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Yang K, Ruan M, Li X, Han Y, Li Q, Chen J, Liang Q, Xu H, Li N. Andrographolide promotes lymphangiogenesis and lymphatic vessel remodeling to alleviate secondary lymphedema. Biochem Biophys Res Commun 2024; 723:150179. [PMID: 38820623 DOI: 10.1016/j.bbrc.2024.150179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 05/25/2024] [Indexed: 06/02/2024]
Abstract
Lymphedema, a prevalent, multifaceted, and chronic ailment, is mainly managed through physical manipulation and suffers from a lack of specific pharmacological treatments. Secondary lymphedema is mainly caused by impaired lymphatic drainage. Therapeutic lymphangiogenesis is a promising strategy in the treatment of lymphedema. Andrographolide, a natural product from Andrographis paniculata, is unknown whether andrographolide promotes lymphangiogenesis to improve secondary lymphedema. By using the murine tail lymphedema model, we demonstrated that andrographolide can reduce the thickness of subcutaneous tissue in the mice's tail and enhance lymphatic drainage. Moreover, immunofluorescence staining showed that the number of capillary lymphatic vessels in the ANDRO25 group was significantly more than that in the ANDRO50 and Model groups. Near-infrared lymphography images showed that highlighted sciatic lymph nodes could be seen in the ANDRO25 and ANDRO50 groups. In vitro, andrographolide could promote the proliferation and migration of LEC. In conclusion, andrographolide enhanced the recovery of lymphatic vessels, and promoted lymphatic drainage in the murine tail lymphedema model by promoting the proliferation of lymphatic endothelial cells, thereby reducing the symptoms of lymphedema. This suggested andrographolide may be used as a potential therapeutic drug or medical food ingredient to help patients with secondary lymphedema.
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Affiliation(s)
- Kunru Yang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China; Spine Institute, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China
| | - Ming Ruan
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China; Spine Institute, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China
| | - Xuanru Li
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China; Spine Institute, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China
| | - Yunxi Han
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China; Spine Institute, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China
| | - Qiang Li
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China; Spine Institute, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China
| | - Jinman Chen
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China; Spine Institute, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China
| | - Qianqian Liang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China; Spine Institute, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China
| | - Hao Xu
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China; Spine Institute, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China.
| | - Ning Li
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China; Spine Institute, Shanghai University of Traditional Chinese Medicine, 725 Wan-Ping South Road, Shanghai, 200032, China.
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Braizat O, Jarrar S, El-Debs M, Al-Adwan MAO, Syaj S, Abuzanouneh F, Mohammed M, Mohammedali S, Quazi SJ, Muneer M. Comparing Different Donor Sites After Vascularized Lymph Node Transfer to the Lymphedematous Upper Limb: A Systematic Review and Meta-analysis of Clinical Outcomes. Ann Plast Surg 2024; 93:130-138. [PMID: 38885169 DOI: 10.1097/sap.0000000000003918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
BACKGROUND Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes from a donor site into a limb affected by lymphedema to restore the normal flow of lymphatic fluid. Despite the increasing clinical experience with VLNT, there remains insufficient data to support its routine use in clinical practice. Here, we aim to evaluate the effectiveness and safety of VLNTs for upper limb lymphedema and compare clinical outcomes when using different donor sites. METHODS We carried out a systematic search of the literature through PubMed and Scopus databases for studies on VLNT for upper limb lymphedema. Primary and secondary outcomes included circumference reduction rate (CRR) and infection reduction rate by postoperative cellulitis episodes for the efficacy and safety of VLNT. Pooled analysis was performed using the inverse variance weighting meta-analysis of single means using the meta package in R software. Subgroup analyses were performed for donor and recipient sites, age groups, follow-ups, and symptom durations. Quality assessment was performed using the Newcastle-Ottawa Scale for nonrandomized studies. RESULTS A total of 1089 studies were retrieved from the literature, and 15 studies with 448 upper limb lymphedema patients who underwent VLNT were included after eligibility assessment. The mean CRR was 34.6 (18.8) and the mean postoperative cellulitis episodes per year was 0.71 (0.7). The pooled analysis of CRR was 28.4% (95% confidence interval, 19.7-41.1) and postoperative cellulitis episodes showed a mean of 0.59 (95% confidence interval, 0.36-0.95) using the random-effect model. Subgroup analyses showed significant group differences in recipient site for CRR and postoperative cellulitis episodes with the wrist comprising the highest weights, and patients younger than 50 years showing a lower postoperative infection. CONCLUSIONS Vascularized lymph node transfer using gastroepiploic flaps at the wrists has shown a significant difference in reductions of limb circumference and cellulitis episodes in upper limb lymphedema patients when compared with other donor sites. However, further prospective studies are needed to consolidate this finding.
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Affiliation(s)
- Omar Braizat
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Salma Jarrar
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed El-Debs
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
| | | | - Sebawe Syaj
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Faris Abuzanouneh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mazin Mohammed
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Shiyas Mohammedali
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Sohail Jamiluddin Quazi
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Muneer
- From the Department of Plastic and Reconstructive Surgery, Hamad Medical Corporation, Doha, Qatar
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Pirincci CS, Mete O, Yasa ME, Dalyan M. A comparative evaluation of the efficacy of complete decongestive therapy in the treatment of unilateral breast cancer-related lymphedema with and without metabolic syndrome. Support Care Cancer 2024; 32:473. [PMID: 38949715 PMCID: PMC11217042 DOI: 10.1007/s00520-024-08676-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 06/21/2024] [Indexed: 07/02/2024]
Abstract
AIM This study aimed to investigate the effect of the presence of metabolic syndrome (MetS) on the limb volume and quality of life (QoL) of patients who underwent complex decongestive therapy (CDT) due to unilateral breast cancer-related lymphedema (BCRL). METHODS Forty female patients with unilateral BCRL, of whom 20 had MetS (MetS group) and 20 did not have MetS (control group), were included in the study. The participants received CDT 5 days a week for 3 weeks. The participants' limb volume (percentage of excess volume (PEV) and percentage reduction of excess volume (PREV) was determined using a tape measure, and their QoL was assessed using the Lymphedema Quality of Life questionnaire (LYMQoL) before and after treatment. RESULTS After the treatment, the PEV and PREV values and LYMQoL-symptoms scores of the patients improved (p < 0.05); however, the LYMQoL-function, appearance/body image, mood/emotions, and overall QoL scores did not change in the MetS group (p > 0.05). In the control group, the PEV and PREV values and the LYMQoL-appearance/body image, mood/emotions, and overall QoL scores improved (p < 0.05), but the LYMQoL-symptoms and LYMQoL-function scores did not change (p > 0.05). There was a greater increase in the post-treatment PEV and PREV values of the control group compared to the MetS group (p < 0.001). CONCLUSION The study yielded that CDT was an effective treatment in BCRL with and without MetS; however, the improvement was greater in BCRL cases without MetS than in those with MetS. Therefore, the presence of MetS should be taken into account in the treatment of lymphedema in patients who develop BCRL. TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT05426993. Registered 2022-06-16. https://clinicaltrials.gov/search?cond=NCT05426993.
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Affiliation(s)
- Cansu Sahbaz Pirincci
- University of Health Sciences, Gulhane Faculty of Physiotherapy and Rehabilitation, Ankara, Türkiye
| | - Oguzhan Mete
- University of Health Sciences, Gulhane Faculty of Physiotherapy and Rehabilitation, Ankara, Türkiye.
| | - Mustafa Ertugrul Yasa
- University of Health Sciences, Gulhane Faculty of Physiotherapy and Rehabilitation, Ankara, Türkiye
| | - Meltem Dalyan
- Ankara City Hospital, Physical Medicine and Rehabilitation, Ankara, Türkiye
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Nuwayhid R, Langer S, von Dercks N. [Cost comparison of conservative vs. surgical treatment of chronic lymphedema]. CHIRURGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00104-024-02123-9. [PMID: 38940836 DOI: 10.1007/s00104-024-02123-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/07/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Lymphedema is primarily treated conservatively using complex physical decongestion treatment (CDT). Lymphovenous anastomosis (LVA), vascularized lymph node transplantation (VLNT) and liposuction are available as surgical treatment methods; however, reimbursement in the diagnosis-related groups (DRG) system is sometimes inadequate or only possible following an individual application. The costs of these relatively new surgical procedures have not yet been set in relation to those of CDT. METHOD The costs of conservative treatment were determined in accordance with the guidelines. The costs for LVA, VLNT and liposuction of the upper and lower extremities were estimated on the basis of the DRG reimbursement per case and the expected reduction in conservative measures according to current knowledge. The annual treatment costs were then compared. RESULTS The annual treatment costs of LVA and VLNT are already lower than conservative treatment alone in the second postoperative year. Liposuction reaches this point in the 6th (upper extremity) or 47th postoperative year (lower extremity). CONCLUSION The evidence for the positive effects of lymphatic surgery is still limited; however, it is recognizable that the curative surgical approach can significantly reduce the treatment costs and improve the quality of life of lymphedema patients; however, there is a lack of adequate reflection of the surgical effort in the reimbursement.
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Affiliation(s)
- Rima Nuwayhid
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland.
| | | | - Nikolaus von Dercks
- Bereich Medizinmanagement, Universitätsklinikum Leipzig AöR, Liebigstraße 18, 04103, Leipzig, Deutschland
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Gracia M, Alonso-Espías M, Zapardiel I. Impact of sentinel node use in lymphedema formation among gynecologic cancer patients. Curr Opin Oncol 2024:00001622-990000000-00181. [PMID: 39007239 DOI: 10.1097/cco.0000000000001059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
PURPOSE OF REVIEW The most common surgical procedure associated with lymphedema formation is the regional lymphadenectomy. One of the advantages of sentinel node biopsy is the reduction of the risk of lymphedema formation. The purpose of this review is to collect and analyze the most relevant and recent evidence of the use of sentinel node biopsy and its implication on the development of postoperative lymphedema in gynecological cancer. RECENT FINDINGS The current evidence of the use of sentinel node biopsy in cervical cancer to reduce lymphedema is heterogeneous and more data is needed to establish its role.Sentinel lymph node biopsy in endometrial cancer is a staging procedure with lower surgical complications, as well as lymphedema formation; while the results of prospective trials evaluating its impact on quality of life are still lacking.Sentinel lymph node biopsy in vulvar cancer minimizes the need for extensive dissection and reduces the incidence of complications associated with overharvesting of lymph nodes such as lymphedema without compromising oncological outcomes. SUMMARY The prevalence of lymphedema in gynecological cancer varies based on the surgical treatment or additional therapies applied. Over the past years, one of the most important surgical modifications to decrease lymphedema formation has been implementation of sentinel lymph node technique mainly in vulvar cancer patients.
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Affiliation(s)
- Myriam Gracia
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
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Santos APO, Rizzi SKLDA, Facina G, Nazário ACP, Elias S. Translation and Cross-Cultural Adaptation of the LYMPH-ICF Instrument for Lymphedema into Portuguese/Brazil. Rev Bras Enferm 2024; 77:e20230137. [PMID: 38896704 PMCID: PMC11178305 DOI: 10.1590/0034-7167-2023-0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/02/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVE The aim of this study is to cross-culturally adapt the Lymphoedema Functioning, Disability and Health Questionnaire Lymphoedema (LYMPH-ICF) instrument into Brazilian Portuguese and conduct a pilot application (n = 10), without psychometric pretensions. METHOD Methodological research was conducted, following the steps of translation, synthesis, back-translation, and evaluation by the expert committee. Two translators, two back-translators, and twelve professionals participated in the expert committee. A pretest was carried out with 10 patients with secondary lymphedema due to breast cancer. The degree of agreement was determined by the content validity coefficient. RESULTS It was necessary to modify 8 out of the 29 questions comprising the questionnaire, which exhibited idiomatic disagreement. However, despite these changes, there were no indications of impairments, as content reliability was achieved through a validity coefficient of 0.90. FINAL CONSIDERATIONS The instrument was successfully translated and cross-culturally adapted for Brazil with a high level of agreement.
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Affiliation(s)
| | | | - Gil Facina
- Universidade Federal de São Paulo. São Paulo, São Paulo, Brazil
| | | | - Simone Elias
- Universidade Federal de São Paulo. São Paulo, São Paulo, Brazil
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Zouboulis CC, Bechara FG, Fritz K, Goebeler M, Hetzer FH, Just E, Kirsten N, Kokolakis G, Kurzen H, Nikolakis G, Pinter A, Podda M, Rosinski K, Schneider-Burrus S, Taube KM, Volz T, Winkler T, Kristandt A, Presser D, Zouboulis VA. S2k‐Leitlinie zur Therapie der Hidradenitis suppurativa/Acne inversa – Kurzfassung. J Dtsch Dermatol Ges 2024; 22:868-892. [PMID: 38857106 DOI: 10.1111/ddg.15412_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/27/2024] [Indexed: 06/11/2024]
Abstract
ZusammenfassungDie S2k‐Leitlinie der Hidradenitis suppurativa/Acne inversa (HS/AI) soll eine akzeptierte Entscheidungshilfe für die Auswahl/Durchführung einer geeigneten/suffizienten Therapie liefern. Hidradenitis suppurativa/Acne inversa ist eine chronisch‐rezidivierende, entzündliche, potenziell mutilierende Hauterkrankung des terminalen Haartalgdrüsenapparats, mit schmerzhaften, entzündlichen Läsionen in den apokrinen drüsenreichen Körperregionen. Ihre Punktprävalenz in Deutschland ist 0,3%, sie wird mit einer Verspätung von 10,0 ± 9,6 Jahren diagnostiziert. Abnormale Differenzierung der Keratinozyten des Haartalgdrüsenapparats und eine begleitende Entzündung bilden die zentrale pathogenetische Grundlage. Primäre HS/AI‐Läsionen sind entzündliche Knoten, Abszesse und drainierende Tunnel. Rezidive in den letzten 6 Monaten mit mindestens zwei Läsionen an den Prädilektionsstellen verweisen auf eine HS/AI mit einer 97‐prozentigen Genauigkeit. HS/AI‐Patienten leiden an einer deutlichen Einschränkung der Lebensqualität. Zur korrekten Therapieentscheidung sollen Klassifikation und Aktivitätsbewertung mit einem validierten Instrument erfolgen, wie dem International Hidradenitis Suppurativa Severity Scoring System (IHS4). Hidradenitis suppurativa/Acne inversa wird nach der Ausprägung der nachweisbaren Entzündung in zwei Formen eingeteilt: aktive, entzündliche (milde, mittelschwere und schwere nach IHS4) und vorwiegend inaktive, nicht entzündliche (Hurley‐Grad‐I, ‐II und ‐III) HS/AI. Orale Tetrazykline oder eine 5‐tägige intravenöse Therapie mit Clindamycin sind mit der Effektivität von Clindamycin/Rifampicin vergleichbar. Subkutan applizierbares Adalimumab, Secukinumab und Bimekizumab sind für die Therapie der HS/AI zugelassen. Für die vorwiegend nicht entzündliche Erkrankungsform stehen verschiedene operative Verfahren zur Verfügung. Medikamentöse/chirurgische Kombinationen gelten als ganzheitliches Therapieverfahren.
