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Lymphland International Lymphedema Online
1. Breast Cancer Res Treat. 2010 Feb 24. [Epub ahead of print]
Effect of air travel on lymphedema risk in women with history of breast cancer.
Kilbreath SL, Ward LC, Lane K, McNeely M, Dylke ES, Refshauge KM, McKenzie D, Lee MJ,
Peddle C, Battersby KJ.
Faculty of Health Sciences, University of Sydney, PO Box 170, Lidcombe, NSW, 1825, Australia,
sharon.kilbreath@sydney.edu.au.
To assess the impact of air travel on swelling of the 'at risk' arm of women treated for breast cancer.
Women treated for breast cancer from Canada (n = 60) and from within Australia (n = 12) attending a
dragon boat regatta in Queensland, Australia participated. Women were measured within 2 weeks prior
to their flight, on arrival in Queensland and, for 40 women travelling from Canada, measured again 6
weeks following return to Canada. Changes to extracellular fluid were measured using a single-frequency
bioimpedance device (BIA). Each arm was measured separately using a standardized protocol to obtain
the inter-limb impedance ratio. An increase in the ratio indicates accumulated fluid. Information regarding
medical management of participants' breast cancer, use of compression garment and history of exercise
were also obtained. For most women (95%), air travel did not adversely affect the impedance ratio. The
BIA ratio of long-haul travellers was 1.007 +/- 0.065 prior to the flight and 1.006 +/- 0.087 following the
flight. The ratio of short-haul travellers was 0.994 +/- 0.033 and following the flight was 1.001 +/- 0.038.
Air travel did not cause significant change in BIA ratio in the 'at-risk' arm for the majority of breast cancer
survivors who participated in dragon boat racing. Further research is required to determine whether these
findings are generalizable to the population of women who have been treated for breast cancer.
PMID: 20180016 [PubMed - as supplied by publisher]
2. Cell. 2010 Feb 19;140(4):460-76.
Lymphangiogenesis: Molecular mechanisms and future promise.
Tammela T, Alitalo K.
Molecular/Cancer Biology Laboratory and Haartman Institute, University of Helsinki, Finland.
The growth of lymphatic vessels (lymphangiogenesis) is actively involved in a number of pathological
processes including tissue inflammation and tumor dissemination but is insufficient in patients suffering from
lymphedema, a debilitating condition characterized by chronic tissue edema and impaired immunity. The
recent explosion of knowledge on the molecular mechanisms governing lymphangiogenesis provides new
possibilities to treat these diseases. 2010 Elsevier Inc. All rights reserved.
PMID: 20178740 [PubMed - in process]
3. Eur J Vasc Endovasc Surg. 2010 Feb 20. [Epub ahead of print]
Primary Lymphoedema and Lymphatic Malformation: Are they the Two Sides of the Same Coin?
Lee BB, Villavicencio JL.
Division of Vascular Surgery, Georgetown University School of Medicine, Washington, DC 20007,
USA; Georgetown University Hospital, 4th floor PHC, 3800 Reservoir Road NW, Washington, DC
20007, USA.
OBJECTIVES: To clear the confusion regarding the relationship between the 'primary lymphoedema' and
(truncular) lymphatic malformation (LM); the latter is one of congenital vascular malformations.
MATERIALS & METHODS: A literature review was carried out on the primary lymphoedema either
existing as an independent LM lesion or as a component of the Klippel-Trenaunay syndrome.
RESULTS: The review was able to provide a contemporary guide/conclusion on the definition and
classification, clinical evaluation and clinical management regarding conservative (physical) therapy,
reconstructive surgical therapy and ablative/excisional surgical therapy, for the primary lymphoedema as
an LM.
CONCLUSIONS: Primary lymphoedema can be considered as 'congenital' since its majority represents
a clinical manifestation of the truncular type of LM arising during the later stages of lymphangiogenesis.
Such embryological staging information of the LM is critical for proper management of the primary
lymphoedema when it exists with other congenital vascular malformations (Klippel-Trenaunay syndrome).
2. Basic non-invasive to minimally invasive tests will provide an adequate diagnosis and lead to the
correct multidisciplinary, specifically targeted and sequenced treatment strategy. 3. The mainstay of
current management of the primary lymphoedema/truncular LM is complex decongestive therapy; and the
reconstructive as well as ablative surgical therapy remain adjunctive therapies at best. Copyright © 2010
European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
PMID: 20176496 [PubMed - as supplied by publisher]
4. Clin Nutr. 2010 Feb 17. [Epub ahead of print]
Do patients with lymphoedema cholestasis syndrome 1/Aagenaes syndrome need dietary counselling
outside cholestatic episodes?
Drivdal M, Løken EB, Hagve TA, Bergstad I, Aagenæs O.
Regional Department of Eating Disorders, Division of Psychiatry, Building 37A, Oslo University Hospital,
Ullevaal, N-0407 Oslo, Norway.
BACKGROUND&AIMS: Patients with lymphoedema cholestasis syndrome 1/Aagenaes Syndrome
need a fat reduced diet when cholestatic. We wanted to assess the need for dietary counselling outside
cholestatic episodes, and hypothetized that no counselling was needed.
METHODS: Fifteen patients above 10 years of age without symptoms of cholestasis were compared
with a sex and age matched control group. Diet from a four-day weighed record and blood samples were
compared between the two groups and with general Norwegian recommendations.
RESULTS: The patients had a similar diet to the healthy controls, except for statistically significant lower
intake of energy from total fat (p=0.04) and saturated fat (0.02), and fish (0.05). The patients met the
dietary recommendations for macronutrients, except for saturated fat, monounsaturated fat, refined sugar
and fibre. Supplements were needed to meet the micronutrient recommendations. Patients had a
significantly lower serum level of alpha-tocopherol (0.01) compared with the control group, and the
serum 25-OH D level was below reference ranges.
CONCLUSIONS: The patients would benefit from counselling on fat quality, carbohydrates including
fibre intake, and individual needs for vitamins D and E. To secure serum 25-OH D and alpha-tocopherol
levels within reference ranges, regular examinations to determine the need for supplementary vitamins D
and E are recommended.
Copyright © 2009 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights
reserved.
PMID: 20170991 [PubMed - as supplied by publisher]
----------------------
1. Microsurgery. 2010 Mar 2. [Epub ahead of print]
Prevention of lymphatic injuries in surgery.
Francesco B, Corrado C, Giuseppe M, Emanuela B, Chiara B, Francesco P, Corradino C.
Department of Surgery, Unit of Lymphatic Surgery and Microsurgery, San Martino Hospital, University
of Genoa, Italy.
BACKGROUND:: The problem of prevention of lymphatic injuries in surgery is extremely important if
we think about the frequency of both early complications such as lymphorrhea, lymphocele, wound
dehiscence, and infections and late complications such as lymphangites and lymphedema. Nowadays, it is
possible to identify risk patients and prevent these lesions or treat them at an early stage. This article helps
to demonstrate how it is important to integrate diagnostic and clinical findings to better understand how to
properly identify risk patients for lymphatic injuries and, therefore, when it is useful and proper to do
prevention.
METHODS:: Authors report their experiences in the prevention and treatment of lymphatic injuries after
surgical operations and trauma. After an accurate diagnostic approach, prevention is based on different
technical procedures among which microsurgical procedures. It is very important to follow-up the patient
not only clinically but also by lymphoscintigraphy.
RESULTS AND CONCLUSIONS:: It was identified a protocol of prevention of secondary limb
lymphedema that included, from the diagnostic point of view, lymphoscintigraphy and, as concerns
therapy, it also recognized a role to early microsurgery. It is necessary to accurately follow-up the patient
who has undergone an operation at risk for the appearance of lymphatic complications and, even better,
to assess clinically and by lymphoscintigraphy the patient before surgical operation. (c) 2010 Wiley-Liss,
Inc. Microsurgery, 2010.
PMID: 20198663 [PubMed - as supplied by publisher]
2. Horm Res Paediatr. 2010;73(3):210-214. Epub 2010 Mar 3.
Tall Stature and Gonadal Dysgenesis in a Non-Mosaic Girl 45,X.
Fernandez R, Pasaro E.
Department of Psychobiology, University of A Coruña, Campus Elviña, A Coruña, Spain.
Turner's syndrome, also known as 'monosomy X', is a genetic disorder that occurs in 1/2,500 female
births and is hypothesized to result from haploinsufficiency of certain genes expressed from both sex
chromosomes that escape X inactivation. While the classic karyotype related to Turner's syndrome is 45,
X, the majority of those affected actually have a mosaic chromosomal complement, most often with a
second normal cell line (46,XX). The resulting phenotype is variable and related to the underlying
chromosomal pattern, but it is characterized by three cardinal features: short stature (around 100%),
ovarian failure (>90%) and congenital lymphedema (>80%). In this paper we report a molecular and
cytogenetic investigation of a 26-year-old female with non-mosaic 45,X karyotype, who has a stature of
170 cm without GH treatment, and whose only apparent Turner feature is gonadal dysgenesis. The only
possible explanation for the absence of Turner phenotype is the hidden mosaicism combined with an
untreated gonadal dysgenesis. Our results support the theory that significant ascertainment bias exists in
our understanding of Turner's syndrome. Copyright © 2010 S. Karger AG, Basel.
PMID: 20197675 [PubMed - as supplied by publisher]
3. Plast Reconstr Surg. 2010 Mar;125(3):935-43.
The intravascular stenting method for treatment of extremity lymphedema with multiconfiguration
lymphaticovenous anastomoses.
Narushima M, Mihara M, Yamamoto Y, Iida T, Koshima I, Mundinger GS.
Tokyo, Japan; and Baltimore, Md. From the Department of Plastic and Reconstructive Surgery, Tokyo
University School of Medicine, and the Division of Plastic, Reconstructive, and Maxillofacial Surgery,
Johns Hopkins Hospital.
BACKGROUND:: In secondary extremity lymphedema, normal antegrade lymphatic flow is disrupted by
the disease state. Attempts to capture aberrant retrograde lymphatic flow by means of microsurgical
lymphaticovenous anastomoses have been hindered because of technical limitations. The authors applied
the intravascular stenting method to the surgical correction of extremity lymphedema to generate
multiconfiguration lymphaticovenous anastomoses capable of decompressing both proximal and distal
lymphatic flow.
METHODS:: Lymphatic channels were detected using indocyanine green injection and infrared scope
imaging. Sites felt to be adequate for lymphaticovenous anastomosis were accessed through 2-cm skin
incisions under local anesthesia. Using the intravascular stenting method, the authors performed a total of
39 lymphaticovenous anastomoses (15 flow-through, 11 end-to-end, eight end-to-side, two double end-
to-end, two end-to-end/end-to-side, and one pi-type) on both the proximal and distal ends of lymphatic
channels in 14 female patients with upper (n = 2) and lower (n = 12) extremity lymphedema.
RESULTS:: At an average follow-up of 8.9 months, average limb girth decreased 3.6 cm (range, 1.5 to 7
cm) or 11.3 percent (range, 4 to 33 percent). There was a greater reduction in cross-sectional area with
increasing number of lymphaticovenous anastomoses per limb.
CONCLUSIONS:: The intravascular stenting method facilitated multiconfiguration lymphaticovenous
anastomoses capable of decompressing both antegrade and retrograde lymphatic flow. This approach
resulted in durable reduction of both upper and lower extremity lymphedema. As multiconfiguration
lymphaticovenous anastomoses are now technically feasible, the influence of the number of
lymphaticovenous anastomoses and the effectiveness of specific lymphaticovenous anastomosis
configurations for the treatment of lymphedema deserves further study.
PMID: 20195120 [PubMed - in process]
4. Am J Med. 2010 Mar;123(3):e3-4.
Nocturia: an uncommon presentation of lower-limb lymphedema.
Cagnati P, Colombo BM, Gulli R, Russo R, Puppo F, Boccardo F,
Campisi C, Murdaca G.
PMID: 20193816 [PubMed - in process]
5. An Bras Dermatol. 2009 Dec;84(6):659-62. published Feb 2010.
[Yellow nail syndrome: case report]
[Article in Portuguese]
Machado RF, Rosa DJ, Leite CC, Martins Neto MP, Gamonai A.
Universidade Federal de Juiz de Fora, MG, Brasil. ronaldofigueiredo@hotmail.com
The yellow nail syndrome is a rare disease, in which there is a triad of lymphedema, pleural effusion and
slow-growing dystrophic yellow nails. Many associations have already been described; among them,
chronic respiratory tract diseases, autoimmune disorders, malignancies and immunodeficiency conditions.
Only one third of cases in the literature show all findings. The case reported next is an example of the
classical triad.
PMID: 20191179 [PubMed - in process]
----------------------
1. Ann Plast Surg. 2010 Mar 11. [Epub ahead of print]
Preservation of Toes in Advanced Lymphedema: An Important Step in the Control of Infection.
Karonidis A, Chen HC.
From the Department of Plastic Surgery, E-Da Hospital/I-Shou University, Yan-Chau Shiang, Kaohsiung
County, Taiwan, Republic of China.
ABSTRACT:: In advanced lymphedema, the most important goal of treatment is the control or
eradication of infection. Toes are the major cause of infection mainly due to lack of space at the webs.
The fibrosis of the soft tissue with impaired circulation of the toes certainly contribute to infection of the
toes, foot, and even proximal to the leg.Between 2004 and 2008, 20 patients with severe lymphedema
and fibrosis of lower limbs were treated with Charles' procedure and included in this study. The toes were
preserved. Excisional therapy is the only choice to decrease the lymphatic load and control the infection.
The toes can be preserved if there is only swelling without previous cellulites or verrucous hyperkeratosis
and neither deformity nor osteomyelitis of the toes. The surgical technique to treat the toes includes (1)
excision of the soft tissue at the dorsum of the toes with preservation of the extensor tendon and its
paratenon, to facilitate the take of skin graft, and (2) preservation of skin flaps at the web spaces. This
avoids contracture at the web spaces and crowding of the toes, improves foot hygiene, and hence
prevents infection.Proper aesthetic and functional results were obtained in all patients and 18 of 20
patients have been free of recurrent infection at 3-years follow-up.In the treatment of advanced
lymphedema of the lower extremity, the toes are the major determinant of future infection after surgery.
For preservation of toes, careful selection of patients and correct surgical procedure are essential for
success.
