WOUND MANAGEMENT

Lymphedema: An Overview Here’s a close look at this unappreciated circulatory system.

By James McGuire, DPM and Claire-Iphanise Michel, BS, MS

What Is ? connection between the or- Lymphedema affects ap- Lymph Capillaries in the Tissue Spaces gans—also serve as a great proximately 300 million peo- reservoir of fluid and molec- ple worldwide. Although Tissue cells ular substances that must parasitic filariasis is the most be continually drained from common cause affecting ap- Lymph capillary the spaces. There is a vast proximately 100 million peo- Tissue spaces system of delicate open-end- ple,1 phlebolymphedema or ed lymphatic capillaries and Venule secondary lymphedema due Arteriole pre-collectors that passive- to long-standing chronic ve- ly receive these fluids (Fig- Tissue fluid nous insufficiency (CVI) is Lymphatic vessel ure 1). They actively move 109 the most common type seen them from the periphery in the United States.2 Lymph- through lymphatic capillar- occurs because of lym- Figure 1: Lymph capillaries. Source: Wiki Commons ies to the lymph nodes and phatic system dysfunction larger lymphatic veins to a that affects the body’s ability to re- the lack of education of caregivers series of places along the venous move excess fluid from the extremi- in proper treatment of lymphedema, system where the fluids re-enter the ties, or other organs. In addition, the the incidence will almost certainly circulation, the largest of which is lymphatic system is an immunolog- increase in upcoming decades.”2 the thoracic duct (Figure 2). Fluid ical defense system that triggers the production of lymphocytes (natural killer cells, T cells, and B cells). The Lymphedema occurs because of lymphatic system millions of channels of the system collect infecting micro-organisms and dysfunction that affects the body’s ability to remove antigenic substances that find their way into the interstitium and trans- excess fluid from the extremities, or other organs. port them to the lymph nodes, where they are eliminated from the system or antibodies are produced that rap- Anatomy movement is facilitated by a series idly neutralize the offending agents. The lymphatic system is made of one-way valves and delicate mus- Immunodeficiencies ensue when up of three primary components— cles known as lymphangions. the lymphatic system is impaired, the lymph fluid it transports, the The lymph nodes act as a fil- and lymphedema is present, allowing transportation network, and the tration system to remove foreign for infections and increased risk of lymphatic organs. The system is materials and invading organisms malignancies and/or metastases. an open-ended circulatory system from the blood and expose them to Phlebolymphedema is a second- that completes the closed system we the immune cells, which mount an ary lymphedema that develops in are most familiar with. The closed attack on the unwanted invaders. patients with chronic venous insuffi- system consists of the heart, arter- The nodes are part of an adaptive ciency (CVI). There are a number of ies, arterioles, capillaries, venules, immune system where the B and T factors that contribute to an increase and veins. If this were all we had lymphocytes and other white blood in the incidence of lower extremi- to transport nutrients and gather cells recognize and engulf or pro- ty edema in the population. These waste from the tissues, we would duce antibodies to the substances. include: increased survival of heart quickly die because the system is Aberrant cells such as cancer cells failure patients, numerous medica- porous and fluid continually leaks are also identified and engulfed, tions associated with edema, and the out into the interstitial spaces. The whereas toxins are passed on to the increased incidence of obesity. “With myriad nooks and crannies in the liver and kidneys that complete the the aging of the baby boomers and connective tissues—the structural Continued on page 110 www.podiatrym.com AUGUST 2018 | PODIATRY MANAGEMENT WOUND MANAGEMENT

