2013 Vol. 24 No. 4 2013 24 4 447-456 10 20 2012 10 31 32 2012 3 Consensus Document 1 Table 1 combined physical therapy; CPT CPT 2 77
Table 1 Conservative treatment of lymphedema 1 1. Physical therapy a. Combined physical therapy (CPT) b. Intermittent pneumatic compression c. Massage alone d. Wringing out e. Thermal therapy f. Elevation 2. Drug therapy a. Diuretics b. Benzopyrones c. Antimicrobials d. Filariasis e. Mesotherapy f. Immunological therapy g. Diet 3. Psychosocial rehabilitation 3 http://ganjoho.jp 2 Newsletter 2012 Supplement 3 I IIA IIB III 4 Fig. 1 Table 2 IIA IIB 5 78
2013 Vol. 24 No. 4 Fig. 1 Early detection of lymphedema. Edema appearing on skin surface causes thickening of skin of the affected limb that can be lifted up with fingers. Table 2 Cause of edema Pathogenesis of edema Generalized edema Localized edema Increased capillary pressure Congestive heart failure Venous disease (varicosis deep vein thrombosis) Chronic renal failure Disuse syndrome Decreased plasma colloid osmotic pressure Increased capillary permeability Decreased skin compliance Liver cirrhosis Nephrotic syndrome Protein-losing gastroenteropathy Extensive burn Poor nutritional state Allergy Infection Quinckes edema Disuse syndrome Weakness of connective tissue Others Thyroid disease Lipoedema Cushing syndrome Rheumatoid arthritis Diabetes Collagen disease Drug-induced edema Advanced cancer Idiopathic edema Drug-induced edema Disorder of lymphatic system Lymphedema (plimary, secondary) Fig. 2 6 IIA I 7 Dermal Backflow Dermal Backflow IIA 8, 9 ICG Dermal Backflow Fig. 3 10, 11 79
Fig. 2 Differences in ultrasonic findings between healthy limb and affected limb. Left: Normal, A: Epidermis and Dermis, B: subcutaneous tissue, C: Muscle Right: Affected limb, A: Low echogenicity in epidermis and dermis, B: Low contrast in subcutaneous tissue and destruction of layer structure. Fig. 3 Dermal Backflow. Characteristic findings of lymphedema on fluorescence lymphography. Showing a reflux of the lymph from the lymph vessel of subcutaneous tissue to the skin surface. IIB MRI 12 IIB IIB CT MRI 3D CPT CPT IIA CPT manual lymph drainage; MLD 1 80
2013 Vol. 24 No. 4 IIB 13 III 1 IIA CPT I 14 IIA CPT CPT CPT CPT 1 Fig. 1 2 3 MLD 15 MLD MLD IIA 16 IIA MLD MLD 81
17 6 MLD MLD 18 40 mmhg IIA 19 MLD IIA MLD MLD 20 21, 22 23 Dermal Backflow 1 24 82
2013 Vol. 24 No. 4 Fig. 4 Severe edema after chemotherapy. A 54-year-old woman received chemotherapy for recurrence of right breast cancer after surgery. Thereafter, severe edema appeared on all over the right upper limb but was left untreated. 30 mmhg IIA MLD Fig. 4 25 Fig. 5 Case of inappropriate use of elastic stocking. Elastic stocking may bite into the femoral region and rather worsen edema. DVT DVT DVT Fig. 5 83
2 23 60 70 mmhg IIA 26 24 MLD IIA 27 28 CPT MLD 84
2013 Vol. 24 No. 4 CPT 70 1 International Society of Lymphology: The diagnosis and treatment of peripheral lymphedema. 2009 Concensus Document of the International Society of Lymphology. Lymphology 2009; 42: 51 60 2 2012 pp. 2 75 3 Browse N: 7. Etiology and Classification of Lymphedema. Browse N, Burnard KG, Nortimer PS: Disease of the Lymphatics, London, 2003, Arnold, pp. 151 156 4 2003 pp. 31 39 5 Bernas M, Witte M, Witte C, et al: Limb volume measurements in lymphedema: issues and standards. Lymphology 1996; 29: 199 202 6 2003; 43: 281 284 7 J Med Ultrasonics 2007; 34: 27 34 8 Yuan Z, Chen L, Luo Q, et al: The role of radionuclide lymphoscintigraphy in extremity lymphedema. Ann Nucl Med 2006; 20: 341 344 9 Maegawa J, Mikami T, Yamamoto Y, et al: Types of lymphoscintigraphy and indications for lymphaticovenous anastomosis. Microsurgery 2010; 30: 437 442 10 Kitai T, Inomoto