Lymphedema: Difference between revisions
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}}</ref> or obtaining arterial grafts, peripheral vascular surgery, lipectomy, burns, burn scar excision, and insect bites. | }}</ref> or obtaining arterial grafts, peripheral vascular surgery, lipectomy, burns, burn scar excision, and insect bites. Minimally invasive techniques for harvesting venous grafts are being used, in part, to reduce the risk of postoperative lymphedema. <ref>{{citation | ||
|journal = Tex Heart Inst J. | year = 1999 | volume = 26| issue =2 | pages = 120–123 | |||
| title = Endoscopic harvesting of the greater saphenous vein for aortocoronary bypass grafting. | |||
| author = G J Carrizo, J J Livesay, and L Luy | |||
| url = http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=325615&blobtype=pdf}}</ref> | |||
===Primary lymphedema=== | ===Primary lymphedema=== | ||
[[Lymphedema]] may have a genetic cause.<ref name=pmid18519967>{{citation | [[Lymphedema]] may have a genetic cause.<ref name=pmid18519967>{{citation | ||
Revision as of 19:47, 5 September 2009
In medicine, lymphedema exhibits as fluid retention due to damage to, or dysfunction of the lymphatic system. There may be multiple comorbid causes of fluid retention, such as metabolic disturbances.
Etiology
Lymphedema may be primary, with a genetic etiology, or secondary, as a result of another disorder or physical damage. The secondary forms are probably common, although the primary versus secondary distinction may not be important in treatment.[1]
- "In the United States, the highest incidence of lymphedema is observed following breast cancer surgery, particularly among those who undergo radiation therapy following axillary lymphadenectomy. Among this population, 10-40% develop some degree of ipsilateral upper extremity lymphedema.
- Worldwide, 140-250 million cases of lymphedema are estimated to exist, with filariasis, infection with the parasite Wuchereria bancrofti, being the most common cause.[2]
Secondary lymphedema
"Secondary lymphedema has an identifiable cause that destroys or renders inadequate the otherwise normal lymphatics."[1] Besides cancer treatment or tumor effects, other causes include vein stripping for treatment of varicose veins[3] or obtaining arterial grafts, peripheral vascular surgery, lipectomy, burns, burn scar excision, and insect bites. Minimally invasive techniques for harvesting venous grafts are being used, in part, to reduce the risk of postoperative lymphedema. [4]
Primary lymphedema
Lymphedema may have a genetic cause.[5] Several types have been reported in the literature. They vary in in age of onset, site of edema, associated features, inheritance patterns, and underlying genetic cause. Determining the representative phenotype for different types of genetically determined primary lymphedema has been successfully achieved with Milroy's disease and the lymphedema-distichiasis syndrome. Phenotype characterization facilitates the identification of causative genes, as has been demonstrated with VEGFR3 and FOXC2, in Milroy's disease and lymphedema-distichiasis respectively.
Using transgenic and gene transfer techniques, the defects have been produced in mice, giving "initial clues to the development of a biologically based therapy for primary lymphedema. Of more importance from a public health perspective is the fact that manipulation of this pathway may lead to effective therapies for the more prevalent forms of secondary lymphedema."[6] The known mutations leading to lymphatic phenotypes, however, explain fewer than half the cases of lymphedema.[7] Nevertheless, there are research directions for treatment, based on lymphangiogenesis, the triggering of new lymphatic system growth.[8]
Malformation would mean either few lymph vessels or they may be in excess. Both would cause a hindrance to the smooth working of the lymphatic system resulting in the pooling of fluids.