Lymphedema (from page 109) Causes of Secondary Lymphedema removal process. Additional Cervical lymph nodes Thoracic duct Cancer-associated lymph- components of the system Thymus edema arises as a result of are the lymphatic organs Lymphatics of the obstructed or infiltrated lym- (the spleen and the thymus), mammary gland Axillary lymph nodes phatic channels or nodes, responsible for regulation of lymphadenectomy, regional Cisterna chyli Spleen the blood components, and lymph node irradiation, or additional immune response the adverse effects of some Lumbar lymph nodes and manufacture of T lym- Lymphatics of the medications.5,8 The most upper limb phocytes (Figure 3). Pelvic lymph nodes common cancer associated with lymphedema is breast Pathophysiology of Lymphatics of the Inguinal lymph nodes cancer secondary to lymph- Lymphedema lower limb adenectomy of the axillary When the normal lym- nodes.9–10 The manifestations phatic flow is disrupted, of lymphedema usually ap- protein-rich fluid accumu- pear within one to five years lates in the tissues, trigger- of the surgery.11 Cancers ing a chronic inflammatory associated with lymphede- reaction that manifests it- Figure 2: Lymph system. Source: Wiki Commons ma include sarcoma, lower self in swelling of what the extremity melanoma, cer- NY Times reported as the newest the dermis and subcutaneous tis- vical, Hodgkin’s lymphoma, and undiscovered organ, the intersti- sues. On a cellular level, this skin prostate.9 The addition of radiation 110 tium.1 White blood cells are attract- change interferes with antigen pro- to lymphadenectomy exponential- ed to the area by the presence of cessing, stagnates immune cells, ly increases the risk of lymphede- extracellular proteins, and release and in some regions impairs Lang- ma compared to lymphadenectomy cytokines, calling other inflamma- erhans cells and keratinocytes, re- alone. In breast cancer treatment, tory cells to the area. The macro- sulting in a thickening of the tissues lymphadenectomy and adjuvant ra- phages ingest foreign materials and and a loss of skin barrier function. diation have an approximately 24% microbes and use lysosomes con- increased rate of lymphedema com- taining free radicals, peroxide, and Types of Lymphedema pared to lymphadenectomy alone.12 hypochlorous acid to denature pro- Primary lymphedema can be de- Parasitic infections such as lym- teins and oxidize cell membranes scribed as a hereditary or congenital phatic filariasis, and skin infections of invading organisms. The macro- disorder, affecting females more than such as cellulitis and erysipelas can phages also release cytokines and males, associated with impaired lym- lead to the development of lower activate fibroblasts, which are stim- phatic vessel development and result- extremity lymphedema. Wuchereria ulated to produces collagen scar ing in lymphedema. Primary lymph- bancrofti, Brugia malayi, and Brugia tissue, resulting in fibrosclerosis of edema can be divided into three forms timori are parasitic roundworms en- depending upon age of demic to Africa, Southeast Asia and Lymph onset: congenital lymphede- Eastern South America that enter the flow ma (at birth), lymphedema body in a larval stage when the host praecox (1-35), and lymph- is bitten by a carrier mosquito. The Lymphatic nodule Capsule edema tarda (35+).4 Some adult nematodes mature in the lym- of the conditions associated Cortex phatic channels and lymph nodes, Trabecula with congenital lymphede- producing a devastating lymphatic ma include: Meige disease, elephantiasis in the affected limb. It Efferent Milroy’s disease, Aagenaes is usually acquired in tropical and Medulla lymphatic vessel syndrome, and Turner syn- subtropical territories during one’s drome. childhood but can be asymptomat- Lymph Secondary lymphedema ic in those younger than five years flow is caused by an acquired old.13 Valve impairment of the lymphat- In the United States, elephan- ic system due to several tiasis from parasites is very rare Vein causes: cancer and its treat- but repetitive cellulitis from mul- Afferent Artery ment, infection, inflamma- tiple insect bites from an infesta- lymphatic Blood capillaries tory disorders, obesity, long vessels around lymphatic tion of mosquitoes or fleas may in nodule standing venous insufficien- rare cases produce an inflammatory cy (phlebolymphedema) secondary lymphedema similar in Figure 3: Lymph node. Source: www.anatomynote.com and other chronic forms of appearance to elephantiasis. In pa- Used with permission, 2018 lymphatic overload.2,5–7 Continued on page 111

