Lymphdmes des membres

S. Vignes, Unit de Lymphologie,

Hpital Cognacq Jay, Paris

Systme lymphatique
Prsent chez les vertbrs de grande
taille ( mollusques, arthropodes :
insectes, crustacs)

Ayant un systme cardiovasculaire

complexe (reptiles, amphibiens: cur
lymphatique contre le lymph backflow)

Ncessitant un systme
"secondaire" pour maintenir
l'quilibre des fluides
Ganglions : mammifres +++
quelques oiseaux aquatiques)

(et

Production de la lymphe
"Fuite" de plasma partir des
capillaires, due la pression
artrielle
Lymphe
globules blancs
cellules prsentatrices d'Ag
protines
ions
lipides (tube digestif)

Anatomie
2 rseaux
superficiel
80% du drainage
membre +++
profond : 20% du drainage
peu connects entre eux
Abouchement au niveau des
ganglions axillaires (MS),
inguinaux (MI)

Alitalo K et al. Nature 2005;438:946

dmes MI : physiopathologie
dmes : liquide interstitiel
ultrafiltration, rsorption
veineuse ou lymphatique
Favoriss par pression
veineuse, pression oncotique,
pression hydrostatique

Physiopathologie
Rgulation, quilibre +++
1. Entre le transfert issu du
capillaire (pression de
filtration)
2. Et le drainage par retour
vasculaire ou lymphatique

Mc anismes de dmes
1. pression hydraulique capillaire
volume intravasculaire
(rtention sode)
hyperpression veineuse
2. pression oncotique plasmatique
(albumine < 25 g/l)
3. drainage lymphatique
4. permabilit capillaire
(mdicaments, dmes
cycliques ?)

Causes oublies, rares

Mdicaments : inhibiteurs Ca, surtout
dihydropyridines ( permabilit
capillaire)
Hypothyrodie (TSH)
strognes, AINS ( pression
hydrostatique capillaire), arrt
diurtiques (pour poids)
dmes cycliques idiopathiques
(priode prmenstruelle)
Entropathie exsudative (perte digestive
protique), maladie de Waldmann

Mcanismes des lymphdmes

Stase lymphatique
accumulation de protines
pression oncotique tissulaire
afflux hydrique pression
interstitielle

Physiopathologie du lymphdme

Szuba A & Rockson S. Vasc Med 1997;2:321

Les lymphdmes (LO)

Lymphdme
diagnostic clinique +++
le plus souvent facile (curage gg)
Aprs avoir limin les causes
cardiaque, rnale (prot. 24 h,)
Examens complmentaires : non
indispensables (cho-Doppler veineux :
N, lymphoscintigraphie, scanner ou cho
abdomino-pelvien)

Lymphdme aprs cancer du sein

53000 nx cas de cancer par an
Frquence aprs traitement
13-28% aprs curage axillaire
dfinitions diffrentes
2 cm : diagnostic en consultation
200 ml
+10%

Ozaslan C et al. Am J Surg 2004;187:69

Clark B et al. Q J Med 2005;98:343
Armer J et al. Lymph Res Biol 2005;3:208
DiSipio T et al. Lancet 2013;14:500

Lymphdme aprs cancer du sein

Dlai dapparition variable

post-chirurgie
quelques semaines aprs voire
plusieurs annes aprs
mdiane survenue : 2 ans
(peut-on prvenir un vnement
survenant des annes aprs ?)

Topographie

atteinte proximale initiale puis phase

descendante
mais linverse est possible

FDR lymphdme

Curage ganglionnaire axillaire

Radiothrapie externe
mme si exclusion axillaire
creux sus/sous clav., chane
mammaire interne, sein)
Obsit lors du cancer : risque
(IMC > 30 kg/m2, OR: 3,6)
+ le poids + le LO est volumineux
Consquences : poids, volume LO
Shaw C et al. Cancer 2007;110:1868
Vignes S et al. Acta Oncol 2007;46:1138
Ridner SH et al. Support Care Cancer 2011;19:853

Obsit en France

Mathias Francois, Ph.D.,3 Kaltin Ferguson,2 Monika Janda, Ph.D.,1 Patsy Yates, P
2,*
1,*
and
Sandra
C.
Hayes,
PhD
Amanda
B.
Spurdle,
Ph.D.,
Possible Genetic Predisposition to Lymphedema

after Breast Cancer

Abstract

Beth Newman, Ph.D.,1 Felicity Lose, Ph.D.,2 Mary-Anne Kedda, Ph.D.,1

Mathias Francois, Ph.D.,3 Kaltin Ferguson,2 Monika Janda, Ph.D.,1 Patsy Yates, Ph.D.,4
Amanda B. Spurdle, Ph.D.,2,* and Sandra C. Hayes, PhD1,*

Background: Known risk factors for secondary lymphedema only partially explain who devel
following cancer, suggesting that inherited genetic susceptibility may influence risk. Moreove
LYMPHATICsignatures
RESEARCH ANDcould
BIOLOGYfacilitate lymphedema risk prediction prior to surgery or lead
molecular
Original Articles
Volume 10, Number 1, 2012
Mary Ann
Liebert,
Inc.
therapies
for
prevention
or treatment. Recent advances in the molecular biology underlying de
Abstract
DOI: 10.1089/lrb.2011.0024
lymphatic system and related congenital disorders implicate a number of potential candidate g
Background: Known risk factors for secondary lymphedema only partially explain who develops lymphedema
relation
to cancer,
secondary
lymphedema.
120
femmes
: inherited
98 sans
et 22 avec
lymphdme
following
suggesting that
genetic susceptibility
may influence
risk. Moreover, identification of
Methods
and
Results:
We
undertook
a
nested
case-control
study,
with
participants
molecular signatures could facilitate lymphedema risk prediction prior to surgery
or lead
to effective who
drug had
(apparu
6-18
mois
aprs
la
chirurgie)
therapies after
forPossible
prevention
treatment.
Recent
advances
the molecular
biology
development
of the
phedema
surgicalor intervention
within
thein first
18 months
of underlying
their breast
cancer diagnosi
Genetic
Predisposition
to
Lymphedema
related congenital
disorders
implicate
a number
of potential
genesfrom
to explore
in
(n =lymphatic
andsystem
thoseand
without
lymphedema
serving
as
controls
(n =gnes
98),candidate
identified
a prospe
22) Etude
polymorphisme
de plusieurs
candidats
relation to secondary lymphedema. after Breast Cancer
based,
cohort study in Queensland, Australia. TagSNPs that covered all known genetic varia
Methods and Results: We undertook a nested case-control study, with participants who had developed lymSOX18,
VEGFC,
VEGFD,
VEGFR2,
VEGFR3,
RORC,
FOXC2,
LYVE1,
ADM,
andasPROX1
phedema
after surgical
intervention
within the
first 18 months
of their
breast cancer
diagnosis
serving
cases
1
2
1
(n = 22) and those
without
lymphedema
controls
= 98), identified
from
a prospective,
genotyping.
Multiple
within
three as
receptor
genes,
VEGFR2,
VEGFR3,
andpopulationRORC, wer
BethSNPs
Newman,
Ph.D.,serving
Felicity
Lose,
Ph.D.,(n
Mary-Anne
Kedda,
Ph.D.,
3
2
1
4
based,
cohort
study
in
Queensland,
Australia.
TagSNPs
that
covered
all
known
genetic
variation
in
the
genes
Francois,
Ph.D., Kaltinsignificance
Ferguson, Monika
Janda,
Ph.D.,
Patsy Yates,
Ph.D.,
lymphedemaMathias
defined
by statistical
(
p
<
0.05)
or
extreme
risk
estimates
(OR
< 0.5
2,
1,
* and
* (Retinoic

Rsultats
:
VEGFR3,
VEGFR2
et
RORC
SOX18,
VEGFC, VEGFD,Amanda
VEGFR2,
VEGFR3,Ph.D.,
RORC,
FOXC2,
LYVE1,
ADM,
PROX1 were selected for
Sandra
C.
Hayes,
PhDand
B. Spurdle,
Conclusions:
These SNPs
provocative,
albeit
preliminary,
findings
genetic
genotyping. Multiple
within three
receptor
genes, VEGFR2,
VEGFR3,regarding
and RORC, possible
were associated
withpred
acid
receptor-related
Receptor
gamma)
=>
ondary
lymphedema
breast cancer
treatment
warrant
further
attention
for
potential
lymphedema
defined
byfollowing
statistical significance
( pOrphan
< 0.05)
or extreme
risk estimates
(OR
<
0.5 or > 2.0).
Conclusions:
These provocative, albeit preliminary, findings regarding possible genetic predisposition to seclarger
datasets.
organognse
lymphode, lymphangiognse
ondary
lymphedema following breast cancer treatment warrant further attention for potential replication using
Abstract
larger datasets.
Background: Known risk factors for secondary lymphedema only partially explain who develops lymphedema
following cancer, suggesting that inherited genetic susceptibility may influence risk. Moreover, identification of
molecular signatures could facilitate lymphedema risk prediction prior to surgery or lead to effective drug

