6. Very Brief Lymphedema Review Flashcards
What are Initial Lymphatics?
Lymphatic capillaries
- Passive starting point of the lymph system
- Unidirectional, single layer of endothelial cells
- Located between the skin and muscle
- Empty into collecting vessels
What are Collecting Vessels?
Thin vessels with weak muscular walls
Require pressure changes to move lymph fluid
Contain unidirectional valves that prevent back flow
Empty into lymph nodes
What are lymph nodes?
Filtering stations for cleansing lymph fluid
Trap bacteria, CA, broken cells
Centers for growth and storage for lymphocytes
Empty into ducts
What does the Thoracic Duct drain?
Drains LUE and B LEs. Empties into junction of left internal jugular and left subclavian veins (R thoracic duct does RUE and empties at same spot but on the R)
What is the Cisterna Chyli?
Most inferior part of the thoracic duct
What are functions of the Lymph?
Immune System Defense Nutrition (intestinal lymph vessels absorb digested fats) Fluid Balance (Filtration and Reabsorption)
What is Filtration?
Blood capillary pressure > Plasma osmotic pressure
Greater out
What is Reabsorption?
Plasma osmotic pressure > Blood capillary pressure
Greater in
What is Sterling’s Law of the Capillaries?
The direction and rate of fluid exchange (filtration/reabsportion) between capillaries and the interstitial space are dictated by the hydrostatic and osmotic pressures of the two fluids
What is Lymph Obligatory Load?
10% of capillary ultrafiltrate resorbed as lymph obligitory load - includes proteins too large to return through the venous system
Lymphatic capillaries resorb lymphatic fluid and transfer it back into the venous system
What is most common problem in lymphatic system?
Lack of ability to reabsorb
You see 2 swollen legs, what is likely wrong?
CV problem
What is Chronic Venous Insufficiency?
Occurs due to vein blockage or insufficient valves of the veins
Risk factors: age, female (progesterone), being tall, genetics, hx of LE DVT, obesity, pregnancy, sitting or standing for a long time
Increased pain with standing but decreased pain with LE elevation. Ulcers on legs and ankles. Fibrotic skin changes on the legs and ankles (lipodermatosclerosis)
Is Swelling a symptom?
Yes…a symptom that needs a diagnosis
How do you treat generalized clinical edema?
Proper dx and medical management (localized requires apporopriate therapy)
Is lymphedema often misdiagnosed?
Yes
What is Lymphocytosis?
Elevated WBC
Lymphomas?
Acquired injury to DNA of a lymphocyte, causing a malignant transformation into a liquid tumor (Hodgkin’s (young adults) and non-Hodgkin’s
IS HIV/AIDS a lymphatic system disorder?
yes
Lymphocele -
A lymph-filled collection in the retroperitoneum devoid of any epithelial lining; post-op complication of radical gyn surgery
Lymphadenitis?
Infection of the lymph nodes, often due to bacterial infections
Lymphangitis?
Infection of lymph vessels, often due to bacterial infections
What is LIPIDema?
Chronic disease of lipid metabolism
- Symmetrical impairment of nodular fatty tissue distribution and storage combined with the hyperplasia of individual fat cells
- Usually occurs in women w/ family hx
- Diagnosis is based on clinical history and physical examination
- Associated with HYPERmobility syndrome
Where does lipidema usually present?
In the upper arm and LEs (but SPARES THE FEET!)
- Usually symmetrical
- Often painful to palpation (secreted cytokines/toxic enzymes)
- Negative for Stemmer’s Sign
- Often assoicated with a estrogen/progesterone hormonal disturbance (estrogen metabolites in tissue can make fat cells develop)
When does lipidema usually onset?
Onset typically at puberty due to high hormone levels (pregnancy and menopause may also exacerbate)
When diagnosing Lipidema, what other causes must you rule out?
Superior VEna Cava syndrome, hypothyroidism, dental abcesses, Inferior Vena CAva Syndrome
What is Hypoproteinemia?
Low protein levels in blood, high levels in urine
-Swelling due to increased lymph-to-plasma ratio
Hypoalbuminemia?
Liver failure, cirrhosis, metastasis
Amyloidosis?
Abnormal amyloid protein accumulation in tissues
Multiple Myeloma?
Hematological cancer
Diffuse myexedema?
Severe hypothyroidism, fluid accumulation assoicated with proteoglycans in the interstitial space of the dermis
When does lymphedema occur?
When lymphatic load exceeds transport capacity - results in a stagnation and subsequent accumulation of protein-rich lymphatic fluid
Due to lymph drainage failure, obliterated lymphatics, or obstructed lymphatics
Can be orthopedic pain but usually no pain w/ palpation
What is Primary Lymphedema and which gender is it more common in?
Lymphangiodysplasia - malformation of the lymph system in utero. Occurs more often in females; usually bilateral
Starts DISTALLY and progresses prox; possible genetic component
What are the three different Primary Lymphedema Onset Categories?
Milroy’s Disease - presents at birth (LEs involved; congenital)
L. Praecox (before age 35; onset at puberty)
L. Tarda - After age 35 (non-hereditary)
Is lipidema primary or secondary?
