Factors associated with cellulitis in lymphoedema of the arm - an international cross-sectional study (LIMPRINT)

BACKGROUND

Lymphoedema is a globally neglected health care problem and a common complication following breast cancer treatment. Lymphoedema is a well-known predisposing factor for cellulitis, but few have investigated the risk factors for cellulitis in this patient cohort on an international level. The aim of this study was to identify the frequency of cellulitis in patients with lymphoedema of the arm, including potential risk factors for cellulitis.

METHODS

An international, multi-centre, cross-sectional study including patients with clinically assessed arm lymphoedema. The primary outcome was the incidence of cellulitis located to the arm with lymphoedema within the last 12 months, and its potential associated risk factors. The secondary outcome was life-time prevalence of cellulitis. Adults with clinically-assessed arm lymphoedema/chronic oedema (all causes) and able to give informed consent were included. End-of-life-patients or those judged as not in the patient's best interest were excluded. Both univariable and multivariable analysis were performed.

RESULTS

A total of 2160 patients were included from Australia, Denmark, France, Ireland, Italy, Japan, Turkey and United Kingdom. Secondary lymphoedema was present in 98% of the patients; 95% of these were judged as related to cancer or its treatment. The lifetime prevalence of cellulitis was 22% and 1-year incidence 11%. Following multivariable analysis, factors associated with recent cellulitis were longer swelling duration and having poorly controlled lymphoedema. Compared to having lymphoedema less than 1 year, the risk increased with duration: 1-2 years (OR 2.15), 2-5 years (OR 2.86), 5-10 years (OR 3.15). Patients with well-controlled lymphoedema had a 46% lower risk of cellulitis (OR 0.54, 95% CI 0.39-0.73, p < 0.001). More advanced stages of lymphoedema were associated with cellulitis even after adjustment for swelling duration and control of swelling by logistic regression (stage II OR 5.44, stage III OR 9.13, p = 0.002), demonstrated in a subgroup analysis.

CONCLUSION

Patients with advanced arm lymphoedema are at particular risk of developing cellulitis. Prevention of lymphoedema progression is crucial. The results lend towards a positive effect of having well-treated lymphoedema on the frequency of cellulitis.

Dermal Structure in Lymphedema Patients with History of Acute Dermatolymphangioadenitis Evaluated by Histogram Analysis of Ultrasonography Findings: A Case-Control Study

BACKGROUND

Acute dermatolymphangioadenitis (ADLA) is a risk factor for increasing of edema and worsening severity. Reducing ADLA frequency is an important objective of lymphedema management because ADLA episodes are strongly associated with poor quality of life. Lymphedema changes dermal and subcutaneous structure, favoring ADLA; ADLA recurrence may be caused by structural change of the dermis. However, the structure of the skin following ADLA episodes has not been studied in depth. The aim of this study was to examine changes in the skin after episodes of ADLA in breast cancer-related lymphedema (BCRL) using histogram analysis of ultrasonography findings.

METHODS AND RESULTS

This was a case-control study with matching for the duration of lymphedema. We compared 10 limbs (5 BCRL patients, Cases) with a history of ADLA and 14 limbs (7 BCRL patients, Controls) without. Ultrasonography was performed using a 20-MHz probe, and measurements were made at a site 10 cm proximal to the ulnar styloid process. We compared "skewness" of the images in the dermis from the histogram analysis. This study was approved by the Ethics Committee of Kanazawa University. Skewness was significantly different between the affected and unaffected limbs (p = 0.02). Cases showed a positive value (median 0.74, range -0.18 to 1.26), whereas Controls showed a negative value (median -0.21, range -0.45 to 0.31).

CONCLUSIONS

Episodes of ADLA changed the distribution of echogenicity on imaging, which indicates a change in the collagen fibers in the dermis. These findings might contribute to improving the management of lymphedema and prevention of recurrent ADLA.