Attention
Peu douloureux, plutt pesant, lourd
Si douleurs : plexopathie
post-radique
par envahissement (douleurs,
dficit sensitif et/ou moteur,
d'volution rapide)
TDM, IRM creux axillaire
Pathologies paule associes +++
Syndrome du canal carpien
Toxicit chimioT (neuropathies)

Mesures "prventives"

poids (Shaw C et al. Cancer 2007;110:1868)

Rducation paule, massage
cicatrice (Torres Lacomba M et al. BMJ 2010)
Eviter "piqres" en post-op. (Clark B et
al. QJM 2005;98:343)

Activits physiques : femmes

avec LO, QOL (Johansson K et al.
Lymphology 2002;35:59), intense :
haltrophilie (Schmitz K et al. JAMA
2010;304:2699)

Pas de DLM post-opratoire

(Devoogdt N et al, BMJ 2011)

1955
1962
1998
2006
2009

2010
2005

Ann Surg Oncol. Author manuscript; available in PMC 2014 August 05.

NIH-PA Author Manuscript

Published in final edited form as:

Ann Surg Oncol. 2013 March ; 20(3): 842849. doi:10.1245/s10434-012-2631-9.

Lifestyle Risk Factors Associated with Arm Swelling among

Women with Breast Cancer
Shayna L. Showalter, MD1, Justin C. Brown, MA2, Andrea L. Cheville, MD3, Carla S. Fisher,
MD1, Dahlia Sataloff, MD4, and Kathryn H. Schmitz, PhD, MPH2
1Department
2Center

of Surgery, University of Pennsylvania, Philadelphia, PA 19104

for Clinical Epidemiology and Biostatistics University of Pennsylvania, Philadelphia, PA

1. Etude prospective
19104

3Department

(cohorte PAL : Physical Activity

of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905

Lymphedema)
4Department of Surgery, Pennsylvania Hospital, Philadelphia, PA 19107

NIH-PA Author Manuscript

2. Questionnaire
sur 30 items (FDR
Abstract
potentiels) 3, 6 et 12 mois
3. LO dfini > 5% (volumtrie eau) 3,
6 et 12 mois
BackgroundBreast cancer-related lymphedema (BCRL) is a feared complication for breast
cancer patients who have undergone axillary surgery. Although clinical risk factors for BCRL are
defined; data are sparse regarding common exposures that might induce incident arm swelling.
The goal of this study was to quantify the association between common exposures thought to be
potential risk factors, and the occurrence of incident arm swelling, among breast cancer survivors
with or at-risk for BCRL.

MethodsThis is a prospective sub-analysis of the PAL trial, a randomized controlled trial of

295 breast cancer survivors. Participants reported their exposure to 30 different potential riskfactors at three month intervals for one year. Incident arm swelling was defined as a 5% increase
in inter-limb water volume difference between two consecutive time points.
ResultsTwenty-seven participants (9%) experienced incident arm swelling and 268 patients
(91%) did not. Sauna use was the only exposure that was significantly predictive of incident arm

NI

NIH-PA Author Manuscript

Baseline clinical characteristics of study participantsa

Characteristic

Total
Sample
(n=295)

Incident Arm
Swelling
(n=27)

No Incident Arm
Swelling (n=268)

BMI kg/m2

29.26.1

29.05.9

29.26.1

0.74

Cancer stage no. (%)

0.55

Ductal in situ

1 (1%)

1 (4%)

0 (0%)

143 (48%)

6 (22%)

137 (51%)

15 (5%)

8 (30%)

7 (3%)

97 (33%)

1 (4%)

96 (36%)

Unknown

39 (13%)

11 (41%)

28 (10%)

No. of nodes removed

11.77.9

9.38.3

11.98.0

0.05

Chemotherapy no. (%)

220 (76%)

22 (81%)

198 (74%)

0.58

Radiation no. (%)

229 (78%)

16 (59%)

213 (79%)

0.005

Tamoxifen

69 (23%)

3 (11%)

66 (25%)

0.27

Aromatase inhibitor

2 (<1%)

0 (0%)

2 (<1%)

0.80

61.629.4

54.631.1

61.240.1

0.39

Current receipt of drugs no. %

NIH-PA Author Manuscript

Months since cancer diagnosis

Lymphedema Diagnosis no. (%)

0.09

With lymphedema

141 (48%)

10 (37%)

131 (49%)

At-Risk for lymphedema

154 (52%)

17 (63%)

137 (51%)

Common Toxicity Criteria lymphedema

grade no. (%)b

0.14

12 (9%)

3 (30%)

9 (7%)

30 (21%)

2 (20%)

28 (21%)

58 (41%)

3 (30%)

55 (42%)

41 (29%)

2 (20%)

39 (30%)

Hypertension

86 (29%)

9 (33%)

77 (29%)

0.66

Diabetes

30 (10%)

3 (11%)

27 (10%)

0.74

a
Plus-minus values are means SD. Percentage may not sum to 100% due to rounding error
b

cohort of patients treated for breast cancer and screened for lymphedema.

Patients and Methods

Between 2005 and 2014, patients undergoing treatment of breast cancer at our institution were
Impact of Ipsilateral
Blood
Draws,
Blood Pressure
screened prospectively
for lymphedema.
Bilateral
arm Injections,
volume measurements
were performed
,
Measurements,
andusing
Air aTravel
on the
Risk
of Lymphedema
for the
preoperatively
and postoperatively
Perometer.
At each
measurement,
patients reported
e
number ofPatients
blood draws,
injections,
pressure
measurements, trauma to the at-risk arm(s),
Treated
for blood
Breast
Cancer
and number of ights taken since their last measurement. Arm volume was quantied using the
Chantal M. Ferguson, Meyha N. Swaroop, Nora Horick, Melissa N. Skolny, Cynthia L. Miller, Lauren S. Jammallo,
relative volume
changeJean
andA.weight-adjusted
change
Linear
random
effects models were
Cheryl Brunelle,
OToole, Laura Salama,
Michelle formulas.
C. Specht, and
Alphonse
G. Taghian
used to assess the association between relative arm volume (as a continuous variable) and nonchusetts General
treatment risk factors, as well as clinical
characteristics.
A
B
S
T
R
A
C
T
f

edical School, Boston,

Results Purpose
In 3,041 measurements,
there
no signicant
association
relative
volume
The goal of this study
was was
to investigate
the association
betweenbetween
blood draws,
injections,
blood change
pressure readings,
cellulitis
the at-risk arm,one
and air
increases
in arm
a
or weight-adjusted
changetrauma,
increase
andin undergoing
ortravel
moreand
blood
draws
(P volume
= .62),ininjections
d No. R01CA139118
cohort of of
patients
treated
andand
screened
(P = .77), number
ights
(one for
or breast
two [Pcancer
= .77]
three for
or lymphedema.
more [P = .91] v none), or duration of
No. P50CA089393
stional Cancer Institute,
and[P
Methods
ights (1 toPatients
12 hours
= .43] and 12 hours or more [P = .54] v none). By multivariate analysis, factors
tnnon Research Fund
Between 2005 and 2014, patients undergoing treatment of breast cancer at our institution were
signicantly
associated with increases in arm volume included body mass index $ 25 (P = .0236),
elated Lymphedema.
screened prospectively for lymphedema. Bilateral arm volume measurements were performed
ened in the
glossary, lymph
axillary
node dissection
(P , .001),
lymph
node
irradiation patients
(P = .0364),
and
preoperatively
and postoperatively
usingregional
a Perometer.
At each
measurement,
reported
the cellulitis
this article and online
(P , .001).number of blood draws, injections, blood pressure measurements, trauma to the at-risk arm(s),

l of print at
ead
scember 7, 2015.

and number of ights taken since their last measurement. Arm volume was quantied using the

Conclusionrelative volume change and weight-adjusted change formulas. Linear random effects models were
This study used
suggests
that
cellulitis
of lymphedema,
to assess
thealthough
association
betweenincreases
relative armrisk
volume
(as a continuous ipsilateral
variable) andblood
non- draws,
risk factors,
as well and
as clinical
characteristics.
injections, treatment
blood pressure
readings,
air travel
may not be associated with arm volume increases.
y the responsibility of
es not necessarily
The resultsResults
may help to educate clinicians and patients on posttreatment risk, prevention, and
l views of the National
In
measurements, there was no signicant association between relative volume change
management3,041
of lymphedema.
the National Institutes

an Antonio Breast
, San Antonio, TX,
14.

