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      A comprehensive overview on the surgical management of secondary lymphedema of the upper and lower extremities related to prior oncologic therapies

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          Abstract

          Secondary lymphedema of the upper and lower extremities related to prior oncologic therapies, including cancer surgeries, radiation therapy, and chemotherapy, is a major cause of long-term morbidity in cancer patients. For the upper extremities, it is most commonly associated with prior oncologic therapies for breast cancer, while for the lower extremities, it is most commonly associated with oncologic therapies for gynecologic cancers, urologic cancers, melanoma, and lymphoma. Both non-surgical and surgical management strategies have been developed and utilized, with the primary goal of all management strategies being volume reduction of the affected extremity, improvement in patient symptomology, and the reduction/elimination of resultant extremity-related morbidities, including recurrent infections. Surgical management strategies include: (i) ablative surgical methods (i.e., Charles procedure, suction-assisted lipectomy/liposuction) and (ii) physiologic surgical methods (i.e., lymphaticolymphatic bypass, lymphaticovenular anastomosis, vascularized lymph node transfer, vascularized omental flap transfer). While these surgical management strategies can result in dramatic improvement in extremity-related symptomology and improve quality of life for these cancer patients, many formidable challenges remain for successful management of secondary lymphedema. It is hopeful that ongoing clinical research efforts will ultimately lead to more complete and sustainable treatment strategies and perhaps a cure for secondary lymphedema and its devastating resultant morbidities.

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          Most cited references 48

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          Lymphedema: a comprehensive review.

          Lymphedema is a chronic, debilitating condition that has traditionally been seen as refractory or incurable. Recent years have brought new advances in the study of lymphedema pathophysiology, as well as diagnostic and therapeutic tools that are changing this perspective. To provide a systematic approach to evaluating and managing patients with lymphedema. We performed MEDLINE searches of the English-language literature (1966 to March 2006) using the terms lymphedema, breast cancer-associated lymphedema, lymphatic complications, lymphatic imaging, decongestive therapy, and surgical treatment of lymphedema. Relevant bibliographies and International Society of Lymphology guidelines were also reviewed. In the United States, the populations primarily affected by lymphedema are patients undergoing treatment of malignancy, particularly women treated for breast cancer. A thorough evaluation of patients presenting with extremity swelling should include identification of prior surgical or radiation therapy for malignancy, as well as documentation of other risk factors for lymphedema, such as prior trauma to or infection of the affected limb. Physical examination should focus on differentiating signs of lymphedema from other causes of systemic or localized swelling. Lymphatic dysfunction can be visualized through lymphoscintigraphy; the diagnosis of lymphedema can also be confirmed through other imaging modalities, including CT or MRI. The mainstay of therapy in diagnosed cases of lymphedema involves compression garment use, as well as intensive bandaging and lymphatic massage. For patients who are unresponsive to conservative therapy, several surgical options with varied proven efficacies have been used in appropriate candidates, including excisional approaches, microsurgical lymphatic anastomoses, and circumferential suction-assisted lipectomy, an approach that has shown promise for long-term relief of symptoms. The diagnosis of lymphedema requires careful attention to patient risk factors and specific findings on physical examination. Noninvasive diagnostic tools and lymphatic imaging can be helpful to confirm the diagnosis of lymphedema or to address a challenging clinical presentation. Initial treatment with decongestive lymphatic therapy can provide significant improvement in patient symptoms and volume reduction of edematous extremities. Selected patients who are unresponsive to conservative therapy can achieve similar outcomes with surgical intervention, most promisingly suction-assisted lipectomy.
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            Lymphedema: a primer on the identification and management of a chronic condition in oncologic treatment.

            The primary goals of oncologic therapy are the compassionate care of cancer patients, eradication of disease, and palliation of symptoms. Advances in various targeted therapies such as highly conformal and image-guided radiotherapy techniques, sentinel lymph node dissection, and molecularly targeted agents hold the promise of allowing those goals to be reached with fewer treatment-related complications. Unfortunately, certain side effects remain problematic due to the inability to completely avoid injuring normal tissues. Lymphedema, a chronic condition that occurs as a result of the body's inability to drain lymph fluid from the tissues, is a common treatment-related side effect experienced by cancer patients. In this review, many of the important aspects of lymphedema with which clinicians who treat cancer patients should be familiar are outlined, including the anatomy, pathophysiology, diagnosis, and management of this condition. The authors also identify some of the resources available both to cancer patients with lymphedema and to the clinicians who treat them. It is hoped that this review will convey the importance of the early identification and management of this incurable disorder because this is essential to minimizing its complications. (c) 2009 American Cancer Society.
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              A comparison of four diagnostic criteria for lymphedema in a post-breast cancer population.

              Breast cancer survivors are at life-time risk of developing lymphedema (LE). The goal of this research was to describe LE incidence over time among women treated for breast cancer. Limb volume changes (LVC) were evaluated by two measurement methods, circumferences and perometry, among 118 participants followed preoperative to 12 months postdiagnosis. Four diagnostic criteria were used: 200 mL perometry LVC; 10% perometry LVC; 2 cm circumferential increase; and report of heaviness or swelling, either "now" or "in the past year." Using 200 mL, the estimated LE rate was 24% (95% CI = 17%-32%) at 6 months, and 42% (31%-53%) at 1 year. Using 10% LVC, the estimated LE rate was 8% (2%-13%) at 6 months, and 21% (12%-30%) at 1 year. Using 2 cm, the estimated LE rate was 46% (36%-56%) at 6 months, and 70% (60%-79%) at 1 year. Based on reported symptoms of heaviness or swelling, the estimated LE rate was 19% (11%-26%) at 6 months, and 40% (30-59%) at 1 year. In the absence of a gold standard, we can only say that the different LE definitions are not equivalent, but cannot say which is "best". From this data, it appears that 10% LVC corresponds to a more conservative definition, whereas the 2 cm difference corresponds to a more liberal definition. These preliminary findings also document the importance of baseline (preoperative) anthropometric and symptom data and monitoring of changes over time. Further investigation of LE occurrence over an extended time period is warranted.
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                Author and article information

                Contributors
                Ramongarza3@gmail.com
                roman.skoracki@osumc.edu
                karen.hock@osumc.edu
                stephen.povoski@osumc.edu
                Journal
                BMC Cancer
                BMC Cancer
                BMC Cancer
                BioMed Central (London )
                1471-2407
                5 July 2017
                5 July 2017
                2017
                : 17
                Affiliations
                [1 ]PRMA Plastic Surgery, San Antonio, TX 78240 USA
                [2 ]ISNI 0000 0001 1545 0811, GRID grid.412332.5, Department of Plastic Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, , The Ohio State University Wexner Medical Center, ; Columbus, OH 43210 USA
                [3 ]ISNI 0000 0001 1545 0811, GRID grid.412332.5, Division of Oncology Rehabilitation Services, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, , The Ohio State University Wexner Medical Center, ; Columbus, OH 43210 USA
                [4 ]ISNI 0000 0001 1545 0811, GRID grid.412332.5, Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, , The Ohio State University Wexner Medical Center, ; Columbus, OH 43210 USA
                Article
                3444
                10.1186/s12885-017-3444-9
                5497342
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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                © The Author(s) 2017

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