Publications about Lymphedema in English We have listed for you all the publications formatted in ENGLISH and in the category LYMPHEDEMA that are registered in our database.
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Obesity in breast cancer surgery and the development of lymphedema
Introduction: Lymphedema of the upper limbs is one of the complications in breast cancer treatment and is associated with risk factors such as axillary surgery, obesity and infection and is chiefly correlated with postoperative radiotherapy and the number of lymph nodes resected. Objective: The objective of the current study was to evaluate the association of obesity with lymphedema after breast cancer surgery. Methods: Ninety patients, randomly selected from the hospital records of a government healthcare clinic in Catanduva-Brazil, who were submitted to the surgical treatment of breast cancer, were interviewed. The inclusion criterion was to have been submitted to breast cancer surgery with axillary lymphadenectomy. The patients’ weights and body mass indexes at the time of the surgery were evaluated as was the presence of lymphedema diagnosed by clinical and volumetric criteria. The Fisher’s exact test was utilized for statistical analysis, with an alpha error of 5% (p-value < 0.05) being considered significant. Results: The mean age of the patients was 54.8 ± 11.7 years, the mean weight was 69.2 kg ± 12.5 kg and the mean body mass index was 27 kg/m2. The body mass index was > 25 kg/m2 in 60/90 patients, > 30 kg/m2 in 22/90 and > 35 kg/m2 in 5/90 patients. Lymphedema occurred in 23/60, 9/22 and 4/5 patients, with p-values of 0.059, 0.049 and 0.001, respectively. Conclusion: Obesity at the time of breast cancer surgery indicates a greater probability of developing lymphedema with the risk increasing together with the body mass index.
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Subclinical systemic lymphedema caused by increased BMI in patients with lower limb lymphedema
Lymphedema is a clinical condition that results from the buildup of macromolecules in the interstitial space leading to an accumulation of fluids. The objective of the present study is to correlate intracellular and extracellular fluid variations by comparing patients with lymphedema and different body mass indexes (BMIs): between 25 and 30, between 31 and 37 and greater than 37. Sixty consecutive medical records of patients with stage III lymphedema (elephantiasis) of the legs treated were evaluated in a cross-sectional study. The only inclusion criteria were clinical stage III lymphedema of the lower limbs and BMI greater than 25. Patients were evaluated by bioimpedance (InBody S10) to measure the intracellular and extracellular fluid content. Patients were divided into three groups depending on their BMI (25-30, 31-37 and >37). Fisher\'s exact test was used for statistical analysis with an alpha error of 5% (p-value < 0.05) being considered statistically significant. Significant abnormal increases (the difference between the actual and expected values) were found for both extracellular and intracellular fluids dependent on the increase of BMI. Obesity and its progression are associated with greater retention of intracellular and extracellular fluid, confirming the changes to the lymphatic system observed in animal studies. This aspect produces a specific type of subclinical systemic lymphedema involving body edema.
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Lymphedema in patients in different BMI ranges and therapeutic response to intensive treatment
The aim of the present study was to evaluate the therapeutic response to intensive treatment for lymphedema in different body mass index (BMI) ranges (25 to 30, 30 to 40 and > 40 kg/m2). A cross-sectional study was conducted involving 59 patients with grade III lower limb lymphedema (elephantiasis) who arrived consecutively at the Godoy Clinic in São Jose do Rio Preto, Brazil. The diagnosis was based on the clinical history, physical examination as well as intracellular and extracellular volumes, which were determined using electrical bioimpedance analysis (InBody S10 device). Statistical analysis involved the paired t-test and Kruskal-Wallis test with the Conover-Inman post hoc test, considering an alpha error of 5%. Results: Significant increases in intracellular and extracellular water were detected with the increase in BMI range. Intensive treatment led to significant reductions in intracellular and extracellular water in all BMI ranges, with the exception of intracellular water in the 25-to-30 kg/m2 range.
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Changes in Body Mass and Fat Mass Indexes in Patients Submitted to Intensive Treatment for Lymphedema
Background: Lymphedema is a medical condition that is an externalization of a lymphatic insufficiency. The aim of this study was to assess the effect of intensive lymphedema treatment on the body mass and fat mass Indexes. Method and Results: A clinical trial was performed using bio impedance to evaluate changes in the body mass and fat mass Indexes of 30 consecutive patients submitted to intensive lymphedema treatment of the legs (8 hours/day for one week) in the Clínica Godoy between 2013 and 2015. The paired t-test and Fisher’s exact test were used for statistical analysis with an alpha error of 5% being considered acceptable. Significant changes in the mean body mass (p-value = 0.0001) index was identified by comparing evaluations before and after treatment however there was no significant improvement in the fat mass index. In these cases, morbid obesity was associated with age over 40 years (Fisher’s exact test: p-value 0.01). Conclusion: A significant reduction of edema during the intensive treatment of stage III lymphedema can reflect in a significant reduction in the body mass index.