or weight-adjusted change increase and undergoing one or more blood draws (P = .62), injections
(P = .77), number of ights (one or two [P = .77] and three or more [P = .91] v none), or duration of
s of potential
conictsOncol 33. 2015 by American Society of Clinical Oncology
J Clin
ights (1 to 12 hours [P = .43] and 12 hours or more [P = .54] v none). By multivariate analysis, factors
d in the article online at
signicantly associated with increases in arm volume included body mass index $ 25 (P = .0236),
or contributions are
axillary lymph node dissection (P , .001), regional lymph node irradiation (P = .0364), and cellulitis
this article.
the efcacy of such precautionary behaviors
(P , .001).
or: Alphonse G.
INTRODUCTION

Department of
, Massachusetts

Conclusion

do
not exist, highlighted in a recent statement by the
5

EMG avec aiguilles

Difficults techniques dues au volume du

lymphdme
Autres gestes invasifs possibles si ncessaire
(infiltration, chirurgie du canal carpien), car
la perception du lymphdme dpend des
autres problmes associs
Ridner SH et al. Support Care Cancer 2005;13:904

Lymphdme primaire
Membre infrieur +++
Formes sporadiques
sex ratio : 8 F / 2 H
ge < 25 ans (voire moins)
atteinte

unilatrale de tout le membre

distale bilatrale

Maladie de Milroy : formes

familiales de LO congnital,
hypoplasie, mutation VEGFR-3

Lymphdme : diagnostic clinique

dme lastique du dos du pied
Accentuation des plis de flexions
Signe de Stemmer
Orteils "carrs"
Tendance des ongles tre
verticaliss
Signes prsents si atteinte distale

Causes des LO secondaires MI

Atteintes des aires ganglionnaires
pelviennes

cancers utrins (col, corps),

ovaires
cancer de la prostate, vessie

Atteinte des aires ganglionnaires

inguinales

biopsie, exrse
maladies bnignes (tuberculose)
maladies malignes : mlanome
MI, cancer marge anale, verge,
vulve,
lymphomes non hodgkiniens ou
de Hodgkin: biopsie ou radioT

contrast, having at least one positive pelvic node was associated with an increased risk of SPOL (aOR, 4.4; 95%CI,
Complications of lymphadenectomy for gynecologic cancer
1.2e16.3) (Table 3).

cite this article in press as: Achouri A, et al., Complications of lymphadenectomy

(2012), http://dx
EJSO xx (2012) 1e6 for gynecologic cancer, Eur J Surg Oncol
www.ejso.com
6/j.ejso.2012.10.011

A. Achouri a,b,*, C. Huchon a,b,c, A.S. Bats a,b,d, C. Bensaid a, C. Nos a, F. L!ecuru a,b,d
a

Service de Chirurgie Canc!erologique Gyn!ecologique et du Sein, H^opital Europ!een Georges Pompidou, AP-HP, Paris, France
b
Facult!e de m!edecine, Universit!e Paris-Descartes, Paris, France
c
EA 7285 Risk and Safety in Clinical Medicine for Women and Perinatal Health, University of Versailles St-Quentin (UVSQ), Versailles, France
d
INSERM UMR-S 747, Universit!e Paris e Descartes, Paris, France

Lower-limb lymphedema

Accepted 12 October 2012

Available online - - -

Of the 88 patients, 10 (11.4%; 95%CI, 5e18) had LLL.

Mean time
from surgery
1. Femmes
: 88 to LLL diagnosis was 7.5 " 6.3
months. A single
lower
limb was
affected in 9 of the 10 pa- 17 : K
col utrin
(24%)
tients. One -patient
treatment.
35 : Kdeclined
endomtre
(11%) The other 9 patients
received the- 36
standard
of care
consisting of manual lymph
: K ovaires
(6%)
drainage,2.loose
wrapping,subjective
and advice
Apprciation
LOon diet and lifestyle.
No ulcers
infections
were recorded.
3. orDlai
dapparition
: 7,5 mois
LLL 4.
wasPasmore
common
the group
with cervical
de FDR
de LO in
(analyse
multivarie)
cancer (4/17,
23.5%)
than
in the groups with ovarian cancer
(RT,
curage,
IMC,)
Abstract

Introduction: Symptomatic postoperative lymphocysts (SPOLs) and lower-limb lymphedema (LLL) are probably underestimated complications of lymphadenectomy for gynecologic malignancies. Here, our objective was to evaluate the incidence and risk factors of SPOLs and
LLL after pelvic and/or aortocaval lymphadenectomy for gynecologic malignancies.
Methods: Single-center retrospective study of consecutive patients who underwent pelvic and/or aortocaval lymphadenectomy for ovarian
cancer, endometrial cancer, or cervical cancer between January 2007 and November 2008. The incidences of SPOL and LLL were computed with their 95% confidence intervals (95%CIs). Multivariate logistic regression was performed to identify independent risk factors for
SPOL and LLL.
Results: We identified 88 patients including 36 with ovarian cancer, 35 with endometrial cancer, and 17 with cervical cancer. The overall
incidence of SPOL was 34.5% (95%CI, 25e45) and that of LLL was 11.4% (95% confidence interval [95%CI], 5e18). Endometrial cancer
was independently associated with a lower risk of SPOL (adjusted odds ratio [aOR], 0.09; 95%CI, 0.02e0.44) and one or more positive
pelvic nodes with a higher risk of SPOL (aOR, 4.4; 95%CI, 1.2e16.3). Multivariate logistic regression failed to identify factors significantly associated with LLL.
Conclusion: Complications of lymphadenectomy for gynecologic malignancies are common. This finding supports a more restrictive use of
lymphadenectomy or the use of less invasive techniques such as sentinel node biopsy.
! 2012 Elsevier Ltd. All rights reserved.
Keywords: Ovarian cancer; Uterine cancer; Lymphadenectomy; Lymphedema; Lymphocyst

Table Introduction
2

POLs are organized collections of lymph that are usually

asymptomatic and identified only upon routine imaging stud-

Examens complmentaires

Lymphoscintigraphie MI
Examen simple, peu invasif,
reproductible
Possible chez l'enfant
Collodes rsorbs par le systme
lymphatique (sulfocollode de rhnium ou
d'albumine)
Etudes morphologique et fonctionnelle
voies de drainage (superficielle,
profonde)
comparaison D/G

Erysiple
LO : risque rysiple 70
Clinique systmique
1. Fivre leve > 40C
2. Frissons, tremblements
3. vomissements

Clinique locale
1. Puis MI rouge, chaud, douloureux,
2. volume
Touche la zone atteinte par le LO (parfois
infraclinique)

Erysiple
Erysiples MS, MI
parfois rcidivants
porte d'entre non toujours
retrouve
Traitement : 10-14 jours
amoxicilline, 3 g/j ou
pristinamycine (Pyostacine), 3 g/j
fivre : 48 h, rougeur : 7 j, volume
en quelques semaines
Si rcidives frquentes, > 3/an
(ABprophylaxie : benzathinebenzylpnicilline, 2,4 MUI/2S, dure ?)
Becq-Giraudon B. Ann Dermatol Venereol 2001;128:368

Autres complications / associations

Psychologiques
Tumorales : Stewart Treves
(angiosarcome), rares, pronostic
mdiocre
Plexopathie post-radique,
ostoradioncrose
Associations : pb paule,
atteinte vasculaire post-radique,
canal carpien

Lipdme

Lipdme
Terme anglo-saxon "lipedema",
dcrit par Allen et Hines en 1940
chez 5 femmes obses, dbutant
partir de la pubert (<1% : homme)
Dfinition : accumulation de tissus
adipeux du bassin jusqu'aux chevilles

Touchant presque exclusivement

femmes obses : entit plutt que
maladie
Allen EV et al. Proc Staff Mayo Clin 1940;15:1984
Harwood CA et al. Br J Dermatol 1996;134:1

Lipdme
Terme peu appropri car pas
d'dme vrai sauf aprs
orthostatisme
Autres dnominations utilises
dans la littrature :
"lipodystrophy", "painful fat
syndrome"
Confusion frquente avec le
lymphdme des MI

Lipdme : signes cliniques

Gne la marche si volume
important
Peau
souple
pincement douloureux
("cellulalgies")
douleurs superficielles :
avec ge
ecchymoses faciles (bleus)

Traitement du lipdme
Objectif : compression des MI
Elvation MI : 0
Traitement lymphdme : inefficace
Compression lastique
morphologie : difficult enfilage,
utilisation difficile, souplesse
tolrance bonne (plis cheville, pied)
principal intrt : dme aprs
orthostatisme

Hydratation de la peau
Natation, aquagym ++++

Traitement des lipdmes

Liposuccions par tumescence
(Schmeller W et . Br J Dermatol 2012;166:161)

plusieurs sances ncessaires

amlioration douleurs >>> volume
facilite port compressions
lastiques
Liposuccions + exrse cutanes
(Ketterings C. Ann Plast Surg 1988;21:536)

=> risque de destruction de vaisseaux

lymphatiques avec apparition vritable LO
dfinitif (Rudkin GH et al. Plast Reconstr Surg 1994;94:841-9)

Surtout : "rassurer" (entit clinique)

Vignes S. J Mal Vasc 2012;37:213

Traitement des lymphdmes

Prise en charge des

lymphdmes
Education thrapeutique
Bandages peu lastiques
Auto-apprentissage des bandages
Drainages lymphatiques manuels
Compression lastique
Soins cutans locaux
Autres : pressothrapie,
chirurgie ?