Tumor-infiltrating lymphocyte response in cutaneous melanoma in the elderly predicts clinical outcomes

Tumor-infiltrating lymphocytes (TILs) and regression are manifestations of the host immune response to tumor, but their influence on outcome remains undefined. There is a paucity of data on the elderly who represent a growing proportion of melanoma patients. The aim of this study was to evaluate the influence of TILs and regression as an indirect measure of immunity on outcome in elderly patients with melanoma. From a prospective database, we identified 250 consecutive cutaneous melanoma patients aged at least 65 years at the time of diagnosis. Data were verified by record review. Within the primary melanoma, a brisk TIL response was present in 66 (31%), nonbrisk TILs in 36 (17%), and absent in 111 (52%). The presence of a brisk infiltrate conferred a three-fold increased risk of sentinel lymph node (SLN) metastasis (P=0.02). Despite this, nonbrisk or absent TILs were associated with a five-fold increased risk of recurrence (P=0.0001). In multivariate analysis, nonbrisk or absent TILs were independently associated with recurrence (P<0.0001), diminished 5-year disease-free survival (76 vs. 91%, P=0.0006), and 5-year melanoma-specific survival (82 vs. 95%, P=0.0008). Regression was not an independent predictor of SLN metastasis, disease-free survival, or melanoma-specific survival. Our study demonstrates that an active antitumor immune response exists in elderly melanoma patients that, paradoxically, predicts both SLN metastasis and improved melanoma-specific outcomes. Further investigation to characterize this lymphocytic infiltrate and to confirm its clinical significance as a predictor of nodal status, patient outcome, and response to immunotherapy in elderly melanoma patients appears warranted.

Radical Reduction of Lymphedema With Preservation of Perforators

BACKGROUND

Surgical management of lymphedema of the lower extremity is indicated in select patients when conservative measures have failed. The excisional approach has traditionally consisted of a staged excision procedure or total excision of diseased tissue. Based on an improved knowledge of vascular anatomy and understanding of perforator flap surgery, radical reduction of lymphedema with preservation of perforators (RRPP) applies an excisional approach and microsurgical principles to the radical reduction of lymphedema.

METHODS

Fifteen patients underwent RRPP during the period of June 1993 to February 2002 and were included in this study. Medial and lateral skin flaps were raised through incisions on the anterior and posterior leg, preserving a 4-cm skin bridge in the central portion of the incisions. The skin flaps were reduced to 5 mm in thickness, except in the vicinity of the lateral and medial septae, which contain perforators from the posterior tibial and peroneal arteries.

RESULTS

At an average follow-up period of 13 months, a statistically significant reduction in lymphedema was achieved (P < 0.05). The average percentage in reduction above the knee was 51%, below the knee 66%, at the ankle 44%, and at the level of the foot 41%. The average overall lymphedema reduction for the patients was 52%. There were no cases of wound breakdown or skin flap necrosis. Complications consisted of cellulitis in 3 patients and seroma and hematoma in 1 patient.

CONCLUSIONS

Based on angiosome principles and application of perforator principles to the surgical reduction of lymphedema, effective, long-lasting, and cosmetically appealing results are achieved in a single-stage procedure.

Inflammation, lymphatic function, and dendritic cell migration

The lymphatic system is not only essential for maintenance of normal fluid balance, but also for proper immunologic function by providing an extensive network of vessels, important for cell trafficking and antigen delivery, as well as an exclusive environment, the lymph node (LN), where antigen-presenting cells (APCs) and lymphocytes can encounter and interact. Among APCs, dendritic cells (DCs) have a remarkable capacity to traffic from peripheral tissues to the draining LN, which is critical for execution of their functions. To reach the LN, DCs must migrate towards and enter lymphatic vessels. Here, the authors review what is known about the factors that drive this process. They touch particularly on the topic of how DC migration is affected by inflammation and discuss this in the context of lymphatic function. Traditionally, inflammatory mediators are regarded to support DC migration to LNs because they induce molecules on DCs known to guide them to lymphatics. The authors recently showed that inflammatory signals present in a strong vaccine adjuvant induce swelling in LNs accompanied by lymphangiogenesis in the draining LN and radius of peripheral tissue. These increased lymphatics, at least for several days, lead to a more robust migration of DCs. However, the density of lymphatic vessels can become overly extended and/or their function impaired as observed during lymphedema and various chronic inflammatory reactions. Diseases characterized by chronic inflammation often present with impaired DC migration and adaptive immunity. Gaining a better understanding of how lymphatic vessel function may impact adaptive immunity by, for example, altering DC migration will benefit clinical research aiming to manipulate immune responses and manage chronic inflammatory diseases.

Recurrence of lymphoedema-associated cellulitis (erysipelas) under prophylactic antibiotherapy: a retrospective cohort study

OBJECTIVE

To identify the predictors of successful antibiotic prophylactic treatment using benzathin-penicillin G to prevent recurrence of erysipelas in patients with secondary upper limb lymphoedema.