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Pilot study using bioimpedance to evaluate the treatment of arm lymphedema using diosmin and micronized hesperidin
BACKGROUND: There is no consensus on a single therapy for the treatment of lymphedema, and thus a combination of therapies is recommended. The aim of this study was to evaluate the effectiveness of diosmin with hesperidin as monotherapy to reduce breast cancer-related lymphedema as assessed by bioimpedance. METHODS: Thirteen patients aged from 46-57 years old (mean: 52.4 years) submitted to breast cancer treatment were evaluated in the Clinica Godoy in 2014 and 2016. All patients complained of swelling of the arm. Patients were included in this study if it was their first episode of swelling and edema was confirmed by bioimpedance (InBody S10). Diosmin and micronized hesperidin (Daflon®) were prescribed for one month after which the arm was again evaluated by bioimpedance. The paired t-test was used for statistical analysis with an alpha error of 5% being considered acceptable. RESULTS: Significant reductions in limb volume were detected (paired t-test: P value <0.04). CONCLUSIONS: The use of diosmin together with micronized hesperidin at the onset of breast cancer-related lymphedema can temporarily control the swelling.
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SUBCLINICAL SYSTEMIC LYMPHEDEMA MANIFESTING EARLY IN PATIENTS WITH CLINICAL LYMPHEDEMA
Objective: The objective of the present study is to compare intracellular and extracellular fluid variations in patients with lymphedema and body mass indexes between 25 and 37 witha control group. Subjects: A cross-sectional study was carried out of 30 consecutive patients with grade III (elephantiasis) leg lymphedema and BMI between 25 and 37 treated at the Clinica Godoy in São Jose do Rio Preto-Brazil. Variations in intracellular and extracellular fluid were evaluated by bioelectrical impedance analysis. Diagnosis of lymphedema was made by the clinical history, physical examination, and measurement of intracellular and extracellular fluid levels. The unpaired t-test and Fisher\'s exact test were used for statistical analysis with an alpha error greater than 5% (p-value <0.05) being considered significant. Results: Obese patients with lymphedema have more intracellular and extracellular fluid compared to obese patients without lymphedema. Conclusion: Subclinical systemic lymphedema caused by obesity manifests earlier in patients with lymphedema and worsens with the progression of obesity.
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A Rare Case of Acute Venolymphatic Insufficiency in a Neonate
We report a neonate with acute venolymphatic insufficiency after an endovascular procedure. The case of a newborn baby, who evolved with phlegmasia cerulea dolens, one type of acute venolymphatic insufficiency, after a venous endovascular procedure, is reported. Soon after the procedure, the child evolved with cyanosis that led to phlegmasia cerulea dolens following reperfusion of the limb. Lymphovenous drainage of the deep and superficial systems was performed that resulted in recovery of the limb. The drainage was performed for the periods of 20 min/h. The child required analgesic sedation to reduce movement of the limb, thereby diminishing blood flow. After 15 days, the patient no longer required analgesic sedation or lymph drainage.
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Mobilization of Fluids in the Intensive Treatment of Primary and Secondary Lymphedemas
interstitial space with a consequent buildup of fluids. Aim. The objective of this study was to compare the therapeutic response to treatment that mobilizes fluids between primary and secondary lymphedemas. Method. Thirty-three patients with severe leg lymphedema who underwent intensive treatment for five consecutive days in 2013 and 2014 at the Clínica Godoy were evaluated in a prospective clinical trial. Diagnosis was based on the patient’s history and physical examination. Treatment consisted of eight hours/day of Mechanical Lymphatic Therapy using an electromechanical device (RAGodoy®) that performs plantar flexion and extension associated with 15 minutes of Cervical Lymphatic Therapy, a technique developed by Godoy and Godoy that involves stimulation in the cervical region and a grosgrain compression stocking alternated with elastic bandages. The unpaired -test and Fisher’s exact test were used for statistical analysis with an alpha error of 5% ( value < 0.05) being considering acceptable. Secondary lymphedema was more prevalent in women (Fisher exact test value < 0.01). Results. The age of patients with secondary lymphedema was greater than those with primary lymphedema (unpaired -test: value < 0.03). The mean volume losses were 64.62% and 48.35% for the patients with secondary and primary lymphedema, respectively ( value < 0.03). Conclusion. Women are more prevalent and older in the secondary lymphedema group. Volumetric reductions below the knee are faster with intensive treatment for secondary rather than for primary lymphedema.
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Lymph Drainage of Posttraumatic Edema of Lower Limbs
Objective. /e present study was aimed at evaluating the use of mechanical and manual lymphatic therapy as a treatment for lymphedema resulting from orthopedic surgery that became painful after an episode of erysipelas. Case Report. A 70-year-old male patient su6ered direct trauma resulting in a compound fracture of the tibia and 7bula of the left leg. He was treated with an external 7xator for four months followed by plaster cast immobilization for three weeks. He presented with fever and paresthesia in the lower left limb that resulted in an episode of erysipelas, and the patient evolved with painful lymphedema. Treatment using the Godoy and Godoy technique was proposed, including manual and mechanical lymphatic therapy. Water displacement volumetry was used to quantify the leg size reduction. Results. After 10 sessions of therapy, the patient presented a signi7cant reduction in the limb volume and remission of symptoms. Conclusions. /e method used may be a promising option for the treatment of posttraumatic edemas with pain.
