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Ly mph ede m a:: class ifi cati ,0 In, dli a 9 n OS15 and th e ra py

Abltirar:1;: innis re!.ili .. prl!l!!l!ll'Its tne' di:egI'l0l5tI1c, ~ElInUlrei!, tl'i;e patl'llQphYliQlogy lind tile ava i,~O!bl e tner.!lpi es ~'or' Iyrnlphedeml!, Tlhi5 diS!!II~ liiS ofillln, cl!lbl~t(} Ibe' diagilOSeC!llev lits chiOltaCle:riMic dil'li~,· . ~il' p~esel1~.!!tiOI1." yet. j,n sonne cases, oil nciU"ry tem m.ig'nt bl!!! I'IIICI!!I!S!lI'Y trl I!Ist!lbilic!:h time' di.a ill" nosrs, p!ll'1licull1l1rlry in tile eBr!y:otagle6 (l.f thl!!l dh,eO!si!!I ,! nd ~In eCemll$ of mixeil.'! ,e1io!cgry .Th'~$e ~i,agliFIQ$tic mlodali~ies !lr'e '!J~o u!l!Ifu II i'n clinie!!ll studies.

Av~iJa,blS1 ,m od!lli~ies ii rnC~i.J.C!!l isotop ie lymph ost:ilmi!gr~phy. ,n,d i reC"l lind dlilre~l Iym~ihog rilpny., flul!gnetie r,e.SOrlB,Il1ICe ilii'l"lIaging" computed tomogrl!!phy and ultr.!lsQl'logr,!lphy, Lymphedema, may be pr~ma,ry 'Or seooli'ld,!!:; tothepr![ls!!ln~ Qt other diS!~!lse:& ·an,dtQ!r to the cOl'Isequlemces of~!.!r" geIY, Prim!ry Ilymphedlem<!! mlY ()Ccuirlll 8ny ph·~~e of IIi~e but it mest ,commonly appears at pUIDerty. Seoond!!!1'Y Iympl'lledem!l lseneeu mlt!!fed more Qlen. iI1he mes.t prevO! le'nt worldMr~de c!llise of Iy;mphedem!l isf IB!rillsi~" wlfi!ich i~, IPlHtiCWI'!a rly eo mmo." iln 50u,tn"e<ist A~ia_ ~ i'I 'tn~ USA, post~1J r'g icall lymp!neaemO! ,o,f the eX!I~l'!I"Iity fO revails" C:om plliicati ons ,of I::hfOni~ I~mtl, lympneaemll Ii n~luole' reCl~'rrei"l~ ceU'i,Jlitis; .!Ii"ld Ilympna'ngiQ~a.l"(;omli.

MOM p!ltil!!lnts !Ire' tI~elllea, MfiliEi'iiVi'lti,,,,eIV, by me~~S of y,illriOUliforms of compression 'tne~apy. ii rncl!u di ng cQmp~e)! physica I rhe'ri!i!py" Pi\,HI,UIiTlMiic pu mps .!!!'I!d oompre$~iiVli!i g!!lrmelmts, VQlu me 'recl~cit'lgl sur,gelry is performed: rlreiy.lympli!!~tic m~CrQS!urgelry is st!i'll ~n 81"1 expelrimenta,l, ~lage • .ell/thou g 1m ill {"W centers 'CQn~.i~HlrnUy NlOOr! f8VQrabie o!lJlt.co rnes,

:Key words; compress;ive 'timerapy; Iymlpinedem!: ivmph,cs(ii Il1ItigrlllPhy; mllII'llUII~ Ilymplfl.ll!lic ,a,rain·

!!IS e; m iCrQV;;!SCII"lIOl,r l~ilIrogelry; pneL,i1n"iJ!illiic oo'mrp,~~.!s~o!n .

Definit:ion II nd d.lcr'i!ption of different tYiPSB of Ilymphedema

Lym:p.hed¢rna can be d~li]lcd as tbe 'l:issu! llIuic:l accumulatien llilal arrsesas .81 CQnSO(_lIl,elil<!e Qfimpa~red ]ymphatk dra]oag!!l •. Thh;. Mtll,l'ctkm ef lymphatkflow carl mS1:Ih from ei,tml.e.F col1lgenirnJ o:racqll~red anonml.ies of lympbatic eetflow. Alil.ougb lYmJI~ U$~)' ~t5 oo.e: or .~. of ~he Ii-m.lbs. i~ ,effects ~ manUm in other cq!uu.\\I'hirtever the pathogienes;is. It is moS:l otite.. a ,chr-oltic. urn, ~dhio[l. posll"lg:long~lerm. physa.ca,]anCil psychological ficuhilfls fOJ tire ~liern anda cJO:mp]ex tliLera:peu~ic clla]~enge Jor ~be pnysic:iallJ.

He:reditary IYlillphedema (TIl.lhilel k and heritab~e eond,i~~ons associat!d witlil ~ymJ1:heden'!a.al:¢ nlth~r rare: thl! re]lOli1ed frequency vanes from sing.h~ 'C::!S-e m!:pons to an ~sumat~ appm::dm.~tillg 1 i500 lh"e binbs I(K]incfeiltefs symdrome,.,I 1111 contrndis[~~tlQl'i. Ulffl is .;:l l.3r~~ .. and gf{JW'· in;g.prev,~I~~~Qf ~uired forms of ]ympl:loCd~m.a 6f the ~x(r¢mity . This is as-cribabl:e atmosl e,:Ii;clusively to, dle' .Iarge ~~mkf of plUh:f1t~ submitted for breast and [peh'i.ccance;r sUQery and due. paradoxicaUy. to 1m: rn.c.reasll:lgly s'Uccess" fu] outcomes after oncologic ~hempy.

Diagnostic method.

hl rn:an;y cases of advanced sUistai.n.ed disease. a typical his,' ~ory and chiaracleristic clif!j~a'I ~~lJIl!Hio;n !:$taibl:isbllull'

Di".isiO!ii, IDr'C-wil!¥&~~~l<lt M~i~i~.,S~nfGl'd UmjlolersllY S~hoo~ of Medii· ~i~ S1:l!t!.ftml. CA. USA

AddFcss fQt ~,5PCOOCo:t~ StI!!!IO'y e Rockso~.D~YisDi of Cmli;m'a~c!jj, 13r M!!i;lOC"I!!.!!. S'ta~~r;m;I lJ!I~~ersil)' s.rnool of M~r;I~,trne. f'.aJk Cairdlj)~'n!:l~ 13r Re~~ Cenle1'. Slallifo.t'd. C'A 9431):5,,, U:s.A,

e Arnoldi .1998

Chromo.somal atrer,ICl/oic{y Turner ~'YF1ldf!Df!l;e

KI i lmeieHter ~Yfldlrome Trisomy:21

Tr1i::i:Qmy 13

Trisomv 18

Tfiiploidy

D)smo.rpf!'Qgenic--g.enetiC ,dr"~ IKlippel"Treln8I.1nllv-W~~~~yndrQme Noo~<!! n $vndr,ocrne

Nool'lle4l'lil roy heredu,I'V IVlmp!l'ui!defl'Wll Mliligll lympI'lMh!ii'mi

Neiuro,flb~omato6Is tripe ~, h'Clfl Recklli itl9hauSEN'I~ Dhi,tiohillsis II,ymphedemli i;vmiph(ld![lm~-hvpoj:)iI!rMhYiroidj$m syn,dl~ome

aia,gno.sis of lymphedema w.itl:inearcertOli.llity. Nev'i!l!I~elcss. additional tests Ilil'esorn.elimes necessary 10 col1lfiml the presence of i mpalrcd Iymphati.c How andlor lb~ typica:l. p.at· tern. of Dboor.ma] nu~dI distrilnuti.Olil wirhln the tissues. The di~gnos~sis m.~ difficu~t to :IliSc~lin!~n if) thtctlfly .st.agt\S, particl1lar]y WMI'I edel'rul! is mlildQrimeooi,nenL

A viii! ~bl~ ~eMS in,ltu:ie i5Ql.Opiclympbowindgraphy. im:'llireol and direc!llympilogli'dphy .Iymphatk eapll laroscopy •. magml~ic resunanee ima.g:iml:g (MRlha)!ial. ~.o:m08m. phy and I1hli3SO:no!!'r,aptily.

Dircc'llympbogr.lipl:ly is now ral"¢ly lJ~d: its 1iIS"e shOldd b= resrrietedte those plltien;~ 'who uepolential candidates fm Iympha[!.c $IUrgtl}'. Lym,natic cap:iUamscopy i;savi'lil~ ab~.e only ~n $peci!di~ eenters. In eentrast, lndieect ~ym~ phognphy. tholJJg~ ~(n oOmimml1y employed, is q!,du a PH" fu] di.a.gIllQSli.c modality.

lso1opic Eympho.scintig.raphy

I~o.pic lymphQM;'inligraphyisiii :re]~able .!'!!td ~,eprodudbl~ method for confinni1!lB the diagnosis. oflymphede:lfia. M The radiQlabelled. l1il:ilIiCfQmQI:ec:utilir tracer (~Tc'lLI'Idmony 5U!lIlide COIlOiid (I.r ·ifflIoJc-r.il.e]llum sulfate, among others.) ~s :injoc:tr.d inlr.a- (If 511bderrnaUy within one of tile imeuJigita] spaces ofl'be afft-Clcd limb. The I,ymj:!hatk transport off th¢ macromofeclile is trac:bdl with a gamma camera .. Thr. raie of 'tracer disappearIlllcj!!J from ~he i:qjecticm site and the ;l.C'Cu'm:ulal:ion of C(!iUi!lts whhi.n the lymp.1i nede ;Hie both .quantifiable. Variol!ls stress 'lests have been mcommended to pr0d!~e :n:liabll!i i~llWillti~ative resulis, ~.J.J Altr.oug:lt, vanous routes of administrat.ion 1lUIy' be utililtd. su.bd.ennilil i'1jeC'llC1!l has been recommend~d for optifMll eval:wuiofl ,of tbe ,ep:i~;}sc.ial ]ympn<litic U'i.Rspan. J Thi 5 fflaJY ad~ l115efu.1 i.llIfotmllti.on to'Wairds the: i::va]uinioo of e4:em.a:lI:col)rd~ng UI .Br.iililLi,s:am el al, (Ill I}' evaluat~on of both ,epifasci3!1 and sebfas.c:i al: .Iymphiitk oomp.alitmen:1:s wm permit a1ilacc:urate assessment of ~)'m:pil,aLic ~nmspon ilil t~ lower e"lremities ... ~ i1L.ymphosci ndgraphy j!!J]Hl.ll<les thes:deq aate assessment of Iymplilll!tk:_~\mction Il.!'!d the visuaUz:llioo ofmiijor lymphatic t!I'Unks Md lymph nooes. Typical .. il!bnormalilies observed in lymphedern_a ~inc]!,Ide de:m1!11 backflow. absent or delayed trall.spon of tracer, cross-O¥¢i!' fiUillig 'With fe1rograde bact~ How. lind ,e~ther abse~t or delayed visualization of l1he lymlPh nodes.l.~,6

