Topography of accumulation of stagnant lymph and tissue fluid in soft tissues of human lymphedematous lower limbs

Effectiveness of six-step complex decongestive therapy for treating upper limb lymphedema after breast cancer surgery

BACKGROUND

Complex decongestive therapy (CDT) is currently recommended as the standard treatment for lymphedema. CDT is a four-step detumescence therapy that can effectively treat upper limb lymphedema after breast cancer surgery, and is considered non-invasive, painless and without side effects.

AIM

To determine the effectiveness of a six-step CDT involving a foam granule bandage for the treatment of upper extremity lymphedema pressure after breast cancer surgical intervention.

METHODS

The study included 100 patients with upper extremity lymphedema after breast cancer surgery. The surgical methods were mastectomy plus axillary lymph node dissection and breast preservation plus sentinel lymph node biopsy. The study population was further divided into the experimental group and control group with 50 cases in each group. The control group was given conventional CDT (four-step method), which included skin care, freehand lymphatic drainage, foam granule pressurized bandage, and functional exercise. In the experimental group, a six-step CDT method was applied that involved a foam particle bandage combined with air wave pressure therapy in addition to the four steps of conventional CDT. Patients in both groups were given one course of treatment daily (20 times), and the changes in body moisture and subjective symptoms were measured before and after treatment, preoperatively and 20 times after treatment.

RESULTS

No statistically significant differences in 50-Hz bioelectrical impedance and extracellular moisture ratio were observed between the two groups before treatment, suggesting comparability of the baseline data. After treatment, the 50-Hz bioelectrical impedance of the experimental group was significantly higher than that in the control group, and the extracellular moisture ratio was significantly lower than that in the control group. A comparison of the differences between the two groups before and after treatment indicated that the treatment effect in the experimental group was better than that in the control group. After 20 treatments, according to subjective evaluations, the tightness and swelling of the limbs in the experimental group were significantly reduced as compared with those in the control group.

CONCLUSION

The six-step CDT method can effectively reduce lymphedema, promote lymphatic circulation, and alleviate the subjective symptoms of patients, and thereby improve the quality of life and treatment compliance among patients.

From physical to ultrasound examination in lymphedema: a novel dynamic approach

In daily practice, medical history and physical examination are commonly coupled with anthropometric measurements for the diagnosis and management of patients with lymphatic diseases. Herein, considering the current progress of ultrasound imaging in accurately assessing the superficial soft tissues of the human body; it is noteworthy that ultrasound examination has the potential to augment the diagnostic process. In this sense/report, briefly revisiting the most common clinical maneuvers described in the pertinent literature, the authors try to match them with possible (static and dynamic) sonographic assessment techniques to exemplify/propose an 'ultrasound-guided' physical examination for different tissues in the evaluation of lymphedema.

Assessing breast lymphoedema following breast cancer treatment using indocyanine green lymphography

PURPOSE

Breast lymphoedema is a largely unrecognised survivorship issue for women following breast cancer treatment. While a few objective methods have previously been applied to assess breast lymphoedema, none are capable of imaging breast lymphatics or identifying lymphatic morphological changes indicative of breast lymphoedema. The purpose of this study was to determine if indocyanine green (ICG) lymphography, a validated assessment technique in breast cancer-related lymphoedema), can visualise breast lymphatics and identify breast lymphoedema. Additionally, ICG lymphography was utilised to investigate lymphatic drainage pathways of the affected breast following breast-conserving therapy.

METHODS

Twenty female participants (10 breast lymphoedema and 10 healthy controls) were recruited for this pilot study. All underwent a medical history, physical breast assessment, tissue dielectric constant measures of breast water content, and ICG lymphography.

RESULTS

ICG lymphography identified lymphatic morphological changes in all breast lymphoedema participants (dermal backflow patterns = 10, collateral lymphatic drainage = 9) and none in the control group. The dominant lymphatic drainage pathway to the ipsilateral axilla was observed in all control participants but in only four breast lymphoedema participants. Collateral drainage pathways in the breast lymphoedema group were to: parasternal (6/10); contralateral axilla (4/10); intercostal (3/10); and clavicular (2/10) regions.