Education

Explication de la maladie +++

chronicit (malgr la gurison du

cancer)
ncessit de soins et surveillance
prolongs (risque aggravation)
motivation +++
Hygine de vie : conseils empiriques
pargne du membre atteint mais
latralit (MS : port de charge
lourde, sport violent, tches
mnagres,)
viter les portes dentre
infectieuses (piqre, griffure)

Table 3

Preventive measure and evidence to support either fact or fiction.

NIH-PA Author Manuscript

NIH-PA Author Manuscript

P
r

v
e
n
t
i
o
n

Preventive measure

Best scientific evidence for

Best scientific evidence against

Fact/Fiction/To be determined

Avoid needle sticks of any

type

Clark [10] level 2 prospective

observational study (188 patients),
findings that 44% patients with
needle stick developed lymphedema
as compared with 18% of those
without needle sticks

Winge 18Level 3 questionnaire

study (311 patients of which 88 had
intravenous procedures in affected
limb). Only 4 patients developed
lymphedema in relation to
venipuncture

To be determined

Avoid Pressure

Louden & Petrek [15, 16] level 5,

expert opinion hypothesising that
blood pressure monitoring, tight
clothing increases blood pressure in
at risk limb resulting in increased
lymph production.

Dawson [22] level 3,

retrospective cohort (317 patients),
no new cases or exacerbations of
lymphedema in 15 patients with a
history of lymph node dissection
who subsequently had elective
hand surgery with tourniquet

Probably fiction

Leg/Limb precautions

Ryan [24] level 5, expert opinion,

crossing legs hinders venous return,
prolonged standing/sitting results in
pooling of blood in legs and hence
increased interstitial fluid leakage.

None found

To be determined

Avoid Air travel/wear

compressive garments for
air travel

Casley-Smith [28] level 4,

questionnaire based retrospective
study (531 patients), 27 patients
reported lymphedema symptoms
started after aircraft flight & 67
patients reported worsening
lymphedema symptoms after flying.

Graham [29] level 2, Cohort

study (293 patients), no cases of
permanent or new onset
lymphedema found after aircraft
flight taken.

Probably fiction

Maintain a normal body

weight

Shaw [41] level 1, randomised

clinical trial (21 patients),
interventions designed to promote
weight loss after surgery
significantly reduced excess arm
volume and lymphedema.

Villasor [6] level 3 nonconsecutive cohort (51 patients),

47% patients with lymphedema had
normal weight, no correlation
between lymphedema formation
and obesity or weight found.

Fact

Avoid extremes of
temperature/apply
sunscreen/avoid burns

Hettrick [48] level 4 prospective

analysis, 1% of burn population
found to have lymphedema.

Chang [45] level 1 double blind

randomized study (60 patients),
heat added to placebo, or
benzopyrone therapy significantly
improved symptoms of
lymphedema compared to placebo
or benzopyrone alone.

Fiction

Avoid vigorous exercise

Petrek/Foldi [1] level 5 Expert

opinion rationalising that vigorous
exercise increases blood flow and
consequently lymphatic fluid
production.

Schmitz [52] level 1 randomized

trial (141 patients), no increased
incidence of lymphedema in
exercise group compared to nonexercise control group.

Fiction

NIH-PA

Cemal Y et al. J Am Coll Surg 2011;213:543

Sports et lymphdmes

ayo Clinic,
reprint reepartment
gy, Univerrdian Dr.,
PA 19104penn.edu.

lifting involving 141 breast-cancer survivors with stable lymphedema of the arm. The
primary outcome was the change in arm and hand swelling at 1 year, as measured
through displaced water volume of the affected and unaffected limbs. Secondary
outcomes included the incidence of exacerbations of lymphedema, number and
severity of lymphedema symptoms, and muscle strength. Participants were required
to wear a well-fitted compression garment while weight lifting.

al Society.

Results

The proportion of women who had an increase of 5% or more in limb swelling was
similar in the weight-lifting group (11%) and the control group (12%) (cumulative
incidence ratio, 1.00; 95% confidence interval, 0.88 to 1.13). As compared with the
control group, the weight-lifting group had greater improvements in self-reported
severity of lymphedema symptoms (P = 0.03) and upper- and lower-body strength
(P<0.001 for both comparisons) and a lower incidence of lymphedema exacerbations
as assessed by a certified lymphedema specialist (14% vs. 29%, P = 0.04). There were
no serious adverse events related to the intervention.
Conclusions

In breast-cancer survivors with lymphedema, slowly progressive weight lifting

had no significant effect on limb swelling and resulted in a decreased incidence
of exacerbations of lymphedema, reduced symptoms, and increased strength.
(ClinicalTrials.gov number, NCT00194363.)

1.
2.
3.
4.

Haltrophilie et lymphdme
Ces articles vont l'encontre des
recommandations habituelles
Ide majeure : ne pas
dconditionner le MS +++
Muscler sans hypertrophier
(lutter contre les agressions
quotidiennes)
Effet prventif (Schmitz et al. JAMA
2010;304:2699)

Haltrophilie et lymphdme
Activit physique encadre,
progressive, guide par la
patiente : bnfices > effets
dltres
Participe aussi la bonne sant
globale des femmes traites pour
cancer du sein en amliorant leur
qualit de vie
Diminution de 20-30%
du risque de rechute

Activits physiques
Encadre (professionnels forms)
Progressive
Guide par la patiente
Avec une compression (si
possible)
NE RIEN INTERDIRE

Buts du traitement des lymphdmes

1. Rduction de volume : phase
"intensive"
hospitalire ou ambulatoire
bandages peu lastiques quotidiens
2. Maintien du volume rduit : phase
"d'entretien" en ambulatoire
compression lastique et
bandages (frquence plus faible)

http://www.has-sante.fr/portail/jcms

Rduction de volume :
bandages monotypes peu lastiques
Bandes allongement court < 100%
(Partsch H, et al. Dermatol Surg 2006;32:224)

Bandages multicouches (2-4) MAIS

monotypes ( pathologies vasculaires)
Intrt : pression de repos faible mais
forte en mvt (gymnastique, marche, vlo)
Effet contensif >>> compressif

Traitement intensif hospitalier (ou ambulatoire)

Dure de 1 4 semaines
Bandages peu lastiques
quotidiens
renouvels 5j/7
gards 24 h/24 h
Diminution volumtrique de 30
60%
Foldi E et al. Ann Plast Surg 1989;22:505
Johansson K et al. Lymphology 1999;32:103
Ko DS et al. Arch Surg 1998;133:452
Szuba A et al. Am J Med 2000;109:296
McNeely ML et al. Breast Cancer Res Treat 2004;86:95
Vignes S et al. Breast Cancer Res Treat 2006;98:1

Education thrapeutique
Propose chaque patient
(consentement crit) avec objectifs
Base sur des ateliers en groupe ou
individuels
Thmes : compression lastique,
tout savoir sur le lymphdme,
thorie des auto-bandages,
apprentissage des auto-bandages
Evaluation des patients et des
soignants (kins, mdecins, IDE)

Apprentissage des auto-techniques

Auto-bandages ( auto-DLM)
avec un kinsithrapeute
technique simplifie +++
seules entourage
Traitement d'entretien : frquence
(min: 3/semaine la nuit)
Intgration dans un programme
dEducation Thrapeutique du
Patient (ETP) (ateliers collectifs,
individuels)

