Biologic Background

Common idea: Lymph is ~90% reabsorbed in venous end
New theory: NO reabsorption in capillary!

RT decreases no. of dermal…
RT -> hypoxia -> lymphatic endothelial senescence -> increased lymphangiogenesis (which is abnormal, with increased permeability)

Factors

Head and Neck Cancer

Breast Cancer

Gynecologic Cancer

Assessment

Circumference measure

• Conventionally… Elbow, 10cm proximal and distal, wrist, MCP
• Difference ≥2cm

Perometer

• Utilizes an array of moving optoelectronic infrared sensors
• No reimbursement.. Only 3 institutions

Bioimpedence

• Limb index ratio = resistance of unaffected/affected
  • >1.139 if the affected arm was the dominant arm
  • >0. …

Radionuclide lymphoscintigraphy

• Uptake pattern of regional LNs.
• Uptake pattern of main lymphatic vessels
• Presence of dermal backflow
• Presence of collateral lymphatic vessels

Indocyanine green (ICG) lymphography

Ultrasound

• Skin and SQ thickness..

CT lymphangiography

• Pts prefer over MR bc it’s quick and cheap (1/10).

MR lymphangiography

• T2 high SI. Contrast-enhancement is required

Treatments

Intensive Care

• Skin care
• Exercise/movement
• MLD
• MLB (multi-layer bandage)
• ±IPC

Maintenance

Bandages and Compression

MLB

Tubular bandage -> elastic fixation bandage -> padding (for even-pressurizing) -> short-stretch (저탄력) bandage

Pneumatic compression

More chambers than DVT prophylactic compressor

Elastic stocking

Arms: class 1-2
Legs: class 3-4

Differences between stockings & bandages

• Working pressure increase is more evident in bandage

Alternative compression materials

• Adjustable compression wraps, with foam block,

Pharmacologic treatment

• Flavonoids:entelon
• Naftazone?
• On clinical trial
  • Tacrolimus?

Surgical Treatment

Lymphovenous anastomosis (LVA)

Vascularized LN transfer (VLNT)

Liposuction

---

AMC pf 권진근

Lower level LASER Therapy (LLLT)

(LITT, 1st gen)

(PDT, 2nd gen)

(PBM, 3rd gen)

• Reimbursement: up to 20 min, >2 min for each location

Physical grounds

	Continuous LASER	Pulsed LASER
	DNA impairement	Activates repair mechanism

Surgical Methods

AMC pf 권진근

Past: Charles’ procedure
Current: Microsurgery

Lymphatico-venous anastomosis; LVA, 림프관정맥간 문합술

Making detour to Vein

• Preop evalulation
  • MRI / ICG lymphangiography / USG
  • vein should be in proximity, functioning lymphatic duct is essential
• Intraop evaluation
  • Milking test

Lymph node to vein anastomosis; LNVA 림프절정맥간 문합술

Vascularized lymph node transfer; VLNT 혈관문합 림프절 이식수술

Omental VLNT
Inguinal VLNT

Indication

• Already had LVA, having contraction

Removing adipose tissue

• Ablative surgery
• Liposuction
  • Usually 1L, up to 5L

Biobridge insertion

FDA-approved

No 5yr f/u data.

Postop management

Can walk on the day of the surgery!

Compression bandage

• 24hr for 6 months, and then tapering

Weight reduction, hydration

Lymphatic Duct Injuries

Traumatic thoracic duct cyst

Surgical management

• Mass removal + TD mass ligation
• Complete excision 이 표준
• 흉관 mass ligation이 동반

Intervention

Observation

Nontraumatic chylothorax leak

Due to e.g., lymphoma..
Duct ligation – not essential

• Hard to find a leak point
• Chemical pleurodesis – may be curative
• Chemotherapy – may regress with disease
• Radiotherapy – should pinpoint the leakage site. Highly effective, but localization is always the problem.