DESIGN

A retrospective cohort study.

SETTING AND PATIENTS

Patients with secondary arm lymphoedema were recruited in a single lymphology unit between 1990 and 2003. All patients had had at least three recurrences of erysipelas. Patients were given 2.4 MU benzathin-penicillin G intramuscularly at 14-day intervals. For each patient, the following data were recorded: characteristics of breast cancer treatment (type of surgery, radiotherapy, hormone therapy), number of erysipelas recurrences before inclusion, patient characteristics including body mass index (BMI) and lymphoedema volume at inclusion.

MAIN OUTCOME MEASURES

The outcome studied was the occurrence of erysipelas on the affected arm under antibiotic prophylactic treatment.

RESULTS

With a 4.2-year median follow-up from the onset of antibiotic prophylactic treatment, 23 of 48 women experienced recurrence of erysipelas. The median duration of erysipelas recurrence-free period under this treatment was 2.7 years. The estimated rate of recurrence was 26%[95% confidence interval (CI) 13-38%] at 1 year and 36% (95% CI 22-50%) at 2 years. No patient stopped the treatment because of side-effects. No predictive factor of erysipelas recurrence under antibiotic prophylactic treatment was identified.

CONCLUSIONS

Antibiotic prophylaxis using benzathin-penicillin is a well-tolerated treatment of erysipelas recurrence in patients with upper limb lymphoedema secondary to breast cancer. The rate of erysipelas recurrence was 26% at 1 year in patients who had a history of at least one erysipelas. We did not find any predictor of erysipelas recurrence.

Sweet's syndrome on the area of postmastectomy lymphoedema

BACKGROUND

Sweet's syndrome (SS) has been reported in association with many conditions, including malignancy, infections, autoimmune disorders, pregnancy and drugs.

MATERIALS AND METHODS

We reviewed patients with SS-like lesions on the lymphoedema area seen in our department. Clinical manifestations, histopathologic characteristics, treatment and outcome data were recorded and analysed.

RESULTS

We report seven women with a history of surgery for breast cancer with axillary lymphadenectomy. Six of them were on tamoxifen. All of them had various lesions consistent with SS localized predominantly on the limb affected by the postmastectomy lymphoedema, and on the ipsilateral chest, trunk and back. One of them presented bullous lesions. Three of the cases underwent spontaneous remission, two resolved with antibiotic therapy, one healed with corticosteroids, and one with corticosteroids plus antibiotic.

CONCLUSIONS

Erythematous tender plaques on the area of postmastectomy lymphoedema could be considered an unusual manifestation of Sweet's syndrome. We have found only three similar cases in the literature. Although it is difficult to elucidate the pathogenesis of this entity, it has been suggested that it could be due to immune surveillance impairment.

Risk of Angiosarcoma Following Breast Conservation: A Clinical Alert

Approximately 100 cases of angiosarcoma following breast-conserving therapy have been reported. The prevalence of angiosarcoma following breast conservation has not been accurately established and optimal treatment has not been defined. The goal of this article is to clarify both issues. The Fisher's exact test was used to compare the prevalence of postirradiation angiosarcoma seen in our private practice to the prevalence reported from the two largest national database studies. A literature review was performed to determine optimal treatment guidelines. The results of the comparison indicated that the prevalence of postirradiation angiosarcoma seen in our practice was significantly higher than that reported in the two national database studies at p-values of 0.0124 and 0.0080. Also, results from the literature review suggest that early detection and aggressive treatment lead to improved outcomes. The data are insufficient to draw firm conclusions, but suggest that the current literature underestimates the prevalence of angiosarcoma following breast-conserving therapy. Since elderly women derive less benefit from radiation and may be more prone to develop postirradiation angiosarcoma, confirmation of our findings could lead to a reappraisal of the management of elderly patients with early stage breast cancer.

Chronic lymphoedema and angiosarcoma

Angiosarcoma has frequently been described arising within chronic lymphoedema of the upper limb following mastectomy and radiotherapy for carcinoma of the breast. We report a case of angiosarcoma arising in a lymphoedematous leg that had been subjected to radiotherapy 20 years previously for Hodgkin's disease. The diagnosis was expedited once the patient noticed the development of bleeding nodules. Prognosis of angiosarcoma is poor with treatment options being wide-excision surgery, palliative radiotherapy or chemotherapy. Unusual bruised areas or bleeding nodules developing within chronic lymphoedematous limbs should be biopsied to exclude the diagnosis.