissue involved, is an important prerequisite for lymph nodeneogenesis.

Effect of sequential intermittent pneumatic compression on both leg lymphedema volume and on lymph transport as semi-quantitatively evaluated by lymphoscintigraphy.

Abstract: Sequential Intermittent Pneumatic Compression (SIPC) is an accepted method for treatment of peripheral lymphedema This prospective study evaluated the effect in 11 patients of a single session of SIPC on both lymphedema volume of the leg and isotope lymphography (99Tc dextran) before SIPC (control) and 48 hours later after a 3 hour session of SIPC Qualitative analysis of the 2 lymphoscintigrams (LS) was done by image interpretation by 3 physicians on a blind study protocol The LS protocol attributed an index score based on the following variables: appearance, density and number of lymphatics, dermal backflow and collateral lymphatics in leg and thigh, visualization and intensity of popliteal and inguinal lymph nodes Volume of the leg edema was evaluated by measuring limb circumference before and after SIPC at 6 designated sites Whereas there was a significant reduction of circumference in the leg after SIPC (p<005), there was no significant difference in the index scores of the LS before and after treatment This acute or single session SIPC suggests that compression increased transport of lymph fluid (ie, water) without comparable transport of macromolecules (ie, protein) Alternatively, SIPC reduced lymphedema by decreasing blood capillary filtration (lymph formation) rather than by accelerating lymph return thereby restoring the balance in lymph kinetics responsible for edema in the first place

Ultrasonography of arm edema after axillary dissection for breast cancer: a preliminary study.

Abstract: This work examined whether ultra­ sonography (US) provides detailed information about physical characteristics of lymphedema and whether there is agreement between imaging and clinical data. The study popula ­ tion included 46 women with chronic arm edema after axillary dissection for breast cancer. US showed in each patient an increase of subcutaneous tissue thickness compared with the contralateral arm. Fluid accumula­ tion was seen in 16 patients (34.7%), fibrosis in 12 (26.0%), and a mixed picture (fibrosis and fluid) in 18 (39.1%). Correlation with clinical information ("soft," "medium," "hard, "and "pitting" edema) demonstrated that US documented interstitial fluid in 68.4% of soft edema, mixed fluid and fibrosis in 64.2% of medium edema, andfibrosis in 76.9% of hard edema. Ultrasonography also showed that in soft and medium edema, fibrosis may already have formed. US is useful to follow progres­ sion, composition, and management of arm lymphedema after axillary dissection.

Morphology of lymphatics in human venous crural ulcers with lipodermatosclerosis.

Abstract: A morphological evaluation of lymphatic vessels of skin leg ulcers was performed in 39 human subjects with longstanding venous insufficiency and lipodermatosclerosis. Light and electron microscopy demonstrated that the superficial fibrin and inflammatory cell layers and intermediate blood capillary layer of the ulcer bed, which were primarily granulation tissue, did not contain lymphatics. Moreover, lymphatic capillaries were present only sporadically in the transition zone from granulation tissue to the deeper collagenous scar layer of the ulcer. In some instances, in the deepest part of the ulcer bed near the crural fascia, there were one or two thicker lymphatic collectors with valves, which were continuations of collectors from the plantar foot region. Lymphatics were present at the border of the ulcer and in lipodermatosclerotic skin, but the endothelium and muscle lining layer were partially destroyed. Lymphatic capillaries were characterized by open interendothelial junctions in conjunction with subendothelial edema. In lipodermatosclerotic skin, the morphologic changes suggest that absorption of interstitial fluid and lymph is markedly disturbed adjacent to the ulcer bed, which likely contributes to both slow healing and high recurrence of skin ulcers associated with longstanding venous insufficiency.

Minimizing secondary arm lymphedema from axillary dissection.

Abstract: Regional complications after axillary lymphadenectomy are common and usually involve perioperative skin dehiscence, wound infection, and seroma formation and later arm lymphedema. Gentle handling of tissues during operation, and routine use of closed catheter suction drainage with direct external axillary compression with immobilization of the shoulder after nodal dissection are advocated to minimize both the early and late sequelae. Healing by primary intent is facilitated and the opportunity for reconnection of divided lymphatics (lymphangiogenesis and lymphvasculogenesis) are thereby optimized.

A retrospective study of the effects of the lymphapress pump on lymphedema in a pediatric population

Abstract: We studied the effects of the Lymphapress pump (LP; Global Medical Imports, Digby, NS, Canada) retrospectively on 16 children with primary or secondary lymphedema of the upper or lower extremities by measuring the volume and circumference of the limbs before and after treatment. We reviewed medical charts for data on age, sex, length of disease process, grade of lymphedema, frequency and duration of treatment, and pump pressures used. We recorded changes in limb size before and after pumping in terms of the mean percentage difference between the affected and unaffected limb at both time points to allow for growth of the child and the extremity. On volumetric measures, thirteen (93%) of the subjects showed a clinical trend towards sustained maintenance or reduction in size of the lymphedematous limb(s). The reduction in the pump pressure at start of the treatment to that required to maintain the size of the limb was statistically significant (p = 0.0036). Fourteen (88%) of the subjects had no complications directly attributable to the pump, whereas two had complications that were probably unrelated to LP. Overall, there was a clinical trend towards reduction or maintenance of the lymphedematous limb size in children using LP without notable adverse sequelae.