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Affiliation(s)
- Christos C Zouboulis
- Hochschulklinik für Dermatologie, Venerologie und Allergologie, Immunologisches Zentrum, Städtisches Klinikum Dessau, Medizinische Hochschule Brandenburg Theodor Fontane und Fakultät für Gesundheitswissenschaften Brandenburg, Dessau, Deutschland
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
| | - Falk G Bechara
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Klinik für Dermatologie, Venerologie und Allergologie, Ruhr-Universität Bochum, Bochum, Deutschland
| | - Klaus Fritz
- Zentrum für Dermatologie, Laser und Ästhetische Medizin, Landau, Deutschland
- Dermatologie II, Colentina Klinik, Carol-Davila-Universität für Medizin und Pharmazie, Bukarest, Rumänien
| | - Matthias Goebeler
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | | | - Elke Just
- Deutsche Akne Inversa Patientenvereinigung in Gründung, Kreis Coesfeld, Deutschland
| | - Natalia Kirsten
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Institut für Versorgungsforschung (IVDP), Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg, Deutschland
| | - Georgios Kokolakis
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Klinik für Dermatologie, Venerologie und Allergologie, Charité-Universitätsmedizin Berlin, Berlin, Deutschland
| | - Hjalmar Kurzen
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Haut- und Laserzentrum, Freising, Deutschland
| | - Georgios Nikolakis
- Hochschulklinik für Dermatologie, Venerologie und Allergologie, Immunologisches Zentrum, Städtisches Klinikum Dessau, Medizinische Hochschule Brandenburg Theodor Fontane und Fakultät für Gesundheitswissenschaften Brandenburg, Dessau, Deutschland
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
| | - Andreas Pinter
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland
| | - Maurizio Podda
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Hautklinik, Klinikum Darmstadt, Deutschland
| | | | - Sylke Schneider-Burrus
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Zentrum für Dermatochirurgie, Havelklinik Berlin, Berlin, Deutschland
| | - Klaus-M Taube
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Thomas Volz
- Klinik für Dermatologie und Allergologie, Technische Universität München, München, Deutschland
| | | | - Anna Kristandt
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Deutschland
| | - Dagmar Presser
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Viktor A Zouboulis
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Medizinische Fakultät, Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg, Deutschland
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Zouboulis CC, Bechara FG, Fritz K, Goebeler M, Hetzer FH, Just E, Kirsten N, Kokolakis G, Kurzen H, Nikolakis G, Pinter A, Podda M, Rosinski K, Schneider-Burrus S, Taube KM, Volz T, Winkler T, Kristandt A, Presser D, Zouboulis VA. S2k guideline for the treatment of hidradenitis suppurativa / acne inversa - Short version. J Dtsch Dermatol Ges 2024; 22:868-889. [PMID: 38770982 DOI: 10.1111/ddg.15412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/27/2024] [Indexed: 05/22/2024]
Abstract
The S2k guideline on hidradenitis suppurativa/acne inversa (HS/AI) aims to provide an accepted decision aid for the selection/implementation of appropriate/sufficient therapy. HS/AI is a chronic recurrent, inflammatory, potentially mutilating skin disease of the terminal hair follicle-glandular apparatus, with painful, inflammatory lesions in the apocrine gland-rich regions of the body. Its point prevalence in Germany is 0.3%, it is diagnosed with a delay of 10.0 ± 9.6 years. Abnormal differentiation of the keratinocytes of the hair follicle-gland apparatus and accompanying inflammation form the central pathogenetic basis. Primary HS/AI lesions are inflammatory nodules, abscesses and draining tunnels. Recurrences in the last 6 months with at least 2 lesions at the predilection sites point to HS/AI with a 97% accuracy. HS/AI patients suffer from a significant reduction in quality of life. For correct treatment decisions, classification and activity assessment should be done with a validated tool, such as the International Hidradenitis Suppurativa Severity Scoring System (IHS4). HS/AI is classified into two forms according to the degree of detectable inflammation: active, inflammatory (mild, moderate, and severe according to IHS4) and predominantly inactive, non-inflammatory (Hurley grade I, II and III) HS/AI. Oral tetracyclines or 5-day intravenous therapy with clindamycin are equal to the effectiveness of clindamycin/rifampicin. Subcutaneously administered adalimumab, secukinumab and bimekizumab are approved for the therapy of HS/AI. Various surgical procedures are available for the predominantly non-inflammatory disease form. Drug/surgical combinations are considered a holistic therapy method.
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Affiliation(s)
- Christos C Zouboulis
- Departments of Dermatology, Venereology, Allergology and Immunology, Staedtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, Dessau, Germany
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
| | - Falk G Bechara
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Department of Dermatology, Venereology and Allergology, Ruhr-University Bochum, Bochum, Germany
| | - Klaus Fritz
- Dermatology and Laser Consultation Center, Landau, Germany
- Dermatology II, Colentina Clinical Hospital, Carol-Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Matthias Goebeler
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Department of Dermatology, Venereology and Allergology, Würzburg University Hospital, Würzburg, Germany
| | | | - Elke Just
- German Acne Inversa Patient Association in Formation, Kreis Coesfeld, Germany
| | - Natalia Kirsten
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Georgios Kokolakis
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hjalmar Kurzen
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Freising Skin and Laser Center, Freising, Germany
| | - Georgios Nikolakis
- Departments of Dermatology, Venereology, Allergology and Immunology, Staedtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, Dessau, Germany
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
| | - Andreas Pinter
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Maurizio Podda
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Department of Dermatology, Medical Center Darmstadt, Darmstadt, Germany
| | | | - Sylke Schneider-Burrus
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Center for Dermatosurgery, Havelklinik Berlin, Berlin, Germany
| | - Klaus-M Taube
- Department of Dermatology and Venereology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Thomas Volz
- Department of Dermatology and Allergology, Technical University of Munich, Munich, Germany
| | | | - Anna Kristandt
- Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Dagmar Presser
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Department of Dermatology, Venereology and Allergology, Würzburg University Hospital, Würzburg, Germany
| | - Viktor A Zouboulis
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Faculty of Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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Li XP, Sun XL, Liu X, Wen Z, Jiang LH, Fu Y, Yue YL, Wang RG. Tuberous sclerosis complex combined with primary lymphedema: A case report. World J Clin Cases 2024; 12:2642-2648. [PMID: 38817219 PMCID: PMC11135441 DOI: 10.12998/wjcc.v12.i15.2642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/08/2024] [Accepted: 04/09/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) and primary lymphedema (PLE) are both rare diseases, and it is even rarer for both to occur in the same patient. In this work, we have provided a detailed description of a patient's clinical presentation, imaging findings, and treatment. And a retrospective analysis was conducted on 14 published relevant case reports. CASE SUMMARY A 16-year-old male came to our hospital for treatment due to right lower limb swelling. This swelling is already present from birth. The patient's memory had been progressively declining. Seizures had occurred 1 year prior at an unknown frequency. The patient was diagnosed with TSC combined with PLE through multimodal imaging examination: Computed tomography, magnetic resonance imaging, and lymphoscintigraphy. The patient underwent liposuction. The swelling of the patient's right lower limb significantly improved after surgery. Epilepsy did not occur.after taking antiepileptic drugs and sirolimus. CONCLUSION TSC with PLE is a rare and systemic disease. Imaging can detect lesions of this disease, which are important for diagnosis and treatment.
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Affiliation(s)
- Xing-Peng Li
- Department of Radiology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Xiao-Li Sun
- Department of Radiology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Xin Liu
- Department of Lymph Surgery, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Zhe Wen
- Department of Nuclear Medicine, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Li-Hua Jiang
- Department of Radiology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Yan Fu
- Department of Radiology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Yun-Long Yue
- Department of MRI, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Ren-Gui Wang
- Department of Radiology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
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10
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Wei M, Wang L, Wu X, Wu B, Xiao S, Zhang Y, Min P, Deng C. Synchronous supraclavicular vascularized lymph node transfer and liposuction for gynecological cancer-related lower extremity lymphedema: a clinical comparative analysis of three different procedures. J Vasc Surg Venous Lymphat Disord 2024:101905. [PMID: 38761979 DOI: 10.1016/j.jvsv.2024.101905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/08/2024] [Accepted: 04/23/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE Gynecological cancer-related lower extremity lymphedema (GC-LEL), a chronic, progressive condition, lacks a standardized treatment. Currently, supraclavicular vascularized lymph node transfer (SC-VLNT) is a favored approach in the treatment of lymphedema, and there is a trend toward combination technology. This study conducts a comparative analysis of three techniques for treating GC-LEL with simultaneous SC-VLNT and liposuction. METHODS A cohort of 35 patients with GC-LEL was examined, comprising 13 patients who underwent single lymph nodes flap with a skin paddle (SLNF+P), 12 who received single lymph nodes flap without a skin paddle (SLNF), and 10 who accepted dual lymph nodes flap without a skin paddle (DLNF). Patient demographics and outcomes were meticulously documented, covering intra- and postoperative variables. RESULTS The median limb volume reduction were 56.4% (SLNF+P), 60.8% (SLNF), and 50.5% (DLNF) in stage II, and 54.0% (SLNF+P), 59.8% (SLNF), and 54.4% (DLNF) in stage III. DLNF group procedures entailed longer flap harvesting and transplantation times. The SLNF+P group, on average, had an 8-day postoperative hospitalization, longer than others. All patients noted subjective improvements in Lymphedema Quality of Life scores, with lymphoscintigraphy revealing enhanced lymphatic flow in 29 of the 35 cases. A notable decrease in cellulitis incidence was observed. Additionally, the occurrence of cellulitis decreased significantly, except for DLNF (Stage Ⅱ). The median follow-up time was 16 months (range, 12-36 months), with no reported severe postoperative complications. CONCLUSIONS For advanced GC-LEL, SLNF combined with liposuction is a preferred treatment, offering fewer complications, shorter operative time, and hospitalization.
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Affiliation(s)
- Miaomiao Wei
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Liangliang Wang
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xiangkui Wu
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China; Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Bihua Wu
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China; Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Shune Xiao
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China; Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Peiru Min
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Chengliang Deng
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China; Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China.
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11
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Gabriele G, Nigri A, Chisci G, Massarelli O, Cascino F, Komorowska-Timek E, Kazuki K, Hara H, Mihara M, Gennaro P. Combination of Supramicrosurgical Lymphatico-Venular Anastomosis (sLVA) and Lymph-Sparing Liposuction in Treating Cancer-Related Lymphedema: Rationale for a Regional One-Stage Approach. J Clin Med 2024; 13:2872. [PMID: 38792415 PMCID: PMC11121812 DOI: 10.3390/jcm13102872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/06/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
Objective: Cancer-related lymphedema represents a potential complication of cancer treatment. The aim of this study is to evaluate the effectiveness of the combination of lymphatico-venular anastomosis and liposuction in the treatment of secondary lymphedema. Methods: We present a retrospective analysis of patients affected by cancer-related unilateral limb lymphedema. Inclusion criteria included previous neoplastic pathology with the consequent development of unilateral limb lymphedema, while the exclusion criteria included the presence of comorbidities and the persistence of cancer, as well as previous lymphatic surgery. The outcomes to be included were a reduction in the limb volume and lymphangitis rate, and an improvement in the quality of life. Patients' data were assessed before surgery and 1 year after surgery. Perioperative management included clinical and ultrasonographical evaluations. Under local anesthesia, lymphatico-venular anastomosis with the supramicrosurgical technique and the liposuction of the affected limb was performed in the same surgical session. Results: A total of 24 patients were enrolled in the study. One year after the surgery, an average volume reduction of 37.9% was registered (p = 0.0000000596). The lymphangitis rate decreased after surgery from 4.67 to 0.95 per year (p = 0.000007899). The quality-of-life score improved from 68.7 to 16 according to the LLIS scale. Conclusions: The combination of LVA and liposuction represents a valid strategy for treating cancer-related lymphedema, ensuring stable results over time. In addition, it can be performed under local anesthesia, resulting in being minimally invasive and well-tolerated by patients. This paper reports on the short-term efficacy of this combined technique.
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Affiliation(s)
- Guido Gabriele
- Department of Maxillo-Facial Surgery, Faculty of Medicine and Surgery, University of Siena, 53100 Siena, Italy; (O.M.); (F.C.); (P.G.)
| | - Andrea Nigri
- Department of Economics, Management and Territory, University of Foggia, 71122 Foggia, Italy;
| | - Glauco Chisci
- Oral Surgery School, Department of Medical Biotechnologies, University of Siena, Via Ricasoli 18, 58100 Grosseto, Italy
| | - Olindo Massarelli
- Department of Maxillo-Facial Surgery, Faculty of Medicine and Surgery, University of Siena, 53100 Siena, Italy; (O.M.); (F.C.); (P.G.)
| | - Flavia Cascino
- Department of Maxillo-Facial Surgery, Faculty of Medicine and Surgery, University of Siena, 53100 Siena, Italy; (O.M.); (F.C.); (P.G.)
| | - Ewa Komorowska-Timek
- Advanced Plastic Surgery, Michigan State University, East Lansing, MI 48502, USA;
| | - Kikuchi Kazuki
- Department of Plastic Surgery, Nadogaya Hospital, 2-1-1 Shinkasiwa, Kashiwa 277-0084, Japan; (K.K.); (H.H.); (M.M.)
| | - Hisako Hara
- Department of Plastic Surgery, Nadogaya Hospital, 2-1-1 Shinkasiwa, Kashiwa 277-0084, Japan; (K.K.); (H.H.); (M.M.)
| | - Makoto Mihara
- Department of Plastic Surgery, Nadogaya Hospital, 2-1-1 Shinkasiwa, Kashiwa 277-0084, Japan; (K.K.); (H.H.); (M.M.)
| | - Paolo Gennaro
- Department of Maxillo-Facial Surgery, Faculty of Medicine and Surgery, University of Siena, 53100 Siena, Italy; (O.M.); (F.C.); (P.G.)