LymphO'scimigraphy is probably me best of the readily avai]ab:lem.e~ for ~e, fUllClicmaJ evalu8!tion ·of ~e lyma :pbali~ :systcm. Neven:]le]e$$. the tedhnique d<:a require stmdardiziitiQ!l for tbe type 3f!d .iimmu'lt ,of injected u:acer. for the sire of i~j",lio:n !'~Qtl"ade:l'mllli OT suiMe.rmal) •. !lDd! tor dli: stress. protocol used.~'

Magnetic r~ohillnce imaging

Thc[,echnique of MRI can be useful ill tlac diffl!ilielllial diagmosis of limb edema, In ~)'m.p;nedemil. the images reveal. II. C:ilaraC'~r,islic: distributi£lnl of edema witkialhe epl fascial 'COmpllltme:nt. discl(ls~n.g ahQ.fIcycomb paKem a10Ilg wi.dt th.ickell!ing of lh~ ski 11. 1m v~~us edimla.. both the C:Pl5 a.nd subf~d;d compartments are affecledi. wni~ ~!l; .ipe&ma. tberie ~$fat accumul.lIlion wi'liioul fllUjd ""III' Ma.gnetic· Jeson:· ance imagmng is also he~prlll in the iden,rificatioo or lymph nmes, ,el'll,arg~ Iymphalic ·lnIinb. and in.lh.e diffeKnti.atiQfI ~f the various causes of IY·li!ilphillic OO:M!'UClion illl 5eoOmh'1 lymphedema. The anatomic information deri¥ed from Mil. may romptemem the fUDCliooilW as;S.essmi!l'lt prov~ded by lym.pb:oocimi81llphy... At ti~s. llililese 'com:ph!menblfY soun::-es of infol'1lUllion are necessary 'tQ establ.ish the diag~osis Qtld lO millke the requ.is;ite' therapeunc dl!c1s-ioflS .. 6

. Magne:I'icl'e's?mmce images ,of lhe lymphatic sYS4:em C~ be ¢~han,ced \!;Ini:! 'liewer ~Olill~ rnedlia. !nee prepararlions of illlnOx.ide. These have ah:c.adybeel:l mowlii te have promising appUcallOn!i. jllan:imaW &ludiJes.I~.!j The iniUa~ l:1uma!'lsll!ldies with. ~rQtl ,coUoid oove demonstrated the S3ife~y of 'Ililis ~gent in nQm'lal ... 'oJunteers.il~

Computed tomograpby

Comp\l~ed tomograplily (oCT) abo- has a diagnostic use ~I') rh:e e\'.iilu,:;Ilionof the !;wollien l~mb..I.~· The cr r«h!niquepro\fide" ~m Iln:l.tomk defiliihio,o O,f edema ~ocal!iZlllion (slIbfascial l.'ersl.l.s epifascLan_ nnd c.alll identify skin thitkenl~f!g as w~U as. ~!he: ch~rat:leriSt,i~ hODeyoom.b ,attem of tbe !i!u~lIItancol!l_'" tissue if! lymphedema. CorniP'1Jted tomogn~

t~(iU'ut('1F Mt'(ild~lt! 1998~ J.: 14S-~S6

phy scans m:li)' be used to monitor responses 10 Iherap.~ 1.11 Iy,mpr.edema ~hrolllJJ:liI s.erial me"'Sn.l~m;i!fm;· of the cmss'sl!r:ltonli~ area Sind t~sstre de'nsity in the li~sue cOmpi.lnmim~~. of lIilLere,st.11 ~

Indi~tct Iymph:angi~rapby

lnd.lrect lymphW'l@:iogrophy Uli.HZi:1> wme:f-Siolub].e. iooiliil~ed CORl:rnSt mi!d~allh.u are i.nfllS¢!l il'iw.!.derm.illlya:nd emerthe lymphatics. P\icu,tres of ille lymphatics are .obtained 'usin~, :mammography films· or xeroradiog:rap\hy .. :~·I~This ledm.~qu.e ~$ pW1icularly lIsefu] in visl.I.alizi:ng 1.0(;.11 sJdn lymplllHicli 0'100 ~ymphalic trunks. Us:ing this r:lIi!dlOd. four types of Iym· p.natic pathQIQ.iD' in. lymp.h«le-mf.! have bee:n d'e£cribed. lbased lIi[X)tI t!i.e vi.sua:li.zed pauem:s of 'Initial and! periph. fi'fld Iymphtics. '~.I ~

In addition to hs imvesl:ig:ative applicatioflS. indirect lyrnpbangiography maybe useful ~n the m.sessrnent oi lymp.h.atic anatomy prior U) recoastructi ve surgery ..:.IS w~N <II' i:1I :llle assessment Qflym:pbmic anammy In pililJI!fi[s w]th .Iocalized 'changL!:&,II'IJ and. more .ge!leral~J'·. !IS fllD30d in the diagnos:is of th~ more complex presenratiens of b·mphede.

llliil,J _ .

'Contrast Iymphograpby

ConUoUt ~ymph()graplUJy i.saccQm:phshed through the direct ~Il.iection of iQ(line'~bas.¢d, Hp~d-solub!e contrast media huo wbc:ut!lf!eQf:I:(; ~ymphatil:s. which ar·e firstidel'ltifled by 'Ihe 5ubcutanecn.is i1l1jectioo of me dye. patent blue, iU'ld ~u'bS¢ql.Jelul:y caIlinu1attd. 'The tl!chnique was first performed by ServeUe2tl• and later refiRed Midstandardiz.~d by Kin~ mon;lh.lll~ C'Of:UrMl 1ymph.ograp.1i(y ~s. useful for lhe\l:isIl!alintionl of the l)'mphatic anatomy and! is used prior '1.0 re:wIl~tn .. u:tivelymp:utic slilrgery. However. its use W!~} declimedrece!1llly aad been suPerseded by lymptlOsdn[igfll~ I!'hy as tlui primary diagnostic tool fo~ tile assessmel'lt of rnympha:Lic fUl1ctiOlil. In ,iddhkrn-. the tedmklll.~ (lIf rontrasil. lymphography ~s dlstinet technical. difficuItLlii:s. ami may. im fi'ICi. ~nduce e:xacerbatioll of :iym:p'natic ma]wllcti·ofi. ~hl'Ql!.!g~. acc!.lm.III],"~oni:lnd pool.ing of Ithe o]I.-based eoatmst rnedi.a.

UlUuouod examination.

UltmSOi;lnd ,exami:nalioo is III~ii[iud M a complementary moo] for Ihe' rno:n~illl,;".ui vt eval'llatiOfl ,of the s:wonefl extRmi~.y .• I:npati:ents w~th Wymphedema. thickell.ing !af theCUt3IlMl!.S •. ~pi rasc~iIl! and sllW'ascial compal1:ments has !.leen 'ultra.~ODO-· graphi.caUy o~rved. This contrast$ with MIU o~rvat~ons. wiilert the subf:aM;ial companmelU was '~~It to be unaff~:'i!·lo Hi:gb fr-eqll.!e'Jilcy ul~m~olJnd f2o. MHz) :reveals characteristic p.a;liIetns of cut3!l!eOUS: fluid local:i:mt~oo i:!1 various types of edema. In Ilymphedema. there is a distill.Cdvedy u1iIiformpalilem of di~triblJ~:iol:l. ~.~ Th is rnmagimg lee-hoiqllle has applications both in d.ifre.refl~~a~ diagllOsb'-and ~D tMj'a.peulic monitoring. although fllnher refinem!!!'!l may beQom.e 'necessary to better cl:uur:aclefize fhe spe'::Crum ef subcutaneous fibrosis ~I:ta.t Clio be 'i!I.lI;Ounlerea ilD ·Iymph.e<k.

malQ1I5. skin. _

Pathogene. I. and olini'ca. Ipre •• ·nt.tion Lymptli~dema call be primary Or secondiuy' <liS a OOIl!5eq .... eBOe of surgery and/or oth.c'f di:5eases .(Tables I .. :2ahd 3).

F tequeru;:y2U ,,;u.J!Ii

~% ot en primo!ilr\l forms)

COilgenifBf ion.set <2 years 8'frer birth,},

familial. ,!lJutoSOI'YlB,I'oomii'i1i1lt fN,orma-Miilroy dis.a;el' Fllmmal, OOI!N:lomin!Slnt

in heritii'l'Ic.e

SpOr,Eleie fmos,t eO'mmon ctll1lgelnitelf,D rmJI

l ~mph,e~m.!! prft(;o}( {onset be,tweet! 2-35 -¥!I'll'S'

f,mi!;ial, ,!lJutQSOfTIiilll reC~5$lve (Me ige d~sease)

Sporadic !8J:-!l4,% of alii l'vl'l'lIphed,ma 1~:)'re.cO)!~

,LYfflphedeml1 tlm:J~ lonsiu ,;JTter 35 years of ~geJ'

f7-94

'T'II~" 3: L ymp hlll,n9iogfa;phiC c:IIIHuifiC!ltlon ,01' prim.ary IVmphldem!i.2i.

U Co,ngenil!il ar.lliilSiElI or ihVJ)olJl'asia of peripherall lymphatics fedema presem lilt, or ",ppellriing within. 2

'Yllllllf,G cd bi rthl.· '-

2) CQ.l1Iglnltalllbn,ormalities ,of til 8 abdom i no! II Of flloraci~ llymph frW.rrlk5.