Lymphedema praecox
Lymphedema praecox, or Meige disease, occurs after birth but before 35 years; the age of onset is generally in adolescence is the most common form of primary lymphedema. By definition, it becomes clinically evident after birth and before age 35 years. This condition accounts for 65-80% of all primary lymphedema cases and most often arises during puberty. Females are affected 4 times as often as males. About 70% of cases are unilateral, with the left lower extremity being involved more often than the right. Histologically, these patients are likely to demonstrate a hypoplastic pattern, with the lymphatics reduced in caliber and number.[1]
Milroy's disease
"Congenital lymphedema that is present at birth and associated with an autosomal dominant familial history is called Milroy disease."[9] The differential diagnosis includes *Arteriovenous Malformations
- Cellulitis
- Secondary Lymphedema
- Meigs Disease
- Neurofibromatosis
- Sclerema neonatorum
The condition is generally apparent in the legs, usually in one leg, but in some cases, it may be seen in both legs. Doctors diagnose the condition by studying the swelling present in the legs right from birth. Deeper enquiries may result in finding a family history of such type of swelling. In order to confirm the diagnosis, tests may be conducted. A dye is injected into the leg which is traced by a computer to find out where the blockages are present. Milroy's Disease is treated with decongestive therapy. Patients may experience complications like fibrosis in the limb tissues, lymphangitis or cellulitis.
Lymphedema-distichiasis syndrome
Caused by mutations in the FOXC2-gene, the lymphedema-distichiasis syndrome involves malformations of both the lymphatic and vascular systems. It "is characterized by late childhood or pubertal onset lymphedema of the limbs and distichiasis (double row of eyelashes). While the latter is the most common expression of LD, venous insufficiency occurs in half of the patients. Other associations have been reported, including congenital heart disease, ptosis, cleft lip/palate and spinal extradural cysts"[10]
Lymphedema Tarda
Present in 10% of the cases of primary lymphedema, the lymphadema aspect of this disease manifests after age 35.[9]
The initial indication of the genetic disorder may be cleft palate.[11]
...and the first signs of the condition are a swelling below the waist, red patches on the skin, inflammation and discomfort. Again, this hereditary lymphedema is diagnosed by observing the swelling and the family history confirming the verdict. Some other hints could be yellow nail syndrome or pulmonary hypertension. As with all other lymphedema treatments, decongestive therapy is the ideal choice here as well. Treatment must be started at the initial phase of the condition.
Meige's Disease
As the rarest form of primary lymphedema, it accounts for only 10% of cases. does not become clinically evident until age 35 years or older. Histologically, patients are likely to demonstrate a hyperplastic pattern, with tortuous lymphatics increased in caliber and number. They often display absent or incompetent valves.[1]
...Also known as Hereditary Lymphedema Type III /Delayed Onset Lymphedema, as the name suggests, this condition becomes apparent only after the age of thirty five. Swelling may be present in either one or both the legs. Women are more at risk for this ailment than men. Very often, family history of a similar swelling is observed.
Diagnosis
Lymphedema should be distinguished from edema, myxedema, and lipedema.[12] Lipedema is more likely to spare the dorsum of the foot.
It is possible, however, to have comorbid edema and lymphedema. For example, a vasodilator used to treat hypertension can cause edema in a patient with cardiac disease. If that patient has had the lymphatics of the lower leg damaged by stripping the saphenous vein for use as an arterial graft, that damage can cause lymphedema to coexist with edema.
Physical examination
On physical examination, fast recovery of pitting is associated with lower serum albumin levels.[13] Fast recovery within 2-3 seconds, is more sensitive than specific at detecting hypoalbuminemia. Presumably this is related to the viscosity of the interstitial fluid thus hypoalbuminemic interstitial fluid can reform more quickly.[13]
Imaging
Imaging should begin with the least invasive methods, such as Color Doppler duplex ultrasound is useful in evaluating venous abnormalities; it is also key to ruling out deep venous thrombosis, along with D-dimer determinations.
X-ray-contrast lymphography remains the gold standard mode of demonstrating lymphatic collectors and lymph nodes, but the technique is invasive as it involves direct cannulation of the lymphatics. It is rarely used since the advent of lymphoscintigraphy (isotope lymphography).[14]
Whole-body lymphangioscintigraphy may help in the diagnosis.[15]
Magnetic resonance imaging may help in the diagnosis.[16]
Treatment
Physical therapies are the core of treatment:
- External compression (hosiery/multilayer bandages)
- Exercise
- Skin care
- Massage
Drugs have not been shown to be effective for lymphedema proper, although they may be useful with comorbidities. Diuretics, for example, have no role in the disorder, but are indicated in comorbid edema from vascular disorders or medication effects.