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12
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Cristina de Sousa Pedrosa B, Machado Manhães de Castro P, Santos LVSE, Lima de Andrade D, Florencio Vilaça A, Pinheiro Júnior JEG, Paula de Lima Ferreira A, Lins EM, Maia JN, do Amparo Andrade M, de Castro CMMB. Effects of complex decongestive therapy and aquatic physiotherapy on markers of the inflammatory process in individuals with lymphedema. Physiother Theory Pract 2024; 40:900-908. [PMID: 36394217 DOI: 10.1080/09593985.2022.2143252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic lymphedema is a progressive and inflammatory disease caused by impaired lymphatic transport. PURPOSE This study evaluates the effects of complex decongestive therapy (CDT) and aquatic physiotherapy on markers of the inflammatory process and lower limb volumes in individuals with lymphedema. METHODS A randomized controlled clinical trial was carried out with three groups: patients with lymphedema submitted to CDT, patients with lymphedema submitted to aquatic physiotherapy, and control group of individuals without lymphedema. The evaluation was performed through blood count, CRP measurements, C3, C4 complement, measurement of serum levels of cytokines interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), interleukins 4 (IL-4), 6 (IL-6), and 10 (IL-10), and the volume of a lower limb using the volume formula of a truncated cone. The study was registered with the Brazilian Clinical Trials Registry (RBR-4tpkszn). RESULTS Our work showed a reduction in the TNF-α levels of patients in the CDT group (p = .028). Significant differences were found between the control group and the CDT group for IL-10 (p = .049) and Monocytes (p = .039). No significant reduction in limb volume was found. CONCLUSION Our results show that CDT was able to significantly reduce the inflammatory marker TNF-α in patients with lymphedema, suggesting an anti-inflammatory effect of the therapy.
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Affiliation(s)
| | | | | | | | - Adriano Florencio Vilaça
- Laboratório de Imunopatologia Keizo Asami, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
| | | | | | - Esdras Marques Lins
- Department of Surgery, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
| | - Juliana Netto Maia
- Department of Physiotherapy, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
| | | | - Célia Maria Machado Barbosa de Castro
- Laboratório de Imunopatologia Keizo Asami, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
- Department of Tropical Medicine, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
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13
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Meroni M, Scaglioni MF. Perforator-to-perforator SCIP-based vascularized lymphnode and lymphatic vessels transfer: A first report. Microsurgery 2024; 44:e31167. [PMID: 38549397 DOI: 10.1002/micr.31167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/22/2024] [Accepted: 02/28/2024] [Indexed: 04/02/2024]
Affiliation(s)
- Matteo Meroni
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Mario F Scaglioni
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
- Zentrum für Plastische Chirurgie, Pyramid Clinic, Zurich, Switzerland
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14
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Breckwoldt T, Niggemann P, Grünherz L, Weinzierl A, Lindenblatt N. Arm lymphedema after vascularized lymph node harvest following Covid-19 vaccination. Case Reports Plast Surg Hand Surg 2024; 11:2342332. [PMID: 38645421 PMCID: PMC11028028 DOI: 10.1080/23320885.2024.2342332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 03/14/2024] [Indexed: 04/23/2024]
Abstract
There is evidence that COVID-19 vaccines may affect the lymphatic system. We report a case of a 40-year-old female who had undergone lymph node transfer for treating primary lymphedema of the legs. Six months later, the patient developed lymphedema of the right arm closely related to mRNA vaccination against COVID-19.
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Affiliation(s)
- Tabea Breckwoldt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Pia Niggemann
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Lisanne Grünherz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Andrea Weinzierl
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Nicole Lindenblatt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
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15
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Li X, Wen Z, Hao K, Liu M, Ren J, Guo J, Zhang Y, Hao Q, Sun X, Yue Y, Wang R. The value of the dermal rim sign on nonenhanced magnetic resonance imaging for predicting dermal backflow in patients with primary lower extremity lymphedema. J Vasc Surg Venous Lymphat Disord 2024:101890. [PMID: 38636733 DOI: 10.1016/j.jvsv.2024.101890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/17/2024] [Accepted: 04/02/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE The dermal rim sign (DRS) on nonenhanced magnetic resonance imaging has been shown to predict dermal backflow (DBF) in patients with secondary upper limb lymphedema. However, whether the DRS has the same effects on primary lower extremity lymphedema (PLEL) has not been clearly reported. Therefore, this study aimed to explore whether the DRS can be used to diagnose DBF on lymphoscintigraphy in patients with PLEL. METHODS A total of 94 patients who were diagnosed with PLEL were recruited for this retrospective study from January 2022 to December 2023. All the patients were divided into two groups according to the lymphoscintigraphy findings: no DBF and DBF. The magnetic resonance imaging data of the two groups were recorded and statistically compared for the following indicators: range of lymphedema involvement (left, right, whole lower limbs, only thigh, only calf and ankle), signs of lymphedema (notable thickening of skin, parallel line sign, grid sign, honeycomb sign, band sign, lymph lake sign, crescent sign, DRS), and lymphedema measurement (skin thickness, band width). The DRS is characterized by notable thickening of the skin plus the grid sign and/or honeycomb sign, plus the band sign. RESULTS The following statistically significant differences in the following indicators were found between the two groups (P < .05): notable skin thickening, parallel line sign, grid sign, honeycomb sign, band sign, DRS, skin thickness, and band width. The sensitivity, specificity, and accuracy for predicting for DBF with the DRS was 82%, 64%, and 77%, respectively. CONCLUSIONS This study confirmed good consistency between the DRS and DBF from the perspective of imaging. This tool is suitable for children, adolescents, and patients with contraindications to lymphoscintigraphy. The DRS has important value in assessing the severity of PLEL. The DRS is suggested for the clinical use of combined surgical treatment of PLEL.
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Affiliation(s)
- Xingpeng Li
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Zhe Wen
- Department of Nuclear Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Kun Hao
- Department of Lymph Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Mengke Liu
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jie Ren
- Department of MRI, Beijing Shijitan Hospital, Peking University Ninth School of Clinical Medicine, Beijing, China
| | - Jia Guo
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yimeng Zhang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Qi Hao
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xiaoli Sun
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yunlong Yue
- Department of MRI, Beijing Shijitan Hospital, Peking University Ninth School of Clinical Medicine, Beijing, China
| | - Rengui Wang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.
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16
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Saeed GT, Ahmad D, Al Smady MN, Awatramani G, Abdul Hamid T, Janahi F. Isolated scrotal lymphedema in a 43-year old male patient: A case report. Int J Surg Case Rep 2024; 117:109403. [PMID: 38490031 PMCID: PMC10955660 DOI: 10.1016/j.ijscr.2024.109403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/10/2024] [Accepted: 02/13/2024] [Indexed: 03/17/2024] Open
Abstract
INTRODUCTION Lymphedema of the external genitalia is a rare condition characterized by swelling of the scrotal skin and subcutaneous tissue, resulting from a pathology in lymphatic drainage. Over time, the development of fibrosis leads to a considerable impairment in the patient's quality of life. While conservative management is generally the first-line approach, surgical cases may necessitate surgical intervention to achieve comprehensive and lasting improvements. CASE PRESENTATION We present the case of a 43-year-old obese male patient who presented to the clinic with a complaint of persistent bilateral scrotal swelling for three months. Clinical examination revealed a pressure-indolent, soft, and massively enlarged swelling of the scrotum on both sides. Ultrasound findings confirmed a diffusely thickened edematous scrotal wall. The patient was advised to start physiotherapy and adhere to conservative management. Due to the debilitating size of the mass, the patient opted for excision of the scrotal swelling followed by scrotoplasty. CLINICAL DISCUSSION This case report explores the presentation, signs and symptoms, impact on patients' lives, and various management options for scrotal lymphedema. It underscores the intricacies involved in the diagnosis and treatment decision-making process, emphasizing the need for a tailored and multidisciplinary approach. CONCLUSION It is imperative to initially rule out life-threatening causes of scrotal lymphedema to ensure optimal patient care. The integration of surgical interventions should be carefully considered in the overall management strategy for optimal and comprehensive results. Scrotoplasty, in the context of scrotal lymphedema, not only improves the quality of life but also positively influences sexual function. COMPETENCIES Interpersonal and communication skills, Medical knowledge, Patient care, Practice-based learning and improvement.
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Affiliation(s)
- Ghazal Talal Saeed
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Donia Ahmad
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | | | - Gunjan Awatramani
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | | | - Farhad Janahi
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates; Department of urology surgery, Mediclinic City Hospital, Dubai Healthcare City, Dubai, United Arab Emirates.
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Kumegawa S, Sakata Y, Fujimoto K, Takagaki Y, Yamada G, Asamura S. Effectiveness of lymphaticovenular anastomosis for adult-onset primary lower limb lymphedema: A retrospective study. J Plast Reconstr Aesthet Surg 2024; 91:191-199. [PMID: 38422920 DOI: 10.1016/j.bjps.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 12/22/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Surgical treatments such as lymphaticovenular anastomosis (LVA) are widely used in addition to conservative treatment of secondary lymphedema. However, their indications and effectiveness for primary lymphedema are unclear. This study aims to objectively demonstrate the effectiveness of LVA for adult-onset primary lymphedema from various perspectives. METHODS We retrospectively examined patients with primary lower limb lymphedema who underwent LVA between January 2018 and December 2021 and were 21 or older. Treatment effects were evaluated using lymphoscintigraphy, questionnaires, body mass index, extracellular fluid ratio, and lymphedema index preoperatively and 6 months postoperatively. The LVA was performed under general anesthesia. RESULTS We evaluated 11 patients (11 lower limbs). Out of seven patients with complete obstruction preoperatively, all presented partial obstruction according to the Taiwan Lymphoscintigraphy Staging classification with a significant decrease in the score. Significant improvements were observed in clinical symptoms ("hardness") and in quality of life ("appearance" and "ease of wearing compression garments") assessments. A significant change was observed in the extracellular water ratio but not in lower extremity lymphedema index (LELindex). CONCLUSION LVA was suggested as one of the potential treatment options for patients with adult-onset primary lymphedema in whom lymphatic flow was confirmed by lymphoscintigraphy. In addition to clinical symptoms and physical examination, the evaluation of adult-onset primary lymphedema should include the patient's quality of life.
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Affiliation(s)
- Shinji Kumegawa
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Wakayama Medical University, Wakayama, Japan.
| | - Yasuhiro Sakata
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Kota Fujimoto
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Wakayama Medical University, Wakayama, Japan
| | | | - Gen Yamada
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shinichi Asamura
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Wakayama Medical University, Wakayama, Japan
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18
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Bowman C, Rockson SG. The Role of Inflammation in Lymphedema: A Narrative Review of Pathogenesis and Opportunities for Therapeutic Intervention. Int J Mol Sci 2024; 25:3907. [PMID: 38612716 PMCID: PMC11011271 DOI: 10.3390/ijms25073907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Lymphedema is a chronic and progressive disease of the lymphatic system characterized by inflammation, increased adipose deposition, and tissue fibrosis. Despite early hypotheses identifying lymphedema as a disease of mechanical lymphatic disruption alone, the progressive inflammatory nature underlying this condition is now well-established. In this review, we provide an overview of the various inflammatory mechanisms that characterize lymphedema development and progression. These mechanisms contribute to the acute and chronic phases of lymphedema, which manifest clinically as inflammation, fibrosis, and adiposity. Furthermore, we highlight the interplay between current therapeutic modalities and the underlying inflammatory microenvironment, as well as opportunities for future therapeutic development.
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Affiliation(s)
- Catharine Bowman
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Stanley G. Rockson
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
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19
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Lian Y, Sandhu S, Asefa Y, Gupta A. The Effect of Exercise on Reducing Lymphedema Severity in Breast Cancer Survivors. Cancers (Basel) 2024; 16:1367. [PMID: 38611045 PMCID: PMC11011010 DOI: 10.3390/cancers16071367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Exercise has been repeatedly shown to be safe and beneficial for cancer survivors. However, there is no normative guideline for exercise prescription, and it is still under exploration. Therefore, this literature review aims to provide some advice for the formulation of exercise prescriptions for patients with breast cancer-related lymphedema (BCRL) from the perspective of reducing lymphedema severity. A review of relevant studies published before November 2023 was conducted using three scientific databases: PubMed, Embase, and Scopus. A total of 2696 articles were found. Eventually, 13 studies fulfilled the inclusion criteria and were included in this literature review. We concluded that daily, or nearly daily, exercise at home can be recommended. Moreover, reduced lymphedema severity may not be maintained after ceasing the exercise program, so exercise should be a lifelong practice.
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Affiliation(s)
| | | | | | - Ananya Gupta
- Department of Physiology, University of Galway, H91-TK33 Galway, Ireland; (Y.L.); (S.S.); (Y.A.)
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20
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Kharroubi A, Benzmane K, Lakhal O, Kaddouri L. Elephantiasis Nostras Verrucosa of the Lower Limb: A Case Report and Literature Review. Ann Vasc Dis 2024; 17:43-49. [PMID: 38628934 PMCID: PMC11018103 DOI: 10.3400/avd.cr.22-00113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 07/30/2023] [Indexed: 04/19/2024] Open
Abstract
Elephantiasis nostras verrucosa (ENV) is a rare complication of chronic lymphedema, leading to progressive cutaneous hypertrophy and disfigured lower extremities. We present an unusual case of a 79-year-old man with ENV, who had an episode of erysipelas treated and cured with antibiotics. The patient presented with progressive painless lymphedema of the lower limb years ago, complicated with skin changes. The biology and radiology test does not objective any causes. The compression therapy was proposed to the patient. ENV is characterized by lymphedema and skin anomaly. Management of ENV is often challenging, but a variety of successful medical and surgical treatment strategies have been reported.
