Pediatric Lymphedema: Study of 180 Patients Referred to a Tertiary Lymphedema Clinic

BACKGROUND

Lymphedema is due to dysfunction of the lymphatic system. It can be primary or secondary. Pediatric lymphedema is more often primary and is a chronic disease with a heavy burden on quality of life.

METHODS

Medical records of patients under 18 years of age referred between 1996 and 2021 to the specialized lymphedema clinic at the Sainte-Justine University Hospital Center were reviewed. Demographic data, sex, age at presentation, location of the lymphedema, clinical features, genetic testing, symptoms, complications, investigations, and treatment were collected.

RESULTS

Of 180 referred patients, lymphedema was confirmed in 151, and 137 were primary lymphedema. Median age of apparition of primary lymphedema was 7.00 years and was significantly lower in boys than in girls. Primary congenital lymphedema was more frequent in boys (51.0%, 27.3% in girls, P = .007), and onset of primary lymphedema during adolescence was more frequent in girls (53.4%, 25.0% in boys, P = .001). Lower limbs were the most impacted (88.3%). Sixty patients had genetic testing, and 38 (63.3%) of them were discovered to have a pertinent genetic mutation. The most common mutated gene was the FLT4 gene (in 9 patients). Seven patients (5.1%) had associated extensive/central lymphatic malformation and 24 (17.6%) had a polymalformative syndrome/syndromic lymphedema.

CONCLUSIONS

Pediatric lymphedema is more frequent in girls, usually involves lower limb, and is most often sporadic, but often associated with a genetic mutation, and genetic testing should be performed.

Treatment Outcomes of Manual Lymphatic Drainage in Pediatric Lymphedema

BACKGROUND

Pediatric lymphedema can result in irreversible, debilitating limb swelling, tissue fibrosis, skin ulcers, infection, and impaired limb function in children at an early age. Manual lymphatic drainage (MLD) is a noninvasive technique, which is a part of intensive decongestive therapy to reroute lymphatic flow to healthy channels used to manage lymphedema. Outcomes of this treatment option in children have not been studied. We evaluated the effect of decongestive therapy involving MLD in pediatric patients with complex lymphatic anomalies by measuring treatment progress and functional outcomes via changes in limb circumference, limb functionality, dexterity, skin quality, and pain.

METHODS

A single-institution retrospective study on a cohort of 8 pediatric patients with lymphatic anomalies who completed a course of MLD was conducted from 2015 to 2017 to investigate the role MLD plays in their lymphedema reduction. Pain scores were measured on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable. The functional performance was measured by the Canadian Occupational Performance Measurement questionnaire.

RESULTS

Among all patients, there were 4 cases affecting the upper extremities, 4 affecting the lower extremities, and 3 affecting the truncal region. Five of 8 patients demonstrated a reduction in lymphedema with an average girth reduction of 8.2% in the lower extremities, 3.0% in the upper extremities, and 7.4% in the truncal regions. In unilateral cases, the difference in limb circumference between the affected and normal extremity decreased by an average of 25.6%. Four patients completed the Canadian Occupational Performance Measurement questionnaire with an average improvement of 30% in daily task performance. Three patients reported complete resolution of pain.

CONCLUSIONS

MLD can be used as a reliable noninvasive method for decongestion and analgesia to delay the onset of lymphedema-associated fibrosis and long-term disability in children with complex lymphatic malformations.

Primary lymphedema French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins)

Primary lymphedema is a rare chronic pathology associated with constitutional abnormalities of the lymphatic system. The objective of this French National Diagnosis and Care Protocol (Protocole National de Diagnostic et de Soins; PNDS), based on a critical literature review and multidisciplinary expert consensus, is to provide health professionals with an explanation of the optimal management and care of patients with primary lymphedema. This PNDS, written by consultants at the French National Referral Center for Primary Lymphedema, was published in 2019 (https://has-sante.fr/upload/docs/application/pdf/2019-02/pnds_lymphoedeme_primaire_final_has.pdf). Primary lymphedema can be isolated or syndromic (whose manifestations are more complex with a group of symptoms) and mainly affects the lower limbs, or, much more rarely, upper limbs or external genitalia. Women are more frequently affected than men, preferentially young. The diagnosis is clinical, associating mild or non-pitting edema and skin thickening, as confirmed by the Stemmer’s sign (impossibility to pinch the skin on the dorsal side or the base of the second toe), which is pathognomonic of lymphedema. Limb lymphoscintigraphy is useful to confirm the diagnosis. Other causes of swelling or edema of the lower limbs must be ruled out, such as lipedema. The main acute lymphedema complication is cellulitis (erysipelas). Functional and psychological repercussions can be major, deteriorating the patient’s quality of life. Treatment aims to prevent those complications, reduce the volume with low-stretch bandages, then stabilize it over the long term by exercises and wearing a compression garment. Patient education (or parents of a child) is essential to improve observance.

