is it lymphedema? and what do you do ......of post-mastectomy lymphedema •maldenado et al, mexico,...

P A U L A S T E W A R T M D , M S , L A N A - C LT

IS IT LYMPHEDEMA?

AND WHAT DO YOU DO?

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this presentation

SCHEMATIC OF THE LYMPHATIC SYSTEM AND

BLOOD CIRCULATION

THE DIFFERENCES BETWEEN THE LYMPHATIC

TRANSPORT SYSTEM AND THE BLOOD

CIRCULATION

• Lymphatic system is not a circuit

• The is no central pump in the lymphatic system

• Lymph transport is interrupted by lymph nodes

• Lymph flows into the venous system

ANATOMY OF THE LYMPHATICS

LYMPHATIC CAPILLARIES

• Lymphatic capillaries form lymph by absorbing lymph load

into the lymph system

• Lymphatic load includes protein, water, cellular debris,

particles and fat.

• The water transported in the lymphatic load is essential in

fluid regulation of the body and it serves as a solvent for

other lymphatic loads.

LYMPH CAPILLARIES

LYMPH CAPILLARIES

• Structure:

• SINGLE LAYER

• TIGHT JUNCTIONS WITH OPEN JUNCTIONS

• ANCHORING FILAMENTS ALLOW OPEN JUNCTIONS TO STAY OPEN

WITH HIGH TISSUE PRESSURE

• NO VALVES THUS FLUID FROM CAPILLARIES MOVES INTO

PRECOLLECTORS DUE TO LOWER RESISTANCE.

LYMPHATIC CAPILLARY AND A

PRECOLLECTOR

PRECOLLECTORS

• Precollectors are vessels that move lymph from the

capillaries to the collectors.

• They may have valves and smooth muscle and they may

have open junctions and thus absorb lymphatic load.

LYMPHATIC CAPILLARIES AND

PRECOLLECTORS

LYMPH FLOW IN LYMPH NODES

LYMPH COLLECTORS

• The walls have an inner layer of endothelial cells a middle

layer of smooth muscle and an outer layer of collagen

• There are valves every 6-20mm which define the borders of

the angions and prevent flow of lymph distally

• Contraction frequency at rest is 10-12 contractions per

minute

• All collectors in a territory transport lymph to regional lymph

nodes

• Lymphatic territories are separated by lymphatic

watersheds

LYMPH NODE STRUCTURE

LYMPH NODES

• 600-700 in number and the majority are in the head and

neck or the intestines

• Three functions:

• Protection

• Immune function via lymphocytes: T cells and macrophages and B

cells

• Fluid regulation through absorption of fluid by blood capillaries in the

nodes

SUPERFICIAL LYMPHATICS

DEEP LYMPHATICS OF THE INTESTINES

LYMPHATIC TRUNKS

• Lymph collectors transport lymph from the superficial and

deep lymphatics to the trunks which in turn transport the

lymph to the venous angles.

• The trunks: 1. Thoracic duct• 2. Left jugular trunk

• 3. left subclavian trunk

• 4. left bronchomediastinal trunk

• 5. intercostal lymph collectors

• 6. Cisterna chyli

• 7. Gastrointestinal trunk

• 8. Lumbar trunks

• 9. Right lymphatic duct

• 10. Right bronchomediastinal trunk

• 11. Right subclavian trunk

• 12.right jugular trunk

LYMPH DUCTS

PHYSIOLOGIC PRINCIPLES

• Diffusion: molecules move from an area of higher

concentration to lower concentration. This process is

influenced by:

• Temperature

• Concentration gradient

• Size of the molecules

• Surface area

• Diffusion distance

OSMOSIS

• Osmosis: the movement of water molecules from a higher

to lower concentration across a membrane permeable to

water only.

MECHANISMS THAT INCREASE CAPILLARY

FILTRATION AND THUS EDEMA

• Increased venous capillary pressure

• Valvular incompetence

• Dependency

• Venous obstruction

• Heart failure

• Reduced osmotic gradient across the capillary wall

• Nephrotic syndrome

• Liver failure

• Starvation all cause a reduced albumin

• Increased vascular permeability

• Inflammation

• Estrogen as seen in idiopathic cyclic edema

FUNCTIONAL RESERVE

• Transport capacity is the maximum lymph time volume

• Dynamic insufficiency is a high volume failure of active and

passive protective mechanisms that results in edema.

• Mechanical insufficiency is a low volume failure of the

lymphatic system that results from a reduction of the

transport capacity of the lymphatic system.