3], t.olngEulliitiil~ v!llvYllf i1f'ioompetl,noe ~a IWlly"S !!I1;jj)ocilitlld with megalymphaties i!lndl ,often wiil:h chyloJ!ls reflul().

B. Acq,uillla prl.mary f"mp.~deml

n Intr,lumJnal or ,~ntflmlllt.1 Ivrnphangio-obitNCtl .... ,.dem.a.

Ii~ Distal: .acquired1 oblitellrtiQ:1!I of dl'mll lymp,hatiOl. ,cause, \Il'1l(lnQWi'1l.

Ib} ,Pir'DiKi"mal: acqu i r,ed! 'Obliterltion; of tile lym[lhatiC:S in thlll pf(ll(im{l,I! PI!'l 01 the' limb .• u$uIElIiV !U!i~Cilliid ,"""ittl distill dilatioli, cause Il)Jnknown.

,e,~ Combin.d~ IQq1uir&d ob~iIlerlition at ,III the Iyrn:phiiti~ of 'the limb.

:iU Obstruction of th~ lymph nodes by Ihilslr fibrosis; ma,), ooe:ds,.t w.ittl Ivmpihllflg1o-obstru~tive edlmll, and l:Itq'ui1redl valvular inoomlOOteoce maY' follow.

.Primary .~YDilphtdelQa

Three: types of pr,imary Iy:mph~dema ~a!o'e been :recog~dztd (labile:' 2r!~": eongenirat whicih, ~sp:reseot at biliUil or recogni~ed with.n 2: yean; of binh; prcc.())I" the mosl eemmen subty~ •. w~icih occur" eitller ,at Pu.berty or by the lbegio!lin,g of the third decade .of life~ and! taroa. w~icn begins after ~ine age of 35 yi!llliS,

Congellital ~ymp]lede:ma. may oove ,a (amHii':l di:stribulilo.n .. A pan em 'of a1ilwso,ma] . d(lmina,n,t hns:m~ssiW! ~as beel'! described.l~.n bm aitern<lllivepanems (if inheritance bavl~ bee'll obs~l'Ved also. ~I.~ Nevenheles!'i. sporadic 'Clses, of' ~ymp.hedema: ,are much more rommOIii. ,\IJ-..'~ TIle va:ri.OIU 'forms of primary lymp'hede'ma show 1m assoc.iatiOflW",ith heritable cnOOnlmomat aiblionnaLihes, lite Turner .$,)'0- dro:me. 3~-·A' ye~~Qw DaU syndKIme. ~~ and oUleR crablie 2).

~fI th~ three large series de-~crJb~d by A II en." Sch i:r~ er L" and KunmoIiUh.~2 cong.en.itaJ iym;p;hederna al;'t:tlllmedi f(H: 12. 6 aad l: ~ ~ of eases, reSipe"C'lh:~l>·. It C:.iifl either be pf'e~~ ru :i t birth or arise Iiller. for example. at the onset of ambu!miun. Sw.emllg Ilsualily ]l:Ilvolves Qnly ont lo":er e:l!.lri!mit\". blil mlilh:ip~,e I lmbs .. the !!:eIil.ital~;J and even [h.e face can ~ ... :Iso in,!;''O]y,ed. ~'1 B.iJ!ateral I.I!S; involve 111el'l~ ,<lndwhole' leg ed~ma m-e observed more of Ie II I'tlall ill Ithe precox forrn . .'!There is a higher proportion of affec[,ed males in oongelilital lymphedema ~ihan is [yp:ically seen in. the ]l(re~o'!l t:O"mlI h'itported male:fi!mlll~ Milos·"a:ry. ,e.g .. 6;2.J~ 2:6:: and! 7: ]'}'~I. The lymphedema in patients with Turner syndrome ciln ~jpQl1i. 'n:aneoosl)' di$QPpear~:. i n sueh eases, resol mion has been atuiibuted to the pEesemc¢ of lymphatic ~u,pef.li.d.ilily deep communiciiti,olls. .

Lymphedema. preees is tHe mostcerarson form of pri. mary lYmphedema. The pt:ecox form areOlill'm. for' 77 -94~ of cases in the p.I'eviol!.lily elted series, The term ·M.eig:e d~$easc' snoo]d be reserved for the specihc f:amilial 1'01'0'1 ;of ,Iymphed'ema, wilh i~ reeessive p~ltem of inheritance. widen .appears .ilI1 pubel1)'. ~'1 Kinmomh fm:lI1.d iI film!,1 ial occurrence ~f! 1,6 of 9.5 Don.ooligen1tlll prImm')' ·Iymp.h:edema. pat~elllS~ a!ld Sme1t21er in 7 of 10,5. ~,: L)'mpht-d'ema. '~cox is much mOFe common in f~!'fiii!le :p.;1t~em5. ""htl an, <IIpm:ol(i~ male W: I femal.e:mal~ ruli:o.l;:'il.o,l.~ I A less pronollinced! female preponderance has abo Mel! reponed ([ema]e:m.ale r.llio, 4.8~ I ~.lJ 'fH cd~!ina is IUSl.l1llly uni lateral and Hmited to th~ fool a:nd calf i:llllte mllrjorily -of pj)ti,ents.~! The cornmOIl ll1!itia1 appeanloc-e ,at puberty and preponderance. of ~ffecled females ,bIas led to !:he hypothes..is -that estrogell. may playa. patoogenetic role in the develo'pme:n~ o.f I.y:mp~dlcma.J~

K:imnonth ihas d.a~s.ified thC' onset of disease aflt:J 35 years of ,1I8e as ~ympI:Jede,mi!talrda. He ~ou;nd! 1,:2 such

pa1ieft. U: &moog. his 1~1 .. cueS!)! prif1!!l1. __ ·.~~P~u,"

. The imrOcII.!diOll or lympbop:iiph~ I.e hal, raulted UI.

,a fwd'icr refi.nemen.t of the diagoostic clmlficatiOQ sdlcmll (Table J). ~Uhoogh some alltnori1:ies ha\i\e ql!lcstiooi!:d the valid~ty of this ;}PpOOa.dl.:l~

Wo~f1! aoo KilimonUu.:~~ have pr,o-po,sed prognostic aod cnni,CDI c:orrelat.e.s ~:o the- dUferer:lI: rnymphallgiogr@li'ik: pa-lterns of the disease. mSlal bypopla.sia or ap~asia ,of die' l~.g lymphatics was Pfe~ntin 3~ :9% of padents. ood predIomi,nan.lly com::lated with the presence OF bi lateral peripherail leg Iy~mphed~mi!. This pIliu:emis usua~l,y 5,IQ'w]y progms:silve, ~falaU" after mihe first year. It ,affects, predo!1i'ioa.ndywomen and ran!ly ~quires S!'. A famUlil OCClll1't'!nCI! Was aIDsQ' more f~qu:ern:I~ (:2:2% ~ed proxima] obs~li"e hypoplasia wa;s seen ~o '2 • % ,of the pali.elllS. CI.ill1ic:ally" the whole limb WaS usuany ,a«ec~ed (82%), edema 'l.ended, to inCfta5e w-UhOlml intem!fI:~on and:, ~~ wis ser,i~s..o~te:1I ~qllim1 surgery 02%) .. Distal hypopl.l'i!ii~a affe~ts, warneD and men ,eqll~ ,iny. Tbe presence of ,CQfi(;Uffent distal' and proximam .ym. phatic oecl u:!iiiOllJ 8CcoulUed for 3:l.3% of pW:jl!1lts. M.cgal'ympna!:ics and bib:lCril bype:rp!:a5ia, was observd ·in 14.41% ,of cases"and! meR were more often affecud t'M1I WOmen (1MIe:fem~-e rat~o. .3:2). Edema IIiISLiilUy tmrreasi!d prog~si ... eJy ~n.d vo.llumi!: redudng wrgery 'WM of~n 1!e~lli:redin dll: iflvoivcd e~tumwlY. Patien~ wi:lhmeplym. plul1ics !JlsuaUy bad unilarl:C.ra]. w:tw:lc leg edemll and often presented w,i1ih cutallWt!s anl·iomas or cbyIOiJlsreflux:.

The appearance 'of primary 1yrnp,hede.m.a is wlIIl:I)" spofI~ &aIICQUL al.tihOtigh same palieRU relate iU onHl to' ante~

14S A S~uba and SG Roc.holl'

cedem ll'ijury.~'~ Initi.all}'. the !iwemllg is t),pic,ally puffy and i:nlemlinenl. taler. die' ~nvol\ied snuctures become illdlJ~ ra:t~d andfitwosed.n.;w T.lte e)l~e'm ofthe :swl.dlillig is IIslliaUy demarcated within the: firs:1 yeatM)·:~~ but i.n sorne patieats ,mere ma,y be a ool'lilinual increase 'II] girth,

Although lympi:LBngiogrnphyis now rarelyusedi beca1llse of ~he risk of ,exiUiC'roadng die lymphedema. i1 relmlill5a usdLlI W<l\] for the i.dell,tificatiQI1 of patients who mig!:J;l benefit from reCQrlstrl.!c~ive ~ympfla:lk: slIESery lmd ~t ShOllild be performed if ~C(li:ns~rucli".¢ I~urrge'ry is cOn:ltnlpkned.

Serondary ~ymphedt:ma

Secondary lymphedema develops asa CQfilSC'q1lJence of dl,s,w ~tiO[l 0]' ohs[l'Ii..Ic~ion of the Iymphlltic pathways by surgery orother disease processes, (Tabloe 4). S.woll.dary ~ymp'hede:11UI is much mere ,common than thL!: prima!"}' fOml. Its gJoba] incidence' can be ascribed. :p~domifla.t1tly, 10 "Jom,· asls, which accounts fOI over 90 million aftlicted individ, IlQls.~l Nevenh~leS$.IlIe're is a i!wwin!! nllml.ler of ~Yllilr' .p~elUa cases that iu',e arising as a conseq!llelU::-,e of ROOplasli.c disea~e. ool!b.~rol1gh di reel. Iymphialk lln".aJsiQfI ~d. iatrQgeIlically., lhrol:lgh 'treatment of tile neop]asm.