Multilayer compression bandaging for 2-3 weeks followed by hosiery may reduce the size of limbs with lymphedema.[17]
If there is more than one episode of infection annually, prophylactic oral antibiotics are indicated. [18]
References
- ↑ 1.0 1.1 1.2 1.3 Don R Revis Jr (18 March 2008), eMedicine Specialties > General Surgery > Lymphatic System: Lymphedema
- ↑ Dandapat MC, Mohapatro SK, Mohanty SS (1986 Jun), "Filarial lymphoedema and elephantiasis of lower limb: a review of 44 cases.", Br J Surg 73 (6): 451-3
- ↑ Lahl W, Richter J, Neppach V, Massel R. (1981), "[Leg oedema after surgery of varicose veins (author's transl)] [Article in German]", Zentralbl Chir 106 (23): 1535-42
- ↑ G J Carrizo, J J Livesay, and L Luy (1999), "Endoscopic harvesting of the greater saphenous vein for aortocoronary bypass grafting.", Tex Heart Inst J. 26 (2): 120–123
- ↑ Connell F, Brice G, Mortimer P. (2008), "Phenotypic characterization of primary lymphedema", Ann N Y Acad Sci 1131: 140-6.
- ↑ Ferrell RE (2002 Dec), "Research perspectives in inherited lymphatic disease.", Ann N Y Acad Sci 979: 39-51; discussion 76-9
- ↑ Ferrell RE, Finegold DN (2008), "Research perspectives in inherited lymphatic disease: an update.", Ann N Y Acad Sci 1131: 134-9
- ↑ Nakamura K, Rockson SG (2008), "Molecular targets for therapeutic lymphangiogenesis in lymphatic dysfunction and disease.", Lymphat Res Biol 6 ((3-4)): 181-9
- ↑ 9.0 9.1 Raphael J Kiel (16 October 2008), "eMedicine Specialties > Pulmonology > Idiopathic Lung Disorders: Milroy Disease", eMedicine
- ↑ Vreeburg M, Heitink MV, Damstra RJ, Moog U, van Geel M, van Steensel MA (2008 Nov), "Lymphedema-distichiasis syndrome: a distinct type of primary lymphedema caused by mutations in the FOXC2 gene.", Int J Dermatol 47 (Suppl 1): 52-5
- ↑ Figueroa AA, Pruzansky S, Rollnick BR (1983 Apr), "Meige disease (familial lymphedema praecox) and cleft palate: report of a family and review of the literature", Cleft Palate J. 20 (2): 151-7
- ↑ Loughlin V (May 1993). "Massive obesity simulating lymphedema". N. Engl. J. Med. 328 (20): 1496. PMID 8479476.
- ↑ 13.0 13.1 Henry JA, Altmann P (April 1978). "Assessment of hypoproteinaemic oedema: a simple physical sign". British medical journal 1 (6117): 890–1. PMID 638510. PMC 1603695. [e] PubMed Central
- ↑ Witte CL; Witte MH; Unger EC; Williams WH; Bernas MJ; McNeill GC; Stazzone AM (2000), "Advances in imaging of lymph flow disorders.", Radiographics 20 (6): 1697-719
- ↑ McNeill GC, Witte MH, Witte CL, et al. (August 1989). "Whole-body lymphangioscintigraphy: preferred method for initial assessment of the peripheral lymphatic system". Radiology 172 (2): 495–502. PMID 2748831. [e]
- ↑ Case TC, Witte CL, Witte MH, Unger EC, Williams WH (1992). "Magnetic resonance imaging in human lymphedema: comparison with lymphangioscintigraphy". Magn Reson Imaging 10 (4): 549–58. PMID 1501525. [e]
- ↑ Badger CM, Peacock JL, Mortimer PS (June 2000). <2832::AID-CNCR24>3.0.CO;2-U "A randomized, controlled, parallel-group clinical trial comparing multilayer bandaging followed by hosiery versus hosiery alone in the treatment of patients with lymphedema of the limb". Cancer 88 (12): 2832–7. PMID 10870068. [e]
- ↑ Vignes S, Dupuy A. Recurrence of lymphoedema-associated cellulitis (erysipelas) under prophylactic antibiotherapy: a retrospective cohort study. J. Eur. Acad. Dermatol. Venereol. 20(7), 818-822 (2006).