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Lymphedema (from page 110) tance to infection and , and an increased risk of carcinogen- tients with chronic lymphedema or in esis. Prolonged lymphostasis leads to the later stages of venous insufficien- a state of chronic localized inflamma- cy, there is an increased risk for recur- tion. Another term, lymphostatic der- rent cellulitis and erysipelas infections. mopathy, refers to the changes in the Cellulitis is a common complication in skin that result in a failure of the skin those who have undergone inguinal as an immune organ (Figure 4).15 lymphadenectomy and have developed subsequent lower extremity lymph- Signs and Symptoms edema. Cellulitis can also be a risk Lymphedema is assessed using factor for the onset and progression of several staging systems, the most pop- lymphedema in patients with chronic ular of which is the International Soci- venous insufficiency. ety of Lymphology (ISL). ISL staging Simple uncomplicated lymphede- uses two criteria to diagnose and clas- ma is due to a mechanical failure of sify lymphedema. There is a softness the lymphatic system that results in a scale and one noting changes after el- low flow state. Pathological processes evation. The first evaluates the degree have reduced the ability of the lym- Figure 4: Lymphostatic Dermopathy (mild, moderate, severe) of fibrotic phatic system to move fluid efficiently soft tissue change and the second the from the extremities to the thoracic duct. The system presence of volume change with elevation. Stage 0 is a can no longer manage the normal lymphatic load, re- sub-clinical or latent condition where swelling is not ev- sulting in a backup or overload of the interstitium. ident despite impaired lymphatic transport. Stage 0 may When the ambient pressure in the interstitial tissues is exist for months or years before lymphedema occurs. 111 increased, movement of fluid into the fragile lymphatic Stage I lymphedema or reversible edema is character- collectors decreases and serious swelling can ensue. An Continued on page 112 example of this is a patient with phlebolymphedema due to chronic venous insufficiency who develops an infection from an ulcer or traumatic wound of the lower extremity. The inflammatory response to the infection initially results in the production of a vasodilatory transudate followed by a protein-rich that overwhelms the system, producing a pathohistological state of chronic inflammation, with infiltration by mononuclear cells, stimulation of angiogenesis, and proliferation of connec- tive tissue with fibrosis and fibrosclerosis of the skin.14 This alone is reason for patients with edema to practice diligent skin care to prevent epidermal disruption and secondary infection. The more infections, the more im- mune deficiency, and the more significant the changes in skin morphology. Whether the entire limb is involved or just a small area of a more transient nature, lymphedematous re- gions are highly prone to infections because of a local immune deficiency caused by many factors. Immune cells passing through regions affected by fluid stagnation become sluggish and find it hard to migrate through the thick web of scar tissue produced by overstimulated fibroblasts. Lymph nodes in the area likewise become overwhelmed with protein-rich edema interfering with antigen and microbe processing. Skin function is im- paired, resulting in a loss of normal barrier function provided by the intricate web of lymphatic collectors just below the skin and the Langerhans cells and kerati- nocytes. In addition, areas of congestion have impaired pro- cessing of malignant or abnormal cells and are more prone to malignancy. This is referred to as lymphostat- ic immunopathy and produces a region with low resis- www.podiatrym.com AUGUST 2018 | PODIATRY MANAGEMENT WOUND MANAGEMENT

Lymphedema (from page 111) As limb fibrosis progresses, pit- Visible skin changes and signs ting disappears. Stage III lymph- are also the basis for the classifica- ized by the accumulation of fluid edema is characterized by lym- tion of chronic venous insufficiency during standing and ambulation that phostatic elephantiasis. Pitting is using the CEAP classification (Clini- subsides with limb elevation. Pitting absent, and the skin has notice- cal, Etiologic, Anatomic Pathologic) edema with no evidence of dermal able skin changes that include fatty developed by the American Venous fibrosis may be present. Stage II does deposition, acanthosis, and warty Forum.17 Although the entire clas- not resolve with elevation alone. overgrowths.16 sification is a bit complicated, the clinical portion is quite useful when evaluating the skin lesions associated with developing venous insufficiency and phlebolymphedema: C0: no visible or palpable signs of venous disease. C1: telangiectasies or reticular veins. C2: varicose veins. C3: edema.