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Affiliation(s)
- Abdelkarim Kharroubi
- Vascular Surgery Department, Faculty of Medicine and Pharmacy of Agadir, Sous Massa, University Hospital Center, University Ibn Zohr, Agadir, Morocco
| | - Kenza Benzmane
- Vascular Surgery Department, Faculty of Medicine and Pharmacy of Agadir, Sous Massa, University Hospital Center, University Ibn Zohr, Agadir, Morocco
| | - Oumaima Lakhal
- Vascular Surgery Department, Faculty of Medicine and Pharmacy of Agadir, Sous Massa, University Hospital Center, University Ibn Zohr, Agadir, Morocco
| | - Lahcen Kaddouri
- Vascular Surgery Department, Faculty of Medicine and Pharmacy of Agadir, Sous Massa, University Hospital Center, University Ibn Zohr, Agadir, Morocco
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21
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González-Fernández L, Romero-Morales C, Martínez-Pascual B, Río-González A, Cerezo-Téllez E, López-Martín I. Breast cancer survivors suffering from lymphedema: What really do affect to corporeality/body image? A qualitative study. Breast Cancer Res 2024; 26:47. [PMID: 38486203 PMCID: PMC10941543 DOI: 10.1186/s13058-024-01806-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 03/06/2024] [Indexed: 03/17/2024] Open
Abstract
Breast cancer-related lymphedema is currently one of the most serious complications that most affect the quality of life of women undergoing breast cancer. The aim of this study was to explore in-depth the experience of women who suffer from lymphoedema after breast cancer and how does this condition affect corporeality, with no judgements. For this purpose, a qualitative methodology was followed. In-depth interviews, interviewer's field notes and participants' letters were used for data collection. The participants were twenty Spanish women with lymphoedema after overcome a breast cancer in the past. Healthcare specialists with experience in the topic were also included. Results showed 2 main categories: "From cancer to lymphedema, another disease another disease" and "Potential for transition and transformation towards a new way of life". As a conclusion, the difficulty in accessing adequate treatment, the need for greater awareness of lymphedema and the importance of the emotional and psychological dimension of this chronic disease. Highlighting the attitudes that these women develop for self-care and the concept of new corporeality. After breast cancer, women with lymphedema experience a drastic change that affects all areas of their lives. The adaptation process, and the search for resources and aid, play a fundamental role in overcoming this process.
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Affiliation(s)
| | - Carlos Romero-Morales
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | | | - Angela Río-González
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
- Asociación Española de Linfedema y Lipedema, AEL, Madrid, Spain
| | - Ester Cerezo-Téllez
- Neuromusculoskeletal Physical Therapy in Stages of Life Research Group (FINEMEV), Department of Nursing and Physical Therapy, Faculty of Medicine and Health Sciences, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Inmaculada López-Martín
- Escuela de Enfermería Fundación Jiménez Díaz, Instituto de Investigación Sanitaria - Hospital Fundación Jiménez Díaz, Universidad Autónoma de Madrid (IIS-FJD, UAM), Madrid, Spain
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22
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Nishiyama M, Sakaguchi Y, Morito S, Nagase K, Sakumoto T, Yamashita K, Hashiguchi M, Fukuda M, Toda S, Aoki S. A new lymphedema treatment using pyro-drive jet injection. Hum Cell 2024; 37:465-477. [PMID: 38218753 DOI: 10.1007/s13577-023-01021-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/07/2023] [Indexed: 01/15/2024]
Abstract
Lymphedema, resulting from impaired lymphatic drainage, causes inflammation, fibrosis and tissue damage leading to symptoms such as limb swelling and restricted mobility. Despite various treatments under exploration, no standard effective therapy exists. Here a novel technique using the pyro-drive jet injection (PJI) was used to create artificial clefts between collagen fibers, which facilitated the removal of excess interstitial fluid. The PJI was used to deliver a mixture of lactated Ringer's solution and air into the tail of animals with secondary skin edema. Edema levels were assessed using micro-CT scanning. Histopathological changes and neovascularization were evaluated on the injury-induced regenerative tissue. Regarding tissue remodeling, we focused on connective tissue growth factor (CTGF) and vascular endothelial growth factor (VEGF)-C. PJI markedly diminished soft tissue volume in the experimental lymphedema animals compared to the non-injected counterparts. The PJI groups exhibited a significantly reduced proportion of inflammatory granulation tissue and an enhanced density of lymphatic vessels and α-smooth muscle actin (αSMA)-positive small vessels in the fibrous granulation tissue compared to the controls. In addition, PJI curtailed the prevalence of CTGF- and VEGF-C-positive cells in regenerative tissue. In a lymphedema animal model, PJI notably ameliorated interstitial edema, promoted lymphatic vessel growth, and bolstered αSMA-positive capillaries in fibrous granulation tissue. PJI's minimal tissue impact post-lymph node dissection indicates significant potential as an early, standard preventative measure. Easily applied in general clinics without requiring specialized training, it offers a cost-effective and highly versatile solution to the management of lymphedema.
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Affiliation(s)
- Megumi Nishiyama
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan
| | - Yuko Sakaguchi
- Medical Device Division Life Sciences SBU, Daicel Corporation, Osaka, Japan
| | - Sayuri Morito
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan
| | - Kei Nagase
- Department of Urology, Faculty of Medicine, Saga University, Saga, Japan
| | - Takehisa Sakumoto
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan
| | - Kunihiko Yamashita
- Medical Device Division Life Sciences SBU, Daicel Corporation, Osaka, Japan
| | - Mariko Hashiguchi
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan
| | - Makoto Fukuda
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Shuji Toda
- Department of Pathology, Takagi Hospital, 141-11 Sakemi, Okawa, Fukuoka, 831-0016, Japan
| | - Shigehisa Aoki
- Division of Pathology, Department of Pathology and Microbiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan.
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23
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Gaxiola-García MA, Escandón JM, Manrique OJ, Skinner KA, Kushida-Contreras BH. Surgical Treatment for Primary Lymphedema: A Systematic Review of the Literature. Arch Plast Surg 2024; 51:212-233. [PMID: 38596145 PMCID: PMC11001464 DOI: 10.1055/a-2253-9859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/30/2023] [Indexed: 04/11/2024] Open
Abstract
This is a retrospective review of surgical management for primary lymphedema. Data were extracted from 55 articles from PubMed MEDLINE, Web of Science, SCOPUS, and Cochrane Central Register of Controlled Trials between the database inception and December 2022 to evaluate the outcomes of lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), and outcomes of soft tissue extirpative procedures such as suction-assisted lipectomy (SAL) and extensive soft tissue excision. Data from 485 patients were compiled; these were treated with LVA ( n = 177), VLNT ( n = 82), SAL ( n = 102), and excisional procedures ( n = 124). Improvement of the lower extremity lymphedema index, the quality of life (QoL), and lymphedema symptoms were reported in most studies. LVA and VLNT led to symptomatic relief and improved QoL, reaching up to 90 and 61% average circumference reduction, respectively. Cellulitis reduction was reported in 25 and 40% of LVA and VLNT papers, respectively. The extirpative procedures, used mainly in patients with advanced disease, also led to clinical improvement from the volume reduction, as well as reduced incidence of cellulitis, although with poor cosmetic results; 87.5% of these reports recommended postoperative compression garments. The overall complication rates were 1% for LVA, 13% for VLNT, 11% for SAL, and 46% for extirpative procedures. Altogether, only one paper lacked some kind of improvement. Primary lymphedema is amenable to surgical treatment; the currently performed procedures have effectively improved symptoms and QoL in this population. Complication rates are related to the invasiveness of the chosen procedure.
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Affiliation(s)
- Miguel Angel Gaxiola-García
- Plastic and Reconstructive Surgery Department, Mexico's Children's Hospital (Hospital Infantil de México “Federico Gómez”), Mexico City, Mexico
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Kristin A. Skinner
- Department of Surgical Oncology, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
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24
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Varagur K, Shetty AS, Saoud K, Ochoa E, Skladman R, Skolnick GB, Sacks JM, Christensen JM. Association between Bioimpedance Spectroscopy and Magnetic Resonance Lymphangiography in the Diagnosis and Assessment of Lymphedema. J Reconstr Microsurg 2024; 40:177-185. [PMID: 37236242 DOI: 10.1055/a-2102-0261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND This study assesses associations between bioimpedance spectroscopy (BIS) and magnetic resonance lymphangiography (MRL) in the staging and assessment of lymphedema. METHODS Adults who received MRL and BIS between 2020 and 2022 were included. We collected fluid, fat, and lymphedema severity ratings, and measured fluid stripe thickness, subcutaneous fat width, and lymphatic diameter on MRL. BIS lymphedema index (L-Dex) scores were collected from patient charts. We assessed sensitivity and specificity of L-Dex scores to detect MRL-identified lymphedema, and examined associations between L-Dex scores and MRL imaging measures. RESULTS Forty-eight limbs across 40 patients were included. L-Dex scores had 72.5% sensitivity and 87.5% specificity for detecting MRL-defined lymphedema, with a 96.7% estimated positive predictive value and 38.9% negative predictive value. L-Dex scores were associated with MRL fluid and fat content scores (p ≤ 0.05), and lymphedema severity (p = 0.01), with better discrimination between fluid than fat content levels on pairwise analysis, and poor discrimination between adjacent severity levels. L-Dex scores were correlated with distal and proximal limb fluid stripe thickness (distal: rho = 0.57, p < 0.01; proximal: rho = 0.58, p < 0.01), partially correlated with distal subcutaneous fat thickness when accounting for body mass index (rho = 0.34, p = 0.02), and were not correlated with lymphatic diameter (p = 0.25). CONCLUSION L-Dex scores have high sensitivity, specificity, and positive predictive value for the identification of MRL-detected lymphedema. L-Dex has difficulty distinguishing between adjacent severity levels of lymphedema and a high false negative rate, explained in part by reduced discrimination between levels of fat accumulation.
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Affiliation(s)
- Kaamya Varagur
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Anup S Shetty
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Karim Saoud
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Esther Ochoa
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gary B Skolnick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joani M Christensen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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25
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Markarian B, Toro C, Moreira K, Polam S, Mathew N, Mayrovitz HN. Assessment Modalities for Lower Extremity Edema, Lymphedema, and Lipedema: A Scoping Review. Cureus 2024; 16:e55906. [PMID: 38601427 PMCID: PMC11004507 DOI: 10.7759/cureus.55906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/10/2024] [Indexed: 04/12/2024] Open
Abstract
Lower extremity swelling may be broadly characterized as due to edema, lymphedema, or lipedema. Differentiation between these three conditions is important for providing appropriate treatment. This review analyzes and compares different clinical diagnostic modalities for these conditions, with the aim of assisting in the process of choosing the most appropriate diagnostic modality by highlighting the advantages and limitations of each. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for a systematic search of peer-reviewed literature, the following diagnostic methods for lower extremity swelling were investigated: (1) ultrasound (US), (2) lymphoscintigraphy (LSG), (3) computed tomography (CT), (4) bioimpedance spectroscopy (BIS), (5) tissue dielectric constant (TDC), and (6) magnetic resonance imaging (MRI), including magnetic resonance lymphangiography (MRL). The databases used in the search were PubMed, ProQuest, CINAHL Complete, Web of Science, Embase, and Biomedical Reference Collection. After retrieving 115 studies based on predetermined inclusion criteria, a total of 31 studies were critically evaluated. The main results indicate the following: duplex US is the modality of choice to initially identify lower extremity edema such as deep venous thrombosis (DVT) and venous reflux due to its high sensitivity and specificity. CT venography of the lower extremity appears to bethe preferred option for gynecologic cancer patients with lower extremity swelling post-treatment, as it measures subcutaneous tissue volumes to look for DVTs, lymphoceles, and cancer recurrence. TDC is a recommended modality for a variety of conditions, including edema and lymphedema, in part, due to its noninvasive localized assessment capabilities and ease of use. LSG emerges as an effective imaging modality for lymphedema characterization with minimal invasiveness and high sensitivity and specificity. BIS is widely used to identify and monitor lower extremity lymphedema but has been reported to have low sensitivity and lacks the ability to account for changes in tissue composition such as fibrosis. US and MRL are favored for lipedema diagnosis, with MRL providing comprehensive anatomical and functional insights, albeit with cost and accessibility limitations compared to US. While CT, MRI, US, and TDC are all useful for differentiating lymphedema from lipedema, MRI is the preferred modality due to its anatomical and functional diagnostic capabilities. However, US is a pragmatic alternative for use with obese patients or when MRI is not an option.
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Affiliation(s)
- Biura Markarian
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Carel Toro
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Karina Moreira
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Sneha Polam
- Sports Medicine, Nova Southeastern University Dr. Kiran C. Patel College Of Osteopathic Medicine, Fort Lauderdale, USA
| | - Neethu Mathew
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Harvey N Mayrovitz
- Medical Education, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Davie, USA
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26
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Li X, Li B, Hao K, Liu M, Guo J, Zhang Y, Hao Q, Zhang Y, Sun X, Wang R. Value of the short time inversion recovery sequence of magnetic resonance imaging in the staging of Klippel-Trenaunay syndrome complicated with lymphedema. J Vasc Surg Venous Lymphat Disord 2024; 12:101746. [PMID: 38158121 DOI: 10.1016/j.jvsv.2023.101746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/15/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Currently, the focus on limb lymphedema (LE) is on classification and staging. However, few scholars have conducted staging for Klippel-Trenaunay syndrome complicated LE (KTS-LE). This study aimed to investigate the value of the short time inversion recovery sequence of magnetic resonance imaging (MRI) in the staging of KTS-LE. METHODS Forty-six patients who were diagnosed with KTS-LE were recruited for this retrospective study from July 2011 to November 2022. Referring to the clinical staging standard of lower extremity LE of the International Society of Lymphology in 2020, all patients were divided into three groups: stages I, II, and III. The MRI indicators of the three groups were recorded and statistically compared: LE range (unilateral bilateral, lower limbs, only thighs, only calves and ankles), abnormal parts (skin thickening, abnormal subcutaneous fat signal, abnormal muscle signal, muscle hypertrophy or contraction, abnormal bone signal, hyperostosis), and subcutaneous soft tissue signs (parallel line sign, grid sign, band sign, honeycomb sign, lymph lake sign, crescent sign, and nebula sign). RESULTS There was a significant difference in the honeycomb sign among the three periods (P = .028). There was a significant difference between stage II and stage I disease (P < .05). There was a significant difference between stage II and stage III disease (P < .05). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the honeycomb sign in diagnosing KTS-LE of stage II were 87.5%, 63.2%, 33.3%, 96.0%, and 67.4%, respectively. In contrast, the other signs were not statistically significant among the three periods. CONCLUSIONS The short time inversion recovery sequence of MRI is of great value in KTS-LE. The honeycomb sign is an important imaging indicator for the diagnosis of stage II disease. It is necessary to evaluate the severity of edema with MRI for KTS-LE, which is very important for therapeutic options.