Iatrogenic b'mphMrma

Dis!'Uptlcm Qf the rnympnatic pa:mways ~)" e ca~sed b¥ SYfg:eryandJor radiation chM'lpY. whicb. produce' f:i.bro!l~s. SiJr:gical d~!lfllplio:n of the ]ym.:phSlth; p<l.ihways maybe illtentionld (lymph node' d:issectioll! fOf cancer su.rgery)' O[ ilcciooiWtilIl {e.g. during ~~iO'r~mQ(al revsscLIJI.ariU,lion). In western seeiety, the most cornmen exemples of secondary b-mp:iled!emm. would 'be. tlhe amledema. ~n WOmell arfier axillary Wymph node dlsseetien for breast cancer, and ~.ympl1. edema of the legaA.¢:F inguinal. and pelvic lymph node dis-

section for peMc neoplasms, -

Edema O'f me ann after ax~Ual}' ~ymplh node diJ~~tion ~s ,P.robab.ly the most common ca1!lse of' .Iympmedef'mlj ~I'i the USA. The incidence of edema after masteCl.omy varies slli~ sUlOtiaUy amon.g: dlfftnntpliblishcd series, fmmS:.S% ~:o 80%.0l0i In a ~ilfge series, of ml)i't,lli.an 4000 women who were sLlJrgkaJly trc's.iJ.'ed. for breilSl cancer, Scl:iunemalm

Block_ds .It ,the' level of tn, lymph noatf

Rlgion.al Ivm pih nodie dilOOiofil

Aili;illa,i'V III'JOSN1iIIstectomv Ilympl1iea!emB}

Pelvic: ud pllrl.·ICinic ,lie{! \II nd 'groinl Iymph'lIdeml!l"

INec;1I: (hllid and lII~k liymphedllmal .

INeopllntic diiulase Hod; kin lympnOi'f!lSl Met.l<llalic. cancer Pro&t"lte cancer 'Cervical ,Clne,r irell't: Cilnc:e,r MII.lloma

.DJsrupt;or.r or ,obJitetatir:m pi Jymph.lric chlinnels S!urgell'Y', eo.g. ml').femor.1 'bypa!1l1

Dir&et injurY·, e' .. g tnll:lm. ,of the medi8.~ .!:pect of' the

tnilgh

Radiation,· i ndUi!:ea fibrol"il

Neoplastic. infiltrlltioll 0" Iym'pl'lluic: channels Rheunll!toid IIrt~ritjl;

Fila·rlll'l

Reocur1ren,t, j,nfectiori, 'fI,g. t!IVsipel ••

observed arm I~'mph~dcma ~n :!7''k of tht patieI1iLs.~" He demonstrated m .. nboth the e.xumt of breast su:rgeilr), :i:rad tile Sl.lb&eqll~!l.t U5e of radialion cerrelated w1th a likelihood of PQ$~m3S[eCtom)' edema, Fulithermo:re. ~t wa~ C'onjecnm::d lltal ehaages in surgical technique and the Jlre\'al~l\c~ of radiat~on therapy may have 3cci;lurlleo for tbe ~duced 'illd~ d~nce of lymphedema (fr,om 38',* HI 18'k) in hi.s sene's. Others have aJl.~o de)cribed a (;'O'fre'lation with rodi· atioll'"~.'Itt,,"7 sllrgicaJ ~echniqli.le·4.j.~' ,and obesilty.,j,I·.w....I:!I

The pre\'alelice of' arm swr:dlil1g after breast callcef sergel)' may l~ Yfidc£cstllThllil:ed MCaUSe roi,lde.r deg~s 'of arm edlenw might r-tadily be: overlooked. ]n a careful. prospecuve stud), of 360 patlenrs und~I',g'Olfig b!"least cancer lneraJ,PY", arm 'lymphedema was fOund in 42t;t. oW

Edemiil! of the leg is com;parab]y CO'mmori aJler a pel,,·ic or geni.iAIcaliLc:er ope-ration. partic-u'!arly waen ti:lere has been inguifiii!lfpelvi,c ~ymph ruxI.e'dISS¢CtiOIl Jlldto.r lm1dJiat~O'n. The reported frequem:y varies ~I:weell I.l'k and 47%.ro-s~ Pelvicirradlatien cotrelat.e-JI with aemcrease in me f:req!,l~n~y of leg ~ymphedemill.~~4

Lymphedema has also been! observed foUow:itig other Ilillrgical techn~'lIll:C;s.. like il](I·Je1TlQfal b,ypilSS S:1I:l"gef)'.~s which caR IProdlil.«! If.il!unu:atic or fibroti:e diSI'Uptio.n of!he major ~ymphatics,.

'TraUItl(lric' lymphedema'

InJW'Y of the ~ymplilatk ch:anmds can [ead to obstructioll a!ldthe devdoprriefil' of lymphedema. ~Ii, Cu.riollsly., some' patients with primary Iymphedem.a report ~njuryas an wnlli· ati Ilg, I!'vl!'nt.;i~

P;()shill/e'c#O.IIS I:\'fflphetiemll'

Anen. ~f1 his 'sent's .of 300 patiMts wi,lhlymphed~ma:H f'Ou.ndp,rimaryiaflaf'il.ma~ory Iy:mphedemlli in 41 cases (~1,7%). and described si.ngle or l'Ccurre:nt. auac:b of 5uep~ ~II! cellllUm Of Iympbang:it~iii. which '!'Hulted in sweU· i~g of 'the limb. 'These attac:ks bave a sudden OEIset and are 1lCCcOmpaf:!i>ed wit£! h~gh gmde rever, cl!ilIDs ~d genemru ma~a1s.e-. Thc mnvolved e'xu'iilimity is swollen, hOI, tenderand e[)'[~matoos,. and ·te proxi mal: lymph nodes are SWOUi!'R lIod ll.e:nde'r. Afte.res6Juii:O!1i. v.,·.h:idl. req.1.lires 4 '10 14 days. (!Ie edema of die limb pen.ists and VI'Ol"'SeI'lS after subs.cq.'IJIe-l'U a1W::k.s. S·m~lh'" reporied thai 43 of the 80 pati,ents in his senesof secondary :lympl1eckma ~ad, swelUng as I ~onstquence of infection.. 111 21 of these cases lt was ,asmbable t'Q recurrent cellulitis ~nd Jymphangiti.s. iIfld in W4. active rrichophYlOSi.5. Affected pat'ierlls were uS'1lIaUy be(weu 30 ,and S9 years 'old. wilh neW' gender tlallilnce. The: aIiIlhors· oW,n ,experie~<:e W5, ,5~mi lar to K.il'lnUlnlh' s~~:imd ~ndil;ues that :primary in:flauuuatory ~ma. as describedl by Allen.,;~11 is n;ow ratber faR, This cjJang~ hltl'ie' eliologic ~cha!l~sm may be illmbll;~ ~(l' the w.idesp.read use .of pot~nt an:l:ibm~nic5.but. ~~ recul1l"el'l[ I.Ympban.giljs and ceUuUtis. whh:h PIIDctllBlea.1'!d agSliaval:e theeourse of pre-cxistinl lympIiedema. femaillidififi.cLlih to OOllitrol.

FUllriasis is Ole most common clluse O'f Ilymphedemii lin 'libe WOl'ld. h is ,estirmlCd~at up [0 90 ndllioo people ,IIU :infected.d."", MO~l of the symptomatic patiel!lu, :haI .... c Jym~ phedemil: i:n.a recent study from India. ~hi5 if:!i;idenoe ,~",cetded .85'.t.$9 Fi1ari:tic- lymphedemEli can affect UP! 10 J ]'iof t~ popull!Jliom ln ,endemic arl!a5.·!>0.61 whieh ue loca~cd in tmpied lOnes, dnrolligliool the world. WUchl!'reria banrrq!ti, BI'~jsia ,rna.l(J~·i and Brusia nmon De tile organi5m.!Sres:pon~

sible for hu:ma:l'lfilarias~s. Many o.the.rspecies of Wyche;. ,eria and .8meia have ooell de$crib~d ill animals. with the po<tendal to" eross-rafeet hllm&Il~.;~ Various p8Jthologi, i:n~Cl1l1"1llSf!'iS :may become illvo]v,edi in the lymJlha[t~ des~ru;ctiQn ~n tbi~ disease: dkocr. toxic df~ts of rhe worm. ~he' host's immune ,respol'I,se~~ iind ,stlpe!'impos~d bacterial i:lllf~ctione~,63 bave all been proposed. The parashil: i~~ trans.mined by at mO,5QIt.lilo veC~(lf wil:i(;'H earr,ies l!'l,e ini$cth'e' larvae. The acute clillical. manifeslalions, ,of filarias~s, Iru:;11!Ide episodic lltta.cl\s of adenolymphangili!). with fever. In most of ~Ile cases, iymph~dema of (he' lower e'xUemity dcwelop$ and! pfOgre.s&e:~ after these feCUrn',ntilttacKs of .ad.e.llo.lymphangiliil.~!11~ .

Neopt'tmi.c: di$€a$t'

Neop.lssric: Q:bli~er8ition of Ille' 1ymphalic: vessejs, '!r'mph nodes (met3StDes) a:nd .Iympbati~ dllcU (ex.ternal romp:I1!s~iol'l ~ c'l!J'Cinomatous I)'mphan:gir:i:s.) is a major C.iIIIliSe c,r .secondary lYmphedelll.a. The mOSil frtque,lli causes, Bl:Ie beast ,clLt'l(;eii:n l.yriiphedenw of the ann. ·and pnlSla~e canoer in disease of the leg."

Olil'e,r CQU,S(!!S ,0j'stC'ondary .lympltedtma

Iso]iUed cases ,of lymp.h,eciema iflpaliell,ts Wiitn arthritis an qll:i'le nll.mC'rouS.:~m LYID,pb~!'fIa CaD accompany both rhel.lmam~-~ Wid psoriatic artbritis" 'TO The upper e:x~MmilY is more ]~kie]y to ll:le OItliected.oo,Y,7lI but lower ,extremity ~I:wol\'emcfit has ibee']I described.'01M' TJiI~ paf!i1og:en.esis, is coojectW'ed tQ be ,eitber lymphatic Qb!\;trucdQ:!'I

or Iy:m,han~jlis., -

L.ymphatic abmml1l1li[ies ue a1:w o~ ~fI oilier types of chronic' ,edema, such as cibl'Ol'ii:c WllOWi il'lS'lilffici:en~y' I-l~ 8:Ild J~pedcma. 14

Com,p1katloos

CMmie 1~ is ,often complicated by mcwmu lympb_tis/.ceUIlUtis and in die IOQg-5tanding di~. numerou;s ne(ip~astic COB'Ipli.catiQiiS ha\i\e been del!criibed.