T, Miwa M, et al: Fluorescence navigation with indocyanine green for detecting sentinel lymph nodes in breast cancer. Breast Cancer 2005; 12: 211 215 11 Unno N, Nishiyama M, Suzuki M, et al: Quantitative lymph imaging for assessment of lymph function using indocyanine green fluorescence lymphography. Eur J Endovasc Surg 2008; 36: 230 236 12 Ruehm SG, Schroeder T, Debatin JF: Interstitial MR lymphography with gadoterate meglumine: initial experience in humans. Radiology 2001; 220: 816 821 13 Dini D, Del Mastro L, Gozza A, et al: The role of pneumatic compression in the treatment of postmastectomy lymphedema. A randomized phase III study. Ann Oncol 1998; 9: 187 190 14 2011; 34: 28 31 15 de Godoy JM, Batigalia F, Godoy Mde F: Preliminary evaluation of a new, more simplified physiotherapy technique for lymphatic drainage. Lymphology 2002; 35: 91 93 16 2009; 101: 141 147 17 2 2010 pp. 1 8 18 2 2010 pp. 63 70 19 Kettenhuber G, Shetty-Lee A, Heim C: Dr. Vodder s Manual Lymph Drainage. Lecture Notes for Basic Course. Dr. Vodder Schule. 20 Pecking AP, Gougeon-Bertrand FJ, Floiras JL, et al: Primary prevention of upper limb lymphedema in breast cancer: how, why and what kind of results? Lymphology 1998; 31 (Suppl): 532 537 21 Lymphoedema Framework: Best Practice for the Management of Lymphoedema. International Consensus. London, 2006, Mep Ltd. 22 Williams AF, Vadgama A, Franks PJ, et al: A randomized controlled crossover study of manual lymphatic drainage therapy in women with breast cancer-related lymphoedema. Eur J Cancer Care (Engl) 2002; 11: 254 261 23 King M, Deveaux A, White H, et al: Compression garments versus compression bandaging in decongestive lymphatic therapy for breast cancer-related lymphedema: a randomized controlled trial. Support Care Cancer 2012; 20: 1031 1036 24 2 2010 pp. 109 130 25 85
2006; 60: 13 18 26 Partsch H, Flour M, Smith PC, et al: Indications for compression therapy in venous and lymphatic disease consensus based on experimental data and scientific evidence. Under the auspices of the IUP. Int Angiol 2008; 27: 193 219 27 Mortimer PS: Managing lymphedema. Clin Dermatol 1995; 13: 499 505 28 2 2010 pp. 131 135 Abstract Conservative Treatment of Lymphedema Based on Evidence Yoshihiro Ogawa Limbs Tokushima Clinic Key words: lymphedema, conservative treatment, manual lymphdrainage, compression, skin care Lymphedema is difficult to cure completely once it occurs. However, its proper diagnosis in the early stage of occurrence, and conservative treatment suitable for affected extremities can stabilize symptoms. Conservative treatment of lymphedema includes daily life guidance, and skin care, manual lymph drainage, compression therapy and exercise therapy for affected extremities, but there is little high level evidence-based literature examining the efficacy of each treatment. Although there is a lot of literature showing the efficacy of compression therapy, inappropriate compression therapy led to worsening of symptoms in some patients. Although therapeutic efficacy of manual lymph drainage alone is considered to be insufficient, upper extremity lymphedema in the early stage of occurrence improves with manual lymph drainage alone in some patients. The efficacy of skin care and exercise therapy in affected extremities is difficult to evaluate, but lymphedema whose aggravating factors are repeated inflammation in affected extremities and obesity is likely to be prevented from worsening by control of extremity inflammation and body weight through daily life guidance. Because the conditions of the affected extremities differ among patients, clinical experience is important for treatment selection. Jpn J Phlebol 2013; 24 (4): 447-456 86