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Affiliation(s)
- Xingpeng Li
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Bin Li
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Kun Hao
- Department of Lymph Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Mengke Liu
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Jia Guo
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Yimeng Zhang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Qi Hao
- Department Of Radiology, People's Hospital Of Peking University, The Second School Of Clinical Medicine Of Peking University, Beijing, Pr China
| | - Yan Zhang
- Department Of Radiology, Qilu Hospital, Shandong University, Shandong, Pr China
| | - Xiaoli Sun
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Rengui Wang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China.
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27
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Schiltz D, Eibl D, Mueller K, Biermann N, Prantl L, Taeger CD. Therapist versus Machine-Immediate Effects of Manual versus Mechanical Lymphatic Drainage in Patients with Secondary Lymphedema. J Clin Med 2024; 13:1277. [PMID: 38592094 PMCID: PMC10931544 DOI: 10.3390/jcm13051277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/10/2024] [Accepted: 02/20/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Complex decongestive therapy (CDT) is the standard and basic therapy for lymphedema. The central component of CDT is manual lymphatic drainage (MLD). In addition to CDT, other measures such as intermittent pneumatic compression therapy (IPCT) (active compression machine therapy) are available. In this prospective research study, the objective and subjective effects of MLD and IPCT on lymphedema of the lower extremity were investigated and both therapies were directly compared. Furthermore, the patients' body mass index (BMI) and stage of lymphedema were tested for their effect on the respective therapy. Methods: Patients participating in the study received both therapies (MLD and IPCT) on the same lymphedema-affected limb at an interval of two days. The objective volumetric therapy effect was measured by the digital volume measurement of the affected limb. The subjective effects of the therapies were measured using two specially designed questionnaires. Results: A total of 40 patients were included in the study. There was no significant difference in the volume differences between the interventions, BMI categories, lymphedema, or treatment order regarding the immediate and two-day effect. Conclusions: No significant difference was found in the subjective or objective therapy efficacy of the two methods. Intermittent pneumatic compression therapy is considered a comparable therapeutic procedure when properly indicated.
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Affiliation(s)
- Daniel Schiltz
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany (N.B.); (L.P.)
- Department of Plastic and Aesthetic Surgery, Hand Surgery, Helios Hospital Emil von Behring, 14165 Berlin, Germany
| | - Dominik Eibl
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany (N.B.); (L.P.)
| | - Karolina Mueller
- Center for Clinical Studies, University Hospital Regensburg, 93053 Regensburg, Germany;
| | - Niklas Biermann
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany (N.B.); (L.P.)
| | - Lukas Prantl
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany (N.B.); (L.P.)
| | - Christian Dirk Taeger
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany (N.B.); (L.P.)
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28
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Alemany M. The Metabolic Syndrome, a Human Disease. Int J Mol Sci 2024; 25:2251. [PMID: 38396928 PMCID: PMC10888680 DOI: 10.3390/ijms25042251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
This review focuses on the question of metabolic syndrome (MS) being a complex, but essentially monophyletic, galaxy of associated diseases/disorders, or just a syndrome of related but rather independent pathologies. The human nature of MS (its exceptionality in Nature and its close interdependence with human action and evolution) is presented and discussed. The text also describes the close interdependence of its components, with special emphasis on the description of their interrelations (including their syndromic development and recruitment), as well as their consequences upon energy handling and partition. The main theories on MS's origin and development are presented in relation to hepatic steatosis, type 2 diabetes, and obesity, but encompass most of the MS components described so far. The differential effects of sex and its biological consequences are considered under the light of human social needs and evolution, which are also directly related to MS epidemiology, severity, and relations with senescence. The triggering and maintenance factors of MS are discussed, with especial emphasis on inflammation, a complex process affecting different levels of organization and which is a critical element for MS development. Inflammation is also related to the operation of connective tissue (including the adipose organ) and the widely studied and acknowledged influence of diet. The role of diet composition, including the transcendence of the anaplerotic maintenance of the Krebs cycle from dietary amino acid supply (and its timing), is developed in the context of testosterone and β-estradiol control of the insulin-glycaemia hepatic core system of carbohydrate-triacylglycerol energy handling. The high probability of MS acting as a unique complex biological control system (essentially monophyletic) is presented, together with additional perspectives/considerations on the treatment of this 'very' human disease.
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Affiliation(s)
- Marià Alemany
- Faculty of Biology, Universitat de Barcelona, 08028 Barcelona, Catalonia, Spain
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29
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Nuwayhid R, Warg ML, Heister S, Langer S, Schulz T. Translation, Cross-Cultural Adaptation and Validation of the Lymphedema Quality of Life Questionnaire (LYMQOL) in German-Speaking Patients with Lymphedema of the Lower Limbs. Healthcare (Basel) 2024; 12:409. [PMID: 38338294 PMCID: PMC10855540 DOI: 10.3390/healthcare12030409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 02/12/2024] Open
Abstract
The LYMQOL Leg questionnaire is the most widely used, evidence-based tool for the assessment of health-related quality of life (HRQoL) in patients with lower limb lymphedema (LLL). It has been translated into several languages, but a German version is currently lacking. The aim of our study was to validate a German translation of LYMQOL Leg. Translation and cross-cultural adaptation were performed in accordance with ISPOR principles. A total of 103 patients with LLL from Germany, Austria, and Switzerland were interviewed twice. The content and face validity assessments indicated that the German LYMQOL Leg questionnaire was acceptable for interviewing patients with lymphedema. Comparing the LYMQOL Leg with the SF-36 demonstrated good construct validity. Reliability determined by the test-retest procedure was good (intra-class-correlation coefficients 0.68-0.92). Cronbach's alpha values ranged from 0.76 to 0.90 in both interviews, showing an acceptable internal consistency. The four domains of the questionnaire reached a cumulative variance of 52.7% in the factor analysis. The association between the lymphedema stages and the LYMQOL Leg domain scores was not significant. In conclusion, the validity of the German version of LYMQOL Leg, called LYMQOL Bein, was confirmed and thus represents a suitable tool for measuring HRQoL in German-speaking patients with LLL.
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Affiliation(s)
- Rima Nuwayhid
- Department of Orthopaedic, Trauma and Plastic Surgery, University Hospital Leipzig, 04103 Leipzig, Germany (S.H.); (T.S.)
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30
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Devoogdt N, Thomis S, Belva F, Dickinson-Blok J, Fourgeaud C, Giacalone G, Karlsmark T, Kavola H, Keeley V, Marques ML, Mansour S, Nissen CV, Nørregaard S, Oberlin M, Ručigaj TP, Somalo-Barranco G, Suominen S, Van Duinen K, Vignes S, Damstra R. The VASCERN PPL working group patient pathway for primary and paediatric lymphoedema. Eur J Med Genet 2024; 67:104905. [PMID: 38143023 DOI: 10.1016/j.ejmg.2023.104905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
Lymphoedema is caused by an imbalance between fluid production and transport by the lymphatic system. This imbalance can be either caused by reduced transport capacity of the lymphatic system or too much fluid production and leads to swelling associated with tissue changes (skin thickening, fat deposition). Its main common complication is the increased risk of developing cellulitis/erysipelas in the affected area, which can worsen the lymphatic function and can be the cause of raised morbidity of the patient if not treated correctly/urgently. The term primary lymphoedema covers a group of rare conditions caused by abnormal functioning and/or development of the lymphatic system. It covers a highly heterogeneous group of conditions. An accurate diagnosis of primary lymphoedema is crucial for the implementation of an optimal treatment plan and management, as well as to reduce the risk of worsening. Patient care is diverse across Europe, and national specialised centres and networks are not available everywhere. The European Reference Network on Rare Multisystemic Vascular Diseases (VASCERN) gathers the best expertise in Europe and provide accessible cross-border healthcare to patients with rare vascular diseases. There are six different working groups in VASCERN, which focus on arterial diseases, hereditary haemorrhagic telangiectasia, neurovascular diseases, lymphoedema and vascular anomalies. The working group Paediatric and Primary Lymphedema (PPL WG) gathers and shares knowledge and expertise in the diagnosis and management of adults and children with primary and paediatric lymphoedema. The members of PPL WG have worked together to produce this opinion statement reflecting strategies on how to approach patients with primary and paediatric lymphoedema. The objective of this patient pathway is to improve patient care by reducing the time to diagnosis, define the best management and follow-up strategies and avoid overuse of resources. Therefore, the patient pathway describes the clinical evaluation and investigations that lead to a clinical diagnosis, the genetic testing, differential diagnosis, the management and treatment options and the patient follow up at expert and local centres. Also, the importance of the patient group participation in the PPL WG is discussed.
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Affiliation(s)
- Nele Devoogdt
- Centre for Lymphedema, Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Sarah Thomis
- Centre for Lymphedema, Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Janine Dickinson-Blok
- Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, Drachten, the Netherlands
| | - Caroline Fourgeaud
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, Rue Eugène-Millon, 75015, Paris, France
| | | | - Tonny Karlsmark
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Heli Kavola
- Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Vaughan Keeley
- Derby Lymphedema Service, University Hospitals of Derby and Burton NHS Trust, Derby, UK
| | | | - Sahar Mansour
- Department of Lymphovascular Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christoffer V Nissen
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Susan Nørregaard
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Michael Oberlin
- European Centre for Lymphology, Földi Clinic, Hinterzarten, Germany
| | | | | | - Sinikka Suominen
- Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Kirsten Van Duinen
- Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, Drachten, the Netherlands
| | - Stéphane Vignes
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, Rue Eugène-Millon, 75015, Paris, France
| | - Robert Damstra
- Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, Drachten, the Netherlands.
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Wang X, Cui C, Meng X, Han C, Wu B, Dou X, Zhao C, Zhang Y, Li K, Feng C. Chiral Supramolecular Hydrogel Enhanced Transdermal Delivery of Sodium Aescinate to Modulate M1 Macrophage Polarization Against Lymphedema. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2303495. [PMID: 38037850 PMCID: PMC10837362 DOI: 10.1002/advs.202303495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/21/2023] [Indexed: 12/02/2023]
Abstract
Sodium aescinate (SA) shows great potential for treating lymphedema since it can regulate the expression of cytokines in M1 macrophages, however, it is commonly administered intravenously in clinical practice and often accompanied by severe toxic side effects and short metabolic cycles. Herein, SA-loaded chiral supramolecular hydrogels are prepared to prove the curative effects of SA on lymphedema and enhance its safety and transdermal transmission efficiency. In vitro studies demonstrate that SA- loaded chiral supramolecular hydrogels can modulate local immune responses by inhibiting M1 macrophage polarization. Typically, these chiral hydrogels can significantly increase the permeability of SA with good biocompatibility due to the high enantioselectivity between chiral gelators and stratum corneum and L-type hydrogels are found to have preferable drug penetration over D-type hydrogels. In vivo studies show that topical delivery of SA via chiral hydrogels results in dramatic therapeutic effects on lymphedema. Specifically, it can downregulate the level of inflammatory cytokines, reduce the development of fibrosis, and promote the regeneration of lymphatic vessels. This study initiates the use of SA for lymphedema treatment and for the creation of an effective chiral biological platform for improved topical administration.
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Affiliation(s)
- Xueqian Wang
- State Key Lab of Metal Matrix CompositesShanghai Key Laboratory for Molecular Engineering of Chiral DrugsSchool of Materials Science and EngineeringShanghai Jiao Tong UniversityShanghai200240China
| | - Chunxiao Cui
- Department of Burns and Plastic SurgeryShanghai Children's Medical CenterShanghai Jiao Tong UniversityShanghai200127China
| | - Xinxian Meng
- Department of Plastic and Reconstructive SurgeryShanghai Ninth People's HospitalShanghai Jiao Tong University School of MedicineShanghai200011China
| | - Chengyao Han
- Department of Plastic and Reconstructive SurgeryShanghai Ninth People's HospitalShanghai Jiao Tong University School of MedicineShanghai200011China
| | - Beibei Wu
- State Key Lab of Metal Matrix CompositesShanghai Key Laboratory for Molecular Engineering of Chiral DrugsSchool of Materials Science and EngineeringShanghai Jiao Tong UniversityShanghai200240China
| | - Xiaoqiu Dou
- State Key Lab of Metal Matrix CompositesShanghai Key Laboratory for Molecular Engineering of Chiral DrugsSchool of Materials Science and EngineeringShanghai Jiao Tong UniversityShanghai200240China
| | - Changli Zhao
- State Key Lab of Metal Matrix CompositesShanghai Key Laboratory for Molecular Engineering of Chiral DrugsSchool of Materials Science and EngineeringShanghai Jiao Tong UniversityShanghai200240China
| | - Yixin Zhang
- Department of Plastic and Reconstructive SurgeryShanghai Ninth People's HospitalShanghai Jiao Tong University School of MedicineShanghai200011China
| | - Ke Li
- Department of Plastic and Reconstructive SurgeryShanghai Ninth People's HospitalShanghai Jiao Tong University School of MedicineShanghai200011China
| | - Chuanliang Feng
- State Key Lab of Metal Matrix CompositesShanghai Key Laboratory for Molecular Engineering of Chiral DrugsSchool of Materials Science and EngineeringShanghai Jiao Tong UniversityShanghai200240China
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Gebremariyam ZT, Woldemichael NA. Staged surgical management of advanced leg lymphedema: A successful Charles procedure in a resource-limited setting, case report. Int J Surg Case Rep 2024; 115:109221. [PMID: 38183954 PMCID: PMC10809100 DOI: 10.1016/j.ijscr.2024.109221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/08/2024] Open
Abstract
INTRODUCTION Lymphedema, marked by localized tissue swelling, poses a worldwide challenge. In sub-Saharan Africa, where patients often present in advanced stages, resectional techniques such as the Charles procedure become the sole option. This case report illustrate the staged surgical approach to address extensive lower limb lymphedema through the utilization of the Charles procedure. CASE PRESENTATION A 38-year-old female with a 20-year history of right leg lymphedema underwent a three-stage surgical plan. The first stage involved partial excision of lymphedema mass, the second stage focused on debulking of the rest of the mass and skin advancement, and the third stage comprised a meshed split-thickness skin graft. Despite complications, including necrosis and infection, the patient was discharged after 60 days with significant improvement in quality of life. DISCUSSION In resource-constrained settings, strategic staging and careful perioperative planning are vital for mitigating risks. The presented case underscores the successful utilization of the Charles procedure in sub-Saharan Africa, addressing advanced lymphedema and improving patient outcomes. CONCLUSION The Charles procedure, despite its risks, proves to be a viable option for advanced lymphedema in regions with limited resources. Meticulous staging and perioperative planning play a pivotal role in achieving positive outcomes, enhancing the quality of life for patients in resource-constrained settings.