Chubby Infant - Should One Worry? An Infant with Primary lymphedema - Mini Review and Case Report

Lymphedema is a localized form of tissue swelling, characterized by a progressive accumulation of a tissue fluid in the interstitial compartment as a result of the lymphatic system dysfunction. It is a rare disease in the pediatric population and in the majority of cases it is a consequence of an abnormal formation of the lymphatic system, which is called primary lymphedema. Although its epidemiology is not precise, it is assumed that 1:100 000 children suffer from primary lymphedema. The diagnosis can be made by a proper clinical examination after ruling out secondary causes of lymphedema, particularly in cases with a more asymmetric swelling of the extremities. In this very article we present a case report of an 8-months-old infant with primary lymphedema, who had presented swelling of the extremities from birth and yet no pathology was suspected before. The purpose of this article is to draw attention to the fact that a baby with excessive subcutaneous tissue is not always a healthy, chubby infant with considerable amount of fat tissue.Das Lymphödem ist eine lokalisierte Form des Gewebeödems, die durch eine fortschreitende Ansammlung von Gewebeflüssigkeit im Interstitialraum infolge einer Funktionsstörung des Lymphsystems gekennzeichnet ist. Dies ist eine seltene Erkrankung in der pädiatrischen Bevölkerung und in den meisten Fällen eine Folge der fehlerhaften Bildung des Lymphsystems, das als primäres Lymphödem bezeichnet wird. Obwohl die Epidemiologie nicht genau ist, wird angenommen, dass 1: 100 000 Kinder an einem primären Lymphödem leiden. Die Diagnose kann auf der Grundlage einer geeigneten klinischen Untersuchung gestellt werden, nachdem sekundäre Ursachen für Lymphödeme ausgeschlossen wurden, insbesondere bei asymmetrischeren Ödemen der Gliedmaßen. In diesem Artikel präsentieren wir den Fallbericht eines 8 Monate alten Kindes mit primärem Lymphödem, dessen Ödem der Gliedmaßen seit der Geburt aufgetreten ist, bei dem aber keine Pathologien vermutet wurde. Der Zweck dieses Artikels ist es, die Aufmerksamkeit auf die Tatsache zu lenken, dass ein Kind mit übermäßigem Unterhautgewebe nicht immer ein gesundes, molliges Kind mit übermäßigem Körperfett bedeutet.

Children and adolescents' experiences of primary lymphoedema: semistructured interview study

BACKGROUND

Congenital lymphoedema is a lifelong condition that has detrimental physical and psychosocial outcomes for young patients and burdensome treatment responsibilities that may hamper patients' motivation for self-management. There is limited research from the perspective of young people with primary lymphoedema. We aimed to describe the experiences and views of children and adolescents with lymphoedema to inform patient-centred practice.

METHODS

Twenty patients (aged 8-21 years) with primary lymphoedema were purposively sampled from two paediatric clinics in Sydney, Australia, to participate in a semistructured interview. The transcripts were analysed thematically.

RESULTS

We identified six themes: reinforcing abnormality (damaging self-esteem, self-consciousness, frustrating restrictions and isolation); negotiating uncertainties (fearing condition worsening, deprioritised and sidelined, questioning cause and permanence, widespread unawareness); vulnerability and caution (avoiding pain and discomfort, preventing severe and permanent consequences, depending on permission, limiting goals and aspirations); disruptive transition (resisting change, losing progress and support, avoiding treatment costs); developing resilience (focusing on the positives, embracing individuality, recalibrating normality, prioritising coping) and taking responsibility (individualising treatment, needing support, external pressure and motivation, sticking to a routine, seeking independence).

CONCLUSION

Children and adolescents learn to adjust to the daily demands of lymphoedema management by individualising and accepting their treatment, but many continue to struggle with their self-esteem and lifestyle restrictions. Strategies are needed to empower young patients to advocate for themselves during their transition to adult care. Treatment plans that minimise social restrictions, address emotional consequences and incorporate patients' preferences could improve adherence, satisfaction and outcomes.