L~rntvhan8irisk;elluUtis

Ac¢umulated f:h;lid and pEoteillIS serve as a peneclcu]tun: m.eiij11lm ror 'baclccial grow:lh. Im:p.BIired IYl1i'!I!~iJ'I3Jti:~ dFailna~e impedes the l:ocai immull! fieSfOtllsc. which. in tlml. p:romotes bacteria] ud fun,gal.iilvlSim! ,.'3 The infec'll(iI1ifunh.er j,rDlpaiin I,~mphat~c dra~na~e Wld the' aggravation Qf rbe edema usually persis1$ a:ftef' die lnf'e('hoD 'resol.vecs. W~lb ~um:lItinfecthuu. (heR: ispr-ogn:ssilve damage of th~ Iy.mpft~jc' c.apiUarles.:l\t. The diffe.mn types ,of lymphedema display' a v,arjablc propensity towllfds- the development ,of ee~lllIl.itis;. ,In primary ~ympbed.e.1Q;, tlJe ~~d infec.lion me varies fA)m ~ 3%~ I to 3 W '%~~'., MiI;vy., 011. the omeli hand,; did DOt describeaqy attacks of eeUul:i'lis in the congenital lymphedema '8mi.!), und=r ilis scnlt.ny.~711li sccofidBl1' liym. pb~a, infection bas 'been re-pot:ted ifl41 % of bre~l cancer parie.lUS. n tlI.e most (;~mnlonca~ heilo,g infection by Slr:cpu}'C'oCCUJ.~1.7~ Infection by StNptOC(fC(;US group 0 •. cand S •. JQI1c8uis,'s group :8, beta~.beltlOl)1ic,'9 and eetero,eoccus78 have beC1I reponed., as IIl1Scryp~1 >OCUIi:lills.iH!Brook 8lId Frazi,u fulUld various ,aerobic and aw.er~ obit organisms Md stlg:gcsted a, po:lymicmblal etiology fo!' ,oeUul'itis.ill In a recently RiponM .series. 'Of ~nuliijs cernpJicauns lympbedema, Stliph~lococ(fi md Microoocous species We:I\I!: more oftem ldentinedu ttl!! ~nfective agl!i1ts.,.&~:

VQ.f~ula,. Mdicinl! ,1998~ 3,; 145-,IS6

ID general. if is, difficuh to idellui.fy the in,fec{jou~ faclor in lymphedema pallen.,s with oeiliuliris. Blooo culnH'e~Y ~kiil ioiopsy C1iIltlllres8.t and. n~edle a.spirutes~!I an~ ra:rel~' po(!;i~i ire.

The c:U~ical pierure may "'!iQ' from acuie aUOIcks of a .rap.idly ~rog,~~ive infection (hiZh fever, chills and ge.rlfL'r:J!1 malaise. whh local lzed ,ed!emll. erythema a:nd charac~erislic changes of ~t:iu d'o'f{mge) ta a subc]ink:li COilr5~ wi,rh. erbest, subtl¢ skin cillang,es and nOmla] body ~empef;Jtllrt .. R~CL1!Wcml snacks (if cellu ]hi 5 da:mag~ e,:,istiflg C'l!taneou~ lym,p.h,ulcs. wor~fl5kin cban8C's ilnd! lu!'ith:f;\'-r ugl:!nl!VlIle ,ex~s.ting ,ederu.A.clue attach of ,ceUulitif< usuall~, \lies!)I"..~ qluick1y aft¢f utibioti:c the:rapy but ~end! ~o reoceur. beccrnil18 mon (1:sls~ant to 3f!tibiotic therapy "lin!!.!! the,.. do,. Prophyla:lt]s agail:lSll cenul'i(~s, incl,udc:s meticulous sk.in ~<liM. aVQidoWce of minor tra:llma alld th:~ pro,Pllylaclic use: of ant]·, biiotics. ~!,~

V,arious treatme'nt mgimemls for ]ymphedemo. may also prevent the recurrence: of ceUulids. Thiii has been reponed for h:eal therapy,IIS coumarin ad:m~ninration.,,;b rmmualllym~ phalie ~tu:r3!p)':S'and following lRicrosllri!~I'Y.II~ Othel'$ ascribe' the observed R!ducti(;';n iflrlle freq u~flcy of' ceUulitii! lomedculous skin care' dllri"g pll~umi!llie oomprc$sioo lilerapy I"3Jlh~r than to the co:mpre.ss:iotl il'sel'f.l!~

MaliCrI,QJ'u fumors

In rare cases, d.'liQuic lymphedema may be complicllted by ~he t!elo'clopmaflt of malign,!iI)!t. 1l!lmorswi1'llin lhe il'!vo]ved! Wind!). lR m948, SleWMt and TrevesliO descriibed six. cases of angiosarcoma zn 'Ilie edl!matous ar:ms ·of b~~l cana rtrea~ed women. S~nce that :fi.rst report. over 400 cases h!i!!'fc been dcscribed jn dlelheraltlil:re.~'-9J Mal.igJilSiIl!~ tu:mors of a Iymphedematous e,x,tremityc=ul evel ve from I!ymphedema of .any etiology: ~t$i.I:rgi.ca~. tmu.madc. !Ii larial aI'Idprimary.'M but 'tht phenomenon is most often obSU'o'ed .inpost~ nlUl'e<:lOmY edema of the 8mIt, 'wlilh a described ~ of 'OAS~.t5 1be latency period bctweell ~ .... the dev.e!opmemt of the new malignmC!y may vary from 4 to,44, years. ~ i lfi aile $en,e!! of 418 patients wittl SlIE(:Qmas rel3Jttd to bftasteancer th~py, 9 !'lymphiRg.ioslll't'omata were observed in 46% of the ,cases&! ilnd fion.lymphangiosareo,m-

arr,a in 54%. -

t:y:mphangiosarcoma ii.!~u<lilly p:IIeSC'n1S as a mU~li~llmc I~sion w~th bluish nooUlles. sclerotic plaques or buUow C:~an~!!.?6 Tile TleOpl~5m ils ll$ua~I'y "cry aggressive jn i~ gr"Owtbl panem, IlJi'Id ;~,ear sUrY,iva:1 :fa:lI!S vary from 511i~~ '10 29%.111

Other mal.if,Hant Wmors that appear with :ililcr,eased frequency i:n the ~ym_pl'iedem!l~ou:s Umb include Kaposi's sarA coma. sqy,amollls cen careinoma, rnaUgnant lympooma and melaf!onlJEl.9"

Tre'.ment

Ly,mpl'iedema is a chronic condition whjen 'requires, nr;e- 1008 tr~almmt Far from b=ing incu:rable. tile dise_ now ~as many weatrnem options that ba~ demonsuable ~m.eacy for 1he reduetion of Dfna volume DId the ~veDti.oo Qf Iluid accumulation. Oill th~ otherhaecl. if'me lKlltrnem ,~aimel!! is abuldoDed. ¢OlI.tinu(lU& accumulation of edema wm ~!1lUe. ex,lOetb.itcd! by ~rrent if.lfectiOlll, with IlQUJwJt musiv,e edcma, grosS:ly imparified Umb 'functioll1, psycboso-

elal disability ,ii1Ind life'-thre.:i:~e'ni:ng i nfecti.ous or malignant rompUc~ulons.

Media.ttherapy

Comp/c-x physica.l them]): ..

Complex physical li1ulwap}, {~omplex. decol1ges,t~ve tiler<l:pJr'. ,combined physiolhefa'P~O lsa phys:iatherapemic approa£,n to :Iymphed~mill Ilhat is designed to :improve ~ympha~~c drainage, T!le tbmpeutic ~r1lervc.n:!ion includes .mamllal. I:ympl'la~ic drainllge. exercise. otting: with m:lIl·e:lasmic wrappings and ,compressive ga.nnerus. to,gether with Im'liclillous Sk.bl ,c~+ This, ambu~!Itru'Y l.re'J!lJtment is performed on 01, daily basis fOJi ] to 6 wi!eks. At each sess:ion. manual Iym· phatic dra'ina.ge (MLO) ws perio.rmed after skin d~a!tSiGi! amid Iilbrilcatioll. Mantlal, lympbatic drainagL!! is a sptc,iic RUlUa_ge . Ileclul,iquL!!.. basedupoa principles described by Win~varteJ and Vodeler.lind Foldi.'hIThe i,nl~rll: is 'iO '~l'Ihance and redirect ~ympl1 :flow thr-oogh ~ntElct sk~n ~ym· phaLic;s a:nd '[0' redini;;tlh~s flow to other reg~()ns wi'm a pr,esuv,ed .Iymphatic ciKulaliofi. Accoroin.g to fold.i et a]. who. with 2500 palienls per ye.ar have arguAbly rl1.e- gI1ealest aci;;rued! ¢xperience~09 MW' 51h1ootd be applied! fif$tlO the CQIIIImlIatieral, quadmnt of idle 'tn.!lit. This e~s Iympbaliic c,ol'ltrac.ti]ity and sdmu]au:s .Iymph flow tnrou,gh lym· phialic watC'rshedS. Subsequently. m:a:ssage Is applied! to the root of the ~imb. fonawed by therapy -10 the mOM distal, pans. The parl.lcu]ai massage technique (if MLnis. very gentle aRdis. in fa'Ct. some'limes, compared to the touch of a eat'spaw, NOIiI.·sttetching oompres.siv~ wrappJl'Igs, should Il1e: app]i;ed after eachsess.ion of MlO and wom during ,ex~rcfse. to prt~'ellttncreaCcIlMu]atj,OR of fll,li~and to promote lymph flow during exen~Ofl. e.andlages are not ~moved 'liHUii the subsequent U';~a.tmen[ st'5s;ion.~·looThis, approach is poptdar in EUfOpe and .A!liIstmlia. and bas, been .mo;nstra~ed to be both ,sat:e DId effective. It is _commended fer .an stages of tllevaritJU$ types of ~ymp:hedema.