PMID: 20224333 [PubMed - as supplied by publisher]
2. Lymphology. 2009 Dec;42(4):188-94.
Intermittent pneumatic compression acts synergistically with manual lymphatic drainage in complex
decongestive physiotherapy for breast cancer treatment-related lymphedema.
Szolnoky G, Lakatos B, Keskeny T, Varga E, Varga M, Dobozy A, Kemény L.
Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary. szolnoky@dermall.
hu
The application of intermittent pneumatic compression (IPC) as a part of complex decongestive
physiotherapy (CDP) remains controversial. The aim of this study was to investigate whether the
combination of IPC with manual lymph drainage (MLD) could improve CDP treatment outcomes in
women with secondary lymphedema after breast cancer treatment. A randomized study was undertaken
with 13 subjects receiving MLD (60 min) and 14 receiving MLD (30 min) plus IPC (30 min) followed by
standardized components of CDP including multilayered compression bandaging, physical exercise, and
skin care 10 times in a 2-week-period. Efficacy of treatment was evaluated by limb volume reduction and
a subjective symptom questionnaire at end of the treatment, and one and two months after beginning
treatment. The two groups had similar demographic and clinical characteristics. Mean reductions in limb
volumes for each group at the end of therapy, and at one and two months were 7.93% and 3.06%,
9.02% and 2.9%, and 9.62% and 3.6%, respectively (p < 0.05 from baseline for each group and also
between groups at each measurement). Although a significant decrease in the subjective symptom survey
was found for both groups compared to baseline, no significant difference between the groups was found
at any time point. The application of IPC with MLD provides a synergistic enhancement of the effect of
CDP in arm volume reduction.
PMID: 20218087 [PubMed - in process]
3. Lymphology. 2009 Dec;42(4):176-81.
Axillary web syndrome: nature and localization.
Leduc O, Sichere M, Moreau A, Rigolet J, Tinlot A, Darc S, Wilputte F, Strapart J, Parijs T, Clément
A, Snoeck T, Pastouret F, Leduc A.
Haute Ecole P.H. Spaak, Département de Kinésithérapie, Unité de Lympho-Phlébologie, Bruxelles,
Belgique. oleduc@skynet.be
Axillary Web Syndrome (AWS) is a complication that can arise in patients following treatment for breast
cancer. It is also known variously as syndrome of the axillary cords, syndrome of the axillary adhesion,
and cording lymphedema. The exact origin, presentation, course, and treatment of AWS is still largely
undefined. Because so little is known about AWS, we undertook a case series study consisting of 15
women who had undergone breast cancer surgery and presented with AWS. All subjects received a
clinical examination which included body size determination and detailed measurements of the size and
location of the cords. The cords were found to originate from the axilla, continue on the medial aspect of
the arm up to the epitrochlea region, then to the anteromedian aspect of the forearm, and finally reaching
the base of the thumb. The cords averaged approximately 44% of the limb length. Correlation of the cord
location with anatomical studies shows that in fact this path follows the specific course taken by the
antero-radial pedicle which arises at the anterior aspect of the elbow from the brachial medial pedicule to
anastomose in the axilla at the level of the lateral thoracic chain nodes. Although our series is small, the
correspondence between the physical findings and the anatomical studies strongly supports the notion that
the cords are lymphatic in origin.
PMID: 20218085 [PubMed - in process]
4. Lymphology. 2009 Dec;42(4):152-60.
Lymphedema-distichiasis syndrome without FOXC2 mutation: evidence for chromosome 16 duplication
upstream of FOXC2.
Witte MH, Erickson RP, Khalil M, Dellinger M, Bernas M, Grogan T, Nitta H, Feng J, Duggan D, Witte
CL.
Department of Surgery, University of Arizona College of Medicine, Tucson, AZ 85724-5200, USA.
lymph@email.arizona.edu
A patient with the classical phenotype of Lymphedema-Distichiasis syndrome (OMIM 153400) is
described who showed no mutations in the sequence of FOXC2. Accordingly, a Gene Chip 250k array
analysis was undertaken with dense SNP genotyping of the genomic region surrounding the FOXC2
locus on Chromosome 16 followed by copy number evaluation by real time PCR. The latter assay
showed evidence of a duplicated region 5' of FOXC2 that could be causative for the patient's striking
phenotype, which included both distichiasis and a hyperplastic refluxing lymphatic vascular and lymph
node phenotype associated with pubertal onset lymphedema, scoliosis and strabismus.
PMID: 20218083 [PubMed - in process]
1. Dermatology. 2010 Mar 20. [Epub ahead of print]
Leg Ulceration in Rheumatoid Arthritis - An Underreported Multicausal Complication with Considerable
Morbidity: Analysis of Thirty-Six Patients and Review of the Literature.
Seitz CS, Berens N, Bröcker EB, Trautmann A.
Departments of Dermatology, Venereology and Allergology, University of Würzburg, Würzburg,
Germany.
Background: Rheumatoid arthritis (RA) is a systemic inflammatory disease which may present with extra-
articular symptoms, including cutaneous manifestations. Ulcerated rheumatoid nodules, necrotic vasculitic
lesions and pyoderma gangrenosum are fairly characteristic and well-recognized causes of skin ulcers in
RA. However, most RA patients develop leg ulcers due to other pathophysiological factors posing a
diagnostic and therapeutic challenge and leading to considerable morbidity.
Methods: A retrospective chart analysis of all patients with RA and leg ulcers hospitalized at our
Dermatology Department between January 1998 and March 2008 was performed to evaluate risk
factors and identify underlying conditions that predispose RA patients to the development of leg ulcers.
Results: A total of 36 patients with RA and leg ulcers were identified. Three patients presented with
necrotizing vasculitis and 2 with pyoderma gangrenosum. Chronic venous insufficiency was diagnosed as
the underlying cause of leg ulcers in 8 patients, peripheral arterial disease in 4 patients, and combined
arterial and venous malfunction in 3 patients. Five patients suffered from pressure ulcers. Interestingly, in
11 patients (31%) other underlying causes besides constricted mobility followed by secondary
lymphedema could not be identified, and these ulcers were classified as 'inactivity leg ulcers'.
Conclusions: The majority of leg ulcers in patients with RA are due to underlying venous/arterial
malfunction while vasculitic or traumatic ulcers are less common. Additionally, we identified a relevant
subgroup of patients with 'inactivity ulcers' due to impaired mobility and consecutive lymphedema.
Morphology and localization of ulcerations as well as duplex sonography provide the most important
clues for accurate diagnosis, ensuring adequate treatment. Copyright © 2010 S. Karger AG, Basel.
PMID: 20332595 [PubMed - as supplied by publisher]
1. Microsurgery. 2010 Mar 16. [Epub ahead of print]
Microsurgery for lymphedema: Clinical research and long-term results.
Campisi C, Bellini C, Campisi C, Accogli S, Bonioli E, Boccardo F.
Department of Surgery, Unit of Lymphatic Surgery and Microsurgery, San Martino Hospital, University
of Genoa, Italy.
Objectives: To report the wide clinical experience and the research studies in the microsurgical treatment
of peripheral lymphedema.
Methods: More than 1800 patients with peripheral lymphedema have been treated with microsurgical
techniques. Derivative lymphatic microvascular procedures recognize today its most exemplary
application in multiple lymphatic-venous anastomoses (LVA). In case of associated venous disease
reconstructive lymphatic microsurgery techniques have been developed. Objective assessment was
undertaken by water volumetry and lymphoscintigraphy.
Results: Subjective improvement was noted in 87% of patients. Objectively, volume changes showed a
significant improvement in 83%, with an average reduction of 67% of the excess volume. Of those
patients followed-up, 85% have been able to discontinue the use of conservative measures, with an
average follow-up of more than 10 years and average reduction in excess volume of 69%. There was a
87% reduction in the incidence of cellulitis after microsurgery.
Conclusions: Microsurgical LVA have a place in the treatment of peripheral lymphedema, and should be
the therapy of choice in patients who are not sufficiently responsive to nonsurgical treatment. (c) 2010
Wiley-Liss, Inc. Microsurgery, 2010.
PMID: 20235160 [PubMed - as supplied by publisher]
2. Cancer Res. 2010 Mar 16. [Epub ahead of print]
Imaging of Human Lymph Nodes Using Optical Coherence Tomography: Potential for Staging Cancer.
McLaughlin RA, Scolaro L, Robbins P, Hamza S, Saunders C, Sampson DD.
Authors' Affiliations: Optical + Biomedical Engineering Laboratory, School of Electrical, Electronic, and
Computer Engineering and School of Surgery, University of Western Australia, Crawley, Western
Australia, Australia; and PathWest, QEII Medical Centre and Sir Charles Gairdner Hospital, Nedlands,
Western Australia, Australia.
Histologic assessment is the gold standard technique for the identification of metastatic involvement of
lymph nodes in malignant disease, but can only be performed ex vivo and often results in the unnecessary
excision of healthy lymph nodes, leading to complications such as lymphedema. Optical coherence
tomography (OCT) is a high-resolution, near-IR imaging modality capable of visualizing microscopic
features within tissue. OCT has the potential to provide in vivo assessment of tissue involvement by
cancer. In this morphologic study, we show the capability of OCT to image nodal microarchitecture
through an assessment of fresh, unstained ex vivo lymph node samples. Examples include both benign
human axillary lymph nodes and nodes containing metastatic breast carcinoma. Through accurate
correlation with the histologic gold standard, OCT is shown to enable differentiation of lymph node tissue
from surrounding adipose tissue, reveal nodal structures such as germinal centers and intranodal vessels,
and show both diffuse and well circumscribed patterns of metastatic node involvement. Cancer Res; 70
(7); 2579-84.
PMID: 20233873 [PubMed - as supplied by publisher]
3. Arch Dermatol. 2010 Mar;146(3):337-42.
Large nodular plaque on leg in the setting of chronic lymphedema--quiz case. Angiosarcoma in the setting
of familial lymphedema.
Cronin H, Mowad C, Ferringer T.
Geisinger Medical Center, Danville, Pennsylvania, USA.
PMID: 20231513 [PubMed - in process]
1. Lymphology. 2009 Dec;42(4):188-94.Published March 2010
Intermittent pneumatic compression acts synergistically with manual lymphatic drainage in complex
decongestive physiotherapy for breast cancer treatment-related lymphedema.
Szolnoky G, Lakatos B, Keskeny T, Varga E, Varga M, Dobozy A, Kemény L.
Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary. szolnoky@dermall.
hu
The application of intermittent pneumatic compression (IPC) as a part of complex decongestive
physiotherapy (CDP) remains controversial. The aim of this study was to investigate whether the
combination of IPC with manual lymph drainage (MLD) could improve CDP treatment outcomes in
women with secondary lymphedema after breast cancer treatment. A randomized study was undertaken
with 13 subjects receiving MLD (60 min) and 14 receiving MLD (30 min) plus IPC (30 min) followed by
standardized components of CDP including multilayered compression bandaging, physical exercise, and
skin care 10 times in a 2-week-period. Efficacy of treatment was evaluated by limb volume reduction and
a subjective symptom questionnaire at end of the treatment, and one and two months after beginning
treatment. The two groups had similar demographic and clinical characteristics. Mean reductions in limb
volumes for each group at the end of therapy, and at one and two months were 7.93% and 3.06%,
9.02% and 2.9%, and 9.62% and 3.6%, respectively (p < 0.05 from baseline for each group and also
between groups at each measurement). Although a significant decrease in the subjective symptom survey
was found for both groups compared to baseline, no significant difference between the groups was found
at any time point. The application of IPC with MLD provides a synergistic enhancement of the effect of
CDP in arm volume reduction.
PMID: 20218087 [PubMed - in process]
1. Nucl Med Commun. 2010 Mar 2. [Epub ahead of print]
Intradermal lymphoscintigraphy at rest and after exercise: a new technique for the functional assessment of
the lymphatic system in patients with lymphoedema.
Tartaglione G, Pagan M, Morese R, Cappellini GA, Zappalà AR, Sebastiani C, Paone G, Bernabucci V,
Bartoletti R, Marchetti P, Marzola MC, Naji M, Rubello D.
aUnit of Nuclear Medicine, Cristo Re Hospital bUnit of Medical and Dermatologic Oncology cUnit of
Oncological Rehabilitation, Istituto Dermopatico dell'Immacolata, IDI-IRCCS dUnit of Medical
Oncology, Sant'Andrea Hospital, Rome eDepartment of Nuclear Medicine, PET Centre, Radiology,
Medical Physics, Santa Maria della Misericordia Hospital, Rovigo, Italy fDepartment of Nuclear
Medicine, Hammersmith Hospital, London, UK.
AIM: The aim of this study was to evaluate the effect of implementing a new technique, intradermal
injection lymphoscintigraphy, at rest and after muscular exercise on the functional assessment of the
lymphatic system in a group of patients with delayed or absent lymph drainage.
METHODS: We selected 44 patients (32 women and 12 men; 15 of 44 with upper limb and 29 of 44
with lower limb lymphoedema). Thirty of 44 patients had bilateral limb lymphoedema and 14 of 44 had
unilateral disease; 14 contralateral normal limbs were used as controls. Twenty-three patients had
secondary lymphoedema after lymphadenectomy and the remaining 21 had idiopathic lymphoedema.
Each of the 44 patients was injected with 50 MBq (0.3-0.4 ml) of Tc-albumin-nanocolloid, which was
administered intradermally at the first interdigital space of the affected limb. Two planar static scans were
performed using a low-energy general-purpose collimator (acquisition matrix 128x128, anterior and
posterior views for 5 min), and in which drainage was slow or absent, patients were asked to walk or
exercise for 2 min. A postexercise scan was then performed to monitor and record the tracer pathway
and the tracer appearance time (TAT) in the inguinal or axillary lymph nodes.
RESULTS: The postexercise scans showed that (i) 21 limbs (15 lower and six upper limbs) had
accelerated tracer drainage and tracer uptake in the inguinal and/or axillary lymph nodes. Two-thirds of
these showed lymph stagnation points; (ii) 27 limbs had collateral lymph drainage pathways; (iii) in 11
limbs, there was lymph drainage into the deeper lymphatic channels, with unusual uptake in the popliteal
or antecubital lymph nodes; (iv) six limbs had dermal backflow; (v) three limbs did not show lymph
drainage (TAT=not applicable). TAT=15+/-3 min, ranging from 12 to 32 min in limbs with lymphoedema
versus 5+/-2 min, ranging from 1 to 12 min in the contralateral normal limbs (P<0.001).