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Mirhosseini SM, Soltanipur M, Yarmohammadi H, Rezaei M, Sheikhi Z. Lymphedema after saphenous harvesting for coronary artery bypass surgery: case report and literature review. BMC Cardiovasc Disord 2024; 24:41. [PMID: 38212705 PMCID: PMC10785345 DOI: 10.1186/s12872-024-03712-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024] Open
Abstract
Different causes have been described for secondary lymphedema as reported in this article. A 75-year-old man was diagnosed with lymphedema about one decade after saphenous harvesting for coronary artery bypass surgery. It took two years for him to find out his diagnosis and receive the proper treatment. After standard complete decongestive therapy, his volume and pain decreased and his quality of life was improved, especially its physical aspect. It is important to recognize the possibility of lymphedema development after saphenous harvesting among patients undergoing coronary artery bypass surgery to prevent significant disturbance of quality of life with timely management.
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Affiliation(s)
| | - Masood Soltanipur
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Medical Students Research Committee, Shahed University, Tehran, Iran
- Quality of Life Department, Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran
| | - Hossein Yarmohammadi
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Medical Students Research Committee, Shahed University, Tehran, Iran
- Quality of Life Department, Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran
| | - Mahdi Rezaei
- Medical Students Research Committee, Shahed University, Tehran, Iran
| | - Zahra Sheikhi
- Quality of Life Department, Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran.
- Integrative Oncology Research Group, Breast Cancer Research Center, Motamed Cancer Institute, ACECR, No.146, South Gandi Ave, Vanak Sq, Tehran, 1517964311, Iran.
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Rafn BS, Bodilsen A, von Heymann A, Lindberg MJ, Byllov S, Andreasen TG, Johansen C, Christiansen P, Zachariae R. Examining the efficacy of treatments for arm lymphedema in breast cancer survivors: an overview of systematic reviews with meta-analyses. EClinicalMedicine 2024; 67:102397. [PMID: 38152415 PMCID: PMC10751832 DOI: 10.1016/j.eclinm.2023.102397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 12/29/2023] Open
Abstract
Background Lymphedema affects one in six breast cancer survivors making it a global healthcare challenge. There is considerable debate about the efficacy of different treatments for lymphedema. We aimed to summarize the current evidence for treatments for lymphedema in breast cancer survivors. Methods In this overview of systematic reviews with meta-analyses (SRMAs), five databases were searched for SRMAs of randomised controlled trials (RCTs) reporting effects of medications, surgery, exercise, laser therapy, acupuncture, kinesio taping, or complex decongestive physiotherapy (CDP) for breast cancer-related lymphedema published from database inception up to March 7, 2023. Data extraction was performed for the SRMAs and RCTs, and SRMAs were appraised with AMSTAR2. Random effects meta-analyses of the RCTs provided estimates of the pooled effects sizes (Hedges' g) for each treatment modality. This study is registered with PROSPERO, CRD42020184813. Findings 1569 studies were identified by the search and eighteen SRMAs with 51 RCTs were included, investigating manual lymphatic drainage (MLD), compression pump, exercise, kinesio taping, laser, and acupuncture. Overall, the methodological quality of the SRMAs was low. SRMAs reached different conclusions for all treatment modalities, except for kinesio taping where the two SRMAs found no effect. The analysis of 40 RCTs with 1970 participants revealed a small effect across all interventions compared to any control (g = 0.20, p = 0.047, I2 = 0.79), corresponding to volume reductions of 119.7 ml (95% CI 135-104) and 88.0 ml (95% CI 99-77) in the intervention and control groups, respectively, and a small effect of exercise (g = 0.26, p = 0.022, I2 = 0.44). The between-group differences in volume reduction were small and did not reach statistical significance for any one treatment modality. Interpretation Based on the available data, there is no evidence of superiority of any one treatment on volume reduction nor any solid research refuting these treatments. Thus, definitive conclusions to inform clinical practice about the efficacy of these treatments cannot be drawn. Due to poor-quality evidence, more research is needed to untangle the efficacy of each treatment component for different stages of lymphedema. Funding Danish Cancer Society.
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Affiliation(s)
- Bolette Skjødt Rafn
- Cancer Survivorship and Treatment Late Effects (CASTLE) - Danish Cancer Society National Research Center, Department of Oncology, Copenhagen University Hospital Rigshospitalet, Denmark
| | | | - Annika von Heymann
- Cancer Survivorship and Treatment Late Effects (CASTLE) - Danish Cancer Society National Research Center, Department of Oncology, Copenhagen University Hospital Rigshospitalet, Denmark
| | | | - Sofia Byllov
- Danish Breast Cancer Group Center and Clinic for Late Effects (DCCL), Aarhus University Hospital, Aarhus, Denmark
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Denmark
| | - Tine Ginnerup Andreasen
- Danish Breast Cancer Group Center and Clinic for Late Effects (DCCL), Aarhus University Hospital, Aarhus, Denmark
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Denmark
| | - Christoffer Johansen
- Cancer Survivorship and Treatment Late Effects (CASTLE) - Danish Cancer Society National Research Center, Department of Oncology, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Peer Christiansen
- Danish Breast Cancer Group Center and Clinic for Late Effects (DCCL), Aarhus University Hospital, Aarhus, Denmark
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Denmark
| | - Robert Zachariae
- Danish Breast Cancer Group Center and Clinic for Late Effects (DCCL), Aarhus University Hospital, Aarhus, Denmark
- Unit for Psycho-oncology and Health Psychology, Department of Oncology, Aarhus University Hospital, and Department of Psychology and Behavioural Sciences, Aarhus University, Denmark
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Drobot D, Leitner Shemy O, Zeltzer AA. Biomaterials in the clinical treatment of lymphedema-a systematic review. J Vasc Surg Venous Lymphat Disord 2024; 12:101676. [PMID: 37696416 DOI: 10.1016/j.jvsv.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE Lymphedema is a chronic condition caused by impaired lymphatic fluid drainage, resulting in progressive edema. The current mainstay of lymphedema therapy consists of conservative therapy and surgical therapy. In this systematic review, we investigated the novel role of biomaterials in clinical lymphedema therapy and assessed their objective outcomes and the complication rate associated with their use. METHODS Studies were identified through systematic review using the Embase and PubMed/MEDLINE databases. Only original articles reporting the use of biomaterials for clinical lymphedema therapy were included. The primary outcome measure was the objective reduction in limb volume after biomaterial use. The secondary outcome measure was the assessment of biomaterial safety. RESULTS A total of 354 articles were identified in the first search, of which 10 met our inclusion criteria. These articles described the use of two biomaterials, nanofibrillar collagen scaffolds (NCSs) and silicone tubes (STs), for the treatment of lymphedema. NCS implantation showed an average excess limb volume reduction of 1% to 10.7% and clear evidence of lymphangiogenesis on imaging. No complications were 7documented after NCS implantation. ST implantation showed an average limb volume reduction of 700 to 887 mL and limb circumference reduction of 3.1 to 8 cm in patients with advanced stage lymphedema. Of 177 patients treated with ST implantation, only 11 (6.2%) developed local inflammation. CONCLUSIONS Both NCS and ST implantation showed promising limb volume reduction; however, with the scarce literature available, additional research is needed to determine their effectiveness. Both demonstrated good safety profiles, with no complications after NCS implantation and a complication rate equivalent to other similar implants for ST implantation.
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Affiliation(s)
- Denis Drobot
- Department of Plastic and Reconstructive Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ortal Leitner Shemy
- Department of Plastic and Reconstructive Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Assaf Aviram Zeltzer
- Department of Plastic and Reconstructive Surgery, Rambam Health Care Campus, Haifa, Israel; Bruce and Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.
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Bucan A, Frendø M, Ngo MT, Sørensen JA, Hölmich LR. Surgical lymphedema models in the mice hindlimb-A systematic review and quality assessment. Microsurgery 2024; 44:e31088. [PMID: 37665032 DOI: 10.1002/micr.31088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Lymphedema constitutes a major unsolved problem in plastic surgery. To identify novel lymphedema treatments, preclinical studies are vital. The surgical mouse lymphedema model is popular and cost-effective; nonetheless, a synthesis and overview of the literature with evidence-based guidelines is needed. The aim of this review was to perform a systematic review to establish best practice and support future high-quality animal studies exploring lymphedema treatments. METHODS We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching four databases (PubMed, Embase, Web of Science, and Scopus) from inception-September 2022. The Animals in Research Reporting In Vivo Experiments 2.0 (ARRIVE 2.0) guidelines were used to evaluate reporting quality. Studies claiming to surgically induce lymphedema in the hindlimb of mice were included. RESULTS Thirty-seven studies were included. Four main models were used. (1) Irradiation+surgery. (2) A variation of the surgery used by (1) + irradiation. (3) Surgery only (SPDF-model). (4) Surgery only (PLND-model). Remaining studies used other techniques. The most common measurement modality was the caliper. Mean quality coefficient was 0.57. Eighteen studies (49%) successfully induced sustained lymphedema. Combination of methods seemed to yield the best results, with an overrepresentation of irradiation, the removal of two lymph nodes, and the disruption of both the deep and superficial lymph vessels in the 18 studies. CONCLUSION Surgical mouse hindlimb lymphedema models are challenged by two related problems: (1) retaining lymphedema for an extended period, that is, establishing a (chronic) lymphedema model (2) distinguishing lymphedema from post-operative edema. Most studies failed to induce lymphedema and used error-prone measurements. We provide an overview of studies claiming to induce lymphedema and advocate improved research via five evidence-based recommendations to use: (1) a proven lymphedema model; (2) sufficient follow-up time, (3) validated measurement methods; (4) ARRIVE-guidelines; (5) contralateral hindlimb as control.
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Affiliation(s)
- Amar Bucan
- Department of Plastic Surgery, University of Copenhagen, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Martin Frendø
- Department of Plastic Surgery, University of Copenhagen, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for HR & Education, Copenhagen, Denmark
| | - Mikaella Ty Ngo
- Department of Plastic Surgery, University of Copenhagen, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Jens Ahm Sørensen
- Research Unit for Plastic Surgery, Odense University Hospital, Odense, Denmark
| | - Lisbet Rosenkrantz Hölmich
- Department of Plastic Surgery, University of Copenhagen, Herlev and Gentofte Hospital, Copenhagen, Denmark
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Kurt G, Kiloatar H, Aras B. Knowledge, attitude and practice of physiotherapists about lymphedema: A Turkish perspective. J Bodyw Mov Ther 2024; 37:233-237. [PMID: 38432811 DOI: 10.1016/j.jbmt.2023.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 11/17/2023] [Accepted: 11/26/2023] [Indexed: 03/05/2024]
Abstract
BACKGROUND Physiotherapists are important members of the healthcare team in the management of lymphedema. Therefore, the level of knowledge and awareness of physiotherapists on this disease is substantial. This study was planned to investigate knowledge, attitude, and practice of physiotherapists about lymphedema in Turkey. METHOD This study was a qualitative, prospective, and cross-sectional research. Data were collected with the web-survey which consisted of the demographical characteristics information, evaluation of their own knowledge and practice in lymphedema management, and current knowledge of physiotherapists about lymphedema based on the current literature. RESULTS Two hundred seventy-four physiotherapists (174 Female: 100 Male; mean age: 29.87 ± 6.9 years) completed the web-survey. From 274 physiotherapists, 52.60% of them had no education about lymphedema, 13.90% of them had never seen any patient with lymphedema, and 57.70% of them had not taken part in the management of a patient with lymphedema. 71.90% of the physiotherapists did not think they have enough knowledge about lymphedema. It was identified that physiotherapists' general and risk factors knowledge about lymphedema was sufficient. However, physiotherapists showed a lack of knowledge on the evaluation, treatment, and recommendations for lymphedema. CONCLUSION Physiotherapists' education and experience in lymphedema management are crucial as they are important members of the multidisciplinary team. To raise qualified physiotherapists in this field, from undergraduate education, special training programs about lymphedema should be added to their lifelong learning process.
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Affiliation(s)
- Gamze Kurt
- Department of Occupational Therapy, Kutahya Health Sciences University, Kutahya, Turkey.
| | - Humeyra Kiloatar
- Department of Physiotherapy and Rehabilitation, Kutahya Health Sciences University, Kutahya, Turkey.
| | - Bahar Aras
- Department of Physiotherapy and Rehabilitation, Kutahya Health Sciences University, Kutahya, Turkey.
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Daggez M, Koyuncu EG, Kocabaş R, Yener C. Prophylactic complex physiotherapy in gynecologic cancer survivors: patient-reported outcomes based on a lymphedema questionnaire. Int J Gynecol Cancer 2023; 33:1928-1933. [PMID: 37844965 DOI: 10.1136/ijgc-2023-004811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Abstract
OBJECTIVE Lower extremity lymphedema secondary to cancer treatment impacts quality of life for gynecological cancer survivors. Complex decongestive physiotherapy is applied when lymphedema is diagnosed, but prophylactic physiotherapy is not yet a standard of care. The aim of this study is to evaluate prophylactic complex physiotherapy in patients with gynecological cancer and its effects on patient-reported symptoms based on the Gynecologic Cancer Lymphedema Questionnaire. METHODS The data of patients diagnosed with gynecological cancers who underwent lymphadenectomy from July 2021 to June 2022 was evaluated. All patients were referred to the physiotherapy unit before adjuvant treatment. Patients who accepted prophylactic physiotherapy were informed and massage and exercise training were implemented, whereas patients who declined were solely informed. Bilateral lower extremity circumferences were measured at 1, 3, 6, and 12 months at the levels of 10 cm, 30 cm, and 50 cm above the heels. A translated form of the Gynecologic Cancer Lymphedema Questionnaire was administered to all patients at the last visit. RESULTS A total of 100 patients were included in the study. Patients were diagnosed with endometrial (50%), ovarian (32%), cervical (16%), and vulvar (2%) cancer. Overall, 70% underwent systematic pelvic±para-aortic lymphadenectomy whereas sentinel lymph node mapping was performed in 30%. Lymphedema was seen in 5% (n=3) of the prophylactic physiotherapy positive group and in 60% (n=24) of the physiotherapy negative group. The median score was 3 (range 1-5) in the physiotherapy positive group and 16 (range 9-20) in the physiotherapy negative group. In patients diagnosed with lymphedema in the physiotherapy negative group, systematic lymphadenectomy was performed in 91.7% (n=22) and a higher number of lymph nodes was extracted (median 45.5; p=0.002). CONCLUSION Prophylactic complex physiotherapy is associated with lower rates of lymphedema and better patient-reported symptom scores according to the Gynecologic Cancer Lymphedema Questionnaire.