CONCLUSION

These findings suggest ICG lymphography, through the identification of morphological lymphatic changes, is a potential qualitative objective assessment technique for breast lymphoedema. Furthermore, in this group of breast lymphoedema patients it identified changes to the normal drainage pathway of the breast. Understanding these changes will have implications for clinical management.

Tissue Structure and Edema Fluid Events During Treatment of Lymphedema of Limbs with a Manual Pressure-Calibrated Device, Linforoll

Background: Linforoll is a device composed of handpiece with roller and pressure sensor connected wireless to the computer displaying the pressure curve of the applied force. In a previous study, we proved it to regulate the applied force according to the hydromechanic conditions of the massaged tissues. Standardization of massage based on applied force was repeatable in the same patient; it decreased limb volume and provided evident increase in tissue elasticity. Methods and Results: In this study, we measured additional parameters useful for the understanding of tissue and fluid events and approval of the device for general practice. These were skin stiffness, subcutaneous tissue stiffness independent of skin, skin water concentration, changes in skin temperature, skin capillary blood flow, subcutaneous tissue fluid pressure, volume of the moved edema fluid, and visualization of movement on indocyanine green (ICG) lymphography. Measurements were done before and during the massage. The data were obtained from a group of 20 patients with obstructive lymphedema of lower limbs during the Linforoll massage. There was a lack of significant changes in skin stiffness, skin water concentration, skin surface temperature, and capillary blood flow, but evident increase in the subcutaneous tissue elasticity (tonometry) and lymphography-shown flow of the edema fluid. Conclusions: The skin tissue hydromechanic parameters remained normal proving lack of destructive changes under high massaging pressures. The obtained data evidently show that not the skin but the subcutis accumulated edema fluid that can successfully be moved proximally under pressures of 80-120 mmHg.

Edema Fluid Can Be Successfully Evacuated from the Lymphedematous Limbs by Implantation of Silicone Tubings Bypassing the Site of Flow Obstruction Long-Term Observations

Background: Lymphedema of limbs is caused by partial or total obstruction of lymphatic collectors. In advanced cases all main lymphatics are obstructed and tissue fluid accumulates in the interstitial spaces. The microsurgical lympho-venous shunts cannot be performed. We propose in such cases drainage of fluid accumulations by creating artificial flow pathways to the nonobstructed regions by implantation of silicone tubes. Aim: To present the 3 to over 6 year follow-up results of therapy by subcutaneous implantation of silicone tubes. Methods: In 150 patients with obstructive limb lymphedema after pelvic or axillary lymphadenectomy and irradiation in uterine or breast cancer or following soft tissue inflammation silicone tubes were implanted subcutaneously. Results: There was (1) immediate decrease of limb circumference within days after implantation; (2) in lower limbs in a 3-year follow-up a decrease in mid-calf circumference by a mean -8.7% (p < 0.05) with range of -3.2% to -31.0% corresponding to 90-900 mL volume and in the mid-thigh a mean -1.8% (p < 0.05) with range of -9.3% to +3% equal to 0-900 mL. In the upper limb in the 2-year follow-up the decrease in the mid-forearm was -8.5% (p < 0.01) with a range of -3.0% to -22.0% and in the mid-arm a mean -12% (p < 0.05) with a range of -7% to -22%. That corresponded to 180-700 mL volume for the limb; (3) decreased tissue stiffness; (4) maintenance of tubes patency on control lymphoscintigraphy, contrast opacification, and ultrasonography; and (5) lack of reaction to foreign body and effective control of inflammation at the site of implantation using low doses of benzathine penicillin. Conclusions: The technical simplicity of the surgical procedure, fast decrease of limb edema, and lack of tissue reaction to the implant make the method worth applying in advanced stages of lymphedema.