CONCLUSION: Intradermal injection lymphoscintigraphy gives a better imaging of the lymph drainage
pathways in a shorter time, including cases with advanced lymphoedema. In some patients with
lymphoedema, a 2-min exercise can accelerate tracer drainage, showing several compensatory
mechanisms of lymph drainage. The effect of the exercise technique on TAT and lymphoscintigraphy
findings could result in a more accurate functional assessment of lymphoedema patients.
PMID: 20215978 [PubMed - as supplied by publisher]
2. J Neurol Phys Ther. 2010 Mar;34(1):41-9.
Rehabilitation postfacial reanimation surgery after removal of acoustic neuroma: a case study.
Wilson CM, Ronan SL.
Department of Physical and Occupational Therapy (C.M.W.), William Beaumont Hospital, Troy,
Michigan; Department of Physical Therapy (C.M.W.), School of Health Sciences, Oakland University in
Rochester, Michigan; and Department of Physical Therapy (S.R.), New York Medical College, School
of Public Health, Valhalla, New York.
BACKGROUND AND PURPOSE:: Facial paralysis can have a significant negative impact on an
individual's social, physical, and emotional well-being; however, little information has been reported on the
efficacy of physical therapy interventions for this condition. The purpose of this case study was to
describe the details of a physical therapy evaluation and intervention for a patient who underwent facial
muscle transfer after resection of acoustic neuroma.
CASE DESCRIPTION:: A 29-year-old woman underwent left-sided facial reanimation surgery, which
included transplantation of the temporalis muscle and platysma muscle to the corner of the mouth.
INTERVENTION:: The patient received 30 sessions of physical therapy that included electrical
stimulation, biofeedback, lymphatic drainage, home exercises and facial stretching, and scar management.
OUTCOMES:: The patient exhibited an improvement in the Composite score of the Sunnybrook Facial
Grading System from 17 to 41. She was able to regain function of the left side of her face with gains in
expressions of smiling, frowning, and puckering, but symmetry was not completely restored. The patient
had chronic difficulty with left-sided lymphedema, requiring frequent manual lymphatic drainage.
DISCUSSION:: Data from this case study suggest that physical therapy management improves functional
outcomes for individuals with postoperative changes in facial motor function from facial reanimation
surgery. Further research is required to explore factors that influence the rate and extent of recovery
derived from physical therapy interventions.
PMID: 20212367 [PubMed - in process]
3. Zhonghua Zheng Xing Wai Ke Za Zhi. 2009 Nov;25(6):433-6.
[Interstitial high-resolution MR lymphangiography in patients with lower extremity lymphedema][Article in
Chinese]
Ren YQ, Lu Q, Cao WG.
Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011,
China.
OBJECTIVE: To assess the feasibility of interstitial magnetic resonance lymphangiography (IMRL) with
intracutaneous injection of gadobenate dimeglumine--a commercially available, non-ionic, extracellular
paramagnetic contrast agent.
METHODS: We studied 10 patients with lower extremity lymphedema. A mixture of 7.5 ml gadobenate
dimeglumine and 0.5 ml 2% lidocaine were evenly subdivided into 8 portions and injected
intracutaneously into each web space of both feet. For IMRL, a 3D fast spoiled gradient-recalled echo
T1-weighted images with a fat saturation technique (T1 high resolution isotropic volume excitation,
THRIVE) was performed.
RESULTS: The beaded appearance of lymphatic vessels extending from the injection site were detected
in 11 of 12 lower legs and the best delineation of lymphatic vessels was present at 15-30 minutes after
injection. In 6 of 12 affected thighs, lymphatic vessels could be also visualized with the strongest
enhancement at 45 minutes.
CONCLUSION: IMRL is a safe and technically feasible new method which can effectively visualize the
pathological lymphatic vessels in lower extremity lymphedema.
PMID: 20209934 [PubMed - in process]
Large Nodular Plaque on Leg in the Setting of Chronic Lymphedema—Diagnosis
Arch Dermatol.2010; 146: 337-342.
1. Pediatr Dermatol. 2010 Jan 1;27(1):58-61.
Lymphatic compression by sclerotic patches of morphea: an original mechanism of lymphedema in a child.
Samimi M, Maruani A, Machet MC, Baulieu F, Machet L, Lorette G.
University François Rabelais, Tours, France.
Lymphedema in children is mostly primary, due to lymphatic hypoplasia. Secondary lymphedema is
caused by lymphatic injury or obstruction. We report the case of a child that developed a lymphedema of
the left upper and lower extremities, with a simultaneous onset of ipsilateral hemicorporal morphea. We
concluded that lymphatic obstruction was due to sclerosis from morphea. This is a unique, rarely reported
mechanism of lymphedema. Lymphoscintigraphy revealed attenuated lymphatic flow in the left upper and
lower limbs. Systemic corticosteroids were associated with slow improvement in the sclerotic patches.
We simultaneously noticed an improvement in the lymphedema of limbs. Repeat lymphoscintigraphy
revealed dramatically improved lymphatic function. This case suggests that at least in some cases
lymphedema may be caused by morphea.
PMID: 20199412 [PubMed - in process]
1. Am J Med Genet A. 2010 Mar;152A(3):737-40.
c. 595-596 insC of FOXC2 underlies lymphedema, distichiasis, ptosis, ankyloglossia, and Robin
sequence in a Thai patient.
Tanpaiboon P, Kantaputra P, Wejathikul K, Piyamongkol W.
Faculty of Medicine, Department of Pediatrics, Chiang Mai University, Chiang Mai, Thailand.
tanpaiboon1@yahoo.com
Lymphedema-distichiasis syndrome is a rare primary lymphedema inherited as an autosomal dominant
disorder. The characteristic features consist of late onset-lymphedema and distichiasis together with other
occasionally seen features including varicose vein, cleft palate, ptosis, and congenital heart diseases.
FOXC2 is the gene found to be associated with this syndrome. We report here the first Thai patient who
has characteristic features of this syndrome and the infrequently described features including
ankyloglossia, and Robin sequence which consists of glossoptosis, cleft palate, and micrognathia.
Mutation analysis of FOXC2 revealed c. 595-596 insC. (c) 2010 Wiley-Liss, Inc.
PMID: 20186799 [PubMed - in process]
2. Cases J. 2009 Mar 23;2:6625.
Pneumatic compression devices for in-home management of lymphedema: two case reports.
[No authors listed]
ABSTRACT : The two patients in this case series had experienced long-term difficulty controlling
lymphedema at home. Both patients had used numerous home therapies, including older-generation
intermittent pneumatic compression devices, without success. The Flexitouch(R) system, an advanced
pneumatic device, was prescribed to assist them with in-home efforts by providing therapy to their
affected limbs in addition to the lower trunk area for the patient with lymphedema of the lower extremity;
and the trunk, chest wall, and shoulder areas for the patient with lymphedema of the upper extremity.
Both patients achieved successful home maintenance of lymphedema, as judged by limb volume, clinical
observations, and subjective patient impressions, after incorporating the Flexitouch(R) system. Neither
patient experienced the deleterious effects (worsening genital edema; fibrotic cuff development) that they
had experienced with the older-generation intermittent pneumatic compression devices they had
previously used. Incorporating the Flexitouch(R) system as part of maintenance may improve success for
lymphedema patients who have previously struggled with in-home management.
PMID: 20184680 [PubMed - in process]
3. J Lymphoedema. 2009 Apr 1;4(1):14-18.
30-MONTH POST-BREAST CANCER TREATMENT LYMPHOEDEMA.
Armer JM, Stewart BR, Shook RP.
Jane M Armer, Professor, Sinclair School of Nursing (SSON), Director, Nursing Research, Ellis Fischel
Cancer Center; Bob R Stewart, Professor Emeritus, College of Education, Adjunct Clinical Professor,
SSON; Robin P Shook, Project Development Specialist, Lymphedema Research Project, SSON,
University of Missouri, Columbia, USA.
BACKGROUND: Quantification of lymphoedema (LE) has been problematic, and the reported
incidence of LE varies greatly among women treated with surgery and radiation for breast cancer. AIMS:
This study aims to describe LE occurrence over time among breast cancer survivors using four diagnostic
criteria based on three measurement techniques.
METHODS: Limb volume and symptom assessment data were followed after surgery every three months
for 12 months, then every six months for 30 months. Limb volume changes (LVC) were measured by
circumferences and by perometry, and by symptom experience via interview. Standard survival analysis
methods identified when the criteria indicating LE were met.
RESULTS: Trends in LE occurrence are reported for data from 211 participants. At 30 months post-
treatment, LE incidence ranged from 41-91%, with 2cm being the highest estimation method and self-
reported signs and symtoms (SS) the lowest.
CONCLUSIONS: This 30-month analysis supports the previous 12-month analysis in finding the 2cm
criteria as the most liberal definition of LE. Self-reporting of heaviness and swelling, along with 10%
LVC, represented the most conservative definitions (41% and 45%, respectively).
PMID: 20182653 [PubMed]
4. J Altern Complement Med. 2010 Feb;16(2):145-9.
An integrative treatment for lower limb lymphedema (elephantiasis).
Narahari SR, Aggithaya MG, Prasanna KS, Bose KS.
Department of Ayurveda, Kasaragod, Kerala, India.
PMID: 20180687 [PubMed - in process]
1. Circ Res. 2010 Feb 4. [Epub ahead of print]
Transmural Flow Modulates Cell and Fluid Transport Functions of Lymphatic Endothelium.
Miteva DO, Rutkowski JM, Dixon JB, Kilarski W, Shields JD, Swartz MA.
Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne, Switzerland.
Rationale: Lymphatic transport of peripheral interstitial fluid and dendritic cells (DCs) is important for both
adaptive immunity and maintenance of tolerance to self-antigens. Lymphatic drainage can change rapidly
and dramatically on tissue injury or inflammation, and therefore increased fluid flow may serve as an
important early cue for inflammation; however, the effects of transmural flow on lymphatic function are
unknown.
Objective: Here we tested the hypothesis that lymph drainage regulates the fluid and cell transport
functions of lymphatic endothelium.
Methods and Results: Using in vitro and in vivo models, we demonstrated that lymphatic endothelium is
sensitive to low levels of transmural flow. Basal-to-luminal flow (0.1 and 1 mum/sec) increased lymphatic
permeability, dextran transport, and aquaporin-2 expression, as well as DC transmigration into
lymphatics. The latter was associated with increased lymphatic expression of the DC homing chemokine
CCL21 and the adhesion molecules intercellular adhesion molecule-1 and endothelial selectin. In addition,
transmural flow induced delocalization and downregulation of vascular endothelial cadherin and PECAM-
1 (platelet/endothelial cell adhesion molecule-1). Flow-enhanced DC transmigration could be reversed by
blocking CCR7, intercellular adhesion molecule-1, or endothelial selectin. In an experimental model of
lymphedema, where lymphatic drainage is greatly reduced or absent, lymphatic endothelial expression of
CCL21 was nearly absent.
Conclusions: These findings introduce transmural flow as an important regulator of lymphatic endothelial
function and suggest that flow might serve as an early inflammatory signal for lymphatics, causing them to
regulate transport functions to facilitate the delivery of soluble antigens and DCs to lymph nodes.
PMID: 20133901 [PubMed - as supplied by publisher]
2. Am J Occup Ther. 2010 Jan-Feb;64(1):59-72.
Randomized controlled trial of the Breast Cancer Recovery Program for women with breast cancer-
related lymphedema.
McClure MK, McClure RJ, Day R, Brufsky AM.
Magee-Women's Research Institute, Pittsburgh, PA, USA.
Evidence-based exercise and relaxation recommendations for people with breast cancer-related
lymphedema (BCRL) are needed. We report a randomized controlled study of one program, designed to
achieve synergistic improvements in physical and emotional BCRL symptoms. People in the treatment
group received an exercise and relaxation program, The Breast Cancer Recovery Program (N=16). The
control participants (N=16) continued with health professionals' recommendations. Participants were
tested at entry, 2.5 weeks, 5 weeks, and 3 months. Treatment group participants, compared with control
participants, demonstrated significant treatment effects for improved bioimpedance z, arm flexibility,
quality of life, mood at 3 months, and weight loss. Adherence was high for this safe and effective
program, which improved lymphedema physical and emotional symptoms.
PMID: 20131565 [PubMed - in process]
------------------------------
1. Angiology. 2010 Feb 10. [Epub ahead of print]
Epidemiological Data and Comorbidities of 428 Patients Hospitalized With Erysipelas.
Pereira de Godoy JM, Massari PG, Rosinha MY, Brandão RM, Foroni Casas AL.
The aim of this study was to evaluate the epidemiological data and the main comorbidities of patients with
erysipelas admitted to a tertiary hospital. All patients admitted due to erysipelas during the period from
1999 to 2008 were included in a prospective and cross-sectional study. The Fisher exact test and logistic
regression were used for statistical analysis. A total of 428 individuals were hospitalized with 41
rehospitalizations; 51.17% of the patients were women, the mean age was 58.6 years. The main
comorbidities were hypertension (51.6%), diabetes mellitus (41.6%), chronic venous insufficiency
(36.2%), other cardiovascular diseases (33.2%) including angina, peripheral arterial insufficiency, acute
myocardial infarction, and strokes, obesity (12.1%), chronic renal failure (6.8%), neoplasms (4.9%),
cirrhosis (4.9%), chronic lymphedema (4.2%), and leg ulcers (2.6%). Erysipelas is a seasonal disease
that affects adults and the elderly people, has a repetitive nature, and is associated with comorbidities.
PMID: 20147345 [PubMed - as supplied by publisher]
------------------------------
1. Lymphat Res Biol. 2009 Dec;7(4):239-45.
Topography of accumulation of stagnant lymph and tissue fluid in soft tissues of human lymphedematous
lower limbs.
Olszewski WL, Jain P, Ambujam G, Zaleska M, Cakala M.
1 Department of Surgical Research and Transplantology, Medical Research Center , Polish Academy of
Sciences, Warsaw, Poland .
Abstract Background: The knowledge of where does excess tissue fluid accumulate in obstructive
lymphedema is indispensable for rational physical therapy. However, it has so far been limited to that
obtained from lymphoscintigraphic, ultrasonographic, and MR images. None of these modalities provide
composite pictures of dilated lymphatics and expanded tissue space in dermis, subcutis, and muscles. So
far, only anatomical dissection and histological processing of biopsy material can visualize the tissue
lymphatic network and the sites of accumulation of the excess of mobile tissue fluid.