Figure 5: Lichenification Secondary to Phle- bolymphedema

C4a: pigmentation and eczema. C4b: lipodermatosclerosis and atrophie blanche. C5: healed venous ulcer. C6: active venous ulcer.

The remaining elements of the classification are: an S or A delinea- tion used for whether the skin lesions are symptomatic or asymptomatic; etiology includes Ec congenital, Ep primary, or Es secondary; the ana- tomical portion, s,p,d localizes pa- thology to superficial, perforators, or deep veins; and the pathological portion includes Pr reflux, Po ob- struction, Pr,o reflux and obstruction, and Pn no venous pathophysiology identifiable. Continued on page 113

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Lymphedema (from page 112) macerated or broken by small areas of skin, breakdown referred to as Skin Changes dermal disruption or venous der- Phlebolymphedema develops matitis, lymphorrhea or weeping of slowly and worsens over time. The lymphatic fluid through skin, can swelling is not typically painful occur (Figure 6). with the severity of involvement While lymphorrea is common, marked by skin changes in thick- skin ulcers are not commonly as- ness, texture, and shape. This skin sociated with primary lymphede- change occurs secondary to the ma but are much more common chronic inflammatory response to when lymphedema is secondary the protein-rich interstitium and an to chronic venous insufficiency overgrown stratum corneum. The (phlebolymphedema). Unlike fluid fibrotic proliferation causes hyper- edema, lymphedema affects the dig- keratosis, papillomatosis, and li- its and the resultant brawny fibrotic chenification. Hyperkeratosis pres- edema makes it difficult to pinch ents as a scaly brown/gray patch or tent the skin over the dorsum of of over-proliferated keratin. Pap- the proximal phalanx of the digits illomatosis is lumpy, bumpy skin Figure 6: Lichenification with Warty Projections of the foot, a clinical sign known as or fibrotic wart-like projections of and Lymphorrhea the Stemmer’s sign. Those with a the skin. Lichenification presents as positive Stemmer’s sign have edem- thick, leathery patches of skin that ic or macerated depending on the atous legs with square shaped toes, occur in response to excessive itch- presence of open lesions. When deep creases and folds, fibrotic tis- ing or rubbing, resembling alligator the epidermis is xerotic, there is a sue, and a lack of limb contours 113 skin or tree bark (Figure 5). decreased resistance to infectious (Figure 7). The epidermis can be xerot- organisms. When the epidermis is Continued on page 114

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Lymphedema (from page 113) etiology of edema, lymphatic com- pression, tissue variations, and even Diagnosis the presence of parasites. Duplex US When evaluating a patient for scans also help confirm the existence lymphedema, there are several com- of chronic venous insufficiency and ponents of history that should be DVT. Computed tomography and obtained: age of onset, areas of in- magnetic resonance imaging allow volvement, associated symptoms and one to visualize the accumulation of their progression, past medical his- lymphatic fluid in soft tissue and can tory such as cancer and genetic ab- be used to detect venous disease of normalities, surgical history, travel the lower extremity and is considered history, and family history. Associated to be highly sensitive and specific symptoms would include swelling, (Figure 8).18 pain, and tightness. Unilateral lower Lymph vessels and nodes can extremity swelling can be seen in pa- be further evaluated via: lymph- tients who have undergone inguinal angiography, isotopic lymphoscin- lymphadenectomy. The swelling may tigraphy, and indocyanine-Green initially present in just a portion of the (ICG) lymphography. Lymphangi- distal limb. As the swelling progress- Figure 7: Positive Stemmers Sign ography allows for visualization of es, there may be a decrease in range the content of the lymphatic sys- of motion and activities of daily living. metrically, and affect women primar- tem using a radiocontrast agent. During the physical exam, you ily. Isotopic lymphoscintography in- should always evaluate the arterial Lipedema is an X-linked or auto- volves radio-labeled proteins to 114 vascular system to be sure there is no somal dominant condition character- detect lymph flow, lymph nodes, inflow problem complicating outflow. ized by progressive leg edema sec- and lymph reflux. This test is per- Pitting is variable and may be present ondary to fatty deposition. Lipedema formed during a period of time last- in early stages of lymphedema and is painful, can be complicated by or- ing from 30 minutes to 2 hours, is generally absent in advanced dis- thostatic edema and bruis- ease. It should be noted at this point ing, and generally does that lymphatic always affect not improve with leg ele- both the leg and the foot. When you vation.27 Brawny or fibrotic see an enlarged leg that appears to edema is a classic sign of be lymphedema but spares the foot, advanced lymphedema.1,10 which appears normal, you are deal- ing with lipedema. Lipedema and Diagnostic Imaging Lymphedema may sound alike but The imaging modality are very different. They both cause of choice is the duplex ul- non-pitting edema in the lower ex- trasound which can help tremity, occur bilaterally and sym- indicate the underlying