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Lipolymphedema Associated with Idiopathic Cyclic Edema: A Therapeutic Approach
Idiopathic cyclic edema is a type of generalized edema that mainly affects women. Diagnosis is made by the patient’s clinical history and an evaluation of the accumulation of weight during the day. The objective of this study is to report the clinical control of lymphedema associated with idiopathic cyclic edema using calcium dobesilate. A 55-year-old female patient reported generalized edema for years in that she woke up in the morning with her legs swollen and the edema worsened during the day. The physical examination revealed generalized edema. After four days of treatment with calcium dobesilate, the patient returned to the Clínica Godoy, Brazil, with less edema and reductions in body weight and the amount of extracellular and intracellular fluid. With further treatment, there was a total reduction of the edema. It is concluded that calcium dobesilate helps to control lymphedema secondary to idiopathic cyclic edema.
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Lymphatic Drainage of Legs Reduces Edema of the Arms in Children with Lymphedema
Objective. The aim of the present study is to report on the reduction of edema of lymphedematous arms just by treating the lower limbs. Methods. A 16-year-old girl reported that she has started having right lower limb edema at the age of three. At age 13, she performed a lymphoscintigraphy that confirmed the diagnosis of primary lymphedema of the four limbs. Recently she sought treatment at the Clínica Godoy in São Jose do Rio Preto where she was submitted to intensive treatment for eight hours per day for five days using manual (Godoy & Godoy technique) and mechanical lymphatic therapy (RA Godoy®) of the lower limbs, cervical lymphatic therapy (cervical stimulation), and the continuous use of a grosgrain stocking. Results. At the end of treatment, reductions in the sizes of both arms and legs were noted even without the use of any specific therapy for the arms. After four years, the size of the arms was normal. Conclusion. Treatment of lymphedema of the legs has systemic repercussions that may lead to the reduction in swelling of other untreated regions of the body.
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Adapting Lymphedema Treatment in Patients with a Mental Disability.
Background and Purpose. Mental disability is often characterized by significant limitations in adaptive skills. When this condition is associated with lymphedema, treatment requires greater commitment of the care team. The objective of this study is to report the treatment of lymphedema using only one therapeutic technique, a low-stretch grosgrain stocking. Case Report. We report the case of a 14-year-old mentally challenged female patient with lymphedema of the left leg, motor difficulties, and impaired speech and sight. According to the caregiver, lymphedema was present at birth; however, the patient had not been submitted to specific treatment. Thus, only one technique, an adapted low-stretch grosgrain compression stocking, was proposed as it could be used during daily life activities. The adaptation involved the grosgrain stocking, fastened using eyelets and cord up to the thigh, being sewn onto a pair of cotton shorts. The result was a clinical improvement with reductions in the perimeter and volume due to the compliance of the patient and the family to treatment. Conclusion. The use of a single treatment strategy in the form of a low-stretch stocking in such cases together with the involvement of a multidisciplinary team can lead to good treatment outcomes for chronic lymphedema.
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Mobilization of Fluids in the Intensive Treatment of Primary and Secondary Lymphedemas.
Background. Lymphedema is a clinical condition resulting from the accumulation of macromolecules in the interstitial space with a consequent buildup of fluids. Aim. The objective of this study was to compare the therapeutic response to treatment that mobilizes fluids between primary and secondary lymphedemas. Method. Thirty-three patients with severe leg lymphedema who underwent intensive treatment for five consecutive days in 2013 and 2014 at the Clínica Godoy were evaluated in a prospective clinical trial. Diagnosis was based on the patient’s history and physical examination. Treatment consisted of eight hours/day of Mechanical Lymphatic Therapy using an electromechanical device (RAGodoy®) that performs plantar flexion and extension associated with 15 minutes of Cervical Lymphatic Therapy, a technique developed by Godoy and Godoy that involves stimulation in the cervical region and a grosgrain compression stocking alternated with elastic bandages. The unpaired -test and Fisher’s exact test were used for statistical analysis with an alpha error of 5% ( value < 0.05) being considering acceptable. Secondary lymphedema was more prevalent in women (Fisher exact test value < 0.01). Results. The age of patients with secondary lymphedema was greater than those with primary lymphedema (unpaired -test: value < 0.03). The mean volume losses were 64.62% and 48.35% for the patients with secondary and primary lymphedema, respectively ( value < 0.03). Conclusion. Women are more prevalent and older in the secondary lymphedema group. Volumetric reductions below the knee are faster with intensive treatment for secondary rather than for primary lymphedema.
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CHEST LYMPHEDEMA AFTER BREAST CANCER TREATMENT
One of the main complications in the treatment of breast cancer is lymphedema. The tests are more specific for the diagnosis of lymphedema in the extremities, though the lymphatic drainage of the chest is also compromised and in need. The aim of the current study was to evaluate the prevalence of chest edema in patients who had been submitted to breast cancer treatment. The prevalence of chest edema in 35 women being treated for arm lymphedema due to breast cancer treatment was evaluated in a retrospective randomized quantitative, blind study in the Clinica Godoy in the period from January to October 2012 using bioimpedance of the thorax. For the descriptive analysis of the results will be used prevalence of the event. The patients’ ages ranged from 42 to 82 years old with an average of 63.7 years. Eight patients had a body mass index (BMI) of less than 25, 16 had between 25 to 30 and 10 had a BMI greater than 30. Chest edema was detected by bioimpedance in four (11.42%) patients. Chest lymphedema is less prevalent than upper limb lymphedema in patients submitted to axillary dissection or it improves faster.