These theraptes ~ becoming more PCI[Jular ill tile USAY"1 ~n ene series (if ,)99 patients with benigll .Iympbedema (notcausecl by neopl.asliclymplulilic blockage ),' \'.01- IlmereducltiQn wasa~hieved i:n 95'1} (i:ncl!.lding >50% velumn~ IIleduc:t!Jolli irn.56% of ~he p.Ir~ieintsJ ~mmedji'i!teJy IDle!' completiQil of the therapy. After 3 yem of fo]l.oW"'IiI~' 'lin 1'7 pDltie.IUS.". th~ effecB of th¢ lherapy were sllslain~d in 54'%' of the pmiellts.1ifll' Olher r-eponshave shown similar ,dfic.ll;~y _HtUiill, III~" III.'

Inten'.!ittenr {meWu(:Ifi'c ,CQ,"lIpr:e:ssfon

~nle'rmilh:nt pneumatic compMs:!iion whh singie or tmtlhi~ chlambc:r pumps does eff~Cli vely ~move excess ft u ld from the ex:tremiry and I;;an be used ~!I ,at pri fii'l~ or iidjunc[i'lle th~!'a:py rQf lymphede.ma,,1I'I,UIo!-illlJ Mo.sr studies have ,oomllit~n1ed only on the ,early effects of this .lhe:ropy. but IMg. term resillti. ailtr seqlile'~tilal i:ntll!m'li1lte~U pnel1matic com· pM:'>f-ioo tnernpy. have been reported ~n One s~il!dy of 49 r,ren:lcd ,Iymphederna plitien~s. Me.m foUow.up was 15 months. Of 36 patients., 16 ful]ymaintll.tl1:ed lhebeJileflts, of ~l:Ie Iloe:r,npy and m plrl:ieril!l had a pafl:ially Sil.itiili ncd re~mll. No w(lriSeni~2: or the cdell'Ja W" other complications were ~poned .. ~~ Sgme studies, Sl:IggeSl llIIlI adv;mmg,e gf m,uhi· clto:!mbc:r pump~ ove:r lI:nicol1l'panmel'll!.a1 devices. II 1 II whi Ie oilben, hav,e shown no dif'ere,,".I(j~ AI,though CQ,mpl,i=

Ym"U/(Ij" McJlti(.·.·n.!!' 1998: 3(:14S-1 ~fi

eanons (if compressive ~herl:lipy have net, ge'lIeroJily. been r~po:rl!ec:l. there hatvei been warnings th~t ihe generatedpre« :SUMS mighl d.anl~e skin .Iympha.!ics~ I~.d nand Ihmille res]dual p.I"Q~~ins., which. remaio after forceillll1uid dis,place. mem, can induce ~J1dary :inflammlttioll andaccder:ll~ liilbro.scl,erolk changes, ~Il additio.n. a filig of fibrous tiSSilJI: ean foffl'i. (lV'~f time. .above th~ sleeve of ~Ile 'pneII ma,! ic pillifip. ~lherl!by funner ,compromir.in,g Iymphaiic oatflow:~i!U 11~ Recentlv Bons obs~r\!ed ;m increased incide:ll~e of genital edema· in palients wRen usin.g the: pl1:eumalic pump the-ropy foOl leg Iympbedem.a. q L~ PnelJ!n a lk eompression with lower preSSIil~~ '140' mmKgl; can 3]SO' be df~· hv,e. and may pose a low~~ risk for complicallons .. '!~ T,ne use' of nI'I)' rOlm ,of comprtS5~ve th~!',apy deesrequirea sufficient !ifilerial b]ooo s'i.ipply to tlh~ limb. III cases of limb ischemia, cQ.mpressivil: therapy. which ['lIn coltlpfomis-e artefial bJood _ flow and promO'[e severe ischemiaOind! necrosis, i I' is contra~!1Id.ic;ilt~d. Iselated cases of induced or a.ggroJ.vated Iymph<'lngitis. u ,I ~ and of peroneal :newe pOi~S)' 1 19 have also been re:pm1~ as compliJcatl.ons of seql.lel1tiaI pneurnatie compression.

CCmrpre.uive ,Ilmtents

The' l.niHw~OI1i o,f compmss~\IIe ga:mltl:llS ~s, ,adijl!lnclive loO lll1e' ether forms of lymphedema ther,apy. ReMi'A'!ly n:cm· distemsib,le elastic: sleevesand ,$r,ockin8~ IhOlt transmit high ,grade compression (u:p to ,8C1mmHs) (graduated compE'!ssi;omgru-men1S)i wi:i] prevent reacCll!mulaliOfl of f:l1;l.id after soocessflu) d=rollgesdve treatments, In or-<i:e,r to provide ~he requishc' de~:ree of cornpresslcn, thegarmemrus should be carC1fuUy C~(l5e:n Q~lle' basis of melic~loliIs 11mb measurements, Such ~armen'l$ lose thei r compress~v,e ~aJpabilit~es after .3 to (i. monlths, and ,m[lS,t be rep.IMed. fOli mOlrJiY patients with mUd I,ymphedemill. gr,l'Ide II comp,ress~ol1i (3Q.. 40 mmHg> will suffice. Al1houa;h :iilghergrades of eem:pre:ssiof.l aJ:eomn desirab:le and! reromme~ IlIlI dlcsc are m.uclh less well tolerated by pa~iems,

lilelastic compressien devices stich as CkcAids (Cin:A~doSMedkS!1 .Pit<od!!lC'IS Inc., USA) and UgAss:isl™ (Compress,ion Specialis,ls BSAC. Inc .. USA)! have ~!'ill)' bee'" j,n;!.r(Ic:hlted to pennjl ~uerlong·leEm ma~nlen!!f.ia: of IlmlD ,'ol:IJIDe iln paliemlS withicl:lmlliC' edema, These de"'i,~s. oon.struCited of Velcro stn:p~, C~fiI beeas,i]y fitted 1:0' Ilnl! exnemity. The CircAid device bas been shown, [0 tOe .m~ dfecl'ive th$!I elastic stockill~~ in 'Ihe' maxnte,nallC'e ilheropy of cluonk venous, insufficiency,m It may M usew.1 i!l,I!he maimenan~,e therapy of lymphedema as, wen,

Anoiiher compressilve device. 'Clil:led f.he Re.id s]e~rve. is censtructed from a speciall:y des:igned foam and 'ulilliZies adjusmllie bands ilD provide 8i wide:-r.ange ,of gradie:iU. presslues. The de~e of ai\',iila:b:le cQmp,re.ssiQrI ranges 'from 2'0 lro 40. mmHg. The sleeve i,s designed 10 be worn ovtmigh~ aad is e'a!iUy se.lf·.appJicd. Pn:.limi.na.ry resilits demonstrate a sign.iftcantvo]ume r:ed~lion ,(32%) in paJ!.ieruswitllil .Iyl'llpnedema afler4 we,eir;s of ther,apy. I ~~ Raridomi~ed trials are under' wily to oompare the [h~r~pelilic ,effects of ~l1e Reid s]eeve'~O' Ihose which reseh fn:.m i.IHermiuent plii!lIrmati'C «impression,

.liM' ,rlif'mp.\'

AppU:cadon of loc.al. hypenbermia lO the ~ymphedem<atous hmb h~i been described ,as a ,safe. su.ooessful therapy in cn:ina.I~:I-I:l;!i Uu and OISZcw5k:ill..; d'cscriDed rcgn:ssiml of

the inillammatory changes ln ~ymphedemalOus sk.in foUow" ~r!g heat therapy. A 5fg:llificant reduction in limb volume was also ebserved, Th~treat,mem was ,a;ppHed for 300 to 45 mi.nJd.a;y over ] 5 days, ~J.5.1 ~ Witb the l.uiIJz:a.tion of a. microwave (l'vell as the heal souroe. 'Ihe suticmaneous dssl!l~lem~ perature rises to 39-4{)°C The' pubUstu;:d reSI11ts are: prom~ i 5~r.lg and the m.eln.oo ]$~irnp,]e.

Other physical thtlrtJ~· options;

Sal.zannj and coworkiers • lie, have pu:bH$lhed res,uh$ of ani lmt!$'ti~at~on all postmastectomy a.rm IL'!dL'!:ma. im which u]trasollnd [her,apy for chro.llic: edema. 'W8.'S compared wilh lhl.\' nse of pneumatic eompresslonThey acbi~\'ed a. simdat cf~gree of v,oll!lme reduction in bol:lil grou,ps., but there was ~ greater degree' of sl.lJbjo~[i \''ely per,ce~v~d 'tissue rof~ei'ii ~g in fhe u Itr<lsO'und~[~ated group.