Methods and Results: We visualized the "tissue fluid and lymph" space in skin and subcutaneous tissue of
foot, calf, and thigh in various stages of lymphedema in specimens obtained during lymphatic microsurgical
procedures or tissue debulking, using special staining techniques. The volume of accumulated fluid was
calculated from the densitometric data of stained tissue sections. We found that lymph was present only in
the subepidermal lymphatics, whereas the collecting trunks were obliterated in most cases. Mobile tissue
fluid accumulated in the spontaneously formed spaces in the subcutaneous tissue, around small veins and
above and underneath muscular fascia. Deformation of subcutaneous tissue by free fluid led to formation
of interconnecting channels. The volume of subcutaneous free fluid ranged around 50% of total tissue
volume and there were no significant differences in various stages of lymphedema. This could be
explained by the presence of thick layers of subcutaneous fat tissue even in the most advanced stage of
lymphedema.
Conclusions: In lymphedema caused by obliteration of collecting trunks, lymph is present only in the
subepidermal lymphatics, whereas the bulk of stagnant tissue fluid accumulates in the subcutaneous tissue
and above and beneath muscular fascia. These findings should be useful for designing pneumatic devices
for limb massage as well as for rational manual lymphatic drainage in terms of sites of massage and level
of applied external pressures.
PMID: 20143923 [PubMed - in process]
---------------------------
1. Lymphat Res Biol. 2009 Dec;7(4):239-45.
Topography of accumulation of stagnant lymph and tissue fluid in soft tissues of human lymphedematous
lower limbs.
Olszewski WL, Jain P, Ambujam G, Zaleska M, Cakala M.
1 Department of Surgical Research and Transplantology, Medical Research Center , Polish Academy of
Sciences, Warsaw, Poland .
Abstract Background: The knowledge of where does excess tissue fluid accumulate in obstructive
lymphedema is indispensable for rational physical therapy. However, it has so far been limited to that
obtained from lymphoscintigraphic, ultrasonographic, and MR images. None of these modalities provide
composite pictures of dilated lymphatics and expanded tissue space in dermis, subcutis, and muscles. So
far, only anatomical dissection and histological processing of biopsy material can visualize the tissue
lymphatic network and the sites of accumulation of the excess of mobile tissue fluid.
Methods and Results: We visualized the "tissue fluid and lymph" space in skin and subcutaneous tissue of
foot, calf, and thigh in various stages of lymphedema in specimens obtained during lymphatic microsurgical
procedures or tissue debulking, using special staining techniques. The volume of accumulated fluid was
calculated from the densitometric data of stained tissue sections. We found that lymph was present only in
the subepidermal lymphatics, whereas the collecting trunks were obliterated in most cases. Mobile tissue
fluid accumulated in the spontaneously formed spaces in the subcutaneous tissue, around small veins and
above and underneath muscular fascia. Deformation of subcutaneous tissue by free fluid led to formation
of interconnecting channels. The volume of subcutaneous free fluid ranged around 50% of total tissue
volume and there were no significant differences in various stages of lymphedema. This could be
explained by the presence of thick layers of subcutaneous fat tissue even in the most advanced stage of
lymphedema.
Conclusions: In lymphedema caused by obliteration of collecting trunks, lymph is present only in the
subepidermal lymphatics, whereas the bulk of stagnant tissue fluid accumulates in the subcutaneous tissue
and above and beneath muscular fascia. These findings should be useful for designing pneumatic devices
for limb massage as well as for rational manual lymphatic drainage in terms of sites of massage and level
of applied external pressures.
PMID: 20143923 [PubMed - in process]
2. Lymphat Res Biol. 2009 Dec;7(4):215-9.
Lymphatics in human lymphatic filariasis: in vitro models of parasite-induced lymphatic remodeling.
Bennuru S, Nutman TB.
Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases , Bethesda,
Maryland.
Abstract Lymphatic filariasis characterized by the dysfunction of the lymphatics can lead to severe (and
often) irreversible lymphedema and elephantiasis. Decades of research in the field shows that the
establishment of the adult parasites in the lymphatics triggers a cascade of events that ultimately results in
tissue scarring and fibrosis. In this minireview, we focus on the studies addressing the mechanisms
underlying the parasite-induced lymphatic dilatation that suggests parasite-induced lymphatic remodeling
and lymphangiogenesis may be the prelude towards developing chronic and irreversible filarial pathology.
PMID: 20143920 [PubMed - in process
3. Lymphat Res Biol. 2009 Dec;7(4):205-14.
New approaches to lymphatic imaging.
Lucarelli RT, Ogawa M, Kosaka N, Turkbey B, Kobayashi H, Choyke PL.
Molecular Imaging Program, National Cancer Institute , Bethesda, Maryland.
Abstract Accurate imaging of the lymphatic system can aid in cancer staging, optimize surgical procedures
to reduce lymphedema, and may one day be a means of delivering intralymphatic therapy. The Sentinel
Lymph Node (SLN) concept has been pivotal in driving new imaging techniques. Metastasis to a SLN is
a critical indicator of advanced disease. However, presently, few tools are available for imaging the
lymphatics, and even fewer are available for locating the SLN for biopsy. Recently, new macromolecular
agents, including gadolinium-labeled dendrimers, fluorescent quantum dots, and fluorescently-labeled
immunoglobins, have been used to image the lymphatics and SLN with MRI and optical techniques, and
new fluorescent nanoparticles such as upconverting nanocrystals are potential future agents. Additionally,
multi-modality probes combining two modalities such as optical/MR dendrimers have been designed to
provide both preoperative imaging, and intraoperative guidance during lymph node resections. These
probes can map the lymphatic system for maximal therapeutic benefit while minimizing complications such
as lymphedema. Advances in the understanding of the molecular mechanisms of lymphangiogenesis and
lymphatic spread of tumors offer the opportunity for more targeted imaging of the lymphatic system.
Additionally, these imaging agents could be used as powerful research tools for tracking immunological
cells and monitoring the immune response as well as providing the means to deliver lymphatic-targeted
therapies. The future holds great promise for the translation of these methods to the clinic.
PMID: 20143919 [PubMed - in process]
4. Ann Surg Oncol. 2010 Feb 6. [Epub ahead of print]
The Effect of Providing Information about Lymphedema on the Cognitive and Symptom Outcomes of
Breast Cancer Survivors.
Fu MR, Chen CM, Haber J, Guth AA, Axelrod D.
College of Nursing, New York University, New York, NY, USA, mf67@nyu.edu.
BACKGROUND: Despite recent advances in breast cancer treatment, breast cancer related
lymphedema (BCRL) continues to be a significant problem for many survivors. Some BCRL risk factors
may be largely unavoidable, such as mastectomy, axillary lymph node dissection (ALND), or radiation
therapy. Potentially avoidable risk factors unrelated to breast cancer treatment include minor upper
extremity infections, injury or trauma to the arm, overuse of the limb, and air travel. This study investigates
how providing information about BCRL affects the cognitive and symptomatic outcome of breast cancer
survivors.
METHODS: Data were collected from 136 breast cancer survivors using a Demographic and Medical
Information interview instrument, a Lymphedema Education Status interview instrument, a Knowledge
Test for cognitive outcome, and the Lymphedema and Breast Cancer Questionnaire for symptom
outcome. Data analysis included descriptive statistics, t tests, chi-square (chi(2)) tests, and regression.
RESULTS: BCRL information was given to 57% of subjects during treatment. The mean number of
lymphedema-related symptoms was 3 symptoms. Patients who received information reported significantly
fewer symptoms and scored significantly higher in the knowledge test. After controlling for confounding
factors, patient education remains an additional predictor of BCRL outcome. Significantly fewer women
who received information about BCRL reported swelling, heaviness, impaired shoulder mobility, seroma
formation, and breast swelling.
CONCLUSIONS: Breast cancer survivors who received information about BCRL had significantly
reduced symptoms and increased knowledge about BCRL. In clinical practice, breast cancer survivors
should be engaged in supportive dialogues so they can be educated about ways to reduce their risk of
developing BCRL.
PMID: 20140528 [PubMed - as supplied by publisher]
1. Cancer. 2010 Mar 24. [Epub ahead of print]
A phase I study to assess the feasibility and oncologic safety of axillary reverse mapping in breast cancer
patients.
Bedrosian I, Babiera GV, Mittendorf EA, Kuerer HM, Pantoja L, Hunt KK, Krishnamurthy S, Meric-
Bernstam F.
Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston
Texas.
BACKGROUND:: Axillary reverse mapping (ARM) is a novel technique to preserve upper extremity
lymphatics that may reduce the incidence of lymphedema after axillary lymph node dissection. Early
reports have suggested that ARM lymph nodes do not contain metastatic disease from breast cancer;
however, these studies were conducted in early stage patients with low likelihood of lymph node
metastasis. This study reported a phase 1 trial conducted in patients with cytologically documented
axillary metastasis undergoing axillary lymph node dissection to determine the feasibility and oncologic
safety of ARM.
METHODS:: Thirty patients, 23 (77%) of whom received preoperative therapy (chemotherapy in 22
patients and hormonal therapy in 1 patient), were enrolled. Blue dye was injected in the upper inner
ipsilateral arm. The presence of blue lymphatics was noted, and blue lymph nodes were sent separately
for pathologic evaluation.
RESULTS:: The average time between blue dye injection and axillary exposure was 35 minutes (range,
15-60 minutes). Blue lymphatics were identified in 21 patients (70%) and blue lymph nodes in 15 patients
(50%). The median number of ARM lymph nodes was 1 (range, 0-3 lymph nodes) and the median
number of axillary lymph nodes was 26 (range, 6-47 lymph nodes). Axillary metastases were noted in
60% (18 of 30) of patients. Of 11 patients who had axillary metastasis and at least 1 ARM lymph node
identified, 2 (18%) had metastasis to the ARM lymph node.
CONCLUSIONS:: ARM appears to be a feasible technique with which to identify upper arm lymphatics
during axillary surgery. However, the high prevalence of disease involving ARM lymph nodes in this small
cohort suggested that preservation of these lymphatics is not oncologically safe in women with
documented axillary lymph node metastasis from breast cancer. Cancer 2010. (c) 2010 American
Cancer Society.
PMID: 20336790 [PubMed - as supplied by publisher]
2. Ann Surg Oncol. 2010 Mar 25. [Epub ahead of print]
Prospective Assessment of Postoperative Complications and Associated Costs Following Inguinal Lymph
Node Dissection (ILND) in Melanoma Patients.
Chang SB, Askew RL, Xing Y, Weaver S, Gershenwald JE, Lee JE, Royal R, Lucci A, Ross MI,
Cormier JN.
Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX,
USA.
BACKGROUND: We prospectively assessed the incidence, risk factors, and costs associated with
wound complications and lymphedema in melanoma patients undergoing inguinal lymph node dissection
(ILND).
MATERIALS AND METHODS: A total of 53 melanoma patients were accrued to 2 trials (June 2005
to July 2008) that included prospective evaluations of postoperative complications; 30-day wound
complications included infection, seroma, and/or dehiscence. There were 20 patients who underwent limb
volume measurement and completed a 19-item lymphedema symptom assessment questionnaire
preoperatively and 3 months postoperatively. A multivariate analysis was performed to evaluate potential
risk factors for complications. A microcosting analysis was also performed to evaluate the direct costs
associated with wound complications.
RESULTS: The 30-day wound complications were noted in 77.4% of patients. A BMI >/= 30 (n = 28)
increased the risk for wound complications (odds ratio [OR] = 11.4, 95% confidence interval [95%CI]
1.6-78.5, P = .01), while advanced nodal disease approached significance (OR = 9.0, 95%CI: 0.79-
103.1, P = .08). Other risk factors, including diabetes, smoking, and the addition of a deep pelvic
(iliac/obturator) dissection to ILND, were not significant. Of 20 patients, 9 (45%) developed limb volume
change (LVC) >/=5% at 3 months, with associated mean symptom scores of 6.1 versus 4.6 for those
without LVC. Costs for patients with wound complications were significantly higher than for those without
wound complications.
CONCLUSIONS: Postoperative wound complications and early onset lymphedema occur frequently
following ILND for melanoma. Obesity is an adverse risk factor for 30-day wound complications that can
significantly increase postoperative costs, as is likely the case for advanced disease. Risk reduction
practices and novel treatment approaches are needed to reduce postoperative morbidity.
PMID: 20336388 [PubMed - as supplied by publisher]
1. J Clin Nurs. 2010 Mar 16. [Epub ahead of print]
After axillary surgery for breast cancer - is it safe to take blood samples or give intravenous infusions?
Winge C, Mattiasson AC, Schultz I.
Authors:Charlotte Winge, RN, Division of Surgery, Department of Clinical Sciences, Karolinska Institute
at Danderyd Hospital; Anne-Cathrine Mattiasson, RNT, Professor, Division of Surgery, Department of
Clinical Sciences, Karolinska Institute at Danderyd Hospital and Sophiahemmet University College;
Inkeri Schultz, MD, PhD, Department of Clinical Sciences, Karolinska Institute at Danderyd Hospital and
Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, Stockholm, Sweden.
Aim. To investigate the occurrence of complications after a needle puncture or intravenous injection in the
ipsilateral arm of women who have undergone axillary lymph node clearance for breast cancer.
Background. After axillary lymph node clearance in patients with breast cancer, some women experience
lymphoedema and recurrent infections. To reduce the risk of these postoperative complications, most
women are advised to not have intravenous infusions in, or blood samples taken from, the arm in the
operated side. Very little published data are available regarding the incidence of lymphoedema after
intravenous procedures under clean conditions in the hospital setting. This study set out to investigate the
occurrence of complications after a needle puncture or intravenous injection in the ipsilateral arm of
women who have undergone axillary lymph node clearance for breast cancer is therefore important.
Design. Descriptive. Methods. Self-reported questionnaire. Results. Most of the reported complications
were minor, including itching, bruises and vomiting at the time of the intravenous procedure. The most
serious complication was infection in one patient needing antibiotic treatment and subsequent arm swelling.
Conclusions. This study indicates that if a blood sample is taken or intravenous injection is given
according to the current Swedish guidelines for health care professionals, there should be a very low risk
of complications. Relevance to clinical practice. If intravenous procedures are performed without any
disadvantage in the arm of the operated side in women who have undergone axillary surgery, the clinical
problem of finding a proper vein and the psychological concern of the women can be reduced.