Figure 9: Manual Lymphatic Massage. Source: Alpha Health Ser- vices, Toronto, ON. Used with permission, 2018

and before and after stress activity. Isotopic lymphoscintography is a test that is used to evaluate con- genital lymphedema. Near-Infrared Fluorescence Lymphatic Imaging (NIRFLI) is a technique using an indocyanine green (ICG) dye and near-infrared red fluorescence to visualize lymphatic vessel anato- my, functional capacity, and der- mal reflux. ICG lymphography can be used to see abnormalities prior to the presence of significant swell- Figure 8: NIRFLI montage of right (unaffected) and left (affected) limbs. Source: Eva M Sevick, PhD, In Bur- ing (Figure 8). Near-Infrared Fluo- rows, P. E., Gonzalez-Garay, M. L., Rasmussen, J. C., Aldrich, M. B., Guilliod, R., Maus, E. A., ... & Sevick-Mu- rescence Lymphatic Imaging (NIRF- raca, E. M. (2013). Lymphatic abnormalities are associated with RASA1 gene mutations in mouse and man. LI).1,19–20 Proceedings of the National Academy of Sciences, 110(21), 8621-8626. Used with permission, 2018 Continued on page 115

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Lymphedema (from page 114) ciated with an abnormal psychologi- cal component. Lymphangiography Several systemic conditions, if Simple assessment of approxi- chronic, are associated with bilat- mate limb volume can be obtained eral pitting edema that may lead to by serial measurements of the lower lymphedema. These include: hepatic extremity limb circumference bilat- insufficiency, renal failure, cardiac erally. According to the American decompensation (CHF), and thyroid Physical Therapists Association, disorders. you should take limb circumference measurements at the metatarsal-pha- Conservative Treatment langeal joints, 2 cm superior to the Lymphedema is an “orphan” dis- medial malleolus, 10 cm below the ease with no one medical specialty inferior pole of the patella, and 10 taking up the cause.28 Most patients cm above the superior pole of the are treated by specially trained physi-

Anasarca is general massive swelling of the whole body due to abnormal fluid retention in major sickness and infection