Comptences dadaptation
Compression

Tout savoir sur le

lymphdme

Auto bandage au
quotidien

A lissue de latelier le patient doit tre capable de :

- Renouveler la
compression
lastique
rgulirement
- Remdier aux
effets
indsirables lis
au port de la
compression
lastique

- Comprendre que cest

une pathologie
chronique
- Citer les diffrentes
composantes du ttt
-Citer FR aggravation
(obsit)
-Citer facteurs
damlioration (activit
physique)
-Connatre lrysiple et
la CAT

- Adapter le
traitement en
fonction de
diffrentes situations
(vacances, activits
physiques intenses,
chaleur, aggravation
du lymphdme)
- Mettre en place des
astuces ou de
modifier le traitement
en cas de perte de
motivation

Drainages lymphatiques manuels

Buts : stimuler le systme lymphatique,
dplacer les liquides interstitiels dun milieu
satur vers un milieu sain

Principes des DLM

kinsithrapeutes forms

manuel +++
sens physiologique : proximal vers
distal
dure de 30 minutes au moins
rythme : 1-3 par semaine

Drainages lymphatiques manuels

Nombreuses techniques : Vodder,
Foldi, Leduc, Ferrandez, Schiltz, de
Micas
Quen attendre ?
court terme :
sensation dallgement,
tension cutane
effet relaxant

long terme : effet 0 sur volume

si utiliss seuls

Badger C et al. Cochrane Database Syst Rev 2004

MacNeely M et al. Breast Cancer Res Treat 2004
Vignes S et al. Breast Cancer Breast Treat 2007

Drainages lymphatiques manuels

Drainages lymphatiques manuels

possible petite synergie avec les

bandages peu lastiques
utiles dans les LO proximaux (sein,
thorax)
utile phase intensive, facultatif phase
d'entretien
pas de comparaison des techniques

Badger C et al. Cochrane Database Syst Rev 2004;3:CD003141

Harris SR et al. Lymphology 2001;34:84
Lymphoedema Framework. Best practice for the management of
lymphoedema. International consensus. London: MEP Ltd, 2006
Vignes S et al. Support Care Cancer 2011;19:935

 Importance de la dtection prcoce

dun LO
bio-impdancemtrie (courant de
faible intensit)
mesure de la constante tissulaire
di-lectrique (signal de 300 MHz)
clinique par auto-diagnostic
(ducation du patient)

Prise en charge prcoce

Jamais de DLM en
premire intention
Compression
lastique
Voire bandages
peu lastiques :
rduction LO dbutant

ported.
In
2011,One
Torresstudy
2010reported
and Zimmermann
Publication
status
and date:
New,
in Issue
2, 2015.
training group reported
pain
more often
at three
months
andpublished
six months
compared
to Castro-Sanchez
the control group.
HRQoL
Effects
of interventions
2012 no explicit distinction was made and reported numbers were
Review
content
assessed
as up-to-date:
May 2013.
and found no significant
difference
between
the groups.
Conservative
interventions
for 23
preventing
clinically detectable
See: Summary of findings
for the main comparison
Early

treated as cumulative incidence.

physiotherapy
including
MLD
for
patients
at
risk
for
secondary
Due towho
substantial
clinical
and statistical
heterogeneity
for
upper-limb
lymphoedema
in
patients
are
at risk
of Bossuyt
Patient education, monitoring
and early
intervention
Citation:
Stuiver
MM, ten Tusscher MR, Agasi-Idenburg
CS,
Lucas
C,
Aaronson
NK,
PMM.both
Conservative
in
upper limb lymphoedema after breast cancer treatment; Summary short-term (less than 6 months) and medium-term (more than 6
preventing
clinically
detectable upper-limb
lymphoedema
in cancer
patients who
are at risk of developing lymphoedema afte
developing
after
therapy
of findings
Early of
shoulder
mobilising exercises
compared
tobreast
One study investigated
the 2effects
a lymphoedema
comprehensive
outpatient
follow-up
programme,
patient (I
education,
months,
less than consisting
24 months) of
follow-up,
= 86%, P =exercise,
0.008;
therapy.
Cochrane
Database
ofpatient
Systematic
Reviews
2015,
Issue
2.84%,
Art.PNo.:
CD009765.
DOI:
10.1002/14651858.CD00
delayed
shoulder
mobilising
exercises
for
surgically
treated
and
I
=
<
0.001
respectively
for
RR;
and
I
=
(Review)
monitoring of lymphoedema symptoms and early intervention for lymphoedema, compared to education alone. Lymphoedema84%,
incifor breast cancer; Summary of findings 3 Progressive resistance P = 0.01 for the HR), no meta-analyses were performed. The
dence was lower in the comprehensive outpatient follow-up programme (at any time point) compared to education alone (65 people).
exerciseCopyright
for patients at
for secondary
upper limb
lymphoedemaPublished
risk
2015
The Cochrane
Collaboration.
& Sons,
Ltd.
results ofby
allJohn
studiesWiley
comparing
physiotherapy
with MLD to any
Participants in theafter
outpatient
follow-up
programme
had
a
significantly
faster
recovery
of
shoulder
abduction
compared
to the education
breast cancer treatment
other intervention are summarized in a single forest plot without
Stuiver MM, ten Tusscher MR, Agasi-Idenburg CS, Lucas
C,(see:
Aaronson
Bossuyt
PMM1.2; Figure 4 (Analysis
alone group.
totals
Figure 3 NK,
(Analysis
1.1); Analysis
1.3)), and a narrative summary of the results is provided below. A
Authors conclusions
A B of
S the
T Rmain
AC
T
summary
outcomes
of these studies is also provided
Manual lymph drainage (MLD)
in
Summary
of
findings
table
1.
Based on the current available evidence, we cannot draw firm conclusions about the effectiveness of interventions containing MLD.

Background
The evidence does not indicate a higher risk of lymphoedema when starting shoulder-mobilising exercises early after surgery compared
Breast
cancer-related
can1 be
a debilitating
sequela
of vs
breast
cancer
treatment.
Several
to afor
delayed
start (i.e.clinically
seven
days
after
surgery).
mobility
(that
is, laterallong-term
armincluding
movements
and
forward
flexion)
is better
in thestudies ha
e interventions
preventing
detectable
Figure
3.
Forest
plotlymphoedema
ofShoulder
comparison:
Early
physiotherapy
MLD
no early
physiotherapy
or
effectiveness
treatment
reduce
the
risk
ofthat
breast
cancer-related
lymphoedema.
physiotherapy
without
MLD,
outcome:
1.1 Time
to event
for
lymphoedema.
short term
when starting
shoulder
exercises
earlier compared
tostrategies
later.
Thetoevidence
suggests
progressive
resistance
exercise therapy
mb lymphoedema
in patients
whothe
are
at risk
of of different
ng lymphoedema
after
breast
cancer
therapy
does not increase the risk
of developing lymphoedema, provided that symptoms are closely monitored and adequately treated if they
Objectives
(Review)
occur.
To assess the effects of conservative (non-surgical and non-pharmacological) interventions for preventing clinically-det
Given the degree of heterogeneity
encountered,
limitedcancer
precision,
and the risk of bias across the included studies, the results of this
limb lymphoedema
after breast
treatment.
Tusscher MR, Agasi-Idenburg CS, Lucas C, Aaronson NK, Bossuyt PMM
review should be interpreted with caution.
Search methods

We searched the Cochrane Breast Cancer Groups (CBCG) Specialised Register, CENTRAL, MEDLINE, EMBASE, CIN
PsycINFO, and the World Health Organization (WHO) International Clinical Trials Registry Platform in May 2013.
PLAIN LANGUAG
E S4.UForest
M M plot
A RofYcomparison: 1 Early physiotherapy including MLD vs no early physiotherapy or
Figure
of included
trials and other
systematic reviews were searched.

physiotherapy without MLD, outcome: 1.3 Lymphoedema - medium term follow up.
Conservative interventions for preventing clinically detectable upper-limb lymphoedema in patients who are at risk of developing
Selection
criteria(Review)
lymphoedema after breast
cancer therapy
Copyright 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Randomised controlled trials that reported lymphoedema as the primary outcome and compared any conservative interve
no intervention or to another conservative intervention.
Data collection and analysis

Three authors independently assessed the risk of bias and extracted data. Outcome measures included lymphoedema, in
of motion of the shoulder, pain, psychosocial morbidity, level of functioning in activities of daily life (ADL), and healthof life (HRQoL). Where possible, meta-analyses were performed. Risk ratio (RRs) or hazard ratio (HRs) were reported fo
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
or lymphoedema incidence, and mean differences (MDs) for range of motion and patient-reported outcomes
2015, Issueoutcomes
2

http://www.thecochranelibrary.com
Conservative interventions for preventing clinically detectable upper-limb lymphoedema in patients who are at risk of develop

MLD was well tolerated and safe in all trials.