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CLINICAL TREATMENT OF ARM LYMPHEDEMA IN AN OUTPATIENT SETTING: TWO YEARS OF FOLLOW UP
The aim of this study is to report on a multidisciplinary outpatient approach to the clinical treatment of lymphedema adapting the conditions of an existing work. The reduction in breast-cancer related lymphedema over two years was evaluated in a retrospective study for a group of 31 women with ages ranging between 35 and 83 years old (mean 56.6 years) in the Godoy Clinic in São José do Rio Preto. The treatment involved manual lymph drainage using the Godoy & Godoy technique, active and passive exercises utilizing facilitating apparatuses designed for these patients, a home-made compression sleeve made of a cotton-polyester fabric, nutritional guidance, psychological support, guidance about occupational activities (day-to-day activities, work and handicraft activities) and directed hydrogymnastics. Constant readjustments were made to the compression sleeves by a professional seamstress. Monthly evaluations were made by water-displacement volumetry. Analysis of variance was employed for statistical analysis with an alpha level of 5% (p-value < 0.05) being considered acceptable. The mean reduction in the first year was 55.2% and in the second year it was 75.8%, respectively, both of which were statistically significant (p-value < 0.001). Significant reduction of breast-cancer related lymphedema and maintenance of the results is possible, however routine check-ups and guidance should continue for periods determined by the treatment team.
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CONTROL OF LYMPHORRHEA AND TREATMENT OF WARTY EXCRESCENCES IN ELEPHANTIASIS
Lymphedema usually affects poor populations; there is no cure and little prospect of therapies being developed by the private health sector. This situation is aggravated in less developed countries where the lack of government resources and specialized health care professionals has led to the marginalization of this disease [1]. An association of therapies, which generally includes manual lymph drainage, compression therapy, exercises, and hygienic care, is recommended for the treatment of lymphedema [1, 2]. More recently other options, such as mechanical lymph drainage employing devices that use either active or passive muscle movements, pressure therapy, daily life activities, and hygienic, nutritional and psychological care, have been added to this arsenal [1, 3, 4]. Intensive treatment of lymphedema, which offers the possibility of the rapid control of swelling, has been reported in the literature [5]. However major problems of patients with elephantiasis are dermal lesions and lymphorrhea that make hygiene and the use of compression, which are essential for treatment, more difficult. The aim of this study is to report on the use of an Unna boot that allowed the use of an associated compressionmechanism with a resulting faster reduction in leg volume,thereby offering a new perspective in the treatment of warty excrescences and lymphorrhea in this most severe form of lymphedema.
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ERYSIPELAS AND LYMPHANGITIS IN PATIENTS UNDERGOING LYMPHEDEMA TREATMENT AFTER BREAST-CANCER THERAPY
Aim: The aim of this study was to evaluate the prevalence of erysipelas and lymphangitis in a group of patients under treatment for lymphedema after breast-cancer therapy. Methods: A random observational prospective study of the incidences of lymphangitis and erysipelas was performed for 66 patients with arm lymphedema after breast-cancer treatment. The study was carried out between March 2006 and December 2007 at the Godoy Clinic in São José do Rio Preto, Brazil. The clinical evaluation of the participants was performed weekly before the start of treatment, with patients being required to immediately report any complications to the attending service. Results: The mean time of follow-up of the patients between their treatment for breast cancer and the start of this study was 12.3 months, and three complications (4.5%) occurred; two cases of lymphangitis were reported after insect bites and one case of erysipelas after a hand injury, with repeat episodes reported by all three patients. Conclusion: In spite of prophylactic advice regarding lymphangitis and erysipelas during treatment for lymphedema after breast-cancer therapy, patients are subject to complications; however, this in itself does not justify the use of prophylactic antibiotic therapy.
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ERYSIPELAS AND ULCER OF THE LEGS IN PATIENTS WITH LIPOLYMPHEDEMA
Lipedema is a clinical syndrome that was first described in 1940 by Allen and Hines [1]. It is characterized by a bilateral and symmetrical increase in size of the lower limbs, involving the feet, with the Stemmer sign being negative and may include, among other conditions, cutaneous hypothermia, alterations in the plantar support and hyperalgesia [2]. Lymphedema is an excessive increase of fluids, proteins and other macromolecules in the subcutaneous tissue, resulting from failure of the lymph drainage system [3]. An association has been reported between lipedema and anatomic alterations of the lymphatic system [4]. Lipolymphedema is the progression of lipedema to lymphedema [5]. No association of lipolymphedema with erysipelas and ulcerated lesions has been previously described in indexed publications. A 41-year-old female Caucasian reported that since childhood she had had large thigh and leg circumferences without involvement of the feet and said that her relatives presented with similar characteristics. After the last episode of erysipelas, one year previous to this interview, an ulcerated lesion had formed in the medial and lateral malleolar region of the left leg that did not heal. On physical examination, hard edema with Stemmer sign of both legs was observed, devoid of thumb pitting and cold, but without pain. Verrucous nodular lesions and dermatosclerosis of the anterior face of the ankle of the right foot were observed.
