is it lymphedema? and what do you do ......of post-mastectomy lymphedema •maldenado et al, mexico,...
TRANSCRIPT
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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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No financial implications or disclosures for
this presentation
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SCHEMATIC OF THE LYMPHATIC SYSTEM AND
BLOOD CIRCULATION
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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
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ANATOMY OF THE LYMPHATICS
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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.
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LYMPH CAPILLARIES
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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.
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LYMPHATIC CAPILLARY AND A
PRECOLLECTOR
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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.
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LYMPHATIC CAPILLARIES AND
PRECOLLECTORS
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LYMPH FLOW IN LYMPH NODES
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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
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LYMPH NODE STRUCTURE
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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
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SUPERFICIAL LYMPHATICS
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DEEP LYMPHATICS OF THE INTESTINES
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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
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LYMPH DUCTS
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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
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OSMOSIS
• Osmosis: the movement of water molecules from a higher
to lower concentration across a membrane permeable to
water only.
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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
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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.
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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
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CLASSIFYING LYMPHEDEMA : STAGE I
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STAGE II
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LATE STAGE LYMPHEDEMA SKIN CHANGES
VERRUCAL HYPERPLASIA
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PRIMARY AND SECONDARY LYMPHEDEMA:
CLASSIFICATION
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INCIDENCE OF PRIMARY AND SECONDARY
LYMPHEDEMA
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CONGENITAL PRIMARY LYMPHEDMA
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PRIMARY LYMPHEDEMA AND
HEMIGIGANTISM DUE TO SHUNTING
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SECONDARY LYMPHEDEMA CAUSES
• Surgery
• Radiation
• Trauma
• Filarial disease
• Obesity
• Infection -
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THE OBESITY EPIDEMIC
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OBESITY AS A CAUSE OF LYPHEDEMA
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THE TRANSMISSION OF FILARIAL DISEASE
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FILARIAL DISEASE COMPLICATED BY MOSSY
FOOT OR PODICONIOSIS
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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
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CHECKING FOR PITTING EDEMA
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EVALUATION OF THE PATIENT WITH EDEMA
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LYMPHOSCINTIGRAPHY
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DISTINGUISHING LYMPHEDEMA FROM
LIPEDEMA
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LIPEDEMA:
LOOKALIKES
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LIPOLYMPHEDEMA TREATED
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CHRONIC VENOUS INSUFFICIENCY:
LOOKALIKES
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WHAT IS CVI?
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PHLEBOLYMPHEDEMA
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LOOKALIKES:
MYXEDEMA
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LYMPHEDEMA TREATMENT
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MLD AND BANDAGING FOR TREATMENT OF
LYMPHEDEMA
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TAPING IS SOMETIMES USED INSTEAD OF
MLD AND BANDAGING
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INTERMITTENT MULTICHAMBER SEQUENTIAL
COMPRESSION PUMP
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MASSIVE LOCALIZED LYMPHEDEMA
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THE POD
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MAINTENENCE OF LYMPHEDEMA
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DR. BRORSEN
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LIPOSUCTION FOR ADVANCED LYMPHEDEMA
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POST LIPOSUCTION
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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.
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LYMPH NODE HARVESTING FROM INGUINAL
REGION
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LYMPH NODE TRANSPLANT
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SURGICAL DEBULKING OF GENITAL
LYMPHEDEMA
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RIAN CORP LLLT
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LASER LIGHT
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LOW LEVEL LASER THERAPY
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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
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VEGFS ARE BEING STUDIED AS POSSIBLE
TREATMENT OF LYMPHEDEMA
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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.
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HBO
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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
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CONTRAINDICATIONS FOR TREATMENT
• Acute DVT
• Cellulitis
• Nonterminal malignant lymphedema
• CHF without close (ie in hospital) medical supervision
• If it is not lymphedema
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CELLULITIS IN LYMPHEDEMA
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CELLULITIS
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MALIGNANT LYMPHEDEMA
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ANGIOSARCOMA A CONSEQUENCE OF
UNTREATED LYMPHEDEMA
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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
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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
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RESULTS OF CDT IN LYMPHEDEMA
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SURGICAL DEBULKING OF LEG LYMPHEDMA
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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?
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MASTECTOMY
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SENTINEL LYMPH NODE IDENTIFICATION
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THE SENTINEL NODE BIOPSY
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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.
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PROTECT YOUR PATIENTS FROM/WITH
LYMPHEDEMA
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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
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KEY TO REIMBURSEMENT FOR LYMPHEDEMA