Lymphatic Drainage of Legs Reduces Edema of the Arms in Children with Lymphedema

Objective

The aim of the present study is to report on the reduction of edema of lymphedematous arms just by treating the lower limbs.

Methods

A 16-year-old girl reported that she has started having right lower limb edema at the age of three. At age 13, she performed a lymphoscintigraphy that confirmed the diagnosis of primary lymphedema of the four limbs. Recently she sought treatment at the Clínica Godoy in São Jose do Rio Preto where she was submitted to intensive treatment for eight hours per day for five days using manual (Godoy & Godoy technique) and mechanical lymphatic therapy (RA Godoy^®) of the lower limbs, cervical lymphatic therapy (cervical stimulation), and the continuous use of a grosgrain stocking.

Results

At the end of treatment, reductions in the sizes of both arms and legs were noted even without the use of any specific therapy for the arms. After four years, the size of the arms was normal.

Conclusion

Treatment of lymphedema of the legs has systemic repercussions that may lead to the reduction in swelling of other untreated regions of the body.

[Primary lymphedema in childhood]

Lymphedema results from impaired lymphatic transport with increased limb volume and is divided into primary and secondary forms. In children, primary lymphedema is the most frequent, with a sporadic, rarely familial form or associated with complex malformative or genetic disorders. Diagnosis of lymphedema is mainly clinical and lymphoscintigraphy is useful to assess the lymphatic function of both limbs precisely. The main differential diagnosis is overgrowth syndrome. Erysipelas (cellulitis) is the main complication, but psychological or functional discomfort may occur throughout the course of lymphedema. Lymphedema management is based on multilayer low-stretch bandage, skin care, and eventually manual lymph drainage. The objective of treatment is to reduce lymphedema volume and then stabilize it. Multilayer low-stretch bandage and elastic compression are the cornerstone of treatment. Parent's motivation, including self-management, is required to ensure the child's compliance and improve quality of life.

Near-Infrared Fluorescence Lymphatic Imaging of a Toddler With Congenital Lymphedema

Primary lymphedema in the pediatric population remains poorly diagnosed and misunderstood due to a lack of information on the causation and underlying anatomy of the lymphatic system. Consequently, therapeutic protocols for pediatric patients remain sparse and with little evidence to support them. In an effort to better understand the causation of primary pediatric lymphedema and to better inform clinical care, we report the use of near-infrared fluorescence lymphatic imaging on the extremities of an alert, 21-month-old boy who presented with unilateral right arm and hand lymphedema at birth. The imaging results indicated an intact, apparently normal lymphatic anatomy with no obvious malformation, but with decreased lymphatic contractile function of the affected upper extremity relative to the contralateral and lower extremities. We hypothesized that the lack of contraction of the lymphatic vessels rather than an anatomic malformation was the source of the unilateral extremity swelling, and that compression and manual lymphatic drainage could be effective treatments.

Overexpression of Prox1 Induces the Differentiation of Human Adipose-Derived Stem Cells into Lymphatic Endothelial-Like Cells In Vitro

Constant levels of homeobox transcription factor Prox1 expression are required throughout the life of lymphatic endothelial cells (LECs) to maintain their differentiated identity. Recent studies have demonstrated that using human LECs for cell transplantation therapy may improve secondary lymphedema in a nude rat model. However, the application is currently limited by the low yield of LECs. In this study, Prox1 was overexpressed in human adipose tissue-derived stem cells (hADSCs) by using the transfection of lentiviral vectors to induce the differentiation of hADSCs to LECs. After 14 days of Prox1 overexpression, flow cytometry analysis found that the expression of LEC-specific markers such as Podoplanin and VEGFR3, along with the endothelial cell (EC) marker CD31, on Prox1-overexpressed hADSCs was significantly increased; however, the expression of mesenchymal stem cell markers, such as CD29, CD44, and CD90, was substantially reduced. In addition, the mRNA levels of the LEC-specific markers, such as Prox1, Podoplanin, LYVE1, and VEGFR3, in Prox1-overexpressed hADSCs were significantly increased at day 7 and maintained a continuously increased expression level for 28 observation days, according to real-time reverse transcriptase-polymerase chain reaction results. Western blotting and immunofluorescence staining results further confirmed that overexpression of Prox1 in hADSCs significantly increased the protein levels of Podoplanin, LYVE1, and VEGFR3, as well as those of the EC markers such as VWF and CD144, at day 14. Moreover, these differentiated cells were found to form tube-like structures in matrigel, measured by the tube formation assay. These findings suggested that overexpression of Prox1 in hADSCs successfully induced the differentiation of hADSCs into stable lymphatic endothelial-like cells. This study achieved a long-lasting expression of Prox1 in lymphatic endothelial-like cells, and it provided a potentially useful approach for developing novel therapies for limb lymphedema and lymphatic system-related diseases.