PMID: 20345831 [PubMed - as supplied by publisher]
Effect of air travel on lymphedema risk in women with history of breast cancer.
Kilbreath SL, Ward LC, Lane K, McNeely M, Dylke ES, Refshauge KM, McKenzie D, Lee MJ,
Peddle C, Battersby KJ.
Faculty of Health Sciences, University of Sydney, PO Box 170, Lidcombe, NSW, 1825, Australia,
sharon.kilbreath@sydney.edu.au.
To assess the impact of air travel on swelling of the 'at risk' arm of women treated for breast cancer.
Women treated for breast cancer from Canada (n = 60) and from within Australia (n = 12) attending a
dragon boat regatta in Queensland, Australia participated. Women were measured within 2 weeks prior
to their flight, on arrival in Queensland and, for 40 women travelling from Canada, measured again 6
weeks following return to Canada. Changes to extracellular fluid were measured using a single-frequency
bioimpedance device (BIA). Each arm was measured separately using a standardized protocol to obtain
the inter-limb impedance ratio. An increase in the ratio indicates accumulated fluid. Information regarding
medical management of participants' breast cancer, use of compression garment and history of exercise
were also obtained. For most women (95%), air travel did not adversely affect the impedance ratio. The
BIA ratio of long-haul travellers was 1.007 +/- 0.065 prior to the flight and 1.006 +/- 0.087 following the
flight. The ratio of short-haul travellers was 0.994 +/- 0.033 and following the flight was 1.001 +/- 0.038.
Air travel did not cause significant change in BIA ratio in the 'at-risk' arm for the majority of breast cancer
survivors who participated in dragon boat racing. Further research is required to determine whether these
findings are generalizable to the population of women who have been treated for breast cancer.
PMID: 20180016 [PubMed - as supplied by publisher]
2. Cell. 2010 Feb 19;140(4):460-76.
Lymphangiogenesis: Molecular mechanisms and future promise.
Tammela T, Alitalo K.
Molecular/Cancer Biology Laboratory and Haartman Institute, University of Helsinki, Finland.
The growth of lymphatic vessels (lymphangiogenesis) is actively involved in a number of pathological
processes including tissue inflammation and tumor dissemination but is insufficient in patients suffering from
lymphedema, a debilitating condition characterized by chronic tissue edema and impaired immunity. The
recent explosion of knowledge on the molecular mechanisms governing lymphangiogenesis provides new
possibilities to treat these diseases. 2010 Elsevier Inc. All rights reserved.
PMID: 20178740 [PubMed - in process]
3. Eur J Vasc Endovasc Surg. 2010 Feb 20. [Epub ahead of print]
Primary Lymphoedema and Lymphatic Malformation: Are they the Two Sides of the Same Coin?
Lee BB, Villavicencio JL.
Division of Vascular Surgery, Georgetown University School of Medicine, Washington, DC 20007,
USA; Georgetown University Hospital, 4th floor PHC, 3800 Reservoir Road NW, Washington, DC
20007, USA.
OBJECTIVES: To clear the confusion regarding the relationship between the 'primary lymphoedema' and
(truncular) lymphatic malformation (LM); the latter is one of congenital vascular malformations.
MATERIALS & METHODS: A literature review was carried out on the primary lymphoedema either
existing as an independent LM lesion or as a component of the Klippel-Trenaunay syndrome.
RESULTS: The review was able to provide a contemporary guide/conclusion on the definition and
classification, clinical evaluation and clinical management regarding conservative (physical) therapy,
reconstructive surgical therapy and ablative/excisional surgical therapy, for the primary lymphoedema as
an LM.
CONCLUSIONS: Primary lymphoedema can be considered as 'congenital' since its majority represents
a clinical manifestation of the truncular type of LM arising during the later stages of lymphangiogenesis.
Such embryological staging information of the LM is critical for proper management of the primary
lymphoedema when it exists with other congenital vascular malformations (Klippel-Trenaunay syndrome).
2. Basic non-invasive to minimally invasive tests will provide an adequate diagnosis and lead to the
correct multidisciplinary, specifically targeted and sequenced treatment strategy. 3. The mainstay of
current management of the primary lymphoedema/truncular LM is complex decongestive therapy; and the
reconstructive as well as ablative surgical therapy remain adjunctive therapies at best. Copyright © 2010
European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
PMID: 20176496 [PubMed - as supplied by publisher]
4. Clin Nutr. 2010 Feb 17. [Epub ahead of print]
Do patients with lymphoedema cholestasis syndrome 1/Aagenaes syndrome need dietary counselling
outside cholestatic episodes?
Drivdal M, Løken EB, Hagve TA, Bergstad I, Aagenæs O.
Regional Department of Eating Disorders, Division of Psychiatry, Building 37A, Oslo University Hospital,
Ullevaal, N-0407 Oslo, Norway.
BACKGROUND&AIMS: Patients with lymphoedema cholestasis syndrome 1/Aagenaes Syndrome
need a fat reduced diet when cholestatic. We wanted to assess the need for dietary counselling outside
cholestatic episodes, and hypothetized that no counselling was needed.
METHODS: Fifteen patients above 10 years of age without symptoms of cholestasis were compared
with a sex and age matched control group. Diet from a four-day weighed record and blood samples were
compared between the two groups and with general Norwegian recommendations.
RESULTS: The patients had a similar diet to the healthy controls, except for statistically significant lower
intake of energy from total fat (p=0.04) and saturated fat (0.02), and fish (0.05). The patients met the
dietary recommendations for macronutrients, except for saturated fat, monounsaturated fat, refined sugar
and fibre. Supplements were needed to meet the micronutrient recommendations. Patients had a
significantly lower serum level of alpha-tocopherol (0.01) compared with the control group, and the
serum 25-OH D level was below reference ranges.
CONCLUSIONS: The patients would benefit from counselling on fat quality, carbohydrates including
fibre intake, and individual needs for vitamins D and E. To secure serum 25-OH D and alpha-tocopherol
levels within reference ranges, regular examinations to determine the need for supplementary vitamins D
and E are recommended.
Copyright © 2009 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights
reserved.
PMID: 20170991 [PubMed - as supplied by publisher]
----------------------
1. Microsurgery. 2010 Mar 2. [Epub ahead of print]
Prevention of lymphatic injuries in surgery.
Francesco B, Corrado C, Giuseppe M, Emanuela B, Chiara B, Francesco P, Corradino C.
Department of Surgery, Unit of Lymphatic Surgery and Microsurgery, San Martino Hospital, University
of Genoa, Italy.
BACKGROUND:: The problem of prevention of lymphatic injuries in surgery is extremely important if
we think about the frequency of both early complications such as lymphorrhea, lymphocele, wound
dehiscence, and infections and late complications such as lymphangites and lymphedema. Nowadays, it is
possible to identify risk patients and prevent these lesions or treat them at an early stage. This article helps
to demonstrate how it is important to integrate diagnostic and clinical findings to better understand how to
properly identify risk patients for lymphatic injuries and, therefore, when it is useful and proper to do
prevention.
METHODS:: Authors report their experiences in the prevention and treatment of lymphatic injuries after
surgical operations and trauma. After an accurate diagnostic approach, prevention is based on different
technical procedures among which microsurgical procedures. It is very important to follow-up the patient
not only clinically but also by lymphoscintigraphy.
RESULTS AND CONCLUSIONS:: It was identified a protocol of prevention of secondary limb
lymphedema that included, from the diagnostic point of view, lymphoscintigraphy and, as concerns
therapy, it also recognized a role to early microsurgery. It is necessary to accurately follow-up the patient
who has undergone an operation at risk for the appearance of lymphatic complications and, even better,
to assess clinically and by lymphoscintigraphy the patient before surgical operation. (c) 2010 Wiley-Liss,
Inc. Microsurgery, 2010.
PMID: 20198663 [PubMed - as supplied by publisher]
2. Horm Res Paediatr. 2010;73(3):210-214. Epub 2010 Mar 3.
Tall Stature and Gonadal Dysgenesis in a Non-Mosaic Girl 45,X.
Fernandez R, Pasaro E.
Department of Psychobiology, University of A Coruña, Campus Elviña, A Coruña, Spain.
Turner's syndrome, also known as 'monosomy X', is a genetic disorder that occurs in 1/2,500 female
births and is hypothesized to result from haploinsufficiency of certain genes expressed from both sex
chromosomes that escape X inactivation. While the classic karyotype related to Turner's syndrome is 45,
X, the majority of those affected actually have a mosaic chromosomal complement, most often with a
second normal cell line (46,XX). The resulting phenotype is variable and related to the underlying
chromosomal pattern, but it is characterized by three cardinal features: short stature (around 100%),
ovarian failure (>90%) and congenital lymphedema (>80%). In this paper we report a molecular and
cytogenetic investigation of a 26-year-old female with non-mosaic 45,X karyotype, who has a stature of
170 cm without GH treatment, and whose only apparent Turner feature is gonadal dysgenesis. The only
possible explanation for the absence of Turner phenotype is the hidden mosaicism combined with an
untreated gonadal dysgenesis. Our results support the theory that significant ascertainment bias exists in
our understanding of Turner's syndrome. Copyright © 2010 S. Karger AG, Basel.
PMID: 20197675 [PubMed - as supplied by publisher]
3. Plast Reconstr Surg. 2010 Mar;125(3):935-43.
The intravascular stenting method for treatment of extremity lymphedema with multiconfiguration
lymphaticovenous anastomoses.
Narushima M, Mihara M, Yamamoto Y, Iida T, Koshima I, Mundinger GS.
Tokyo, Japan; and Baltimore, Md. From the Department of Plastic and Reconstructive Surgery, Tokyo
University School of Medicine, and the Division of Plastic, Reconstructive, and Maxillofacial Surgery,
Johns Hopkins Hospital.
BACKGROUND:: In secondary extremity lymphedema, normal antegrade lymphatic flow is disrupted by
the disease state. Attempts to capture aberrant retrograde lymphatic flow by means of microsurgical
lymphaticovenous anastomoses have been hindered because of technical limitations. The authors applied
the intravascular stenting method to the surgical correction of extremity lymphedema to generate
multiconfiguration lymphaticovenous anastomoses capable of decompressing both proximal and distal
lymphatic flow.
METHODS:: Lymphatic channels were detected using indocyanine green injection and infrared scope
imaging. Sites felt to be adequate for lymphaticovenous anastomosis were accessed through 2-cm skin
incisions under local anesthesia. Using the intravascular stenting method, the authors performed a total of
39 lymphaticovenous anastomoses (15 flow-through, 11 end-to-end, eight end-to-side, two double end-
to-end, two end-to-end/end-to-side, and one pi-type) on both the proximal and distal ends of lymphatic
channels in 14 female patients with upper (n = 2) and lower (n = 12) extremity lymphedema.
RESULTS:: At an average follow-up of 8.9 months, average limb girth decreased 3.6 cm (range, 1.5 to 7
cm) or 11.3 percent (range, 4 to 33 percent). There was a greater reduction in cross-sectional area with
increasing number of lymphaticovenous anastomoses per limb.
CONCLUSIONS:: The intravascular stenting method facilitated multiconfiguration lymphaticovenous
anastomoses capable of decompressing both antegrade and retrograde lymphatic flow. This approach
resulted in durable reduction of both upper and lower extremity lymphedema. As multiconfiguration
lymphaticovenous anastomoses are now technically feasible, the influence of the number of
lymphaticovenous anastomoses and the effectiveness of specific lymphaticovenous anastomosis
configurations for the treatment of lymphedema deserves further study.
PMID: 20195120 [PubMed - in process]
4. Am J Med. 2010 Mar;123(3):e3-4.
Nocturia: an uncommon presentation of lower-limb lymphedema.
Cagnati P, Colombo BM, Gulli R, Russo R, Puppo F, Boccardo F,
Campisi C, Murdaca G.
PMID: 20193816 [PubMed - in process]
5. An Bras Dermatol. 2009 Dec;84(6):659-62. published Feb 2010.
[Yellow nail syndrome: case report]
[Article in Portuguese]
Machado RF, Rosa DJ, Leite CC, Martins Neto MP, Gamonai A.
Universidade Federal de Juiz de Fora, MG, Brasil. ronaldofigueiredo@hotmail.com
The yellow nail syndrome is a rare disease, in which there is a triad of lymphedema, pleural effusion and
slow-growing dystrophic yellow nails. Many associations have already been described; among them,
chronic respiratory tract diseases, autoimmune disorders, malignancies and immunodeficiency conditions.
Only one third of cases in the literature show all findings. The case reported next is an example of the
classical triad.
PMID: 20191179 [PubMed - in process]
----------------------
1. Ann Plast Surg. 2010 Mar 11. [Epub ahead of print]
Preservation of Toes in Advanced Lymphedema: An Important Step in the Control of Infection.
Karonidis A, Chen HC.
From the Department of Plastic Surgery, E-Da Hospital/I-Shou University, Yan-Chau Shiang, Kaohsiung
County, Taiwan, Republic of China.
ABSTRACT:: In advanced lymphedema, the most important goal of treatment is the control or
eradication of infection. Toes are the major cause of infection mainly due to lack of space at the webs.
The fibrosis of the soft tissue with impaired circulation of the toes certainly contribute to infection of the
toes, foot, and even proximal to the leg.Between 2004 and 2008, 20 patients with severe lymphedema
and fibrosis of lower limbs were treated with Charles' procedure and included in this study. The toes were
preserved. Excisional therapy is the only choice to decrease the lymphatic load and control the infection.
The toes can be preserved if there is only swelling without previous cellulites or verrucous hyperkeratosis
and neither deformity nor osteomyelitis of the toes. The surgical technique to treat the toes includes (1)
excision of the soft tissue at the dorsum of the toes with preservation of the extensor tendon and its
paratenon, to facilitate the take of skin graft, and (2) preservation of skin flaps at the web spaces. This
avoids contracture at the web spaces and crowding of the toes, improves foot hygiene, and hence
prevents infection.Proper aesthetic and functional results were obtained in all patients and 18 of 20
patients have been free of recurrent infection at 3-years follow-up.In the treatment of advanced
lymphedema of the lower extremity, the toes are the major determinant of future infection after surgery.
For preservation of toes, careful selection of patients and correct surgical procedure are essential for
success.
PMID: 20224333 [PubMed - as supplied by publisher]
2. Lymphology. 2009 Dec;42(4):188-94.
Intermittent pneumatic compression acts synergistically with manual lymphatic drainage in complex
decongestive physiotherapy for breast cancer treatment-related lymphedema.