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EVALUATION OF A CLINICAL MODEL OF BREAST CANCER-RELATED LYMPHEDEMA
One current concern relates to the report of a multidisciplinary outpatient approach to treatment that adapted existing conducts. Breast cancer-related lymphoedema results from impaired lymph drainage after axillary surgery (1). Destruction of the lymphatic system causes a progressive and chronic condition with functional impairment and disabilities, limiting patients in their daily activities and involving nearly all aspects of their quality of life. The follow-up of the clinical treatment of 20 patients with breast cancer-related lymphedema was evaluated over a period of 3 years in the Godoy Clinic in São José do Rio Preto, Brazil. All patients were women with ages that ranged from 35 to 79 years old. Lymphedema was diagnosed by differences of more than 200 mL between the affected and normal arms as identified using water-displacement volumetry. All patients were assessed by a physician, psychologist, nutritionist, physiotherapist, occupational therapist, physical educator, and a professional seamstress. The treatment included manual lymph drainage using the Godoy & Godoy technique, active and passive exercising utilizing facilitating apparatuses developed for these patients, a compression sleeve made of ‘‘gorgurão’’ (a cotton-polyester material) by the seamstress and programed hydrogymnastics (2–6). Lymph drainage was performed one or two times weekly associated with cervical stimulation for 20 minutes followed by manual lymph drainage. The patients had two-onehour sessions of hydrogymnastics per week during which they always used compression sleeves. These sessions included stretching exercises and walking around the swimming pool, group dynamics involving movements of the limbs without exertion that utilized contraction and flection of the elbow, lifting the shoulder, and adduction and abduction of the arm.
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EVALUATION OF THE EXTENT OF MOVEMENT OF THE SHOULDER: AFTER BREAST CANCER TREATMENT
Treatment of breast cancer generally involves quadrantectomy and mastectomy followed by radiotherapy and chemotherapy depending on indication. The object of the present study was to verify the extent of movement of the shoulder after breast cancer treatment and the influence of the type of surgery (quadrantectomy and mastectomy). A total of 90 women submitted to surgery for breast cancer in the Region of Catanduva, Brazil and a control group of 20 women without surgical compromise were evaluated. The extents of bilateral flexion and abduction movements of the shoulders were assessed by goniometry. The non-matched student t-test and Fisher exact test were utilized for statistical analysis with an alpha error of up to 5% being considered acceptable. Differences of 20 degrees or more in the extent of movement of the shoulders of women submitted to surgery were seen in 47.7% of the cases for flexion and in 56.6% for abduction. The compromise to the movement of the shoulder in the control group was less than 20 degrees in 9 (45%) of the women. On comparing the incidence of alterations in the movements of the arms of women submitted to surgery with the control group, a significant difference was identified for both limbs (p-value < 0.01). The articular mobility of both arms of patients submitted to treatment for breast cancer can be affected.
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EVOLUTION OF SKIN DURING REHABILITATION FOR ELEPHANTIASIS USING INTENSIVE TREATMENT
The objective of this study is to describe the evolution of the skin during rehabilitation for elephantiasis using intensive treatment. We report on the case of a 55-year-old patient with a seven-year history of leg edema. The patient reported that it began with repeated outbreaks of erysipelas over several years. One leg evolved with significant edema leading to an inability to ambulate and for about one month the patient said that he could not get out of bed. Moreover the patient was obese weighing 130 kilos and with a BMI of 39. Intensive treatment was performed over three weeks resulting in a significant reduction in limb volume. The treatment consisted ofMechanical LymphaticTherapy (RAGodoy), Cervical Lymphatic Stimulation (Godoy & Godoy technique), and a custom-made inelastic stocking of a grosgrain textile. What caught the attention during therapy were the open wounds resulting from fragmentation of the plaque as the edema reduced; the plaque was about 0.5 cm thick. As the treatment evolved the plaque disappeared and the wounds healed. The limb size decreased bymore than 80% in three weeks after which the patient began to be treated in an outpatient setting with ambulation using a grosgrain stocking.
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FACTITIOUS LYMPHEDEMA OF THE ARM: CASE REPORT AND REVIEW OF PUBLICATIONS
The aim of this study was to report a case of factitious lymphedema of the arm and related lymphoscintigraphic aspects. The case of a 36-year-old patient is reported who started to present with pain, in the 3rd finger of the right hand three years prior to this report, which she associated with her work. Joint effusion was identified and treated using a splint that restricted blood flow leading to edema of the distal third of the forearm. Since then the patient was treated however her condition worsened resulting in edema of the entire arm. Subsequently she was referred to our service. A physical examination identified a restrictive band in the axillary region of the arm that delimited the edema. Volumetry and lymphoscintigraphic examinations of the limb were performed. The lymphoscintigraphy demonstrated acceleration of the flow in the affected limb and dermal reflux. Clinical treatment with removal of the restriction allowed a rapid reduction in the volume of the limb.
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GODOY & GODOY TECHNIQUE IN THE TREATMENT OF LYMPHEDEMA FOR UNDER-PRIVILEGED POPULATIONS
The aim of this paper is to report new options in the treatment of lymphedema for under-privileged populations. Several articles and books have been published reporting recent advances and contributions. A new technique of manual lymph drainage, mechanisms of compression, development of active and passive exercising apparatuses and the adaptation of myolymphokinetic activities have been developed for the treatment of lymphedema. This novel approach can be adapted for the treatment of lymphedema in mass.