Paediatric lymphoedema: A retrospective chart review of 86 cases

AIM

To define the clinical characteristics, investigations, management and outcomes of lymphoedema in a paediatric cohort.

METHODS

A retrospective chart review of children with lymphoedema seen at two tertiary paediatric hospitals since 1998. Telephone interviews with parents were performed when information was missing. Information recorded included demographic data, features of diagnosis and clinical presentation, symptoms, complications and treatment.

RESULTS

A total of 86 patients with lymphoedema were identified. Eighty cases (93%) were primary and six cases (7%) were secondary. Most were female (60%). Location of swelling was most commonly the lower limbs (94%). There were 13 cases (15%) of genital involvement. Swelling presented in the first 12 months of life in 60% of primary lymphoedema patients. Complications of lymphoedema occurred in 73% of patients. Lymphoscintigraphy was the most common investigation used (65%), followed by ultrasound (57%) and magnetic resonance imaging (MRI) (35%). Eight of the 48 (17%) lymphoscintigraphs produced a false negative result or were inconclusive with a correct diagnosis subsequently made clinically and using MRI. Average time to diagnosis was 9 months. Lymphoedema was managed with compression garments (99%), manual lymph drainage (97%) and multilayered bandaging (68%). Eight patients had an operative procedure as a part of management.

CONCLUSIONS

Primary lymphoedema is more common than secondary lymphoedema in children. Onset tends to be during infancy for both males and females, and the lower limb is typically involved. Causes of secondary lymphoedema are diverse and rare. Diagnosis in children is often delayed but is possible based on history and physical examination alone and when further investigation is necessary MRI is effective.

Complex decongestive physical therapy and low-level laser therapy for the treatment of pediatric congenital lymphedema: a case report

[Purpose] We report the case of a pediatric patient with congenital lymphedema treated with complex decongestive physical therapy and low-level laser therapy. [Subjects and Methods] The patient was a 2 year-old girl who had lymphedema in the left upper limb since birth. Complex decongestive physical therapy and low-level laser therapy were administered for 7 sessions. [Results] The circumferences of the middle of the forearm, elbow joint, wrist, and hand of the left upper limb decreased 0.5, 3, 0.5, and 2 cm, respectively. The moisture content of the left upper limb decreased 70 mL (6.66%), while moisture ratio increased by 0.007%. [Conclusion] Complex decongestive physical therapy and low-level laser therapy are effective for reducing lymphedema in pediatric patients.

Lymphedema Quality of Life Inventory (LyQLI)-Development and investigation of validity and reliability

PURPOSE

The purpose of this study was to reduce the 188-item Swedish Lymphedema Quality of Life Inventory (SLQOLI) to an abbreviated, clinically useful version (phase 1) and to test it for reliability and validity (phase 2).

METHODS

In phase 1 correlation analysis, factor analysis, content validity assessment and expert panels were used to reduce the number of items in SLQOLI to 45 items, which was named, Lymphedema Quality of Life Inventory (LyQLI). In phase 2, LyQLI was sent to 200 patients with lymphedema. 126 patients completed the questionnaire twice to determine stability of the instrument over time. SF-36 was sent to the patients once, correlations between the three domains in LyQLI and the two sum scores Physical Health (PCS) and Mental Health (MCS) in SF-36 were used to assess concurrent validity.

RESULTS

The 188-item SLQOLI was reduced to 45-item LyQLI. Four domains were reduced to three: physical, psychosocial and practical. Reliability estimates using ICC for the physical and psychosocial domains were 0.88 (p < 0.01) and 0.87 (p < 0.01), for the practical domain 0.87 (p < 0.01). Cronbach's alpha coefficients for the three domains were 0.88, 0.92 and 0.88, respectively. The physical domain correlated highly significantly with PCS, psychosocial highly significantly with MCS and practical equally highly significantly to both PCS and MCS. Using skewness coefficients, small floor effects in the items were found.

CONCLUSION

The shorter LyQLI demonstrated good reliability and validity with potential use to assess quality of life in clinic settings and in further cross-sectional studies of patients with lymphedema.