Primary
What are Cystic Hygromas?
Forms in utero from embryonic lymphatic tissue
Lymphangiomas?
Congenital malformations involving the skin and subcutaneous tissues
Lymphangiectasias?
Represent superficial lymphatic dilation caused by a wide range of scarring processes
Lymphangiomatosis?
Lymph vessel tumor or cyst most often found in bone and lung
Difference between Grade I and II Lymphedema?
I - soft, pits, (mild, moderate, severe)
II - Fibortic, hard, no pitting
What is Human Lymphatic Filariasis?
Infection secondary to nematode worms - larvae introduced through mosquito bite
Presentation: Emephantiasis, hydrocele, lymphedema - mainly seen in equator and southern hemipshere
What are 4 reasons for a rise in secondary lymphedema?
Increasing age of population
Increasing incidences of obesity
Increased number of cancer survivors
Increased use of radiation therapy due to minimally invasive surgeries
*This is the greatest risk with cancer!
What is the risk of lymphedema assoicated with?
ALND (Axillary LN Disease) and SLNB (Sentinal LN Biopsy)
Risk of Breast Cancer also associated with XRT to the breast post lumpectomy (SLNR and chemo too)
XRT to the axilla/supraclavicular nodes increased the risk of lymphedema, but SLNB has revolutionized the risk reduction of lymphedema
LE Lymphedema risk factors?
LN removal from groin region (including melanoma)
RT to groin area increases risk
LE lymphedema risk is greater due to the gravity dependence of the LEs
Risk factors of genital Lymphedema?
XRT to groin area
Inguinal dissection
LE COMPRESSION PUMPS! Can cause or worsen
(but compression garments can be beneficial)
Head and neck lymphedema risk?
Resection of cervical lymph nodes results in a risk of head and neck lymphedema
XRT to the cervical lymph nodes also increases the risk
As the end point of the lymph system, compromise in this area can result in lymphedema in other regions
Risk factors for cancer proven by research in women?
Obesity
Poor general health
Hx of cancer
What is a Lymphangiography?
(aka lymph node angiogram) It is…a test which utilizes XR technology, along with the injection of a contrast agent, to view lymphatic circulation and lymph nodes for diagnostic purposes
What is lympscintigraphy?
Imaging technique used to identify the lymph drainage basin and determine the number of sentinel nodes - can mark sentinal nodes in breast cancer
Different lymphedema assessment techniques?
Measurements
Water displacement
Tissue tonometry - weighted device on skin measures depth of penatration
Perometry - infrared optoelectronic volumetry (creates circumference profile chart; used for assessment and garment fitting)
Bioelectrical Impedance Analysis - electrically measures water (good for UE edema in FEMALES)
Moisture meter (head and neck h2o content)
Near Infrared (NIR) Fluorescence Imaging
What is Stemmer’s Sign?
A thickened fold of skin at the base of the second toe or second finger that can gently be pinched and folded
-More common in primary
POSITIVE when skin cannot be lifted
(Absence does not rule out possibility of lymphedema)
What are some self-reported outcomes?
FACT-B (v4)
LBCQ
Morbidity Screening Tool
GCQL
What are the 4 major components of Complete Decongestive Therapy?
Manual Lymphatic Drainage
Compression (dis to prox)
Exercise (inc in HR and RR pumps lymph)
Skin Care / Education (lower skin pH)
(avoid cuff weights and machines that press weight down thru shoulders)
What is Charles Procedure?
Removes skin and all underlying at tissue down to the fascia then skin grafted
Liposuction?
MUST wear compression garments of lymphedema recurs
Microsurgery?
Lymphaticovenular Bypass uses lymphangiography to locate appropriate alternate lymphatic vessel to create anastomosis
What is Vascularized Lymph Node Transfer?
Microsurgical node transplant/vessel connection for lymphangiogenesis in area of lymphedema
- Donor sites of groin/contra supraclavicular, axillary
- -Lympedema risk/incidence at donor site region
- -Therefore, use lymphoscintigraphy to determine less significant nodes to harvest
Lifelong compression post-op
Two investigationsal modalities?
High voltage pulsed current
Low level laser therapy
What is Ascites?
the accumulation of fluid in the peritoneal cavity, causing abdominal swelling.
How does SLNB work?
If negative on frozen section, procedure is complete
If positive, surgeon will perform complete dissection of lymph nodes (most tumors aka 75% have 2+)
Is there any data to prove air travel causes lymphedema?
Nope
What is Axillary Reverse Mapping?
Modified lymph node mapping technique for identifying the SLN while preserving the functioning UE lymphatics to minimize the risk of lymphedema
Isosulfan blue dye in injected in the ipsilater upper inner arm along the intramuscular groove…and tracks in the lymphatics to the axilla and serves to identify the lymphatic channels of the arm
What is LYMPHA (Lymphatic Microsurgical Preventive Healing Approach)?
Pioneered by Italian physician Boccardo
Procedure consists of performing lymphatic-venous anastomoses (LVA) at time of completion of AD