patella.21 Actual limb volume can be cal therapists who have received cer- measured by determining water dis- tification in manual lymph drainage placement, optoelectronic volumetry, (MLD), which is part of a total ap- and by using a truncated cone calcu- proach referred to as complete de- lation. Water displacement has been congestive therapy (CDT). The ul- the gold standard to measure limb timate goals are to reduce build-up volume but is considered to be too and edema in lymphatic tissues, re- inconvenient to be used often today. duce limb size, and get the patient on When using water displacement, a a maintenance program that controls limb volume difference of at least what is a life-long problem. Physi- 200mL between opposing limbs in- cians who understand the disease dicates lymphedema.22–23 Perometry and are well trained in the medical uses infrared beams to scan the limb and physical management of it are and calculate its volume. Perometry sorely needed.16–29 is more reliable than the water dis- The primary treatment approach placement.24–25 To use the truncated is CDT, which includes compres- cone formula, the lower extremity sion wraps, garments, and pneu- limb is measured at 4 cm intervals matic pumps to maintain the gains starting from the ankle and an esti- achieved in therapy. Complete de- mated volume is calculated.26 congestive therapy is performed by a physical therapist or lymphedema Differential Diagnosis therapist and requires many hours of is general massive training in the techniques of exercise swelling of the whole body due to and MLD (Figure 10). Manual Lymph abnormal fluid retention in major Drainage).16–29 sickness and infection. Anasarca is Exercise improves venous re- most commonly seen with heart fail- turn, lymphatic drainage, range of ure and pericardial diseases, or sys- motion, relieves tightness, and im- temic allergic reactions. proves strength of ligaments, ten- Factitious lymphedema is a con- dons, and bones. It is recommended dition that is self-induced by appli- that patients with lymphedema not cations of tourniquets, tight clothing, participate in any sports due to the self-inflicted wounds that result in risk of trauma to the skin and the cellulitis, or maintenance of the limb inability of the limb to recover from in a prolonged immobile dependent activity-induced swelling.30 Exercise state. This condition is usually asso- Continued on page 116 www.podiatrym.com AUGUST 2018 | PODIATRY MANAGEMENT WOUND MANAGEMENT

Lymphedema (from page 115) an elastic component; and five RCTs proximally with decreasing pressures suggested significantly faster heal- as it approaches the knee or groin. can be used to control body weight ing with four layers than with short Each segment fills and holds pressure, if done in conjunction with a diet of stretch bandages.31 and then the garment deflates and restricted calories and avoidance of On the other hand, in a compari- the cycle begins again. The peristaltic excessive salt and water. son of elastic and inelastic dressings, waveform mimics the peristaltic ac- Mosti, et al. found that inelastic ban- tion of the intestines. Distal segments Manual Lymphatic Drainage Uses contract just like the sequential Manual lymphatic drainage uses devices but as the pressure pro- gentle skin massage with specific gresses proximally, the distal strokes and light pressure to promote segments release, producing a the movement of lymph from areas massaging effect to the limb. of stagnation to areas of normal flow The key to effective devices (Figure 9). Facilitated by modern im- are the numbers of segments aging studies, MLD can reduce limb and the versatility of the sys- volume significantly. Treatment gains tem to dial in specific pressures are maintained by the application of for individual segments based short stretch wraps that prevent re- on need and areas of pain. bound edema between treatments. More recently, devices have Compression wraps are more ef- been engineered