Szolnoky G, Lakatos B, Keskeny T, Varga E, Varga M, Dobozy A, Kemény L.
Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary. szolnoky@dermall.
hu
The application of intermittent pneumatic compression (IPC) as a part of complex decongestive
physiotherapy (CDP) remains controversial. The aim of this study was to investigate whether the
combination of IPC with manual lymph drainage (MLD) could improve CDP treatment outcomes in
women with secondary lymphedema after breast cancer treatment. A randomized study was undertaken
with 13 subjects receiving MLD (60 min) and 14 receiving MLD (30 min) plus IPC (30 min) followed by
standardized components of CDP including multilayered compression bandaging, physical exercise, and
skin care 10 times in a 2-week-period. Efficacy of treatment was evaluated by limb volume reduction and
a subjective symptom questionnaire at end of the treatment, and one and two months after beginning
treatment. The two groups had similar demographic and clinical characteristics. Mean reductions in limb
volumes for each group at the end of therapy, and at one and two months were 7.93% and 3.06%,
9.02% and 2.9%, and 9.62% and 3.6%, respectively (p < 0.05 from baseline for each group and also
between groups at each measurement). Although a significant decrease in the subjective symptom survey
was found for both groups compared to baseline, no significant difference between the groups was found
at any time point. The application of IPC with MLD provides a synergistic enhancement of the effect of
CDP in arm volume reduction.
PMID: 20218087 [PubMed - in process]
3. Lymphology. 2009 Dec;42(4):176-81.
Axillary web syndrome: nature and localization.
Leduc O, Sichere M, Moreau A, Rigolet J, Tinlot A, Darc S, Wilputte F, Strapart J, Parijs T, Clément
A, Snoeck T, Pastouret F, Leduc A.
Haute Ecole P.H. Spaak, Département de Kinésithérapie, Unité de Lympho-Phlébologie, Bruxelles,
Belgique. oleduc@skynet.be
Axillary Web Syndrome (AWS) is a complication that can arise in patients following treatment for breast
cancer. It is also known variously as syndrome of the axillary cords, syndrome of the axillary adhesion,
and cording lymphedema. The exact origin, presentation, course, and treatment of AWS is still largely
undefined. Because so little is known about AWS, we undertook a case series study consisting of 15
women who had undergone breast cancer surgery and presented with AWS. All subjects received a
clinical examination which included body size determination and detailed measurements of the size and
location of the cords. The cords were found to originate from the axilla, continue on the medial aspect of
the arm up to the epitrochlea region, then to the anteromedian aspect of the forearm, and finally reaching
the base of the thumb. The cords averaged approximately 44% of the limb length. Correlation of the cord
location with anatomical studies shows that in fact this path follows the specific course taken by the
antero-radial pedicle which arises at the anterior aspect of the elbow from the brachial medial pedicule to
anastomose in the axilla at the level of the lateral thoracic chain nodes. Although our series is small, the
correspondence between the physical findings and the anatomical studies strongly supports the notion that
the cords are lymphatic in origin.
PMID: 20218085 [PubMed - in process]
4. Lymphology. 2009 Dec;42(4):152-60.
Lymphedema-distichiasis syndrome without FOXC2 mutation: evidence for chromosome 16 duplication
upstream of FOXC2.
Witte MH, Erickson RP, Khalil M, Dellinger M, Bernas M, Grogan T, Nitta H, Feng J, Duggan D, Witte
CL.
Department of Surgery, University of Arizona College of Medicine, Tucson, AZ 85724-5200, USA.
lymph@email.arizona.edu
A patient with the classical phenotype of Lymphedema-Distichiasis syndrome (OMIM 153400) is
described who showed no mutations in the sequence of FOXC2. Accordingly, a Gene Chip 250k array
analysis was undertaken with dense SNP genotyping of the genomic region surrounding the FOXC2
locus on Chromosome 16 followed by copy number evaluation by real time PCR. The latter assay
showed evidence of a duplicated region 5' of FOXC2 that could be causative for the patient's striking
phenotype, which included both distichiasis and a hyperplastic refluxing lymphatic vascular and lymph
node phenotype associated with pubertal onset lymphedema, scoliosis and strabismus.
PMID: 20218083 [PubMed - in process]
1. Dermatology. 2010 Mar 20. [Epub ahead of print]
Leg Ulceration in Rheumatoid Arthritis - An Underreported Multicausal Complication with Considerable
Morbidity: Analysis of Thirty-Six Patients and Review of the Literature.
Seitz CS, Berens N, Bröcker EB, Trautmann A.
Departments of Dermatology, Venereology and Allergology, University of Würzburg, Würzburg,
Germany.
Background: Rheumatoid arthritis (RA) is a systemic inflammatory disease which may present with extra-
articular symptoms, including cutaneous manifestations. Ulcerated rheumatoid nodules, necrotic vasculitic
lesions and pyoderma gangrenosum are fairly characteristic and well-recognized causes of skin ulcers in
RA. However, most RA patients develop leg ulcers due to other pathophysiological factors posing a
diagnostic and therapeutic challenge and leading to considerable morbidity.
Methods: A retrospective chart analysis of all patients with RA and leg ulcers hospitalized at our
Dermatology Department between January 1998 and March 2008 was performed to evaluate risk
factors and identify underlying conditions that predispose RA patients to the development of leg ulcers.
Results: A total of 36 patients with RA and leg ulcers were identified. Three patients presented with
necrotizing vasculitis and 2 with pyoderma gangrenosum. Chronic venous insufficiency was diagnosed as
the underlying cause of leg ulcers in 8 patients, peripheral arterial disease in 4 patients, and combined
arterial and venous malfunction in 3 patients. Five patients suffered from pressure ulcers. Interestingly, in
11 patients (31%) other underlying causes besides constricted mobility followed by secondary
lymphedema could not be identified, and these ulcers were classified as 'inactivity leg ulcers'.
Conclusions: The majority of leg ulcers in patients with RA are due to underlying venous/arterial
malfunction while vasculitic or traumatic ulcers are less common. Additionally, we identified a relevant
subgroup of patients with 'inactivity ulcers' due to impaired mobility and consecutive lymphedema.
Morphology and localization of ulcerations as well as duplex sonography provide the most important
clues for accurate diagnosis, ensuring adequate treatment. Copyright © 2010 S. Karger AG, Basel.
PMID: 20332595 [PubMed - as supplied by publisher]
1. Microsurgery. 2010 Mar 16. [Epub ahead of print]
Microsurgery for lymphedema: Clinical research and long-term results.
Campisi C, Bellini C, Campisi C, Accogli S, Bonioli E, Boccardo F.
Department of Surgery, Unit of Lymphatic Surgery and Microsurgery, San Martino Hospital, University
of Genoa, Italy.
Objectives: To report the wide clinical experience and the research studies in the microsurgical treatment
of peripheral lymphedema.
Methods: More than 1800 patients with peripheral lymphedema have been treated with microsurgical
techniques. Derivative lymphatic microvascular procedures recognize today its most exemplary
application in multiple lymphatic-venous anastomoses (LVA). In case of associated venous disease
reconstructive lymphatic microsurgery techniques have been developed. Objective assessment was
undertaken by water volumetry and lymphoscintigraphy.
Results: Subjective improvement was noted in 87% of patients. Objectively, volume changes showed a
significant improvement in 83%, with an average reduction of 67% of the excess volume. Of those
patients followed-up, 85% have been able to discontinue the use of conservative measures, with an
average follow-up of more than 10 years and average reduction in excess volume of 69%. There was a
87% reduction in the incidence of cellulitis after microsurgery.
Conclusions: Microsurgical LVA have a place in the treatment of peripheral lymphedema, and should be
the therapy of choice in patients who are not sufficiently responsive to nonsurgical treatment. (c) 2010
Wiley-Liss, Inc. Microsurgery, 2010.
PMID: 20235160 [PubMed - as supplied by publisher]
2. Cancer Res. 2010 Mar 16. [Epub ahead of print]
Imaging of Human Lymph Nodes Using Optical Coherence Tomography: Potential for Staging Cancer.
McLaughlin RA, Scolaro L, Robbins P, Hamza S, Saunders C, Sampson DD.
Authors' Affiliations: Optical + Biomedical Engineering Laboratory, School of Electrical, Electronic, and
Computer Engineering and School of Surgery, University of Western Australia, Crawley, Western
Australia, Australia; and PathWest, QEII Medical Centre and Sir Charles Gairdner Hospital, Nedlands,
Western Australia, Australia.
Histologic assessment is the gold standard technique for the identification of metastatic involvement of
lymph nodes in malignant disease, but can only be performed ex vivo and often results in the unnecessary
excision of healthy lymph nodes, leading to complications such as lymphedema. Optical coherence
tomography (OCT) is a high-resolution, near-IR imaging modality capable of visualizing microscopic
features within tissue. OCT has the potential to provide in vivo assessment of tissue involvement by
cancer. In this morphologic study, we show the capability of OCT to image nodal microarchitecture
through an assessment of fresh, unstained ex vivo lymph node samples. Examples include both benign
human axillary lymph nodes and nodes containing metastatic breast carcinoma. Through accurate
correlation with the histologic gold standard, OCT is shown to enable differentiation of lymph node tissue
from surrounding adipose tissue, reveal nodal structures such as germinal centers and intranodal vessels,
and show both diffuse and well circumscribed patterns of metastatic node involvement. Cancer Res; 70
(7); 2579-84.
PMID: 20233873 [PubMed - as supplied by publisher]
3. Arch Dermatol. 2010 Mar;146(3):337-42.
Large nodular plaque on leg in the setting of chronic lymphedema--quiz case. Angiosarcoma in the setting
of familial lymphedema.
Cronin H, Mowad C, Ferringer T.
Geisinger Medical Center, Danville, Pennsylvania, USA.
PMID: 20231513 [PubMed - in process]
1. Lymphology. 2009 Dec;42(4):188-94.Published March 2010
Intermittent pneumatic compression acts synergistically with manual lymphatic drainage in complex
decongestive physiotherapy for breast cancer treatment-related lymphedema.
Szolnoky G, Lakatos B, Keskeny T, Varga E, Varga M, Dobozy A, Kemény L.
Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary. szolnoky@dermall.
hu
The application of intermittent pneumatic compression (IPC) as a part of complex decongestive
physiotherapy (CDP) remains controversial. The aim of this study was to investigate whether the
combination of IPC with manual lymph drainage (MLD) could improve CDP treatment outcomes in
women with secondary lymphedema after breast cancer treatment. A randomized study was undertaken
with 13 subjects receiving MLD (60 min) and 14 receiving MLD (30 min) plus IPC (30 min) followed by
standardized components of CDP including multilayered compression bandaging, physical exercise, and
skin care 10 times in a 2-week-period. Efficacy of treatment was evaluated by limb volume reduction and
a subjective symptom questionnaire at end of the treatment, and one and two months after beginning
treatment. The two groups had similar demographic and clinical characteristics. Mean reductions in limb
volumes for each group at the end of therapy, and at one and two months were 7.93% and 3.06%,
9.02% and 2.9%, and 9.62% and 3.6%, respectively (p < 0.05 from baseline for each group and also
between groups at each measurement). Although a significant decrease in the subjective symptom survey
was found for both groups compared to baseline, no significant difference between the groups was found
at any time point. The application of IPC with MLD provides a synergistic enhancement of the effect of
CDP in arm volume reduction.
PMID: 20218087 [PubMed - in process]
1. Nucl Med Commun. 2010 Mar 2. [Epub ahead of print]
Intradermal lymphoscintigraphy at rest and after exercise: a new technique for the functional assessment of
the lymphatic system in patients with lymphoedema.
Tartaglione G, Pagan M, Morese R, Cappellini GA, Zappalà AR, Sebastiani C, Paone G, Bernabucci V,
Bartoletti R, Marchetti P, Marzola MC, Naji M, Rubello D.
aUnit of Nuclear Medicine, Cristo Re Hospital bUnit of Medical and Dermatologic Oncology cUnit of
Oncological Rehabilitation, Istituto Dermopatico dell'Immacolata, IDI-IRCCS dUnit of Medical
Oncology, Sant'Andrea Hospital, Rome eDepartment of Nuclear Medicine, PET Centre, Radiology,
Medical Physics, Santa Maria della Misericordia Hospital, Rovigo, Italy fDepartment of Nuclear
Medicine, Hammersmith Hospital, London, UK.
AIM: The aim of this study was to evaluate the effect of implementing a new technique, intradermal
injection lymphoscintigraphy, at rest and after muscular exercise on the functional assessment of the
lymphatic system in a group of patients with delayed or absent lymph drainage.
METHODS: We selected 44 patients (32 women and 12 men; 15 of 44 with upper limb and 29 of 44
with lower limb lymphoedema). Thirty of 44 patients had bilateral limb lymphoedema and 14 of 44 had
unilateral disease; 14 contralateral normal limbs were used as controls. Twenty-three patients had
secondary lymphoedema after lymphadenectomy and the remaining 21 had idiopathic lymphoedema.
Each of the 44 patients was injected with 50 MBq (0.3-0.4 ml) of Tc-albumin-nanocolloid, which was
administered intradermally at the first interdigital space of the affected limb. Two planar static scans were
performed using a low-energy general-purpose collimator (acquisition matrix 128x128, anterior and
posterior views for 5 min), and in which drainage was slow or absent, patients were asked to walk or
exercise for 2 min. A postexercise scan was then performed to monitor and record the tracer pathway
and the tracer appearance time (TAT) in the inguinal or axillary lymph nodes.
RESULTS: The postexercise scans showed that (i) 21 limbs (15 lower and six upper limbs) had
accelerated tracer drainage and tracer uptake in the inguinal and/or axillary lymph nodes. Two-thirds of
these showed lymph stagnation points; (ii) 27 limbs had collateral lymph drainage pathways; (iii) in 11
limbs, there was lymph drainage into the deeper lymphatic channels, with unusual uptake in the popliteal
or antecubital lymph nodes; (iv) six limbs had dermal backflow; (v) three limbs did not show lymph
drainage (TAT=not applicable). TAT=15+/-3 min, ranging from 12 to 32 min in limbs with lymphoedema
versus 5+/-2 min, ranging from 1 to 12 min in the contralateral normal limbs (P<0.001).