• Combined insufficiency is both reduced transport capacity

and increased load.

ARE THERE INTRINSIC FACTORS THAT

CONTRIBUTE TO THE DEVELOPMENT OF

BCRL?

• Stanton et al, St. Georges Hospital, London followed 36 women post op following ALND for breast cancer.

• They measured lymph flow via lymphscintigraphy in the sub cutis and in the deep muscle.

• At 30 months, 19% of the women had developed LE

• All of those women had greater lymphatic flow in both arms compared to the women who did not develop LE and in all cases the deep muscle lymph flow exceeded the subcutis flow.

• They concluded that women with filtration near maximal sustainable rates are at increased risk for LE with even minor injury to the axilla.

• Breast Cancer Res Treat 2009 oct:117(3):549-557

CLASSIFYING LYMPHEDEMA : STAGE I

STAGE II

LATE STAGE LYMPHEDEMA SKIN CHANGES

VERRUCAL HYPERPLASIA

PRIMARY AND SECONDARY LYMPHEDEMA:

CLASSIFICATION

INCIDENCE OF PRIMARY AND SECONDARY

LYMPHEDEMA

CONGENITAL PRIMARY LYMPHEDMA

PRIMARY LYMPHEDEMA AND

HEMIGIGANTISM DUE TO SHUNTING

SECONDARY LYMPHEDEMA CAUSES

• Surgery

• Radiation

• Trauma

• Filarial disease

• Obesity

• Infection -

THE OBESITY EPIDEMIC

OBESITY AS A CAUSE OF LYPHEDEMA

THE TRANSMISSION OF FILARIAL DISEASE

FILARIAL DISEASE COMPLICATED BY MOSSY

FOOT OR PODICONIOSIS

HOW TO DETERMINE IF IT IS LYMPHEDEMA

• Rule out DVT

• Especially in lower extremity edema be certain that CHF,

Renal failure, liver disease is not contributing.

• Rule out anasarca

• Rule out thyroid disease and myxedema

• Rarely, pericarditis, abdominal aortic aneurysm and

lymphoma can cause edema

• Is it dependency edema? Do they sleep in a chair at night?

• Be aware of factious or artificial lymphedema

CHECKING FOR PITTING EDEMA

EVALUATION OF THE PATIENT WITH EDEMA

LYMPHOSCINTIGRAPHY

DISTINGUISHING LYMPHEDEMA FROM

LIPEDEMA

LIPEDEMA:

LOOKALIKES

LIPOLYMPHEDEMA TREATED

CHRONIC VENOUS INSUFFICIENCY:

LOOKALIKES

WHAT IS CVI?

PHLEBOLYMPHEDEMA

LOOKALIKES:

MYXEDEMA

LYMPHEDEMA TREATMENT

MLD AND BANDAGING FOR TREATMENT OF

LYMPHEDEMA

TAPING IS SOMETIMES USED INSTEAD OF

MLD AND BANDAGING

INTERMITTENT MULTICHAMBER SEQUENTIAL

COMPRESSION PUMP

MASSIVE LOCALIZED LYMPHEDEMA

THE POD

MAINTENENCE OF LYMPHEDEMA

DR. BRORSEN

LIPOSUCTION FOR ADVANCED LYMPHEDEMA

POST LIPOSUCTION

VASCULARIZED LYMPH NODE TRANSFER

WITH DEEP INFERIOR EPIGASTRIC

PERFORATORS

• Pioneered by Dr. Corinne Becker in Paris, France, the lymph

node transplant remains very controversial.

• Dr. LoTempio who trained with Becker and Allen is

combining VLNT with DIEP at the Omega Hospital

• Recent study: 23 women with breast cancer related

Lymphedema; 18 with XRT, 5 with SLND

• Results: 15 report no compression necessary after

procedure, all patients reported reductions in

circumference.

LYMPH NODE HARVESTING FROM INGUINAL

REGION

LYMPH NODE TRANSPLANT

SURGICAL DEBULKING OF GENITAL

LYMPHEDEMA

RIAN CORP LLLT

LASER LIGHT

LOW LEVEL LASER THERAPY

EFFECTS OF LOW LEVEL LASER ON BRCL

• Dirican, A. et al. tested the benefits of LLLT on 17 women with BCRL who were undergoing a treatment at the time with either CDT, MLD, or IPC.

• Two cycles of LLLT were added to the ongoing therapies.