to better ad- fective in treating venous insufficien- dress lymphedema. These de- cy and phlebolymphedema. Standard vices operate at a lower pres- compression systems can be applied Figure 10: Intermittent Pneumatic Compression Pumps. sure and mimic the gentle mas- 116 to those with an ABI of at least 0.8 Source: Acute Wound Care—Wound Care Supplies & Compres- saging strokes of CDT. Indica- but reduced compression can be ap- sion Devices, Bonita Springs, FL. Used with permission, 2018 tions for pneumatic compres- plied to those with an ABI between sion include: venous disease, 0.5–0.8 with careful supervision and dages had an overall massaging ef- chronic or transient edema, stasis frequent dressing changes. fect and increased ejection fraction and and/or VLUs, phlebolymphedema, There are three types of wraps for ejection volume more than elastic ban- lymphedema, and arterial disease lower extremity edema: non-stretch, dages and were better tolerated by pa- complicated by edema. short-stretch, and long stretch. tients.32 Hofman, et al. found that ban- Conventional treatment for They all facilitate the foot-calf mus- dage systems that deliver high working lymphedema does not recommend cle pump during ambulation. Non- pressures and lower resting pressures using pneumatic compression be- stretch compression is dependent on (short stretch and non-stretch) have a cause it was felt that pumping does the foot-calf muscle pump during am- better therapeutic effect even in mixed not remove plasma proteins or exu- bulation and does not provide any venous arterial disease.33 date from edematous areas but only resting pressure, making it essentially removes free fluid or transudate. Re- a retention wrap when sedentary. Intermittent Pneumatic cent studies have shown that pro- Short stretch wraps also utilize the Compression Pumps tein removal by the lymphatic system calf muscle pump during ambulation Intermittent pneumatic com- is facilitated by using the segmen- but recoil slightly to provide some pression therapy is externally ap- tal compression pumps. There can resting pressure and to accommodate plied compression delivered to the be higher levels of protein seen ini- the limb as edema decreases. extremity(ies), and possibly torso, tially with pump use because of the Long stretch wraps work with by means of segmented pressurized amount of water processed using the both the mobile and immobile pa- sleeves (garments) (Figure 10). The pump. This is a temporary condition tient but can be risky for those with devices use prescribed air pressures and with continued use of the pump, PAD. The compression can be ap- and pre-determined timing sequences the protein levels also decrease and plied via single or multilayer wraps, in order to mobilize free fluid in an return to more normal levels.34 with multilayer wraps demonstrating edematous limb. a slight edge in effectiveness. The The various waveforms or sequen- Surgical Treatment Cochrane review of 48 RCTs report- tial patterns are used to encourage Surgical procedures have a com- ing 59 comparisons (4,321 partici- proximal migration of free transu- mon goal of bypassing the occluded pants in total) concluded that: some date and exudate into the lymphatic lymphatic channels and/or nodes. compression is better than none; and venous systems to facilitate a re- These surgical options tend to be single component compression ban- duction of limb edema and improve more effective in those with sec- dage systems are less effective than small vessel blood flow. Two common ondary lymphedema than primary multi-component compression; two waveforms are sequential and per- lymphedema. Direct methods such as and three layer systems containing istaltic. Sequential compression be- lympho-lymphatic or lympho-venous an elastic bandage healed more ul- gins with higher pressure compression bypass anastomoses are constructed cers at one year than one without in the distal segments and proceeds Continued on page 117

