Janice N. Cormier, MD, MPH, FACS

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Secondary Lymphedema

• Janice N. Cormier, MD, MPH, FACS
• 1st International NLN Patient Summit
• August 18-20, 2005

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Overview

• Definition
• Common Causes
• Extremity
• Problems with diagnosis
• How?
• When?
• What should we do?

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Secondary LE

• LE which results from the disruption or
  obstruction of the lymphatic pathways
• Reduced lymphatic flow with increased pressure in
  remaining lymphatic channels
• Accumulation of protein-rich fluid in tissues -
  mechanisms are not fully understood
• 90 cases of LE in U.S. are due to tumors or as
  a consequence of treatment

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Common causes

• Malignant tumors
• Trauma
• Surgery
• Radiation

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Malignant Tumors

• Tumors that develop within a limb causing
  obstruction of lymphatic flow
• sarcomas

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Trauma

• Direct injury causing disruption of the
  lymphatic channels

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Surgery

• Surgical disruption of lymphatic system
• Vascular surgery
• Orthopedic procedures
• Tumors that spread to lymph nodes
• Breast cancer
• Melanoma
• Genitourinary (GU)
• Gynecologic (GYN)

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Surgery
Orthopedic procedures
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Axillary metastasis
Upper Extremity

• Breast cancer
• Melanoma

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Breast Cancer

• Removal of level I / II lymph nodes
• Incidence LE 30 - 40
• Quality of life
• Family relationships
• Function
• Depression/anxiety
• Self-esteem

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Melanoma

• Primary sites located on
• extremities
• More extensive in lymph
• node dissections

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Melanoma
Upper Extremity
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Groin Metastasis
Lower Extremity

• Melanoma
• GU malignancies
• Gyn malignancies

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Melanoma
Lower Extremity
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Lower Extremity LE

• Melanoma (40 - 75)
• Gynecological cancers ( 50)
• Genitourinary cancers
• Prostate cancer (1 66)
• Penile cancer (14 57)
• Bladder cancer (10 23)
• Soft tissue
• Sarcoma (12 20)

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Radiation therapy

• Goal is to destroy malignant cells but can also
  damage normal cells
• Causes fibrosis of lymphatics interfering with
  passage of lymphatic fluid

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Radiation

• In combination with surgery, radiation is
  strongly associated with LE (RR 6.9)

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Problems with Diagnosis

• Estimated that 24,000 people diagnosed with LE
  annually in U.S.
• True incidence unknown
• Lack of awareness
• Lack of convenient, accurate, objective
  measurement methods
• Variations in criteria used to define LE
• Inadequate follow-up reporting

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Measurement Methods

• Water displacement gold standard
• Circumference
• Perometry
• Bioelectrical impedance

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Water Displacement

• Gold standard for volume measurement

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Circumference

• Most commonly used method to assess limb volume
• Measurements taken at various points of arm or
  leg
• Time-consuming
• Requires considerable experience

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Perometry

• Imaging device
• Measures limb volume, circumference, contour,
  cross-sectional area
• Convenient
• Expensive

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Bioelectrical Impedance

• Measures extra-cellular resistance
• Measurements are then used to calculate volume
  difference between limbs
• Research

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No standard definition

• Circumference
• gt 2 cm or more difference between limbs
• Clinical grades
• Grade I - Asymptomatic
• Grade II - Mild
• Grade III - Moderate
• Grade IV - Severe
• Volume
• gt 200 mL difference, gt10 volume difference
• Few studies demonstrate correlation between
• volume and function or QOL

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Onset of LE

• Varies
• Average time to onset 14-24 months
• Prevalence increases over time
• Severity often associated with duration of
  symptoms

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Prevention / Management

• Early detection
• Post-operative surveillance
• Prompt reporting of symptoms
• Risk Reduction Practices
• Early referral to LE treatment center

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Summary

• Secondary LE is a common condition associated
  with the surgical treatment of many solid tumors.
• Underreported in the literature
• Education, surveillance and early management are
  critical