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INTENSIVE TREATMENT OF BREAST CANCER-RELATED LYMPHEDEMA IN PATIENTS WITH NEUROLOGICAL INJURIES
A lipedema is characterized by the bilateral and symmetrical enlargement of the lower limbs without the involvement of the feet and a negative Stemmer’s sign; it may cause skin hypothermia,alteration in the plantar support, and hyperalgesia. The current study aims to report a rare type of ulcerative lesion in a patient with lipolymphedema treated with a damp low-stretch bandage. The patient is a female, age 50, with a family history of lipedema, and who has suffered many episodes of erysipelas in the lower left limb for approximately 20 years. For over five years ulcers which are difficult to heal have appeared. She was treated with a damp low-stretch bandage and the healing of the wound has shown significant improvement. Ulcerative lesions are rare in lipolymphedema; however, their occurrence is associated with difficulties in healing.
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INTENSIVE TREATMENT OF LEG LYMPHEDEMA
INTENSIVE TREATMENT OF LEG LYMPHEDEMA
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INTERFERENCE OF THE SURGICAL TREATMENT OF BREAST CANCER ON PERSONAL HYGIENE
One current concern relates to the sequels experienced after surgery and radiotherapy, as the physical, psychic, and social limitations directly affect the quality of life of the women. It is well known that physical limitations frequently limit activities such as brushing the hair and dressing. Personal care is a series of recommendations concerned with the daily activities of patients which are considered important in the prevention of complications following surgery (1,2). The objective of the current study was to evaluate the interference of the surgical treatment of breast cancer on personal hygiene habits.
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INTERMITTENT OCCUPATIONAL-RELATED LYMPHEDEMA
Objective: The aim of this study is to report on the occurrence of intermittent occupational-related lymphedema in sugarcane harvesters in Brazil. Clinical Features: Two cases of cane cutters are reported. The first is a 39-year-old male who reported that his right hand had been swelling during the course of the working day over the previous eight years and the second, a 48-year-old female, had noticed swelling on the back of her hand for five years. Discussion: These reports warn of decompensation of venous and lymphatic return during manual sugarcane harvesting. Swelling and pain may appear in workers due to repetitive movements with a negative impact on their work. The absence of escriptions in respect to sugarcane harvesting is because of a lack of clinical investigations. Conclusion: Cutting sugarcane can cause intermittent workrelated lymphedema. Further clinical investigations may help to improve the quality of life of workers in many different types of jobs that involve repetitive movements.
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IS LYMPHOSTASIS AN AGGRAVANT OF LIPEDEMA?
A 54-year-old female patient reported that a characteristic of her family was ‘fat legs’ with postural edema since adolescence. Over the years the patient had been gaining weight with an increase in fatty tissue in the legs and arms. At the age of 24 years she started taking oral contraceptives and noted worse swelling and pain in the lower limbs. She was advised to suspend the use of the contraceptives and to start using a transdermal lymphatic system drug and physical exercise which partially improved the symptoms. Three years ago she noted that the swelling was increasing without improvement and sought a physician who raised the hypothesis of lymphedema and referred her to a specialized center. Lipedema and lymphedema was diagnosed in the physical examination. A 3-day intensive treatment program (8 h daily) was started for lymphedema which included manual and mechanical lymph drainage associated with short-strech (<50 mm Hg) compression stockings custom made using a cotton-polyester fabric. Volumetry and perimetry were performed before starting and after the treatment and the legs were photographed. Volumetric and perimetric reductions were obtained suggesting the involvement of regional cutaneous lymphostasis in this disease.
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LARGE REDUCTION IN VOLUME WITH THE INTENSIVE TREATMENT OF LYMPHEDEMA: REDUCTION OF FLUIDS?
The aim of this study is to report on the intensive treatment of lymphedema of the legs demonstrating a large reduction in volume in a short period of time. The case of a 29-year-old female patient, who developed the most serious form of lymphedema, associated with verrucosities of the leg and genitalia is reported. Elephantiasis evolved after surgery and radiotherapy. The patient was treated at the Clinica Godoy in Sao Jose do Rio Preto, Brazil using an intensive course of treatment. Baseline and then daily evaluations of the leg perimeter and body weight were performed during treatment. Intensive treatment for 8 hours daily was performed on an outpatient basis using manual and mechanical (RAGodoy device, São Jose do Rio Preto, São Paulo-Brazil) lymph drainage and the continuous use of a compression garment made of a cotton-polyester textile and adjusted every 3 hours. A reduction of 31 kg was seen in 10 days (over 2 weeks); in the first few days, the patient lost 6 kg per day. Due to the excess of skin, the length of intensive treatment sessions was reduced to avoid the compression garment causing a tourniquet effect, the size of the compression stocking was only adjusted once per day and daily walks were included in the treatment program. After 1 month, the size of the leg was reduced by another 4 kg. Intensive lymphedema treatment is an option that rapidly reduces edema, and constant use of low-stretch compression maintains the result achieved and continues to reduce the swelling.