Two trials measured function as range of motion with conflicting results. One trial reported significant within-groups gains for both
groups, but no between-groups differences. The other trial reported there were no significant within-groups gains and did not report
between-groups results. OneFigure
trial measured
and reported1 no
significant
changesbandaging
in either group.
3. Foreststrength
plot of comparison:
MLD
+ Compression
VS Compression bandaging alone for

Manual lymphatic drainage for lymphedema following breast

Immediate Follow Up, outcome: 1.1 Lymphedema Volume (Excess volume remaining in limb after treatment).
Two trials measured QoL, but results were
not usabletreatment
because one trial did not
report any results, and the other trial did not report
cancer
(Review)
between-groups results.

Four trials measured sensations such as pain and heaviness. Overall, the sensations were significantly reduced in both groups over
baseline, but with no between-groups differences. No trials reported cost of care.

Ezzo J, Manheimer E, McNeely ML, Howell DM, Weiss R, Johansson KI, Bao T, Bily L,
Trials were small ranging from 24 to 45 participants. Most trials appeared to randomize participants adequately. However, in four trials
Tuppo CM, Williams AF, Karadibak D

the personformeasuring
theclinically
swelling knew
what treatment the participants were receiving, and this could have biased results.
nterventions
preventing
detectable
lymphoedema
in patients who are at risk of
Authors conclusions
lymphoedema after breast cancer therapy
(b) volume reduction
MLD is (Review)
safe and may offer additional benefit to compression bandaging for swelling reduction. Compared to individuals with moderateAt immediate post-treatment follow-up, two pooled trials showed

to-severe BCRL, those with mild-to-moderate BCRL may be the ones who benefit from adding MLD to an intensive course of treatment
borderline significance favoring MLD (MD 26.21 mL, 95% CI
with
compression
bandaging.
finding,
however,
to83
beparticipants).
confirmed See
by randomized data.
scher MR,
Agasi-Idenburg
CS, Lucas
C, Aaronson
NK,toBossuyt
-1.04 This
mL
53.45PMM
mL;
P = 0.06;needs
2 trials;
Figure 4 (Analysis 1.2).

In trials where MLD and sleeve were compared with a nonMLD treatment and sleeve, volumetric outcomes were inconsistent within
the same trial. Research is needed to identify the most clinically meaningful volumetric measurement, to incorporate newer technologies
Figure
4. clinically
Forest plot
of comparison:
MLDas+ fibrotic
Compression
bandaging VS Compression bandaging alone for
in LE assessment, and to assess
other
relevant
outcomes1such
tissue formation.
Immediate Follow Up, outcome: 1.2 Volume reduction in mL.

Findings were contradictory for function (range of motion), and inconclusive for quality of life.
For symptoms such as pain and heaviness, 60% to 80% of participants reported feeling better regardless of which treatment they
received.
Manual lymphatic drainage for lymphedema following breast cancer treatment (Review)
Copyright 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

(c) per cent reduction

Compression lastique
Complment indispensable pour
maintenir la rduction de volume
Tous les jours, du matin au soir
Motivation patients, soignants +++
Adaptation de la compression :
taille, sur-mesure +++
force de pression importante :
classe 3 (20-36 mmHg) ou 4 (<36
mmHg)

rle des orthsistes +++

Changements rguliers : 3-4 mois

Tricotage rectiligne

AVANTAGES
Se met moins dans les
plis : plus rigide, trs
peu lastique hauteur
Plus contensif que
compressif
Arrt de la compression
sans striction
Tolre des variations
brusques de mesures
Dure de vie plus
longue ?

INCONVENIENTS
Couture longitudinale
Moins "esthtique",
plus pais, ressenti
comme raide
Peu de tolrance aux
erreurs de mesure
Tolre moins les
variations rapides
dun traitement
rducteur
Pas de coton
Cot plus lev

Tricotage circulaire
AVANTAGES
Plus dynamiques
Suit plus le
mouvement
Respecte plus la
mobilit articulaire
Ressenti "moins raide"
Plus esthtique
Moins pais
Pas de couture

INCONVENIENTS
Se met plus dans les
plis
Arrts plus difficiles :
rajout de coutures,
bordures, autofixant
Tolre mal les variations
brusques de mesures
Dure de vie moins
longue ?

Compression lastique
Type de compression
bas jarret (mi bas, chaussettes)
bas cuisse
collant, hmi-collant, panty
manchon avec ou sans main, gantelet

Prfrer MI
MI : bas cuisses aux bas jarrets,
pieds ferms aux pieds ouverts
MS : manchon avec main
attenante
Superposition de 2 bas indispensable MI

Corresponding author: Ian S. Dayes,

MSc, MD, FRCP(C), Juravinski Cancer

Conclusion
This trial was unable to demonstrate a significant impro
therapy compared with a more conservative approach.
been a result of the relatively small size of our trial.

Centre, 699 Concession St, Hamilton,

Randomized
Trial of Decongestive Lymphatic Therapy
Ontario, Canada L8V 5C2; e-mail:
forIan.Dayes@jcc.hhsc.ca.
the Treatment of Lymphedema in Women With
2013 by American Society of Clinical
J Clin Oncol 31. 2013 by American Society of Clinic
Breast
OncologyCancer

Ian S.0732-183X/13/3199-1/$20.00
Dayes, Tim J. Whelan, Jim A. Julian, Sameer Parpia, Kathleen I. Pritchard, David Paul DSouza,
Lyn Kligman, Donna Reise, Linda LeBlanc, Margaret L. McNeely, Lee Manchul, Jennifer Wiernikowski, com
DOI: 10.1200/JCO.2012.45.7192
INTRODUCTION
and Mark N. Levine
sists

phat
skin
treatment
forefficace
breast cancer. Associated
morbidity
Seule
aussi
que
PCD
A B S T R A C T
exce
includes cosmetic deformity, discomfort, infecsur les
lymphdmes
of ly
tion,petits
reduction in arm
function, and emotional
Purpose
1-4
Because of its morbidity and chronicity,
arm lymphedema
remains awith
concerning
complication
reaco
distress.
Factors associated
increased
risk
<
1
an
breast cancer treatment. Although
massage-based
decongestive
therapy
is often
recommended
Dayes
etof
al lymphedema
sugg
include extent
of axillary
surgery,
randomized trials have not consistently demonstrated benefit over more conservative5-8measures
ume
axillary radiation, infection, and patient obesity.
Patients and Methods
clini
The incidence
has been reported to range from 6%
2. Excess
Treatment
Women previously Table
treated
for Volume:
breastSummary
cancerbywith
lymphedema were enrolled from six institutions
to 30%
with
being
a result
(n !calculated
56)
Control
(n !variation
39)
VolumesCDT
were
from circumference
measurements.
Patients
withofa different
minimum of tive
10%
size
periods, andgarment
Treatment
volume difference
between
armspopulations,
were6randomly
assigned
to either
compression
Baseline
6 Weeks
Reduction their Baseline
Weeks definitions,
Reduction follow-up
Effect
3,9,10
or daily
and SD
bandaging
followed
by compression
garment
study
designs.
Mean(control)
SD
Mean
SD manual
Mean lymphatic
SD
Meandrainage
SD
Mean
Mean
SD
Difference
95% CI
P for f
(experimental).
The
primary
outcome
was
percent
reduction
in
excess
arm
volume
from
baselin
The
number
therapies
2,672 640 2,594 664
78
286
2,642 651 A
2,562
666 of 80
299 have been devised to
weeks.
3,422to 6
838
3,094 769
328
480
3,266 781 3,043 785
223
403
treat lymphedema.
One
promising
therapy
is
thes
750 451
500 360 #250
293
624 293
481 297 #143
169
107
13 to 203 .03
Lymphedema is a concerning complication after
See accompanying editorial doi: 10.1200/JCO.2013.51.8373

iations appear at the end of

online ahead of print at

rg on September 16, 2013.

by Grant No. 13260 from the

reast Cancer Research Alliary author fellowship salary

s funded by the Juravinski

ntre Foundation. Bandaging
supplied, in part, by Lohm-

scher International, Germany.