• The results were as follows:

• Circumference (using ^ C) decreased 54% and 73% after the second cycle

• Pain decreased in 14/17

• Scar mobility increased in 13/17

• Shoulder ROM increased in 14/17

• The Short-term Effects of Low Level Laser Therapy in the Management of Breast Cancer Related Lymphedema.

• Support Care Cancer 2011 May ;19(5)685-690

VEGFS ARE BEING STUDIED AS POSSIBLE

TREATMENT OF LYMPHEDEMA

AUTOLOGOUS STEM CELLS FOR TREATMENT

OF POST-MASTECTOMY LYMPHEDEMA

• Maldenado et al, Mexico, Cytology 2011

• Injected ASC in 10 women with post mastectomy lymphedema

• Control group of 10 women treated with compression sleeves.

• Both groups measured for volume 12 weeks in addition to pain

• There was no difference between the groups at 12 weeks however

upon discontinuing the sleeves the control group arms increased in

size whereas the ASC group arms did not.

HBO

HBO

• Lone Gothard, et al. recently completed a phase II study of

HBO in patients with chronic arm Lymphedema.

• 58 participants and after analysis no detectable

improvement in HBO vs controls.

• Radiother Oncol. 2010 oct; 97(1)101-7

CONTRAINDICATIONS FOR TREATMENT

• Acute DVT

• Cellulitis

• Nonterminal malignant lymphedema

• CHF without close (ie in hospital) medical supervision

• If it is not lymphedema

CELLULITIS IN LYMPHEDEMA

CELLULITIS

MALIGNANT LYMPHEDEMA

ANGIOSARCOMA A CONSEQUENCE OF

UNTREATED LYMPHEDEMA

HOW WE GOT HERE….

• 1890s: Dr. Winiwater, a surgeon who recommended skin care, massage, compression and exercise.

• 1930s:The Vodders developed a massage technique they called MLD to direct lymph flow.

• 1950s: Pneumatic compression pumps were used in the US for lymphedema treatment.

• 1970s: Drs. Foldi combined MLD with bandaging, skin care and exercise, now called CDT.

• 1980s: Dr. Lerner introduces the Foldi techniques to the US and opens the first treatment center in NY.

• Currently: NLN, LRF, LANA, NALEA, ALFP, VEGF-C, HBO

WHAT IS PROVEN ABOUT WHAT WE DO?

• Reviewing the literature for studies meeting minimal criteria, the following was concluded:

• There is evidence for the effectiveness of bandaging

• There is evidence for the effectiveness of IPC, short term

• There is not sufficient evidence in the literature for the effectiveness of

• MLD

• Skin care

• Exercise

• Compression garments

• Elevation

• Nor the long term effectiveness of IPC

• Eur.J Obstet Gynecol Repro Biol 2010,Mar 149(1):3-9

• Devooqdt,N. et al.Univ.Hospitals Leuven, Belgium

RESULTS OF CDT IN LYMPHEDEMA

SURGICAL DEBULKING OF LEG LYMPHEDMA

HOW CAN THE INCIDENCE OF LYMPHEDEMA

BE REDUCED

• Sentinel node surgery has reduced incidence from 20-30%

for MRM to 7-10%.

• XRT adds another 10% incidence

• Are there ways to screen those most at risk?

• Are there new approaches to take when Lymphedema

occurs?

MASTECTOMY

SENTINEL LYMPH NODE IDENTIFICATION

THE SENTINEL NODE BIOPSY

CAN BLOCKING CRITICAL LYMPH NODES

FROM XRT PREVENT LE?

• Dr. A. Cheville presented at the San Antonio Breast Cancer

Symposium 12/10 results of a study that used a

combination of SPECT and CT to localize lymph nodes in

the axilla and protect those which drain the arm.

• The cohort is composed of women who have breast cancer

without mets. to the axilla.

• They will be followed for several years to determine if

sparing the lymph nodes draining the arm protects against

BCRL.

PROTECT YOUR PATIENTS FROM/WITH

LYMPHEDEMA

AMERICAN LYMPHEDEMA FRAMEWORK

PROJECT

• Founded by Jane Armer and co-chaired by Dr. J. Feldman.

• The ALFP works closely with the British Framework project

and the International Framework project. The goal is to

create internationally agreed upon metrics and language to

describe lymphedema, and an evidence based treatment

guide. Additionally they are encouraging and sponsoring

research.

• Web site:alfp.org

• Get info on and participate in the ALFP/NALEA survey

KEY TO REIMBURSEMENT FOR LYMPHEDEMA