Lymphatic drainage of the heart in the laboratory rat.

Abstract: We showed in the Sprague Dawley rat that the principal ascending cardiac lymphatic is similar in location to that of man and dog and can be readily visualized by injection of a small amount of T1824 blue dye (Evans) into the apex of the left ventricle. We also showed that it is possible to ligate and thereby obstruct this principal cardiac lymphatic near its entry beneath the left atrial appendage. This latter technique may be useful for studying in a small relatively inexpensive laboratory animal the effects of blocking cardiac lymph drainage on inflammatory and infectious processes implicated in myocardial and coronary artery disease.

Histomorphologic reaction patterns in cervical lymph nodes of different neck sites.

Abstract: Immunologically based studies of host-tumor interactions have gained popularity in headand neck oncology and histopathological determination of lymph node reactivity has been shownto correlate with survival. However, little is known about lymph node reaction patterns in the“normal” neck. In a prospective histomorphologic study 1024 cervical lymph nodes (CLN) weredissected from 25 selected cadavers at autopsy free of head and neck disease. To investigateregional differences of immune reactivity, these lymph nodes were grouped according to necklevels. 242 CLN groups of 50 neck sites were microscopically classified into one of four distincthistomorphologic immune reaction patterns (RP). 14.5% of CLN groups showed lymphocytepredominance (RP 1), 12% showed germinal center predominance (RP 2), 63.2% wereunstimulated (RP 3) and 10.3% displayed regressive changes (RP 4). Distribution of RP washighly significant according to neck level (p<0.001): RP 1 and RP 2 were common in thesubmandibular (Level I) and the upper parajugular groups (Level II) whereas RP 4 was moretypical in the inferior parajugular groups (Level IV) and posterior triangle (Level V). RP 2 andRP 4 showed significant correlation to age and general condition. These findings suggest thattumor independent lymph node reactivity related to neck site, age and general condition of thepatient needs to be differentiated from tumor induced patterns in future morphologicinvestigations of cervical lymph nodes in patients with head and neck carcinoma.

Identification of pelvic lymph nodes with chlorophyllin after injection into the uterine cervix: an experimental and clinical study

Abstract: We investigated the value of staining retroperitoneal lymph nodes with chlorophyllin in normal dogs and in women with malignant uterine tumors undergoing lymphadenectomy. In dogs, after 0.3% chlorophyllin (sodium copper chlorophyllin) was injected into the canine uterus, the concentration of dye in the bloodstream was measured with a spectrophotometer and sections of stained retroperitoneal lymph nodes were examined using light and electron microscopy. The highest blood levels were detected at 4 hrs and nearly all of the chlorophyllin was gone from the bloodstream by 18 hrs but was retained in nodal macrophages for at least 4 days. No morphological changes were found in the excised lymph nodes. Twenty-four patients with cervical carcinoma and 20 patients with endometrial carcinoma undergoing radical hysterectomy and lymphadenectomy were divided into a lymphatic coloration group (23 patients) and a non-coloration (control) group (21 patients). In the lymphatic coloration group (0.3% chlorophyllin) was injected into the cervix 5 days before elective lymphadenectomy. There were no complications attributed to injection of the chlorophyllin. The number of dissected lymph nodes in the coloration group were greater than the control group (p<0.01) and the time of operation was shorter (p<0.01). These results suggest that chlorophyllin is safe and facilitates identification of retroperitoneal lymph nodes, allows more complete nodal excision and shortens the time of operation in patients undergoing radical hysterectomy with lymphadenectomy.

Lymphogenous cyst-vein shunt in the management of chylothorax and chylorrhea.

Abstract: A 36 year-old woman developed marked lymphedema and chylous cysts of the lower abdominal wall, groin, labia, accompanied by chylorrhea. After cyst excision and transplantation of the greater omentum, a left chylothorax occurred. After thoracic duct ligation and left pleurodesis, pleural effusion recurred and worsened. Lymphangioscintigraphy and conventional lymphography suggested that undrained enlarged retroperitoneal lymphatics in the right iliac fossa had disrupted and lymph had leaked into the left chest from the right iliac fossa. Treatment by a lymphatic cyst-vein anastomosis redirected excess chylous lymph into the blood circulation and chylothorax initially remitted. Several years later with recurrence of chylorrhea, the anastomosis was found to be occluded. After a second operative connection between a lymphogenous cyst and the greater saphenous vein, chylorrhea subsided and chylothorax has remitted for more than 4 years.