in part, at theVolume
2009 Annual
the American Society for
Unaffected arm, mL
Oncology, November 1-5,
Affected arm, mL
ago, IL; and the 22nd Inter!
Excess volume, mL
Results
ngress of Lymphology,
Excess volume, %
29
18
20
15
29.0
24
12
19
12
22.6
26.0
6.4
to 20.5 .34
A total
of 103
women
were38.6
randomly
assigned,
and
95 were
evaluable.
Mean #6.8
reduction
of exces
19-20, 2009, Sydney, New
Abbreviations:
CDT,
complex
decongestive
therapy;
SD,
standard
deviation.
es, Australia.
arm volume was 29.0% in the experimental group and 22.6% in the control group (difference
!
Stratified analysis: difference of 111 mL; 95% CI,
16 to 207 mL;downloaded
P ! .02.
Information
jco.ascopubs.org
and
provided
by at BIBL INTERUNIVER
6.4%;severity
95%and
CI,duration
!6.8%
to 20.5%;
P "from
.34).
Absolute
volume
loss
was
Analysis
adjusting
of lymphedema:
difference
of 77 mL;
95% CI, #10
to 163 mL;
P!
.08. 250 mL and 143 mL in th
sclosures
of potential
con- for continuous
Copyright

2013
American
Society
of
Clinical Oncology. All rig
2013
from
194.254.96.35
Stratified
analysis: difference
of 8.0%; 95% CI,and
#5.8%
to 21.5%;
P ! .25. respectively (difference, 107 mL; 95% CI, 13 to 203 mL; P "
erest and
author contribuexperimental
control
groups,

ound at the end of this

information: NCT00201890.

Copyright 2013 by American Society of Clinical

.03). There was no difference between groups in the proportion of patients losing 50% or greate
excess arm volume. Quality of life (Short Form-36 Health Survey) and arm function were no
different between groups.

patients losing 50% or more excess arm volume were 25% and 15%

though all of the effect was restricted to the first 3 weeks (P " .001).

Compression et lymphdmes
Classes leves: 3, 4
Bas cuisse > chaussettes, pieds
ferms
Manchon avec main attenante
Sur-mesure
Superposition MI

Traitement de lIVC et lymphdme

Risque : aggraver le lymphdme

Thrapeutiques et non
esthtiques
Indications rares car compression
fortes
Une mthode est-elle prfrable
une autre: stripping, traitement
endoveineux, sclroses ?

 261 patients de 1989 1997

lymphdme : 68
lipo-lymphdme : 103
lipdme : 90
Stripping, ligatures saphnes, phlbectomies
Lymphdme (apprciation subjective)
aggravation : 71%
stabilit : 28%
amlioration : 1%

perative data (demographics, signs, symptoms,

To evaluate the possible
preoperative
risk
factorsvenous
body mass
index [BMI]), the
preoperative
complications after varicose
veins
surgery:
anuary 2012Lymphatic
andwe
location
of venous
for the appearance ofhaemodynamics
LC after (presence
surgery
com-

om

O
w

risk factors and how to avoid them

pared the data of the patients with LC (118 cases)

DOI: 10.1258/phleb.2012.012S12. Phlebology 2012;27 Suppl 1:139142
with
those
without
P
Pittaluga*
and S
Chastanet* LC complications (5289 cases)
*Riviera Vein Institut, Nice, France; Riviera Vein Institut, Monte Carlo, Monaco
(Table 3). For the group in which an LC occurred
thertrospective
surgery the de
mean
age 2000
was older
(59.6%
1.after
Etude
janvier
octobre
Abstract
vs.
53.3%,
P ,Lymphatic
0.05),complication
the frequency
of (VVs)
C4surgery
C6is anwas
2010
Introduction:
(LC) after varicose veins
annoying
event with a variable frequency in the literature.
2.higher
5407 (22.0%
patients
vs. 6.5%,
P ,all 0.05),
theoutaverage
BMI
Method: Retrospective
study reviewing
surgeries carried
for VVs from January
2000 to

October 2010. Postoperative LC we reported: lymphatic fistula, lymphocele including the

minor ones and lymphoedema.
Results: During the period studied, 5407 surgical procedures for VVs were performed in 3407
patients (74.7% women) with a mean age of 53.4 years. A postoperative LC occurred in 118
cases (2.2%): lymphocele on limb in 1.3%, inguinal LC (fistula or lymphocele) in 0.7% and a
lymphoedema in 0.2%. The population with a LC was older (59.6 vs. 53.3 years, P , 0.05),
had a higher frequency of C4 C6 (22.0% vs. 6.5%, P , 0.05), a higher incidence of obesity
(31.4% vs. 5.4%, P , 0.05) and was more often treated by a redo surgery or a crossectomy
stripping (48.3% vs. 13.4% and 38.1% vs. 21.8%, respectively, P , 0.05). We have observed
a dramatic decrease in incidence of LC after January 2004 (1.3% vs. 5.3%, P , 0.05)
corresponding to a new surgical practice for the treatment of VVs: stripping, crossectomy
and redo surgery at the groin were less frequent (74.6% vs. 7.7%, 74.6% vs. 0.2% and
11.3% vs. 0.1%, respectively, P , 0.05), while isolated phlebectomy was more often
performed during this period (78.4% vs. 8.4%, P , 0.05).
Conclusion: LC after VVs surgery is not rare but frequently limited to lymphocele on limbs.
Older age, more advanced clinical stage and obesity were associated with a higher frequency
of LC. A mini-invasive and selective surgery has significantly reduced the occurrence of LC.

Table 1 Lymphatic complications after varicose veins surgery

Total
Lymphocele on lower limbs
Inguinal lymphocele or fistula
Lymphoedema

Ta
co

Lymphatic complications

Fe
C
Pr

118
68
37
13

2.2
1.3
0.7
0.2

A
BM

Keywords: varicose vein; varicose vein surgery; lymphatic complication; lymphocele;

lymphodema; lymphatic fistula; risk factors

BM

At last, a preoperative skin marking guided perative

by
data (demographics, signs, symptoms,
ultrasounds was performed in 82.4% after January
body mass index [BMI]), the preoperative venous
2004 and only in 20.9% before.
nuary 2012
haemodynamics (presence and location of venous

Lymphatic complications after varicose veins surgery:

risk factors and how to avoid them

Discussion

DOI: 10.1258/phleb.2012.012S12. Phlebology 2012;27 Suppl 1:139142

Our study
thatan
LC after
surgery for VVs
P showed
Pittaluga*
and
S Chastanet*

was not *Riviera

rare, occurring
inNice,
2.2%France;
after the
surgical
Vein Institut,
Riviera
Vein Institut, Monte Carlo, Monaco
Table 3 Comparison of population with and without a lymphatic
complication after varicose veins surgery

Lymphatic Abstract
No lymph.
P
Introduction:
Lymphatic
complication (LC) after varicose veins (VVs) surgery is an annoying
complication
complication

event with a variable frequency in the literature.

5289
Method: Retrospective study reviewing all surgeries carried out for VVs from January 2000 to
Age (average
53.3
,0.0001
October 2010. Postoperative LC we reported: lymphatic fistula, lymphocele including the
years)
minor
ones andcomplications
lymphoedema.
Pittaluga
Chastanet.
Lymphatic
after varicose veins surgery
Original article
Female and S 75.4%
74.9%
NS
Results:
During
the
period
studied,
5407
surgical
procedures
for
VVs
were
performed
in 3407
C4C6
22.0%
6.5%
,0.05
patients
(74.7% women)
Preop
70.3%
70.1%
NSwith a mean age of 53.4 years. A postoperative LC occurred in 118
cases (2.2%): lymphocele on limb in 1.3%, inguinal LC (fistula or lymphocele) in 0.7% and a
symptomatic
able 4 Comparison of the frequency of different types of lymTable 6 Comparison of postoperative lymphatic complications and
Average BMI
28.7
23.9
,0.05
lymphoedema
in
0.2%.
The
population
with a LC was older (59.6 vs. 53.3 years, P , 0.05),
hatic complication in obese (BMI . 30) and non-obese patients
procedures carried out before and after 2004 for the treatment of
BMI . 30
31.4%
,0.05
had a5.4%
higher frequency
of C4 C6 (22.0%
6.5%, P , 0.05), a higher incidence of obesity
BMI,30)
varicosevs.
veins
(31.4% vs. 5.4%, P , 0.05) and was more often treated by a redo surgery or a crossectomy
BMI, body mass index; NS, non-significant
Obese stripping
Non-obese(48.3%
P vs. 13.4%
Ratio
January
P
and 38.1% vs. 21.8%, respectively,Before
P , 0.05). WeAfter
have
observed
January
a dramatic decrease in incidence of LC after January 2004
(1.3% vs. 2004
5.3%,(%)
P , 0.05)
N
324
5083
corresponding to a new surgical practice for the treatment of2004
VVs:(%)stripping, crossectomy
ymphocele on limb
4.0%
1.1%
,0.05
3.6
and redo surgery at the groin were less frequent (74.6% vs. 7.7%, 74.6% vs. 0.2% and
Lymphatic complications
5.3
1.3
,0.05
nguinal complication
5.9%
0.4%
,0.05
14.7
11.3% vs. 0.1%, respectively, P , 0.05), while isolated phlebectomy was more often
Strippingcrossectomy
74.6
0.2
,0.05
ymphoedema
1.5%
0.2%
,0.05
7.5
performed during this period (78.4% vs. 8.4%, P , 0.05).
Redo surgery at the groin
11.3
0.1
,0.05
Conclusion: LC after VVs surgery is not rare but frequently limited to lymphocele on limbs.
MI, body mass index
Endovascular or mini0.0
7.7
,0.05
Older age, more advanced clinical stage and obesity were associated with a higher frequency
invasive ablation
of LC. A mini-invasive and selectiveIsolated
surgery
has significantly reduced
the occurrence
of LC.
phlebectomy
8.4
92.3
,0.05
118
59.6