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LYMPH DRAINAGE IN PREGNANT WOMEN
Aim.The aim of this study was to evaluate the efficacy of lymph drainage to reduce edema of pregnant women. Method. Pregnant women (30 limbs) from the Obstetrics Outpatient Clinic of theMedical School of Santa Casa in S˜ao Paulo in the period December 2009 to May 2010 were enrolled in this quantitative, prospective study. The patients, in the 5th to 8th months of gestation, were submitted to one hour of manual lymph drainage of the legs.The volume of the legs wasmeasured by water displacement volumetry before and after one hour of drainage using the Godoy & Godoy manual lymph drainage technique.The paired
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LYMPHEDEMA IN KLIPPEL-TRENAUNAY SYNDROME: IS IT POSSIBLE TO NORMALIZE?
Theaimof this study is to report the results of intensive therapy of lymphedema associated with Klippel-Trenaunay syndrome.A24- year-old female patient reported that her family had observed edema in her right leg and port wine stains frombirth. For ten years, they consulted with different specialists in the region but the prognosis did not change and no specific treatment was found. In 2014, at the age of 24, with massive lymphedema, a leg ulcer, and recurrent infections, she started treatment at the Cl´ınica Godoy in São José do Rio Preto. She was evaluated by clinical history, physical examination, water displacement volumetry, and bioimpedance. Intensive therapy (8 hours daily) was proposed usingManual Lymphatic Therapy (Godoy & Godoy), Cervical StimulationTherapy, Mechanical Lymphatic Therapy, a grosgrain stocking adjusted several times a day, and the use of Unna boot in the region of the ulcer. The volume of edema was reduced by about 44% within the first week with further reductions in the following weeks and healing of the ulcer. Subsequently, it was possible to control and maintain the reduction in swelling with less intense treatment. It is possible to reduce and maintain the treatment results of lymphedema associated with Klippel-Trenaunay syndrome.
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LYMPHEDEMA POST-BREAST CANCER SURGERY: A POPULATIONAL STUDY
Aim: The aim of this study was to evaluate lymphedema post-breast cancer surgery in a small town in Brazil. Design: Study census-type populational of the town of Palmares Paulista, Brazil in the period from September 2008 to May 2009. Method: The prevalence of lymphedema post breast cancer surgery was evaluated in 1583 women. Home visits were made on Saturdays and Sundays by a physician, physiotherapists and an occupational therapist. In a single visit, female residents were questioned about surgical treatment of breast cancer, time of surgery, outbreaks of erysipelas and the presence of edema after the surgery. A diagnosis of edema was reached from the patients’ personal feeling that the arm became swollen after treatment. Results: Of the 1583 women who participated in the study, 32 had been submitted to the surgical treatment of breast cancer with axillary dissection, with 12 (37.5%) reporting subsequent edema of the arm. Only one episode of erysipelas or cellulitis was reported. The time from surgery varied between 2 and 12 years with a mean of 7 years. Conclusion: Patients submitted to breast cancer surgery suffer a high rate of lymphedema but a low incidence of arm infections.
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MECHANISMS USED TO FACE DIFFICULTIES ENCOUNTERED FOLLOWING SURGICAL TREATMENT FOR BREAST CANCER
Qualitative studies report factors that may affect the quality of life (QoL) of patients after breast cancer treatment. These range from lack of information provided by healthcare professions, in relation to complications, which include lymphedema and inflammatory processes, to emotional problems including shock, fear, revulsion, frustration, a negative body image, anxiety and depression.1,2. Another aspect that is stressed are the social sequelae that include changes in role, lack of social support, pain and aptitude. Pain is an important aspect for psychological and social morbidity resulting in a reduction of the QoL. It has been suggested that researchers should use psychological and social measures, together with the physiological parameters, to evaluate these patients.3 It is important to stress the necessity to evaluate functional losses among breast cancer survivors and to look for an appropriate form of rehabilitation.4,5 Thus, rehabilitation programs for patients after breast cancer treatment show that this approach can improve the QoL by reducing their suffering.2,4 However, mechanisms used by patients to face the difficulties are generally not considered. The objective of the current study was to investigate mechanisms used by patients after breast cancer treatment to overcome difficulties that they encounter.
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PAIN IN BREAST CANCER TREATMENT: AGGRAVATING FACTORS AND COPING MECHANISMS
The objective of this study was to evaluate pain in women with breast cancer-related lymphedema and the characteristics of aggravating factors and coping mechanisms. The study was conducted in the Clinica Godoy, São Jose do Rio Preto, with a group of 46 women who had undergone surgery for the treatment of breast cancer.The following variables were evaluated: type and length of surgery; number of radiotherapy and chemotherapy sessions; continued feeling of the removed breast (phantomlimb), infection, intensity of pain, and factors that improve and worsen the pain.Thepercentage of events was used for statistical analysis. About half the participants (52.1%) performed modified radical surgery, with 91.3% removing only one breast; 82.6% of the participants did not perform breast reconstruction surgery. Insignificant pain was reported by 32.60% of the women and 67.3% said they suffered pain; it wasmild in 28.8% of the cases (scale 1–5),moderate in 34.8% (scale 6–9), and severe in 4.3%. The main mechanisms used to cope with pain were painkillers in 41.30% of participants, rest in 21.73%, religious ceremonies in 17.39%, and chatting with friends in 8.69%. In conclusion, many mastectomized patients with lymphedema complain of pain, but pain is often underrecognized and undertreated.