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Lymphedema (from page 116) to decrease limb volume in lymph- Seems Likely.” The New York Times, The edema patients and the occurrence of New York Times, 21 Mar. 2018, www.ny- between normal distal lymph nodes infections in cancer patients.42 times.com/2018/03/31/health/new-organ-in- or channels and proximal lymph terstitium.html. Autologous lymphocyte injection 4 nodes or channels or to a vein to pre- immunotherapy has been shown to Szuba, A., & Rockson, S. (1998). Lymphedema: Classification, diagno- vent lymphatic reflux. Lympho-ve- decrease excess protein levels in in- sis and therapy. Vascular Medicine. nous bypass anastomosis is more terstitial tissues. In patients with pri- 1998;3(2):145–56. common. If lympho-venous bypass mary lymphedema, gene therapy is 5 Moffatt, C., Franks, P., Doherty, D., is not possible, lympho-venous-lym- currently being explored. In a clinical Williams, A., Badger, C., Jeffs, E., Mortimer, phatic anastomosis is done.34–37 study using model rats with breast P. Lymphoedema: An underestimated health Free lymph node transplanta- cancer, lymph vessel neogenesis oc- problem. Qjm-An International Journal Of tion is an indirect method but has curred via the release of hepatocyte Medicine. 2003;96(10):731–738. not been established as an effective growth factor, while at the same time 6 Joos, Bourgeois, & Famaey. Lymphatic procedure.38–39 Debulking procedures maintaining motor ability of lymph disorders in rheumatoid arthritis. Seminars in Arthritis and Rheumatism. 1993:22(6), allow for the removal of edema- vessels.42 392–398. tous tissues but may cause rebound Physicians are only now becom- 7 Farshid, G. W., & Weiss, S. Massive edema and or expanding fibrosis due ing aware of the importance of the Localized Lymphedema in the Morbidly to the scarring associated from the lymphatic system to limb health and Obese: A Histologically Distinct Reactive Le- procedure.40 Liposuction removes ex- homeostasis. The relationship of lym- sion Simulating Liposarcoma. The American cess fat in areas of lymphedema, re- phatic function to wound healing and Journal of Surgical Pathology. 1998:22(10), ducing limb size but does not address recovery after surgery or injury can- 1277-1283. the underlying lymphatic obstruc- not be overstated. More education 8 Cariati, Bains, Grootendorst, Suyoi, tion and in many cases may actually programs are picking up the ban- Peters, Mortimer, Purushotham. Adjuvant make the problem worse.41 ner for increased basic education for taxanes and the development of breast can- 117 cer?related arm lymphoedema. British Jour- nal of Surgery. 2015:102(9), 1071-1078. 9 Cormier, J., Askew, R., Mungovan, Autologous lymphocyte injection immunotherapy K., Xing, Y., Ross, M., & Armer, J. Lymph- edema beyond breast cancer. Cancer. has been shown to decrease 2010;116(22):5138-5149. 10 Warren, A. G., Brorson, H. J., Borud, excess protein levels in interstitial tissues. L. A., & Slavin, S. Lymphedema: A Compre- hensive Review. Annals of Plastic Surgery, 2007;59(4):464–472. 11 Medical Treatment health professionals and improved Cemal Y, Pusic A, Mehrara BJ. Preven- Prescription medication is avail- healthcare coverage for a highly un- tative measures for lymphedema: Separating fact from fiction. Journal of the American able to decrease edematous extrem- der-funded and under-served public College of Surgeons. 2011;213(4):543-551. ities. Diuretics are not indicated health problem. There is a dire need doi:10.1016/j.jamcollsurg.2011.07.001. for the treatment of lymphedema for more lymphedema therapists, and 12 Erickson, V., Pearson, M., Ganz, P., except for short periods of time in there is a great need for podiatric Adams, J., & Kahn, K. Arm edema in breast cases where the edema is due to hy- physicians educated in lymphatic cancer patients. Journal Of The National pertension or heart disease as they function and treatment to address the Cancer Institute; 2001;93(2):96-111. stimulate water excretion as urine. problems of wound and skin care, 13 Witt, C., & Ottesen, E. (2001). Lym- Because diuretics remove the free mobility issues, and shoe fit prob- phatic filariasis: An infection of childhood. transudate from the limb and leave lems. With many healthcare markets Tropical Medicine & International Health, a concentrated protein rich exudate shrinking, this is one area where po- 6(8), 582-606.Witt, C., & Ottesen, E. Lym- phatic filariasis: An infection of childhood. behind, a rebound edema increase diatric involvement has significant Tropical Medicine & International Health. may be noted. Benzopyrones, such upside potential. PM 2001;6(8):582-606. as coumarin and flavonoids, promote 14 Mortimer P, Pearson I. Lymphatic edematous fluid resorption but can References function in severe chronic venous insuffi- 1 have the adverse effect of hepatop- Szuba A., Shin W.S., Strauss H.W., ciency. Phlebolymphology. 2004;44:253–257. athy. Anti-microbials, including Iv- Rockson S. The third circulation: radio- 15 Carlson JA. Lymphedema and sub- ermectin and Diethylcarbamazine nuclide lymphoscintography in the eval- clinical lymphostasis (microlymphedema) uation of lymphedema. J Nucl Med. citrate, are indicated if there is an facilitate cutaneous infection, inflammatory 2003;44(1):43–57. dermatoses, and neoplasia: A locus minoris underlying infection causing inflam- 2 Farrow W. Phlebolymphedema. 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Dr. McGuire is Chairperson at the Temple Uni- versity School of Podiatric Medicine, Department of Podiatric Medicine and Orthopedics; Director, Leonard S. Abrams Center for Advanced Wound Healing, and has been a member of the faculty since 1992. He has extensive experience in wound management and biomechanics of the foot and ankle. Dr. McGuire is a founding fellow of the American Professional Wound Care Association, and a member of the planning committee for the annual Advances in Skin and Wound Care meeting. Claire-Iphanise Michel is a 4th year stu- dent at the Temple University School of Podiat- ric Medicine.

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