CONCLUSION: Intradermal injection lymphoscintigraphy gives a better imaging of the lymph drainage
pathways in a shorter time, including cases with advanced lymphoedema. In some patients with
lymphoedema, a 2-min exercise can accelerate tracer drainage, showing several compensatory
mechanisms of lymph drainage. The effect of the exercise technique on TAT and lymphoscintigraphy
findings could result in a more accurate functional assessment of lymphoedema patients.
PMID: 20215978 [PubMed - as supplied by publisher]
2. J Neurol Phys Ther. 2010 Mar;34(1):41-9.
Rehabilitation postfacial reanimation surgery after removal of acoustic neuroma: a case study.
Wilson CM, Ronan SL.
Department of Physical and Occupational Therapy (C.M.W.), William Beaumont Hospital, Troy,
Michigan; Department of Physical Therapy (C.M.W.), School of Health Sciences, Oakland University in
Rochester, Michigan; and Department of Physical Therapy (S.R.), New York Medical College, School
of Public Health, Valhalla, New York.
BACKGROUND AND PURPOSE:: Facial paralysis can have a significant negative impact on an
individual's social, physical, and emotional well-being; however, little information has been reported on the
efficacy of physical therapy interventions for this condition. The purpose of this case study was to
describe the details of a physical therapy evaluation and intervention for a patient who underwent facial
muscle transfer after resection of acoustic neuroma.
CASE DESCRIPTION:: A 29-year-old woman underwent left-sided facial reanimation surgery, which
included transplantation of the temporalis muscle and platysma muscle to the corner of the mouth.
INTERVENTION:: The patient received 30 sessions of physical therapy that included electrical
stimulation, biofeedback, lymphatic drainage, home exercises and facial stretching, and scar management.
OUTCOMES:: The patient exhibited an improvement in the Composite score of the Sunnybrook Facial
Grading System from 17 to 41. She was able to regain function of the left side of her face with gains in
expressions of smiling, frowning, and puckering, but symmetry was not completely restored. The patient
had chronic difficulty with left-sided lymphedema, requiring frequent manual lymphatic drainage.
DISCUSSION:: Data from this case study suggest that physical therapy management improves functional
outcomes for individuals with postoperative changes in facial motor function from facial reanimation
surgery. Further research is required to explore factors that influence the rate and extent of recovery
derived from physical therapy interventions.
PMID: 20212367 [PubMed - in process]
3. Zhonghua Zheng Xing Wai Ke Za Zhi. 2009 Nov;25(6):433-6.
[Interstitial high-resolution MR lymphangiography in patients with lower extremity lymphedema][Article in
Chinese]
Ren YQ, Lu Q, Cao WG.
Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011,
China.
OBJECTIVE: To assess the feasibility of interstitial magnetic resonance lymphangiography (IMRL) with
intracutaneous injection of gadobenate dimeglumine--a commercially available, non-ionic, extracellular
paramagnetic contrast agent.
METHODS: We studied 10 patients with lower extremity lymphedema. A mixture of 7.5 ml gadobenate
dimeglumine and 0.5 ml 2% lidocaine were evenly subdivided into 8 portions and injected
intracutaneously into each web space of both feet. For IMRL, a 3D fast spoiled gradient-recalled echo
T1-weighted images with a fat saturation technique (T1 high resolution isotropic volume excitation,
THRIVE) was performed.
RESULTS: The beaded appearance of lymphatic vessels extending from the injection site were detected
in 11 of 12 lower legs and the best delineation of lymphatic vessels was present at 15-30 minutes after
injection. In 6 of 12 affected thighs, lymphatic vessels could be also visualized with the strongest
enhancement at 45 minutes.
CONCLUSION: IMRL is a safe and technically feasible new method which can effectively visualize the
pathological lymphatic vessels in lower extremity lymphedema.
PMID: 20209934 [PubMed - in process]
Large Nodular Plaque on Leg in the Setting of Chronic Lymphedema—Diagnosis
Arch Dermatol.2010; 146: 337-342.
1. Pediatr Dermatol. 2010 Jan 1;27(1):58-61.
Lymphatic compression by sclerotic patches of morphea: an original mechanism of lymphedema in a child.
Samimi M, Maruani A, Machet MC, Baulieu F, Machet L, Lorette G.
University François Rabelais, Tours, France.
Lymphedema in children is mostly primary, due to lymphatic hypoplasia. Secondary lymphedema is
caused by lymphatic injury or obstruction. We report the case of a child that developed a lymphedema of
the left upper and lower extremities, with a simultaneous onset of ipsilateral hemicorporal morphea. We
concluded that lymphatic obstruction was due to sclerosis from morphea. This is a unique, rarely reported
mechanism of lymphedema. Lymphoscintigraphy revealed attenuated lymphatic flow in the left upper and
lower limbs. Systemic corticosteroids were associated with slow improvement in the sclerotic patches.
We simultaneously noticed an improvement in the lymphedema of limbs. Repeat lymphoscintigraphy
revealed dramatically improved lymphatic function. This case suggests that at least in some cases
lymphedema may be caused by morphea.
PMID: 20199412 [PubMed - in process]
1. Am J Med Genet A. 2010 Mar;152A(3):737-40.
c. 595-596 insC of FOXC2 underlies lymphedema, distichiasis, ptosis, ankyloglossia, and Robin
sequence in a Thai patient.
Tanpaiboon P, Kantaputra P, Wejathikul K, Piyamongkol W.
Faculty of Medicine, Department of Pediatrics, Chiang Mai University, Chiang Mai, Thailand.
tanpaiboon1@yahoo.com
Lymphedema-distichiasis syndrome is a rare primary lymphedema inherited as an autosomal dominant
disorder. The characteristic features consist of late onset-lymphedema and distichiasis together with other
occasionally seen features including varicose vein, cleft palate, ptosis, and congenital heart diseases.
FOXC2 is the gene found to be associated with this syndrome. We report here the first Thai patient who
has characteristic features of this syndrome and the infrequently described features including
ankyloglossia, and Robin sequence which consists of glossoptosis, cleft palate, and micrognathia.
Mutation analysis of FOXC2 revealed c. 595-596 insC. (c) 2010 Wiley-Liss, Inc.
PMID: 20186799 [PubMed - in process]
2. Cases J. 2009 Mar 23;2:6625.
Pneumatic compression devices for in-home management of lymphedema: two case reports.
[No authors listed]
ABSTRACT : The two patients in this case series had experienced long-term difficulty controlling
lymphedema at home. Both patients had used numerous home therapies, including older-generation
intermittent pneumatic compression devices, without success. The Flexitouch(R) system, an advanced
pneumatic device, was prescribed to assist them with in-home efforts by providing therapy to their
affected limbs in addition to the lower trunk area for the patient with lymphedema of the lower extremity;
and the trunk, chest wall, and shoulder areas for the patient with lymphedema of the upper extremity.
Both patients achieved successful home maintenance of lymphedema, as judged by limb volume, clinical
observations, and subjective patient impressions, after incorporating the Flexitouch(R) system. Neither
patient experienced the deleterious effects (worsening genital edema; fibrotic cuff development) that they
had experienced with the older-generation intermittent pneumatic compression devices they had
previously used. Incorporating the Flexitouch(R) system as part of maintenance may improve success for
lymphedema patients who have previously struggled with in-home management.
PMID: 20184680 [PubMed - in process]
3. J Lymphoedema. 2009 Apr 1;4(1):14-18.
30-MONTH POST-BREAST CANCER TREATMENT LYMPHOEDEMA.
Armer JM, Stewart BR, Shook RP.
Jane M Armer, Professor, Sinclair School of Nursing (SSON), Director, Nursing Research, Ellis Fischel
Cancer Center; Bob R Stewart, Professor Emeritus, College of Education, Adjunct Clinical Professor,
SSON; Robin P Shook, Project Development Specialist, Lymphedema Research Project, SSON,
University of Missouri, Columbia, USA.
BACKGROUND: Quantification of lymphoedema (LE) has been problematic, and the reported
incidence of LE varies greatly among women treated with surgery and radiation for breast cancer. AIMS:
This study aims to describe LE occurrence over time among breast cancer survivors using four diagnostic
criteria based on three measurement techniques.
METHODS: Limb volume and symptom assessment data were followed after surgery every three months
for 12 months, then every six months for 30 months. Limb volume changes (LVC) were measured by
circumferences and by perometry, and by symptom experience via interview. Standard survival analysis
methods identified when the criteria indicating LE were met.
RESULTS: Trends in LE occurrence are reported for data from 211 participants. At 30 months post-
treatment, LE incidence ranged from 41-91%, with 2cm being the highest estimation method and self-
reported signs and symtoms (SS) the lowest.
CONCLUSIONS: This 30-month analysis supports the previous 12-month analysis in finding the 2cm
criteria as the most liberal definition of LE. Self-reporting of heaviness and swelling, along with 10%
LVC, represented the most conservative definitions (41% and 45%, respectively).
PMID: 20182653 [PubMed]
4. J Altern Complement Med. 2010 Feb;16(2):145-9.
An integrative treatment for lower limb lymphedema (elephantiasis).
Narahari SR, Aggithaya MG, Prasanna KS, Bose KS.
Department of Ayurveda, Kasaragod, Kerala, India.
PMID: 20180687 [PubMed - in process]
1. Circ Res. 2010 Feb 4. [Epub ahead of print]
Transmural Flow Modulates Cell and Fluid Transport Functions of Lymphatic Endothelium.
Miteva DO, Rutkowski JM, Dixon JB, Kilarski W, Shields JD, Swartz MA.
Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne, Switzerland.
Rationale: Lymphatic transport of peripheral interstitial fluid and dendritic cells (DCs) is important for both
adaptive immunity and maintenance of tolerance to self-antigens. Lymphatic drainage can change rapidly
and dramatically on tissue injury or inflammation, and therefore increased fluid flow may serve as an
important early cue for inflammation; however, the effects of transmural flow on lymphatic function are
unknown.
Objective: Here we tested the hypothesis that lymph drainage regulates the fluid and cell transport
functions of lymphatic endothelium.
Methods and Results: Using in vitro and in vivo models, we demonstrated that lymphatic endothelium is
sensitive to low levels of transmural flow. Basal-to-luminal flow (0.1 and 1 mum/sec) increased lymphatic
permeability, dextran transport, and aquaporin-2 expression, as well as DC transmigration into
lymphatics. The latter was associated with increased lymphatic expression of the DC homing chemokine
CCL21 and the adhesion molecules intercellular adhesion molecule-1 and endothelial selectin. In addition,
transmural flow induced delocalization and downregulation of vascular endothelial cadherin and PECAM-
1 (platelet/endothelial cell adhesion molecule-1). Flow-enhanced DC transmigration could be reversed by
blocking CCR7, intercellular adhesion molecule-1, or endothelial selectin. In an experimental model of
lymphedema, where lymphatic drainage is greatly reduced or absent, lymphatic endothelial expression of
CCL21 was nearly absent.
Conclusions: These findings introduce transmural flow as an important regulator of lymphatic endothelial
function and suggest that flow might serve as an early inflammatory signal for lymphatics, causing them to
regulate transport functions to facilitate the delivery of soluble antigens and DCs to lymph nodes.
PMID: 20133901 [PubMed - as supplied by publisher]
2. Am J Occup Ther. 2010 Jan-Feb;64(1):59-72.
Randomized controlled trial of the Breast Cancer Recovery Program for women with breast cancer-
related lymphedema.
McClure MK, McClure RJ, Day R, Brufsky AM.
Magee-Women's Research Institute, Pittsburgh, PA, USA.
Evidence-based exercise and relaxation recommendations for people with breast cancer-related
lymphedema (BCRL) are needed. We report a randomized controlled study of one program, designed to
achieve synergistic improvements in physical and emotional BCRL symptoms. People in the treatment
group received an exercise and relaxation program, The Breast Cancer Recovery Program (N=16). The
control participants (N=16) continued with health professionals' recommendations. Participants were
tested at entry, 2.5 weeks, 5 weeks, and 3 months. Treatment group participants, compared with control
participants, demonstrated significant treatment effects for improved bioimpedance z, arm flexibility,
quality of life, mood at 3 months, and weight loss. Adherence was high for this safe and effective
program, which improved lymphedema physical and emotional symptoms.
PMID: 20131565 [PubMed - in process]
------------------------------
1. Angiology. 2010 Feb 10. [Epub ahead of print]
Epidemiological Data and Comorbidities of 428 Patients Hospitalized With Erysipelas.
Pereira de Godoy JM, Massari PG, Rosinha MY, Brandão RM, Foroni Casas AL.
The aim of this study was to evaluate the epidemiological data and the main comorbidities of patients with
erysipelas admitted to a tertiary hospital. All patients admitted due to erysipelas during the period from
1999 to 2008 were included in a prospective and cross-sectional study. The Fisher exact test and logistic
regression were used for statistical analysis. A total of 428 individuals were hospitalized with 41
rehospitalizations; 51.17% of the patients were women, the mean age was 58.6 years. The main
comorbidities were hypertension (51.6%), diabetes mellitus (41.6%), chronic venous insufficiency
(36.2%), other cardiovascular diseases (33.2%) including angina, peripheral arterial insufficiency, acute
myocardial infarction, and strokes, obesity (12.1%), chronic renal failure (6.8%), neoplasms (4.9%),
cirrhosis (4.9%), chronic lymphedema (4.2%), and leg ulcers (2.6%). Erysipelas is a seasonal disease
that affects adults and the elderly people, has a repetitive nature, and is associated with comorbidities.
PMID: 20147345 [PubMed - as supplied by publisher]
------------------------------
1. Lymphat Res Biol. 2009 Dec;7(4):239-45.
Topography of accumulation of stagnant lymph and tissue fluid in soft tissues of human lymphedematous
lower limbs.
Olszewski WL, Jain P, Ambujam G, Zaleska M, Cakala M.
1 Department of Surgical Research and Transplantology, Medical Research Center , Polish Academy of
Sciences, Warsaw, Poland .
Abstract Background: The knowledge of where does excess tissue fluid accumulate in obstructive
lymphedema is indispensable for rational physical therapy. However, it has so far been limited to that
obtained from lymphoscintigraphic, ultrasonographic, and MR images. None of these modalities provide
composite pictures of dilated lymphatics and expanded tissue space in dermis, subcutis, and muscles. So
far, only anatomical dissection and histological processing of biopsy material can visualize the tissue
lymphatic network and the sites of accumulation of the excess of mobile tissue fluid.