Adaptations in the treatment of congenital lymphedema centered on the quality of life

Case Description. This report describes the evolution, necessary adaptations, and complications in the treatment of a 9-year-old child with primary congenital lymphedema. Description of Intervention. The clinical treatment of lymphedema was started in the first year of the patient's life and for five years she was only treated using the Godoy & Godoy technique of cervical stimulation. Three years ago the patient was prescribed a compression stocking made from a cotton-polyester fabric (grosgrain) because of a sudden increase in the lymphedema after she started to take growth hormones. Outcome and Conclusion. The combination of cervical stimulation and a compression stocking was effective to keep the child's life relatively normal, performing all day-to-day and recreational activities.

The godoy & godoy cervical stimulation technique in the treatment of primary congenital lymphedema

THE AIM OF THE CURRENT STUDY IS TO REPORT ON THE TREATMENT OF PRIMARY LYMPHEDEMA USING A NEW FORM OF THERAPY: cervical stimulation. In a prospective cohort study, 9 boys and 5 girls with primary congenital lymphedema were evaluated over two years. Age ranged from two months to 8.5 years. After diagnosis, all mothers were trained in the new technique. The Godoy & Godoy cervical stimulation technique consists of between 20 to 30 stimuli per minute using light movements in the cervical region. All the children were submitted to perimetric evaluations of the feet and legs; however, in this study only two points, 3 and 6 cm from the base of the big toe nail, were used. The two-tailed t-test was used for statistical analysis with an alpha error of 5% (P<0.05) considered acceptable. The size of the lymphedematous feet was reduced and even normalized (P<0.0001) for all treated children. Cervical stimulation is a new option in the treatment of primary congenital lymphedema; its association with compression stockings has a synergistic effect in reducing the volume of lymphedema.

Assessment of volume measurement of breast cancer-related lymphedema by three methods: circumference measurement, water displacement, and dual energy X-ray absorptiometry

BACKGROUND

Following treatment for breast cancer 12%-60% develop breast cancer-related lymphedema (BCRL). There are several ways of assessing BCRL. Circumference measurement (CM) and water displacement (WD) for volume measurements (VM) are frequently used methods in practice and research, respectively. The aim of this study was to evaluate CM and WD for VM of the BCRL arm and the contralateral arm, comparing the results with regional dual energy X-ray absorptiometry (DXA).

METHODS AND RESULTS

Twenty-four women with unilateral BCRL were included in the study. Blinded duplicate VM were obtained from both arms using the three methods mentioned above. CM and DXA were performed by two observers. WD was performed by a group of observers. Mean differences (d) in duplicated volumes, limits of agreement (LOA), and 95% confidence intervals (CI) were calculated for each method. The repeatability expressed as d (95% CI) between the duplicated VM of the BCRL arm and the contralateral arm was for DXA 3 ml (-6-11) and 3 ml (1-7), respectively. For CM and WD, the d (95% CI) of the BCRL arm were 107 ml (86-127) and 26 ml (-26-79), respectively and in the contralateral arm 100 ml (78-122) and -6 ml (-29-17), respectively.

CONCLUSIONS

DXA is superior in repeatability when compared to CM and WD for VM, especially for the BCRL arm but also the contralateral arm.

Intensive treatment of leg lymphedema

Background:

Despite of all the problems caused by lymphedema, this disease continues to affect millions of people worldwide. Thus, the identification of the most efficacious forms of treatment is necessary.

Aim:

The aim of this study was to evaluate a novel intensive outpatient treatment for leg lymphedema.

Methods:

Twenty-three legs of 19 patients were evaluated in a prospective randomized study. The inclusion criteria were patients with Grade II and III lymphedema, where the difference, measured by volumetry, between the affected limb below the knee and the healthy limb was greater than 1.5 kg. Intensive treatment was carried out for 6- to 8-h sessions in the outpatient clinic. Analysis of variance was utilized for statistical analysis with an alpha error of 5% (P-value <0.05) being considered significant.

Results:

All limbs had significant reductions in size with the final mean loss being 81.1% of the volume of edema. The greatest losses occurred in the first week (P-value <0.001). Losses of more than 90% of the lymphedema occurred in 9 (39.13%) patients; losses of more than 80% in 13 (56.52%), losses of more than 70% in 17 (73.91%) and losses of more than 50% were recorded for 95.65% of the patients; only 1 patient lost less than 50% (37.9%) of the edema.

Conclusion:

The intensive treatment of lymphedema in the outpatient clinic can produce significant reductions in the volume of edema over a short period of time and can be recommended for any grade of lymphedema, in particular the more advanced degrees.