Lymph Drainage from the Chylocyst-Induced Hemodilution in an In Vivo Rabbit Study

To confirm our previous study that abdominal respiration has induced hemodilution in human subjects, we performed in-vivo experiments involving anesthetized rabbits. Fifteen 6- to 7-month-old male Japanese white rabbits were used in the animal experiments. Anesthesia was maintained with 2.5%-3.0% isoflurane under N₂O + 100% O₂ inhalation. Ventilation was maintained at 40 mL/breath for 20 breaths/min. Physiological saline solution was administered at rated 18 mL/h during the experiments. First, we attempted to evaluate lymph flow through the thoracic duct using Sonazoid-based contrast-enhanced ultrasound (CEUS)-guided method and then investigated the effects of manual lymph drainage of the chylocyst on the numbers of red blood cells (RBC), hematocrit (Ht) levels, and the blood concentrations of total protein (TP) and hemoglobin (Hb). In this study, we established surgical methods for identifying the left venous angle and chylocyst using Evans blue dye in anesthetized rabbits. We also confirmed that a Sonazoid-based CEUS-guided method was the most useful technique for producing real-time images of lymph flow through the thoracic duct in anesthetized rabbits. In addition, in present experiments involving anesthetized rabbits, we confirmed that manually massaging the chylocyst produced significant hemodilution. Thus, the procedure produced significant reductions of TP, RBC, Hb, and Ht level in the rabbits.

A New Method for Treatment of Lymphedema of Limbs: Standardized Manual Massage with a New Device Linforoll in Conservative and Surgical Therapy Protocols

OBJECTIVES

Edema fluid in lymphedematous limbs should be evacuated to sites where it can be absorbed. It should be moved either to the hypogastrium or arm/scapular regions along tissue channels or implanted silicon channels or through lymphovenous anastomoses. For that purpose, the manual lymphatic drainage of limb is an effective method. Standardization of manual massage applied force and timing becomes necessary.

AIM

A device with known pressing area and continuously showing the applied force while moving it toward the root of the limb is needed. Moreover, force could be adjusted to the stiffness of the massaged tissues that varies at different levels of the limb. Results from such a device would be repeatable and reproducible by others.

METHODS

In this study we present data on tissue fluid hydromechanics obtained from 20 patients with obstructive limb lymphedema during massage with a massaging roller called Linforoll. Linforoll is composed of a hand piece with roller and pressure sensor connected wireless to the computer displaying the pressure curve of the applied force. Electron microscopy studies for checking eventual tissue changes were done.

RESULTS AND CONCLUSIONS

Linforoll provides the possibilities of: 1) regulating the applied force according to the hydromechanic conditions of the massaged tissues; 2) standardization of massage repeatable in the same patient; 3) decrease of limb volume; 4) evident increase in tissue elasticity; 5) application as a driving force for fluid flow along the surgically implanted tubing and vessels running to the lymphovenous shunts.

Abdominal Respiration Induces Hemodilution and Related Reduction in ADH Concentration of Blood

To establish effective lymph drainage methods and develop concise and accurate clinical techniques for evaluating lymph drainage in healthy individuals and patients with cancer treatment-related lymph edema, we investigated the numbers of red (RBC) and white (WBC) blood cells, and platelets (PLT) in blood, hematocrit (Ht), and the blood concentrations of total protein (TP), albumin (Alb), and anti-diuretic hormone (ADH) before and after 5 min manual lymph drainage, followed by 30 min rest with or without abdominal respiration in the supine or sitting position in 48 healthy volunteers. The 5 min facial, upper and lower extremities lymph drainage, followed by 30 min rest in the supine position induced significant reductions of the TP and Alb in all subjects, and their RBC and Ht levels in some subjects. The 30 min rest only in the supine position without lymph drainage produced also significant reductions of blood TP and Alb. In addition, abdominal respiration in the supine position without manual lymph drainage caused more significant hemodilution, being significant reductions of TP, Alb, RBC, Ht, and ADH in all volunteers. These findings may be related to effective lymph drainage from the chylocyst. Furthermore, it also resulted in a significantly increased micturition desire. In conclusion, abdominal respiration during 30 min rest in the supine position is effective at inducing lymph drainage, and the associated induction of hemodilution and lowering of the blood ADH concentration (and increased micturition desire in some cases) can be used to accurately assess the extent of lymph drainage.