A.jlrolog'Om' .Iym:plw,e:yle hljec/iOll

I[ur~·anen,a~ auwlogol!ls .lymp.hOC'yt~ !nJ~C1:loi'li~ !i!nolb.er proposed therapy for Iympbedema. The 'first observation came from Katoh et. at. I~!! who obscrv,ed reduction ot i,ym~ phedema i iii ~ ve of lS~VL'!:n c~.!1C\er patiems who were tl:leaterl whh autol,ogou.s lymphocyleinjectioll5. Three subsequent eases reports 'f1'(Jm tlte same groll:p;I~'-I:!'J' described th',e addhion.a:1 patlems ~ out of seven) who alsoben.enled from lhi.s therapy, Thi! apiP~MillicC' of HO'1II\e~ proteins i'll the Iy.m~ phedemarous fluid was observed (oUowing the lymphocyte injClClioilS, and it has, been sug~ested that this therapy 'L'!nhanc~ prm:eol),sis .of extracenuLar prQtei:lIs. I ZB, Recently. N agii!la eot a] r-epoJ1led tre:rutme'llt resLllh:s ill 13 :paliems. All of 'lhe :pati,ellls benc'fited from tht 'Lh.erapy. wwth II mean edema reductien 0['63%:il1 ni.ne pa.t.~ef:m. [he tJenefit persisted durin8: 3, mcu:rllls o,f ~ol1ow-U!p. I}(I 11'1111'1 e1xperimen.tali can.ine: rnadel, it has Men. demonstrated mat reductkm 'of'lymph· edema b. accompanied b~ :a rodllclioo :in :skin coHagen ami wuJ prnWfl Qonte!:lt rosetbet with an .~. in addic prttfe:inasead;ivity,i3 a

PJrQmUlcotheropy and di~r

Pharrn<wotllera:py is bel.ng repooted as adjullcdve OT' pri mary thelCapy fm '~'ariotls ~y~jj; (If Iympbedlem;a. CO'umllrin, 1(:5.6· benzo-[a]~pyro:lle) h~s been observed to p.rovi.d~ II. significalilt,. albeit slow" lleducti,QR in various types of ]y~pll~dema. bOlh, in, hLlma:I1~6.m., II.~~ and: ,al1Jimal studies" n~ Coum.:ariWl ~an co:n~ro! proteolY$!s by :ili1~rellSil1g the :neU:lm]

protease acliv~ty of macrop al ihe site of injury. The

dl\l~ a:lso has stimu.latorY eets '01'11 other cells of [Ii~

immune ~,yslem: ~t in~"ases. the T he'lpe.fr SUppl"e'$sor nti,o il:M 5timl.!lates NK cells, Coumarin can IlihiOSIJIP:Pfi'lSS 'the production of tile s.uperoxide anion a:lld hydrog~n peroxide by die mQnocytes l,j~.1 J;& therelfi>y enih3lllcin.s prote~fj ~absorp(iun. N~W)!"!.'beIe-u. ~jSht j!,t, <Ell ~Q~ld n01 oOl'lfirm the Mimu· huory effect of theeeumarins (»l the mac:rophages,' :prote~n. ase ilCti\'jty ill v~tro"m Flavonoids bave been also r,epon~, to have beneficial dfeels. in padent5 wjth .Iymphedema. n~ H;ow'~"iilr. lhese dru,gs do llQ.t e:!'JJjoy '~Ommo.n Ihe:rape1lJ~ic ,applic.ation. ,even to Jarge Iymphedl!ma ~aunent centers, i:W furtherm.on:. in [liCtr ecnseasas document. the ImC!mationilli Socie:tyof Lyropho.logy did flOl endorse ooll.mari,1'I Of' omeii' bcIilZlOPYrone.S i'i.!S SiIiOstit'IJtes for compl.~:!Ir.phy5lca~ therapy. 7 On the ,other hand, sulodexidc bas 'been ~I:omrrumded lIS an 'effective pJlophylactic measure fOli me prevemioll! of poslmas~ectomy I Yll1phcdema" u4ll

In ilIantic lymphedema. medical luanne-lit of ll'l~ filari· asls must accompan), th~ ~enern!, measures Ch,d .ili~ eli rec~¢d [OWi'.if-ds the lymplJede:ma hse If. Effec'~u\"e m~d,i.catl(u,!,s inci ade diethy.icarb3mazi.l'u! ciUiit,c and tn~ mil~rolide ':1111 t i~ biQtii;. i \'enneCt~l'I. Both agent$. are used. for tl'ie,:mTle:nt IIl11d for prophylaxis (e.g, the iJEC~medh~a,tecl salt i~ ,end~mic areas), Ivermectin has the aQ\'iln.te.seof a single dose da:~~y treOUmerlil regimen and fewer :side effects ,-<~

Zinc suppiementation bas been found to cerrect both lht' lymphedema and the mal] clilang~s :l:S5oC'i:iiJed \'\"ith yellow nail syndrome. ~.~ I

Sod et id reponed C1hat di,et3!'Y modinCiuiOfl. by rC'litricLing tlte imake of tbe IOilg-ch3iin triglycerides. prosed to be beneficial 'in two petlems with ~dio.pathtc J,OW~Ji limblymp:h~ma.u~:!

Surgiclll therapy

Surgical ther,iI!p~ for ]ymphedema is !lc'nne'rnUy eil'll:ern:tifi;e~ w'l1e'll mL'!dlcal [!lerapy fails. '11IC're are two main surgk.al apptQa~hes: (1) e:v;cisioliaJ proeedures, wh~rL'!: pall 0.1' aJl of thelymphedema.tous epifaseial tiS$IiJ¢ is r~m(wed!. and (2) microsurgical inte:rvernlions. 1\00" the creation of lympilalico.iymphatlc.. lymphatioQ·veno-'!ympbadc.. ~ym.~ phatico.venoos and Ilymph nadt-venOIl!$ anastomoses. Olll~r surglcal techniQtles ]rlc]ude treatmellilt wiln. transferred om~fil:.al pedicle and m)'lOCl!lt:a:neous flap' lfIJl¢ij)(lsitiOJ:'l.

.Microsllrgery:

To beconsiderced for amicl:losurgkal ~dllJn. me 'Pali~~t' s Iympih~tiic duers should be p3ll1!l1'U below ml!l 100000s of blockage. Gonsequently. die p:roo~dllte iSl.!suaL1y penor~ med eitber in patients witlil pos1sl.I.rg:ic.allymphedema, or in those whh primary lympliledetm:a,w~o have proximal. eeclasion, Postinfiammarory lymphedema omd primary lymphedema with d1sWi oCclusion an: net suitable for nDcmsurgery.m some cases of advanced Iympbedie:ma

I.......t. U "" -b~w.-..I' , .. -...:_, . L.._ ~.

~a.""'" '1' ~ ..... ,' ...... U uu;;u; opc."UOII'IIS,can I~ ~~.~.. .•

R.eQently Ciimpisi. et a1 RPOrud. 'the: long,· term out'come of 64 lymphedema, pllllients who underw,efrll lm.erpositi:oft !l!Ito']ogOlls l.yrn,phadcQ.veflQ\iS,·lymphadc IIrmstomoses •. ~4' Improvement in. limib functiQ:Ii, alld ede.ma volume was obSi!l"V,e.din a~1 patients andthe l"egress~on endured for more tban S yeru's.

Bal.unei,ster penonned aut.olog:oos ~ymphal:ico·l)!'mphalic granwn,g :in 66 patients who had, predominantly, :sec::olildary upper ,lind lower limb lymphMema". 'The mean mdutuQ!l til v,olume after slilFgery WM 60%. This qUmltiitative 'mprovemefJil was ma:inlain:ed during ill follow-up p~ of i to' 3; )'Iears. n.;j"t AlthQugh it has been suggested that bypas~ eperatiens s.Ii1ould be perfumed within thl.\' 2 years' fol1owing IYI"lIp'hatic disrupt~ol'll.'~~ Baumei.str:f has 1luldeft:akefi SU!f'gery Olil p.a:!:ie:nts wh,mc ma.s~~~t>omiie$ occul1iedl-2oQ yCllll'S llI,go.

Lympbalico-v.enoLII$ ,alla~~(lmosi5 (LV A) for .lym,plHdema. :has been perfomled in man)' centers. with varying s~ess roUes. In a series of 233 patie:nts reported by Campisi. with ~l'O :S years' f'Ol~ow·up. a very gooo response was :Si!:im ln ·U •. ~ geed respollseilil UII. 31 f3lidy .good response jn4 j. and no effeol ~tI M pa~:ient!i.I46 FiUpperu et iIII pcrfomled 25 modifii!:d, LV A in 25 JXl'StmasleC~omy p.ali~U Mid dunn!: the 18 mOI:rlhs' follow.up.5,!5% of filiIe pEltie.nU; had I dc:$irable oon:o,me. ~i!7 O' Brian et a1 perfQnncd LV A ;in .~ 34 ~ympIIedema patien.ts. of whi:ch 90 WeN: av'ai1ab!e for a mean f(iilll.ow~up of 4 years. (:5;2 ~ad L VA, 38 LV A wilm Wfgicil~

,£xcisi,cQl1). The average volume reduenon was 44S1-. and ,S-i!ibj~~ili'e improvcrne:nt was seen i n 7~~' of the paJie,I1,t&. NotabLe. ,also. was areductiofl in theincidcncil: of recurrent 'c-ellu]Hts by Sg,~ ,iI~ Howe'vet. otiller ,c,en.ersl'ia ;,'e norbeen Sible 'to' i'C'adi]y dup,lkaJte these results, Glovi:czk:i et <II Rpon,cdj"C1sull$ of LVS in ~ 8 Iymph.edecma patie!ll..s. in whom l4 s1JJcC'essfu~ ly:mplID-venolisalilai$~ol1il~S w~r~ pc,... formed. The mean follow.up was. 36 m,onth5" O.llly one of Seven palients with pri mary lymphedema: <llld four of seven with :secondary lymphedema show,ed s:ignificall,t impmv,ement. ,i 411

Ols~~W5ki 11M presented mOIle than ,81 dec;ld~ of (o:]1ow,· 'lJp of Iym~hedema p,ui,ellll:S will,Q, have been tteated with ,lymph node·\/tl'llOUS (LNVS) all,aSH)rnose~. hi: postsurgic.al lowe:!' limb ,lymptJedem:a. :17 pali~lns were operated en and gQOO results were obiatned ill ,80'* _ :n piui,eflls died from recurrent cancer. Of the five sl,inli"'~ng patients, four have Il:'xperi:enced a sustalaed ben:en[ fOF o'vef 18 years, Out of the Z{I patients with po$tinfl~mmatory I), mph-edemDl who were treeted w.ith L.NVS. oa:!~Y two. showed permf.li"lC'!l.t!mpro\'~, m.enl. Ten pall.enls were openaed on for Ilyperplasli,c lyrnphed~ma. Seven patle-I1.tS had more Uum 10 years' fellowup: ofinese., fi ve sl'l,owed! pern:Hme:l1t i mpro~'l!'me'Ji1.t~nd two patie.n.u showed no improvement. Two ,additio:!'!a1 p!uJellil$ 'worsened in me 1000nccof m.edj~al therapy ~pire ,i!ippli~ calion of conservative measures,. ln ['f!maryidiopouhic lym~em.a. tiD differenoes were: Oib~rved beuween surgi.cal ~Rd oo",servati~'elreatmL'mt.14.'i