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Affiliation(s)
- Mine Daggez
- Department of Gynecologic Oncology, Tekirdag Dr Ismail Fehmi Cumalioglu City Hospital, Tekirdag, Turkey
| | - Esra Gizem Koyuncu
- Department of Physical Medicine and Rehabilitation, Tekirdag Dr Ismail Fehmi Cumalioglu City Hospital, Tekirdag, Turkey
| | - Rukiye Kocabaş
- Department of Physical Medicine and Rehabilitation, Tekirdag Dr Ismail Fehmi Cumalioglu City Hospital, Tekirdag, Turkey
| | - Cem Yener
- Obstetrics and Gynecology, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
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Chen K, Beeraka NM, Zhang X, Sinelnikov MY, Plotnikova M, Zhao C, Basavaraj V, Zhang J, Lu P. Recent Advances in Therapeutic Modalities Against Breast Cancer-Related Lymphedema: Future Epigenetic Landscape. Lymphat Res Biol 2023; 21:536-548. [PMID: 37267206 PMCID: PMC10753987 DOI: 10.1089/lrb.2022.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
Background: Lymphedema is a significant postsurgical complication observed in the majority of breast cancer patients. These multifactorial etiopathogenesis have a significant role in the development of novel diagnostic/prognostic biomarkers and the development of novel therapies. This review aims to ascertain the epigenetic alterations that lead to breast cancer-related lymphedema (BCRL), multiple pathobiological events, and the underlying genetic predisposing factors, signaling cascades pertinent to the lapses in effective prognosis/diagnosis, and finally to develop a suitable therapeutic regimen. Methods and Results: We have performed a literature search in public databases such as PubMed, Medline, Google Scholar, National Library of Medicine and screened several published reports. Search words such as epigenetics to induce BCRL, prognosis/diagnosis, primary lymphedema, secondary lymphedema, genetic predisposing factors for BRCL, conventional therapies, and surgery were used in these databases. This review described several epigenetic-based predisposing factors and the pathophysiological consequences of BCRL, which affect the overall quality of life, and the interplay of these events could foster the progression of lymphedema in breast cancer survivors. Prognosis/diagnostic and therapy lapses for treating BCRL are highly challenging due to genetic and anatomical variations, alteration in the lymphatic vessel contractions, and variable expression of several factors such as vascular endothelial growth factor (VEGF)-E and vascular endothelial growth factor receptor (VEGFR) in breast cancer survivors. Conclusion: We compared the efficacy of various conventional therapies for treating BCRL as a multidisciplinary approach. Further substantial research is required to decipher underlying signaling epigenetic pathways to develop chromatin-modifying therapies pertinent to the multiple etiopathogenesis to explore the correlation between the disease pathophysiology and novel therapeutic modalities to treat BCRL.
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Affiliation(s)
- Kuo Chen
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Narasimha M. Beeraka
- Raghavendra Institute of Pharmaceutical Education and Research (RIPER), Anantapuramu, Andhra Pradesh, India
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Xinliang Zhang
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Mikhail Y. Sinelnikov
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Maria Plotnikova
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Cuiping Zhao
- The 80th Army Hospital of the Chinese People's Liberation Army, Weifang, China
| | - Vijaya Basavaraj
- Department of Pathology, JSS Medical College, JSS Academy of Higher Education & Research (JSS AHER), Mysuru, Karnataka, India
| | - Jin Zhang
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Pengwei Lu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Ferriero G, Invernizzi M, Weiss J, de Sire A, Maggioni S, Magni S, Giordano A, Franchignoni F. Rasch validation and refinement of the Lymphedema Life Impact Scale version 2 in an Italian cohort with secondary lymphedema. Disabil Rehabil 2023; 45:3755-3761. [PMID: 36282101 DOI: 10.1080/09638288.2022.2135773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 10/07/2022] [Accepted: 10/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To produce and validate an Italian version of the Lymphedema Life Impact Scale version 2 (LLISv2-It), a tool measuring the impact of lymphedema on health-related quality of life, and investigate its main psychometric characteristics. METHODS After translation and cross-cultural adaptation of the LLISv2, we administered it to 156 subjects with secondary lymphedema (upper or lower limb), together with (depending on the limb involved) either the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) or the Lower Extremity Functional Scale (LEFS). We analyzed the performance of LLISv2-It using Classical Test Theory and Rasch methods. RESULTS Cronbach alpha was 0.89. Item fit statistics indicated that item #12 was underfitting (Infit MnSQ = 1.56; Outfit MnSq = 1.75). Test-retest reliability of the 17-item version (without item #18, not scored, according to the original authors) and of a 16-item version (without #12 and #18-a unidimensional item set) were both excellent (ICC2.1 = 0.93; 95%). The minimum detectable change was 8.9 points. The correlation of LLISv2-It with DASH and LEFS was r = 0.81 and -0.57, respectively. CONCLUSIONS The Italian version of the LLISv2 is reliable and valid. To make the tool more psychometrically sound, we recommend to not calculate items #12 and #18 in the total score. IMPLICATIONS FOR REHABILITATIONThe Lymphedema Life Impact Scale (LLISv2) is particularly useful as a validated condition-specific health-related quality of life measure for patients with chronic edema/lymphedema. We have validated its Italian version (LLISv2-It).We also examined the psychometric properties of the LLISv2 in individuals with secondary lymphedema of either upper or lower limb, using both classical test theory and Rasch techniques, to provide insights for further refinement of the questionnaire.Based on our results, we recommend not to count item #12 in the total score (besides #18, as already suggested by the original authors). Moreover, we determined that the minimum detectable change of the LLISv2 was 9 points. This information is helpful in clinical practice to understand if the change in score is not due to chance (measurement error).Although further research is warranted, the present validation study of the LLISv2 increases the confidence in the metric quality and clinical utility of the scale to assess lymphedema-specific health-related quality of life in individuals with secondary lymphedema of either upper or lower limb.
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Affiliation(s)
- Giorgio Ferriero
- Physical and Rehabilitation Medicine Unit, Scientific Institute of Tradate, IRCCS, Istituti Clinici Scientifici Maugeri, Tradate, Italy
- Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Marco Invernizzi
- Department of Health Sciences, Physical Medicine and Rehabilitation, University of Eastern Piedmont, Novara, Italy
- Department of Integrated Research and Innovation, Translational Medicine (DAIRI), Hospital S.S. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Jan Weiss
- Department of Physical Therapy, Missouri State University, Springfield, MO, USA
| | - Alessandro de Sire
- Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", Catanzaro, Italy
| | - Serena Maggioni
- Department of Physical Medicine and Rehabilitation, Scientific Institute of Lissone, Istituti Clinici Scientifici Maugeri, Lissone, Italy
| | - Silvia Magni
- Department of Physical Medicine and Rehabilitation, Scientific Institute of Lissone, Istituti Clinici Scientifici Maugeri, Lissone, Italy
| | - Andrea Giordano
- Bioengineering Unit, Scientific Institute of Veruno, IRCCS, Istituti Clinici Scientifici Maugeri, Veruno-Gattico, Italy
| | - Franco Franchignoni
- Physical and Rehabilitation Medicine Unit, Scientific Institute of Tradate, IRCCS, Istituti Clinici Scientifici Maugeri, Tradate, Italy
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41
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Williamson S, Somach S. Firm smooth polypoid nodule within a skin graft. JAAD Case Rep 2023; 41:49-51. [PMID: 37842155 PMCID: PMC10568224 DOI: 10.1016/j.jdcr.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Affiliation(s)
- Sarah Williamson
- Department of Dermatology, MetroHealth Medical Center, Cleveland, Ohio
| | - Stephen Somach
- Department of Dermatology, MetroHealth Medical Center, Cleveland, Ohio
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42
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Liu M, Zhang Y, Li X, Hao Q, Li B, Wang R. MRI-based volume measurement methods for staging primary lower extremity lymphedema: a single-center study of asymmetric volume difference-a diagnostic study. BMC Musculoskelet Disord 2023; 24:810. [PMID: 37828475 PMCID: PMC10568749 DOI: 10.1186/s12891-023-06912-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 09/24/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Lower extremity lymphedema (LEL) staging is mainly assessed by systems that solely depend on physical examinations and lack quantitative assessment based on modern imaging. OBJECTIVE To explore the value of MRI-based asymmetric volume measurements in the clinical staging of primary LEL. METHODS 92 patients with unilateral primary LEL underwent MRI examinations to determine the volume of the mid-calf (Vcl) calculated using the clinical dermatome method as well as the total volume (Vmri), musculoskeletal volume (VM), and subcutaneous volume (VS) volume of the middle calves. The difference between Vmri (DVmri) and VS (DVS) of the affected and unaffected calves was obtained and defined as the asymmetric volume difference. Meanwhile, the volume of the mid-calf (Vcl) and the difference in volume (DVcl) were calculated using the clinical circumferential method. The relationship between the asymmetric volume difference and clinical staging was then evaluated. Interobserver consistency was assessed through the intraclass correlation coefficient (ICC). Volume comparisons between the three groups were performed using the one-way analysis of variance (ANOVA) or the Kruskal-Wallis test. Spearman's correlation was used to assess volume and clinical stage correlation. The receiver operating characteristic (ROC) curve was used to evaluate the value of asymmetric volume difference for clinical staging. RESULTS The asymmetric volume difference was statistically significant in stage I compared to stages II and III (p < 0.05). The asymmetric volume difference (DVmri: r = 0.753; DVS: r = 0.759) correlated more with the clinical stage than the affected Vcl (r = 0.581), Vmri (r = 0.628), VS (r = 0.743), and DVcl (r = 0.718). The area under the ROC curve (AUC) for identifying the clinical stage by the asymmetric volume difference was greater than that for the affected Vcl, Vmri, VS, and DVcl, with DVS (AUC = 0.951) having the largest area under the curve to distinguish between stages I and II. CONCLUSION MRI-based asymmetric volume difference is an adjunctive measure for LEL clinical staging with good reproducibility. DVS could be the best indicator for differentiating between stages I and II of primary LEL.
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Affiliation(s)
- Mengke Liu
- Department of Radiology, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Yan Zhang
- Department of Radiology, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Xingpeng Li
- Department of Radiology, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Qi Hao
- Department of Radiology, Affiliated the ninth Clinical Medical College, Peking University, Beijing, 100038, China
| | - Bin Li
- Department of MRI, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China.
| | - Rengui Wang
- Department of Radiology, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China.
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Smith MS, Sarasua SM, Rogers C, Phelan K, Boccuto L. Lymphedema is associated with CELSR1 in Phelan-McDermid syndrome. Clin Genet 2023; 104:472-478. [PMID: 37232218 DOI: 10.1111/cge.14364] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/27/2023]
Abstract
Lymphedema is a troubling condition present in many disorders including the rare genetic disorder known as Phelan-McDermid syndrome (PMS). The neurobehavioral features of PMS, also known as 22q13.3 deletion syndrome, have been investigated, but little research exists on lymphedema in PMS. In this investigation, clinical and genetic data from 404 people with PMS were reviewed from the PMS-International Registry revealing a prevalence of 5% with lymphedema. Lymphedema was reported in 1 out of 47 people (2.1%) with PMS due to a SHANK3 variant and 19 out of 357 people (5.3%) with PMS due to 22q13.3 deletions. Lymphedema was more common among those in their teens or adulthood (p = 0.0011) and those with deletions >4 Mb. People with lymphedema had significantly larger deletions (mean 5.375 Mb) than those without lymphedema (mean 3.464 Mb, p = 0.00496). Association analysis identified a deletion of the CELSR1 gene to be the biggest risk factor (OR = 12.9 95% CI [2.9-56.2]). Detailed assessment of 5 subjects identified all had deletions of CELSR1, developed symptoms of lymphedema starting at age 8 or older, and typically responded well to standard therapy. In conclusion, this is the largest assessment of lymphedema in PMS to date and our results suggest that individuals with deletions >4 Mb or those with CELSR1 deletions should be assessed for lymphedema.
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Affiliation(s)
- Marie S Smith
- School of Nursing, Healthcare Genetics Program, Clemson University, Clemson, South Carolina, USA
| | - Sara M Sarasua
- School of Nursing, Healthcare Genetics Program, Clemson University, Clemson, South Carolina, USA
| | - Curtis Rogers
- Greenwood Genetic Center, Greenwood, South Carolina, USA
| | - Katy Phelan
- Genetics Laboratory, Florida Cancer Specialists & Research Institute, Fort Myers, Florida, USA
| | - Luigi Boccuto
- School of Nursing, Healthcare Genetics Program, Clemson University, Clemson, South Carolina, USA
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Zhou Z, Sui X, Cao Z, Li X, Qing L, Tang J. Substance P promote macrophage M2 polarization to attenuate secondary lymphedema by regulating NF-kB/NLRP3 signaling pathway. Peptides 2023; 168:171045. [PMID: 37507091 DOI: 10.1016/j.peptides.2023.171045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/25/2023] [Accepted: 06/09/2023] [Indexed: 07/30/2023]
Abstract
Secondary lymphedema often occurs after filariasis, trauma, lymph node dissection and radiation therapy, which is manifested by infiltration of inflammatory cells and fibrosis formation in pathologically. Substance P is a widely used neuropeptide in the field of tissue repair, while the regenerative potential of the substance P has not been proven in the secondary lymphedema. In this study, animal model of secondary lymphedema was constructed by excising the skin and subcutaneous lymphatic network in the tail of mice, and the degree of swelling in the tail of mice was evaluated after 6 weeks under the treatment with substance P. Immunofluorescence staining was also performed to assess immune cell infiltration, subcutaneous fibrosis and lymphangiogenesis. The results revealed that substance P significantly alleviated post-surgical lymphedema in mice. Furthermore, we found that substance P promoted macrophages M2 polarization, a process associated with downregulation of the NF-kB/NLRP3 pathway. After application of disodium clodronate (macrophage scavenger, CLO), the positive effect of substance P in lymphedema is significantly inhibited. In vitro experiments, we further demonstrated the polarizing effect of substance P on bone marrow-derived macrophages (BMDMs), while substance P inhibited the activation of the NF-kB/NLRP3 pathway in BMDMs after the treatment of lipopolysaccharide (LPS). In addition, polarized macrophages were demonstrated to promote the proliferation, tube-forming and migratory functions of human lymphatic endothelial cells (hLEC). In conclusion, our study provides preliminary evidence that substance P alleviates secondary lymphedema by promoting macrophage M2 polarization, and this therapeutic effect may be associated with downregulation of the NF-kB/NLRP3 pathway.