Immune defence in the lymphatic system of the skin

Als Grenzorgan zwischen Außen und Innen ist die Haut prädestiniert für häufigen und intensiven Kontakt mit Pathogenen und ist daher immunologisch besonders gerüstet. Das Immunsystem schützt die Integrität des Organismus mit angeborenen Komponenten wie der physikalisch-chemischen Barrierefunktion der Haut, den Phagozytosezellen und dem Komplementsystem. Das Netzwerk der Langerhans-Dendriten in der Epidermis ermöglicht sofortiges Aufspüren und zügigen Transport von Antigenmaterial in den regionären Lymphknoten und Auslösung einer spezifischen Immunantwort durch T- und B-Zellen. Für immunologische Vorgänge ist die Passage durch die Lymphbahnen entscheidend, da Zellen und Lymphbahnen vielfältig wechselwirken. Einerseits werden durch die Interaktion von dendritischen Rezeptoren mit antigenen Strukturen intrazelluläre Signale getriggert, die die Wanderung durch die Lymphbahn zum Lymphknoten über Chemokine und Chemokinrezeptoren ermöglichen. Die Langerhans-Dendriten andererseits verändern sich auch selbst phänotypisch während der Wanderung durch die Lymphbahnen: sie verlieren die Phagozytosefähigkeit zugunsten der verstärkten Synthese von MHC-Molekülen und werden zu antigen-präsentierenden Zellen.

Intermittent Pneumatic Compression Enhances Formation of Edema Tissue Fluid Channels in Lymphedema of Lower Limbs

BACKGROUND

In lymphedema, tissue fluid steadily accumulates in the subcutaneous space containing loose connective tissue. We documented previously that deformation of the structure of subcutaneous collagen bundles and fat by excess fluid leads to formation of "lakes" and interconnected channels with irregular shape. Since there is no force that could mobilize and propel stagnant fluid to the regions where lymphatics absorb and contract, this task should be taken over by external massage. The most effective in this respect seems to be the sequential intermittent pneumatic compression (IPC).

AIM

The aim of the study was to observe whether IPC would enhance and accelerate formation of tissue fluid channels.

METHODS

Together with the Biocompression Systems (Moonachie, NJ), we designed a high pressure intermittent compression device and used in it our therapy protocol for patients with obstructive lymphedema of lower limbs. The study was carried out on 18 patients with lymphedema stages II-IV. The IPC was applied daily for 1-2 hours. The follow up time was 24-36 months. Lymphoscintigraphy and immunohistopathology of tissue biopsies were used for evaluation of channel formation process.

RESULTS

The forced fluid flow brought about increase of the area of fluid channels in the thigh and groin, with a decrease in the calf. Concomitantly, with decrease of channel area in the calf, there was a decrease of calf circumference. No new lymphatic collectors were observed.

CONCLUSIONS

Compression of limb lymphedema tissues leads to formation of tissue channels as pathways for evacuation of edema fluid.

The effectiveness of intermittent pneumatic compression in long-term therapy of lymphedema of lower limbs

BACKGROUND

The manual lymphatic drainage in lymphedema has proved to be successful; however, this method cannot be applied to millions of patients around the world. The only solution is to offer inexpensive, easily accessible mechanical devices for pneumatic compression (IPC). These devices should be designed on parameters of edema fluid hydromechanics. Recent data point to high pressures and long time of compression.

AIM

To validate the effects of 3 years daily high pressure, long inflation time IPC therapy in terms of decrease of limb circumference/volume, tissue elasticity, histological changes, and incidental complications.

METHODS

A group of 18 patients with unilateral leg lymphedema stage II to IV was treated for a period of 3 years using an 8-chamber sleeve, sequential inflation of chambers to 100-120 mmHg for 50 sec (total 400 sec). Limb circumference and tissue tonicity were measured at monthly intervals. Correlation between decrease in calf and thigh circumference and increase in elasticity was done.

RESULTS

The treatment revealed durable permanent decrease of limb circumference and increased elasticity of tissues. The improvement was most expressed in the calf above the ankle and mid-calf. No complications as thigh ring or chronic genital edema were observed. There was no direct correlation between the decrease in limb circumference and increase in elasticity, most likely due to different mass of fibrous tissue.

CONCLUSIONS

IPC takes over the permanently missing function of the obliterated lymphatics by squeezing edema tissue fluid to the regions with normal lymphatic drainage. The limb circumference is decreased or at least does not further increase, elasticity of tissue is increased and maintained. No complications in limb tissues were observed. The long-term, high pressure IPC, long inflation timed therapy can be safely be recommended to patients with lower limb lymphedema.