The ,en~ero'mes~:!'!"'ri~ bridge operation was designed for patients wi~h pri mary ~,ym.phedema .eSluhin,g: from, pw)\i mal (pelvic) occ]u~io!'l. Ii. .smal.1 segmC'l1t of ileum. withhs in!ac'! mesentery. hi sutured to a jranssected femoral or iOHll'ios] ~ympl:l node. aUowill.g: OJ bypillSS, of tile occluded pe:lvic lym· phadcs. Hurst et a] reported a salutary outcome after 2.510' 7 years fd.llow.lUp im §~ltof eigin of ~he sUJlgicnl patients, I~,~'

A~ o:me:nta] flap with ~nla'i'::l :Iymplilatic Vi!iS:S~~S ,can also, sen·e as a lymphatic bridia!:. The ,earliest atl,empts were riot successful; despite al1. initial improvement. because of sebsequc:ntfibrosi.!i of theemeatal I,OCdi~ 1~.I:'Hl' Orne-mal transfer' has $l!.u;;~~ss:fuUy ameliorated the aC'qujr~d1 Iymphedemil. of .IInimal model sys.ems. I.~., b~ i Reoently. omental u·1l1l1sfiel' \!;rim lymph [lodot1!~vellio1!l's anastomosis W,ElS IU~d! to tre!U 21 p;:uie!ll~widi eli! ronk ]ymp.nedema, -Good resnl'iS w.ere observed in 14 pa~ieillts during ~he 3 to 24 mOlilhs' follow~ up and th~ resl,lhs were salisfaclory illl:live padems,m

Amyocu[;)!leo!.!s, flap isocc~io:nal1y used fOill the treermeillt of pOMrnaMeclO'IiI1Y ~d~ma .. ' ~~~ as well as fOl" I,ower nmb Iymphedlemill. II ~ Howc1II'er. 110 hlil'ger stUidi~$ have been p!1i~fo:rmoed and IOllg.term results will! .substa'lltia1I1umbell's ofpalientsill'ellot a\lai]able.'~

'DebuU.:blg· Pl'()~.·edm'ie.s

S!l!J!i:c .. ~ prceederes, 111 which excesses oflymph~demil~ollis sl!;~n and slJbcutan~ou!; tis5!1l1e are excised. carry lhepolentjaJ 1.0 destroy existi ng CIU:IIlt:OIl5 ]ymp,luilics nnd also C',arry the InS:ks of papillomatos:is.. necrosls oflhe s,kjfl lind! C'xa'Cero IbEitiOlil otf the edema. Indic,otiOil'ls for partial 'C:lC.d!iion lnel u:d'e: <ldiv,iiln£led. 'fiibrosGdi Iym.~ede'ma, and elephuntia5:is.un~'J"'

lhdic,:;ll excision of skln, 5~bcu:tEln.em.lS IliSSUI!l an~ de:e,p fa5da \\"aspnlposed by Charles in 1'912 <lind. until RCe'ntly. hOl$ been performed wn a modified fashion .. 'The pr-ocedLllre alway~ I¢ilves, a :!iigllifilcat:uh' defomle-d Ul1'Ib and cDmies dI.i! ti~k. of seriou~ compl icatiol'llS. iIiCll.ld~liIg hypen:rophi,c scar'",

1V~~(:ul(,lT M'nh'dll<' 1998~ ,J: l,4S~ tS6

ri.I'J~. cutaaeous S¢flSQry impairment. seer contracture. nophy~k kem.tosis. ulcenu~,ol1. ~roft necrosis and aggn:l\-,,· ti.on- of foot lymphedema. wi l:hi p.3Ipil1om.[~Q~i~_ I ~ij St:lged excisien of s'iJbcutatleol.is lis.SlIe w;Jspopularizcd by Homsns lll"ldi is. mought to be safer and able' ,to produce the desired fliln~ioI'JiEli. results, However .th.ls approach never pro(hu;,es comp.l~tl!'; ~~solutio.ll of lymphedema,II.~U,U" Servelle describ~d a '~.hlnique of lOta~ supemcil'd ~~rnp(hangiec~ wmy. which ,entailed a tWo.~latled remova] or l.ym;ph~i:I~m. .uaUs subc:utaneO'lls ti$SIl~ Sind fascia. His 4O-y,ear ,clill'ical experienee will1 thisprocedufie ~ncll1ded 600 pa[h~I:'iIS witlil lower Umb Iymp~demll!. AlthQugh his repertsare not suppetted by stati~l_ical af:I~~y'~S<. fie has reponed very g~ results for up lQ39 yean. foUowins sur~e'ry. ~~

Suenen I.eClmiques can abo 'be: he:lpf'u] for the ramov • .d of exce:ss:ive $libcinaneol.l.s tissueand C1lII 'be tltiliz.ed 11'1 eoneert wilh skin excisioll,I~H~lI'

The- ,eitten~i ve ilJiTay of avall able surgical a:ppro;:lclties 1.0 lymphedema re;flects ~ihe fact that nOi'ieof these -appmaches pI,ovides. a. tl1l.llly sad siac[ory surgical wlUlio:n to the dlsease. Conservative rne-cbanicilll measures still ,constilute tlilepreferred andi!lcreas,ing]y successful approach to'llile conuol Qf edema and to tliIe restoration OffLlillCliofl in ~tlese p.lit.~ents. It ~s heped that increased 3!W;ifCII,e5S of 1lI:e ~mpljcarlolls, of Ibis diBJgnolois wUl 'lead 'to ever :more effective :1'iI'lea51;!I~es,. including appropriate means of PT,evenlion 31Id pharma:c,o· ther~py.

'Conclulion

Lymphedema of U1C e:;;,treml~Y is a common. complex and debUitating diroroer whose biolog~'is StU! inCOl'l'lp]eleJy uaderstecd, AI1ihough many of these piitients have been ~o1ilSigned. historicsll)'. ~D 8. ,~gree of medi,ca~ neglect, increased imtcRst In. lI'Id oom.])Fern:nsiiollJ of, this dismder ba.ve led to enham::l!dmethods of di,agnOS'tic l!\'ailuadonaDd ther,apel.ltk intervention. I~ 1:5 <mlkip.aLcd that funhelr ~fiVef!ti gDilion ~nto the ce Ilutar mechanisms of lymphedema wm mead toever more d:eglillil ref nelillents,in ~he OlbiH()' taeenfrol this diS'ei'ise.

I Green~ee R. HO)'IIIIl 'H" W~~ M. '('rowe P. Wiu~ C. [)e~elopiikijliiill dis@:rdti~o'r .lIe Iympl'l;atc ~,~sttm. L;\~Npiw./(~,i!'Y 199';11: 26E4): 1,:56-6&,

,l CI.IITIDr1Il. itA.. 'Q!o'llUcllki P,. Na.essen~ JM. W~bm~r HW, NOllii'mv~i~ e\'.ilII,iJiilillln Df !hI! lymph;!Jtit' '~yslem willh l~mphDsCiJlliv<!pI!i,)'; ii pw. ~peeti\'ii:'. semi;qoorulltD.ti,\',1! Imml)'!'i~, inl 386 ex,tremilies. J Vu.!'.c' Sll~ 19!I~; 184"5~: 1iJ-'8~:,

J [P.msoh Hi" A~5(!$$mml Dr abl1iiltl1it~~ I}'mph df,BiD~gr :fbr tbe dia,~oosh~ of :1)'mpOO:lell'lill by k~O!:opi~ i~)'mpb;rnl!tot!l:;1phy ~!:I Ily iiml.! reel Iylil'lipnDlrll:phy_ CliJ! Dtmm,.u/ 1'!19:5; 13: +15...$0,

4 T,er'sE, AII:I',-i 1\. .. Kim Cie. Merl! 0 •. LympllOSi:inlil!rapl),'- A I'l!li.b!e lest fOt I~ ,o;!!i~~i'8 of lyiliipn~dt=lIII1i1_ CUll NucE M'ttd 1993: I.HI}; ,~S~-

5 Braiiii~tfI P. VIl~~!K!t w, fl;I)di E, ,K~u:'lC' T. M~ iE. iUbe h't'lpoc· W.:iICie ,af me ~.!!i)fl~~iilli .I)'~till::.5 inl Ith~' dim,~nm,is ,0:1' loW;'« ~ l:mb ~ma~ ~!!\'ef,t~lIliom$ 'W1i.th st:miq~iI!ldt!lti~c ly,mphoKi!1ligFolpny, ,A;tgi(>I"~y 199':k <Ul61: .JM-'711

(" c-. le., Wille' 'CL Wille MH. Ung« EC" Will!:a.m~ WH • .M.~elic re~OOg~ iifiA.!!i~ in hllmlilll Iymphedemll:: colllplllri~ wltJil, lymJhlliji~liili,graphl!'. Mtr~~' R'wm ',,!(Jogill, 1992: Hk4)<.: 549-58-

1 C~ij~ "~mcnt gf !IJ.e' (~I~maliMiiil S~~~I~ I)cT t.lrnphDlo~]I' El:~,vc '~ltnruttcc. l!"I>o; o;!~i~no;!W ~'~!'IJ~m>f,IIlt>r ~ri~ Iym. IF!'!oo:~ ,t,-rrlMf~I.~~~'~ U()I: ~. 'I:I-! 7.

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38 Goy~ P'. UfQ, JO. li':IIu,wei< 'I! u a.l Perillab.l mw1ir&t~ ,of ~ycll_.,:In . ~yn&l'-.l'W1drrln 1~992;. 119(6}l ILIl6-11. '9 S~.A.. HtnUDilEG. J~ Jtot. [~~ifI. ~i._ ,~ Illcuc(, JAM.... 19&1:: Ill': 1l4-l1.

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u s~~ It BJ<.& p, CnfJdWI S •. ~ A.P~on: !III'! lfillv~. ~ i~ or·'~1.il oedema . .ncr ~~l «.b!>I:='!~. me. $~=d:J' J I'kll .ll«DiU/~ :5i{1J H~!td .:fIUJ u~n: l!U~): ~"2'. 45 :!i~~I;MH. Willicb N.SC'l:~ ~,.~ !)('1lIe ;mn'gn· ~I ~ ~ M ~ ~\~ ,2'.!:-t.lfmrllfOur 19'I!l~ 111(4); :?l~,

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