procedures. Nevertheless, in the wide majority of

Preoperative skin marking
20.9
82.4
,0.05
Keywords:
varicose vein;
he cases the LC was minor,
represented
by avaricose vein surgery; lymphatic complication; lymphocele;
lymphodema; lymphatic fistula; risk factors

fidence intervals (CI) across studies.

ults: We found 39 eligible studies (30 were randomized trials) enrolling 8285 participants. Su
onsignificant reduction in the risk of varicose vein recurrence compared with liquid sclerothe
9-1.06) and all endoluminal interventions (RR, 0.63; 95% CI, 0.37-1.07). Studies of l
ation and foam sclerotherapy demonstrated short-term effectiveness and safety. The quality
s review was limited by imprecision
(small number of events), short-term follow-up, and indir
M. Hassan Murad, MD, MPH,a,b,c Fernando Coto-Yglesias, MD,a,d Magaly Zumaeta-Garcia, MD,a
comes).
Mohamed B. Elamin, MBBS,a Murali K. Duggirala, MD,a,c Patricia J. Erwin, MLS,a
f
nclusion:
Low-quality
evidence
supports
safety
and efficacy
the tre
Victor
M. Montori, MD,
MSc,a,c,e
and Peterlong-term
Gloviczki, MD,
Rochester,
Minn; andof
Sansurgery
Jos, Costafor
Rica
JOURNAL OF VASCULAR SURGERY
ort-term62S
studies
the efficacy of less invasive treatments, which
are associated
with less
Muradsupport
et al
May Supplement 2011
Objectives: Several treatment options exist for varicose veins. In this review we summarize the available evidence derived
d pain.from
( Jcomparative
Vasc Surg
2011;53:49S-65S.)
studies about the relative safety and efficacy of these treatments.

A systematic review and meta-analysis of the

treatments of varicose veins

Methods: We searched MEDLINE, Embase, Current Contents, Cochrane Central Register of Controlled Trials
Table II. Commonly reported adverse events
(CENTRAL) expert files, and the reference section of included articles. Eligible studies compared two or more of the
available Surgery
treatments (surgery,
liquid or foam sclerotherapy,
or conservative
Sclerotherapy
Laser ablationlaser, radiofrequency
Radiofrequency ablations,
ablation
Foam therapy therapy
with compression stockings). Two independent reviewers determined study eligibility and extracted descriptive,
Wound infection,
Skin staining
Purpura/bruising, meta-analysis
Saphenous
methodologic,
and outcome
data. or
We used random-effects
tonerve
pool relative Contusion,
risks (RR) and 95%
3%-6%
necrosis,
3%
11%-23%
paresthesia,
13%
bruising,
1
confidence intervals (CI) across
studies.
hematoma, 61%
Results:
We
39 eligible
studiesphlebitis,
(30 were randomized
trials) enrolling
8285 participants.
Surgery
associated with
Sural
orfound
saphenous
Superficial
Erythema, 33%
Superficial
phlebitis,
Skinwas
pigmentation,
nerve injury, 10%22%-27%
51%(RR, 0.56; 95% CI,
a nonsignificant
reduction in
the risk of varicose vein recurrence compared0%-20%
with liquid sclerotherapy
23%
2
0.29-1.06)
and all endoluminal interventions (RR,
0.63; 95% CI, 0.37-1.07).
Studies of laser
and radiofrequency
Hematoma, 31%
Hyperpigmentation,
Hematoma, 7%
Headache, 11%
ablation and foam sclerotherapy demonstrated short-term
effectiveness and safety. The quality of evidence presented in
57%
Superficial
Hypopigmentation,
2%
Thermal
skin injury,
thisreview
wasphlebitis,
limited by imprecision (small number
of events), short-term
follow-up,
and7%
indirectness (use of surrogate
0%-12%
outcomes).
Blistering/sloughing,
Paresthesia, !1%
Conclusion: Low-quality evidence supports long-term
safety and efficacy of surgery for the treatment of varicose veins.
7%
Short-term studies support the efficacy of less invasive
treatments,
whichare
Scaring,
13%
Legassociated
edema, !1%with less periprocedural disability
Telangiectatic matting,
and pain. ( J Vasc Surg 2011;53:49S-65S.)

knowledge, no contemporary s
proximately one-third of men and women aged 18
able to compare all available tre
ears have varicose veins. The high prevalence leads
The Society for Vascular Su
ificant health care expenditure on treatments of
the American Venous Forum
e veins. Surgical treatment of varicose veins inpractice guidelines to improve
high ligation and saphenous vein stripping, with or
venous disease. To assist in ven
t phlebectomy; until the past few years, this procethe SVS and the AVF commi
ad been used most commonly by surgeons world5
28%
systematic review and meta-ana
However, several other less invasive
treatment
Edema, 15%
1%-2%
available evidence about the
ties that are claimed to be as effective Paresthesia,
as surgery
are
Superficial phlebitis, 6%
knowledge, no contemporary systematic synthesis is ava
Approximately one-third of men and women aged 18
different treatments of varicose
ly toavailable,
including
radiofrequency
or
laser
abla1
able to compare all available treatments.
64 years have varicose veins. The high prevalence leads
the
(GSV)
small
saphenous
veins (SSV),
or
The Society for Vascular Surgery (SVS) partnered wi
to great
significant
healthor
care
expenditure
on treatments
of

Types de chirurgie (1)

1.Rsection
ablation de tissus lymphdmateux
(Kim DI, Lymphology 1998;31:190)
liposuction (Brorson et al. Acta Oncol
2000;39:407)

2. Reconstruction
anastomoses lymphoveineuses
(Campisi et al. Microsurgery 2010)

greffe de canaux lymphatiques

(Weiss & Baumeister, Clin Nucl Med
2002;27:788)

Types de chirurgie (2)

3. Transferts tissulaires
greffe ganglionnaire autologue
(transfert ganglionnaire) (Becker
et al. Ann Surg 2006)

transfert pdicul de l'piploon

(Benoit L, Ann Surg Oncol 2005;12:793)

autogreffe de cellules souches

hmatopotiques (Hou C, Jpn J
Clin 2008;38:670)

Chirurgie de rsection cutane

Utile aprs physiothrapie
dcongestive: 3 5 semaines
Bandages peu lastiques
quotidiens
Rduction volumtrique maximale
Exrse plastie des excdents de
peau
Face externe ou interne du mollet
Sens longitudinal
Cicatrisation normale

Chirurgie de rsection cutane

Traitement symptomatique
Ncessitant la poursuite du
traitement contention/compression
Compressions lastiques :
superposition de bas cuisse classe
3, auto-bandages
Pas de complications particulires
ni retard de cicatrisation
OUTIL SUPPLEMENTAIRE dans la
stratgie thrapeutique

Techniques alternatives
Diurtiques interdits, veinotoniques
inefficaces
Pressothrapie pneumatique
Acupuncture, endermologie (LPG)
Balnothrapie, thermothrapie
Oxygnothrapie hyperbare
K-taping
Laser
Absence dvaluation ou absence
defficacit clairement dmontre
Rodrick JR et al. PM R 2013

Conclusions
Maladie chronique : Tt au long cours
Motivation importante +++
Deux piliers du traitement
bandages peu lastiques
compressions lastiques
Autres mesures : stabilisation/
perte de poids, activit physique,
soins cutans
Suivi rgulier ncessaire

Schma de prise en charge

Chirurgien
plasticien

Kins
Orthsiste

Association
de patients

Pdicure

Patient
Oncologue

Mdecins

Infirmire

Nutritionniste
Ditticienne

Psy.