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Affiliation(s)
- Zekun Zhou
- Xiangya hospital of central south university, Changsha, China
| | - Xinlei Sui
- Xiangya hospital of central south university, Changsha, China
| | - Zheming Cao
- Xiangya hospital of central south university, Changsha, China
| | - Xiaoxiao Li
- Changsha Medical University, Changsha, China
| | - Liming Qing
- Xiangya hospital of central south university, Changsha, China.
| | - Juyu Tang
- Xiangya hospital of central south university, Changsha, China.
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45
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Nomura Y, Hoshiyama M, Akita S, Naganishi H, Zenbutsu S, Matsuoka A, Ohnishi T, Haneishi H, Mitsukawa N. Computer-aided diagnosis for screening of lower extremity lymphedema in pelvic computed tomography images using deep learning. Sci Rep 2023; 13:16214. [PMID: 37758908 PMCID: PMC10533488 DOI: 10.1038/s41598-023-43503-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 09/25/2023] [Indexed: 09/29/2023] Open
Abstract
Lower extremity lymphedema (LEL) is a common complication after gynecological cancer treatment, which significantly reduces the quality of life. While early diagnosis and intervention can prevent severe complications, there is currently no consensus on the optimal screening strategy for postoperative LEL. In this study, we developed a computer-aided diagnosis (CAD) software for LEL screening in pelvic computed tomography (CT) images using deep learning. A total of 431 pelvic CT scans from 154 gynecological cancer patients were used for this study. We employed ResNet-18, ResNet-34, and ResNet-50 models as the convolutional neural network (CNN) architecture. The input image for the CNN model used a single CT image at the greater trochanter level. Fat-enhanced images were created and used as input to improve classification performance. Receiver operating characteristic analysis was used to evaluate our method. The ResNet-34 model with fat-enhanced images achieved the highest area under the curve of 0.967 and an accuracy of 92.9%. Our CAD software enables LEL diagnosis from a single CT image, demonstrating the feasibility of LEL screening only on CT images after gynecologic cancer treatment. To increase the usefulness of our CAD software, we plan to validate it using external datasets.
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Affiliation(s)
- Yukihiro Nomura
- Center for Frontier Medical Engineering, Chiba University, 1-33 Yayoi-Cho, Inage-ku, Chiba, 263-8522, Japan.
| | - Masato Hoshiyama
- Department of Medical Engineering, Faculty of Engineering, Chiba University, 1-33 Yayoi-Cho, Inage-ku, Chiba, 263-8522, Japan
| | - Shinsuke Akita
- Department of Plastic, Reconstructive and Aesthetic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Hiroki Naganishi
- Department of Plastic Surgery, Saiseikai Yokohamashi Nanbu Hospital, 3-2-10 Konandai, Konan-ku, Yokohama City, Kanagawa, 234-0054, Japan
| | - Satoki Zenbutsu
- Center for Frontier Medical Engineering, Chiba University, 1-33 Yayoi-Cho, Inage-ku, Chiba, 263-8522, Japan
| | - Ayumu Matsuoka
- Department of Gynecology and Maternal-Fetal Medicine, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Takashi Ohnishi
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, 1133 York Avenue, New York, NY, 10065, USA
| | - Hideaki Haneishi
- Center for Frontier Medical Engineering, Chiba University, 1-33 Yayoi-Cho, Inage-ku, Chiba, 263-8522, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
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Douglas P. Does the Academy of Breastfeeding Medicine's Clinical Protocol #36 'The Mastitis Spectrum' promote overtreatment and risk worsened outcomes for breastfeeding families? Commentary. Int Breastfeed J 2023; 18:51. [PMID: 37670315 PMCID: PMC10481477 DOI: 10.1186/s13006-023-00588-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 08/25/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND In 2022 the Academy of Breastfeeding Medicine (ABM) published Clinical Protocol #36: The Mastitis Spectrum, which aims to update clinical approaches to management of benign lactation-related breast inflammation. The protocol has been timely because of the exponential increase in knowledge about the human milk microbiome over the past decade. This Commentary aims to continue respectful debate amongst clinicians and researchers within the Academy of Breastfeeding Medicine and more broadly, confident that we share a fundamental commitment to promote breastfeeding and support the well-being of lactating women, their infants and their families. ANALYSIS Although Clinical Protocol #36 offers advances, it does not fulfil the principles of best practice implementation science for translation of evidence into clinical guidelines. Clinical Protocol #36 inaccurately represents studies; misrepresents theoretical models as proven aetiologies; does not consistently attribute sources; does not reliably apply the SORT taxonomy; and relies upon single case reports. As a result, various recommendations in Clinical Protocol #36 lack an evidence-base or credible underlying theoretical model. This includes recommendations to use 'lymphatic drainage' massage, therapeutic ultrasound, and oral lecithin. Similarly, based on a contestable theoretical model which is presented as fact, Clinical Protocol #36 makes the recommendation to either reduce frequency of milk removal or to maintain current frequency of milk removal during an episode of breast inflammation. Although Clinical Protocol #36 limits this advice to cases of 'hyperlactation', the diagnosis 'hyperlactation' itself is undefinable. As a result, this recommendation may put breastfeeding women who present with breast inflammation at risk of worsened inflammation and decreased breast milk production. CONCLUSION Clinical Protocol #36 offers some advances in the management of breast inflammation. However, Clinical Protocol #36 also exposes clinicians to two international trends in healthcare which undermine health system sustainability: overdiagnosis, including by over-definition, which increases risk of overtreatment; and antibiotic over-use, which worsens the crisis of global antimicrobial resistance. Clinical Protocol #36 also recommends unnecessary or ineffective interventions which may be accessed by affluent patients within advanced economies but are difficult to access for the global majority. The Academy of Breastfeeding Medicine may benefit from a review of processes for development of Clinical Protocols.
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Affiliation(s)
- Pamela Douglas
- The School of Nursing and Midwifery, Griffith University, Brisbane, Australia.
- General Practice Clinical Unit, The University of Queensland, Brisbane, Australia.
- Medical Director, The NDC Institute, ndcinstitute.com.au, Brisbane, Australia.
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Kwon JG, Kim Y, Jang MY, Suh HP, Pak CJ, Keeley V, Jeon JY, Hong JP. The Quality of Life after Lymphaticovenous Anastomosis in 118 Lower Limb Lymphedema Patients. Arch Plast Surg 2023; 50:514-522. [PMID: 37808336 PMCID: PMC10556310 DOI: 10.1055/a-2117-4478] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 06/15/2023] [Indexed: 10/10/2023] Open
Abstract
Background This is a prospective study on 118 patients who underwent lymphaticovenous anastomosis (LVA) due to secondary lower limb lymphedema between January 2018 and October 2020 to evaluate patients' quality of life (QOL) using the Quality of Life Measure for Limb Lymphedema (LYMQoL) questionnaire. Methods The outcome measurement included the LYMQoL leg scoring system tool evaluating the function, appearance, symptom, mood, and overall outcome. In addition, correlation analysis was performed for three factors: based on International Society of Lymphology (ISL) stages, disease duration, and amount of volume reduction. Results The LYMQoL tool overall satisfaction score significantly increased at all intervals from 4.4 ± 0.2 preoperative to 6.5 ± 0.3 postoperative at 12 months ( p < 0.001). Significant findings were seen for each domain scores compared preoperatively and at 12 months: function score (18.6 ± 0.5 to 15.4 ± 0.6), appearance score (17.8 ± 0.5 to 16.0 ± 0.6), symptom score (11.8 ± 0.3 to 8.9 ± 0.4), and mood score (14.5 ± 0.4 to 11.4 ± 0.5; p < 0.05). The correlation analysis between improvement of the overall score and the ISL stage ( p = 0.610, correlation coefficient [ r ] = - 0.047), disease duration ( p = 0.659, r = - 0.041), and amount of limb volume reduction ( p = 0.454, r = - 0.070) showed no statistical significance. Conclusion The QOL of secondary lower limb lymphedema patients was significantly improved after LVA regardless of the severity of disease, duration of disease, and amount of volume reduction after LVA. Understanding the patient-reported outcome measurement will help the surgeons to manage and guide the expectations of the patients.
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Affiliation(s)
- Jin Geun Kwon
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeongsong Kim
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Young Jang
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyunsuk Peter Suh
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Changsik John Pak
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Vaughan Keeley
- Lymphoedema Service, Royal Derby Hospital, Derby, United Kingdom
| | - Jae Yong Jeon
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joon Pio Hong
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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48
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Doubblestein D, Campione E, Hunley J, Schaverien M. Pre- and Post-Microsurgical Rehabilitation Interventions and Outcomes on Breast Cancer-Related Lymphedema: a Systematic Review. Curr Oncol Rep 2023; 25:1031-1046. [PMID: 37402044 PMCID: PMC10474983 DOI: 10.1007/s11912-023-01439-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/05/2023]
Abstract
PURPOSE OF REVIEW Breast cancer-related lymphedema (BCRL) is a debilitating progressive disease resulting in various impairments and dysfunctions. Complete decongestive therapy embodies conservative rehabilitation treatments for BCRL. Surgical procedures performed by plastic and reconstructive microsurgeons are available when conservative treatment fails. The purpose of this systematic review was to investigate which rehabilitation interventions contribute to the highest level of pre- and post-microsurgical outcomes. RECENT FINDINGS Studies published between 2002 and 2022 were grouped for analysis. This review was registered with PROSPERO (CRD42022341650) and followed the PRISMA guidelines. Levels of evidence were based upon study design and quality. The initial literature search yielded 296 results, of which, 13 studies met all inclusion criteria. Lymphovenous bypass anastomoses (LVB/A) and vascularized lymph node transplant (VLNT) emerged as dominant surgical procedures. Peri-operative outcome measures varied greatly and were used inconsistently. There is a dearth of high quality literature leading to a gap in knowledge as to how BCRL microsurgical and conservative interventions complement each other. Peri-operative guidelines are needed to bridge the knowledge and care gap between lymphedema surgeons and therapists. A core set of outcome measures for BCRL is vital to unify terminological differences in the multidisciplinary care of BCRL. Complete decongestive therapy embodies conservative rehabilitation treatments for breast cancer-related lymphedema (BCRL). Surgical procedures performed by microsurgeons are available when conservative treatment fails. This systematic review investigated which rehabilitation interventions contribute to the highest level of pre- and post-microsurgical outcomes. Thirteen studies met all inclusion criteria and revealed that there is a dearth of high quality literature leading to a gap in knowledge as to how BCRL microsurgical and conservative interventions complement each other. Furthermore, peri-operative outcome measures were inconsistent. Peri-operative guidelines are needed to bridge the knowledge and care gap between lymphedema surgeons and therapists.
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Affiliation(s)
| | | | - Julie Hunley
- Department of Occupational Therapy, Mount Mary University, Milwaukee, WI, USA
| | - Mark Schaverien
- Department of Plastic Surgery, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Finkelstein ER, Crist TE, Shao T, Mella-Catinchi J, Xu KY. The utility of computed tomography venography in the routine evaluation of patients who present to a lymphedema center with lower extremity edema. J Vasc Surg Venous Lymphat Disord 2023; 11:1055-1062. [PMID: 37196921 DOI: 10.1016/j.jvsv.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/13/2023] [Accepted: 05/08/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE Computed tomography venography (CTV) is not routinely used to screen patients presenting with a presumed lower extremity lymphedema diagnosis for left iliac vein obstruction (IVO) or May-Thurner syndrome (MTS). The objective of this study is to determine the utility of routine CTV screening for these patients by evaluating the proportion presenting with clinically significant CTV-identified left IVO. METHODS We retrospectively reviewed 121 patients who had presented to our lymphedema center with lower extremity edema between November 2020 and May 2022. Information regarding demographics, comorbidities, lymphedema characteristics, and imaging reports was collected. Cases of IVO present on CTV were reviewed by a multidisciplinary team to determine the clinical significance of the CTV findings. RESULTS Of the patients with complete imaging studies, 49% (n = 25) had abnormal lymphoscintigraphy findings, 45% (n = 46) had reflux on ultrasound, and 11.4% (n = 9) had IVO on CTV. Seven patients (6%) had CTV findings of IVO and edema of either the isolated left (n = 4) or bilateral (n = 3) lower extremities. Cases of IVO on CTV were determined by the multidisciplinary team to be the predominant cause of lower extremity edema for three of these seven cases (43%; or 2.5% of all 121 patients). CONCLUSIONS Six percent of patients presenting to a lymphedema center with lower extremity edema had left-sided IVO on CTV suggestive of MTS. However, the cases of IVO were determined to be clinically significant <50% of the time or for 2.5% of all patients. CTV should be reserved for patients with isolated left-sided or bilateral lower extremity edema with a greater left-sided component and a history of findings that raise clinical suspicion for MTS.
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Affiliation(s)
- Emily R Finkelstein
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Taylor E Crist
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Tony Shao
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Juan Mella-Catinchi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Kyle Y Xu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL.
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Pieper CC. Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions. Invest Radiol 2023; 58:610-640. [PMID: 37058335 DOI: 10.1097/rli.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
ABSTRACT Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.
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Affiliation(s)
- Claus C Pieper
- From the Division for Minimally Invasive Lymphatic Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn; and Center for Rare Congenital Lymphatic Diseases, Center of Rare Diseases Bonn, Bonn, Germany
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