Methods and Results: We visualized the "tissue fluid and lymph" space in skin and subcutaneous tissue of
foot, calf, and thigh in various stages of lymphedema in specimens obtained during lymphatic microsurgical
procedures or tissue debulking, using special staining techniques. The volume of accumulated fluid was
calculated from the densitometric data of stained tissue sections. We found that lymph was present only in
the subepidermal lymphatics, whereas the collecting trunks were obliterated in most cases. Mobile tissue
fluid accumulated in the spontaneously formed spaces in the subcutaneous tissue, around small veins and
above and underneath muscular fascia. Deformation of subcutaneous tissue by free fluid led to formation
of interconnecting channels. The volume of subcutaneous free fluid ranged around 50% of total tissue
volume and there were no significant differences in various stages of lymphedema. This could be
explained by the presence of thick layers of subcutaneous fat tissue even in the most advanced stage of
lymphedema.
Conclusions: In lymphedema caused by obliteration of collecting trunks, lymph is present only in the
subepidermal lymphatics, whereas the bulk of stagnant tissue fluid accumulates in the subcutaneous tissue
and above and beneath muscular fascia. These findings should be useful for designing pneumatic devices
for limb massage as well as for rational manual lymphatic drainage in terms of sites of massage and level
of applied external pressures.
PMID: 20143923 [PubMed - in process]
---------------------------
1. Lymphat Res Biol. 2009 Dec;7(4):239-45.
Topography of accumulation of stagnant lymph and tissue fluid in soft tissues of human lymphedematous
lower limbs.
Olszewski WL, Jain P, Ambujam G, Zaleska M, Cakala M.
1 Department of Surgical Research and Transplantology, Medical Research Center , Polish Academy of
Sciences, Warsaw, Poland .
Abstract Background: The knowledge of where does excess tissue fluid accumulate in obstructive
lymphedema is indispensable for rational physical therapy. However, it has so far been limited to that
obtained from lymphoscintigraphic, ultrasonographic, and MR images. None of these modalities provide
composite pictures of dilated lymphatics and expanded tissue space in dermis, subcutis, and muscles. So
far, only anatomical dissection and histological processing of biopsy material can visualize the tissue
lymphatic network and the sites of accumulation of the excess of mobile tissue fluid.
Methods and Results: We visualized the "tissue fluid and lymph" space in skin and subcutaneous tissue of
foot, calf, and thigh in various stages of lymphedema in specimens obtained during lymphatic microsurgical
procedures or tissue debulking, using special staining techniques. The volume of accumulated fluid was
calculated from the densitometric data of stained tissue sections. We found that lymph was present only in
the subepidermal lymphatics, whereas the collecting trunks were obliterated in most cases. Mobile tissue
fluid accumulated in the spontaneously formed spaces in the subcutaneous tissue, around small veins and
above and underneath muscular fascia. Deformation of subcutaneous tissue by free fluid led to formation
of interconnecting channels. The volume of subcutaneous free fluid ranged around 50% of total tissue
volume and there were no significant differences in various stages of lymphedema. This could be
explained by the presence of thick layers of subcutaneous fat tissue even in the most advanced stage of
lymphedema.
Conclusions: In lymphedema caused by obliteration of collecting trunks, lymph is present only in the
subepidermal lymphatics, whereas the bulk of stagnant tissue fluid accumulates in the subcutaneous tissue
and above and beneath muscular fascia. These findings should be useful for designing pneumatic devices
for limb massage as well as for rational manual lymphatic drainage in terms of sites of massage and level
of applied external pressures.
PMID: 20143923 [PubMed - in process]
2. Lymphat Res Biol. 2009 Dec;7(4):215-9.
Lymphatics in human lymphatic filariasis: in vitro models of parasite-induced lymphatic remodeling.
Bennuru S, Nutman TB.
Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases , Bethesda,
Maryland.
Abstract Lymphatic filariasis characterized by the dysfunction of the lymphatics can lead to severe (and
often) irreversible lymphedema and elephantiasis. Decades of research in the field shows that the
establishment of the adult parasites in the lymphatics triggers a cascade of events that ultimately results in
tissue scarring and fibrosis. In this minireview, we focus on the studies addressing the mechanisms
underlying the parasite-induced lymphatic dilatation that suggests parasite-induced lymphatic remodeling
and lymphangiogenesis may be the prelude towards developing chronic and irreversible filarial pathology.
PMID: 20143920 [PubMed - in process
3. Lymphat Res Biol. 2009 Dec;7(4):205-14.
New approaches to lymphatic imaging.
Lucarelli RT, Ogawa M, Kosaka N, Turkbey B, Kobayashi H, Choyke PL.
Molecular Imaging Program, National Cancer Institute , Bethesda, Maryland.
Abstract Accurate imaging of the lymphatic system can aid in cancer staging, optimize surgical procedures
to reduce lymphedema, and may one day be a means of delivering intralymphatic therapy. The Sentinel
Lymph Node (SLN) concept has been pivotal in driving new imaging techniques. Metastasis to a SLN is
a critical indicator of advanced disease. However, presently, few tools are available for imaging the
lymphatics, and even fewer are available for locating the SLN for biopsy. Recently, new macromolecular
agents, including gadolinium-labeled dendrimers, fluorescent quantum dots, and fluorescently-labeled
immunoglobins, have been used to image the lymphatics and SLN with MRI and optical techniques, and
new fluorescent nanoparticles such as upconverting nanocrystals are potential future agents. Additionally,
multi-modality probes combining two modalities such as optical/MR dendrimers have been designed to
provide both preoperative imaging, and intraoperative guidance during lymph node resections. These
probes can map the lymphatic system for maximal therapeutic benefit while minimizing complications such
as lymphedema. Advances in the understanding of the molecular mechanisms of lymphangiogenesis and
lymphatic spread of tumors offer the opportunity for more targeted imaging of the lymphatic system.
Additionally, these imaging agents could be used as powerful research tools for tracking immunological
cells and monitoring the immune response as well as providing the means to deliver lymphatic-targeted
therapies. The future holds great promise for the translation of these methods to the clinic.
PMID: 20143919 [PubMed - in process]
4. Ann Surg Oncol. 2010 Feb 6. [Epub ahead of print]
The Effect of Providing Information about Lymphedema on the Cognitive and Symptom Outcomes of
Breast Cancer Survivors.
Fu MR, Chen CM, Haber J, Guth AA, Axelrod D.
College of Nursing, New York University, New York, NY, USA, mf67@nyu.edu.
BACKGROUND: Despite recent advances in breast cancer treatment, breast cancer related
lymphedema (BCRL) continues to be a significant problem for many survivors. Some BCRL risk factors
may be largely unavoidable, such as mastectomy, axillary lymph node dissection (ALND), or radiation
therapy. Potentially avoidable risk factors unrelated to breast cancer treatment include minor upper
extremity infections, injury or trauma to the arm, overuse of the limb, and air travel. This study investigates
how providing information about BCRL affects the cognitive and symptomatic outcome of breast cancer
survivors.
METHODS: Data were collected from 136 breast cancer survivors using a Demographic and Medical
Information interview instrument, a Lymphedema Education Status interview instrument, a Knowledge
Test for cognitive outcome, and the Lymphedema and Breast Cancer Questionnaire for symptom
outcome. Data analysis included descriptive statistics, t tests, chi-square (chi(2)) tests, and regression.
RESULTS: BCRL information was given to 57% of subjects during treatment. The mean number of
lymphedema-related symptoms was 3 symptoms. Patients who received information reported significantly
fewer symptoms and scored significantly higher in the knowledge test. After controlling for confounding
factors, patient education remains an additional predictor of BCRL outcome. Significantly fewer women
who received information about BCRL reported swelling, heaviness, impaired shoulder mobility, seroma
formation, and breast swelling.
CONCLUSIONS: Breast cancer survivors who received information about BCRL had significantly
reduced symptoms and increased knowledge about BCRL. In clinical practice, breast cancer survivors
should be engaged in supportive dialogues so they can be educated about ways to reduce their risk of
developing BCRL.
PMID: 20140528 [PubMed - as supplied by publisher]
1. Cancer. 2010 Mar 24. [Epub ahead of print]
A phase I study to assess the feasibility and oncologic safety of axillary reverse mapping in breast cancer
patients.
Bedrosian I, Babiera GV, Mittendorf EA, Kuerer HM, Pantoja L, Hunt KK, Krishnamurthy S, Meric-
Bernstam F.
Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston
Texas.
BACKGROUND:: Axillary reverse mapping (ARM) is a novel technique to preserve upper extremity
lymphatics that may reduce the incidence of lymphedema after axillary lymph node dissection. Early
reports have suggested that ARM lymph nodes do not contain metastatic disease from breast cancer;
however, these studies were conducted in early stage patients with low likelihood of lymph node
metastasis. This study reported a phase 1 trial conducted in patients with cytologically documented
axillary metastasis undergoing axillary lymph node dissection to determine the feasibility and oncologic
safety of ARM.
METHODS:: Thirty patients, 23 (77%) of whom received preoperative therapy (chemotherapy in 22
patients and hormonal therapy in 1 patient), were enrolled. Blue dye was injected in the upper inner
ipsilateral arm. The presence of blue lymphatics was noted, and blue lymph nodes were sent separately
for pathologic evaluation.
RESULTS:: The average time between blue dye injection and axillary exposure was 35 minutes (range,
15-60 minutes). Blue lymphatics were identified in 21 patients (70%) and blue lymph nodes in 15 patients
(50%). The median number of ARM lymph nodes was 1 (range, 0-3 lymph nodes) and the median
number of axillary lymph nodes was 26 (range, 6-47 lymph nodes). Axillary metastases were noted in
60% (18 of 30) of patients. Of 11 patients who had axillary metastasis and at least 1 ARM lymph node
identified, 2 (18%) had metastasis to the ARM lymph node.
CONCLUSIONS:: ARM appears to be a feasible technique with which to identify upper arm lymphatics
during axillary surgery. However, the high prevalence of disease involving ARM lymph nodes in this small
cohort suggested that preservation of these lymphatics is not oncologically safe in women with
documented axillary lymph node metastasis from breast cancer. Cancer 2010. (c) 2010 American
Cancer Society.
PMID: 20336790 [PubMed - as supplied by publisher]
2. Ann Surg Oncol. 2010 Mar 25. [Epub ahead of print]
Prospective Assessment of Postoperative Complications and Associated Costs Following Inguinal Lymph
Node Dissection (ILND) in Melanoma Patients.
Chang SB, Askew RL, Xing Y, Weaver S, Gershenwald JE, Lee JE, Royal R, Lucci A, Ross MI,
Cormier JN.
Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX,
USA.
BACKGROUND: We prospectively assessed the incidence, risk factors, and costs associated with
wound complications and lymphedema in melanoma patients undergoing inguinal lymph node dissection
(ILND).
MATERIALS AND METHODS: A total of 53 melanoma patients were accrued to 2 trials (June 2005
to July 2008) that included prospective evaluations of postoperative complications; 30-day wound
complications included infection, seroma, and/or dehiscence. There were 20 patients who underwent limb
volume measurement and completed a 19-item lymphedema symptom assessment questionnaire
preoperatively and 3 months postoperatively. A multivariate analysis was performed to evaluate potential
risk factors for complications. A microcosting analysis was also performed to evaluate the direct costs
associated with wound complications.
RESULTS: The 30-day wound complications were noted in 77.4% of patients. A BMI >/= 30 (n = 28)
increased the risk for wound complications (odds ratio [OR] = 11.4, 95% confidence interval [95%CI]
1.6-78.5, P = .01), while advanced nodal disease approached significance (OR = 9.0, 95%CI: 0.79-
103.1, P = .08). Other risk factors, including diabetes, smoking, and the addition of a deep pelvic
(iliac/obturator) dissection to ILND, were not significant. Of 20 patients, 9 (45%) developed limb volume
change (LVC) >/=5% at 3 months, with associated mean symptom scores of 6.1 versus 4.6 for those
without LVC. Costs for patients with wound complications were significantly higher than for those without
wound complications.
CONCLUSIONS: Postoperative wound complications and early onset lymphedema occur frequently
following ILND for melanoma. Obesity is an adverse risk factor for 30-day wound complications that can
significantly increase postoperative costs, as is likely the case for advanced disease. Risk reduction
practices and novel treatment approaches are needed to reduce postoperative morbidity.
PMID: 20336388 [PubMed - as supplied by publisher]
1. J Clin Nurs. 2010 Mar 16. [Epub ahead of print]
After axillary surgery for breast cancer - is it safe to take blood samples or give intravenous infusions?
Winge C, Mattiasson AC, Schultz I.
Authors:Charlotte Winge, RN, Division of Surgery, Department of Clinical Sciences, Karolinska Institute
at Danderyd Hospital; Anne-Cathrine Mattiasson, RNT, Professor, Division of Surgery, Department of
Clinical Sciences, Karolinska Institute at Danderyd Hospital and Sophiahemmet University College;
Inkeri Schultz, MD, PhD, Department of Clinical Sciences, Karolinska Institute at Danderyd Hospital and
Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, Stockholm, Sweden.
Aim. To investigate the occurrence of complications after a needle puncture or intravenous injection in the
ipsilateral arm of women who have undergone axillary lymph node clearance for breast cancer.
Background. After axillary lymph node clearance in patients with breast cancer, some women experience
lymphoedema and recurrent infections. To reduce the risk of these postoperative complications, most
women are advised to not have intravenous infusions in, or blood samples taken from, the arm in the
operated side. Very little published data are available regarding the incidence of lymphoedema after
intravenous procedures under clean conditions in the hospital setting. This study set out to investigate the
occurrence of complications after a needle puncture or intravenous injection in the ipsilateral arm of
women who have undergone axillary lymph node clearance for breast cancer is therefore important.
Design. Descriptive. Methods. Self-reported questionnaire. Results. Most of the reported complications
were minor, including itching, bruises and vomiting at the time of the intravenous procedure. The most
serious complication was infection in one patient needing antibiotic treatment and subsequent arm swelling.
Conclusions. This study indicates that if a blood sample is taken or intravenous injection is given
according to the current Swedish guidelines for health care professionals, there should be a very low risk
of complications. Relevance to clinical practice. If intravenous procedures are performed without any
disadvantage in the arm of the operated side in women who have undergone axillary surgery, the clinical
problem of finding a proper vein and the psychological concern of the women can be reduced.
PMID: 20345831 [PubMed - as supplied by publisher]