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PENILE AND SEXUAL REHABILITATION IN A PATIENT WITH LYMPHEDEMA OF THE PENIS
The aim of this study is to report on penile rehabilitation in lymphedema of the penis with a new compression mechanism and the implantation of a penile prosthesis for sexual rehabilitation. The case of a 72-year-old patient with a history of edema of the penis for 6 years is reported. The patient reported that he had had periods of edema and redness and that the swelling had worsened over time. A clinical diagnosis of lymphedema of unknown etiology was made; the hypotheses were that the etiology was late congenital lymphedema of the penis or lymphedema aggravated by inflammation and/or infection. A new compression mechanism made using a cotton-polyester fabric (low elasticity and ribbed) was employed. The continued use of compression therapy led to almost complete reduction of the edema and the patient tried to return to be sexually active. A specific medication was used for erectile dysfunction; however, it resulted in no improvement and so a penile prosthesis was implanted. The development of lymphedema in advanced disease is distressing for patients and their carers and can prove difficult to manage for health care professionals involved in their care [1] . Penile and scrotal lymphedema produces a monstrous deformity with psychological impact and occasionally extreme mental anguish. Erection and sexual intercourse are very difficult or impossible, and the scrotal enlargement interferes with walking [2] . Surgical treatment is an option in the treatment of lymphedema [3] . The use of compression garments is a well-established practice in treating lymphedema of the penis [4] . The aim of this paper is to report on penile rehabilitation in lymphedema of the penis with a new compression mechanism and the implantation of a penile prosthesis for sexual rehabilitation.The case of a 72-year-old patient with a history of edema of the penis for 6 years is reported ( fig. 1 ). The patient reported that he had had periods of edema and redness and that the swelling had worsened over time. A clinical diagnosis of lymphedema of unknown etiology aggravated by inflammation and/or infection was made. Infectious causes were ruled out and treatment of acute lymphedema was proposed at the moment of treatment.
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PHANTOM BREAST SYNDROME IN WOMEN AFTER MASTECTOMY
The phenomenon of phantom pain was first associated to amputation of injured limbs during the war (1). Individuals who had lost a limb consistently reported a feeling that it still existed, associated in some cases, to severe pain. This type of feeling appears to be common after mastectomies and is often accompanied by other psychological symptoms; even so these syndromes are often underdiagnosed (2). The phantom symptoms can present as a persistent feeling of heaviness, itching or tingling called phantom breast sensation, or just pain, known as phantom breast pain; both can occur in all or part of the phantom breast (3). The pathophysiology of phantom breast pain is not fully understood and it is less studied than phantom limb pain (4). Some studies report a frequency of phantom breast pain ranging from 7 to 17.4% (5,6). On the other hand it is essential to differentiate between phantom pain and chronic pain which is quite commonly felt by women after mastectomies, especially with conservative surgery. Moreover, mastectomy for many women is a stigma of mutilation that is associated with psychological symptoms and severe phantom breast pain is referred to as a symptom of these changes. The aim of this study was to evaluate the presence of phantom breast syndrome and report symptoms such as pain and its intensity, manner of coping, the search for physical and psychological treatment, as well as socio-demo-graphic aspects of mastectomized women.
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POSTURAL HYPOTENSION ASSOCIATED WITH NONELASTIC PANTYHOSE DURING LYMPHEDEMA TREATMENT
The case of a 72-year-old female patient with elephantiasis is reported. The patient was submitted to two surgeries to remove the edema. After surgery, the leg again evolved to elephantiasis and eventually she was referred to the Clinica Godoy for clinical treatment. Intensive treatment was carried out (6 to 8 hours per day) and the patient lostmore than 70% of the limb volume within one week. After this loss, the volume was maintained using grosgrain compression pantyhose for 24 hours per day. During the return appointment, the patient suffered from systemic hypotension (a drop of more than 30mmHg within three minutes) while she was standing after removing the stocking. A further investigation showed that the symptoms only appeared when the stocking was worn for 24 hours. Thus, the patient was advised to use the stocking only during the day thereby avoiding the symptoms of hypotension.
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PREOPERATIVE PREPARATION OF A PATIENT WITH GRADE II LEG LYMPHEDEMAFOR HIS THIRD HIP REPLACEMENT SURGERY
INTRODUCTION: The treatment of lymphedema remains a challenge to modern medicine, due to thecharacteristics of the disease.CASE PRESENTATION: Report on the case of a 75-year-old patient with lower limb lymphedema for treat-ment prior to surgery. At age 45, he made the first hip replacement surgery in the left leg. One year laterhe performed the same surgery on the right leg. At that time his legs had slight ankle edema mainly ofthe left leg and the entire left leg was affected by lymphedema. At 68 years old the patient returned tothe surgeon, who indicated a third surgery to replace the left hip prosthesis. The patient was evaluatedby bioimpedance, which measured the volumes of right and left legs at 5.52 and 7.24 l, respectively. Fivedays of intensive treatment were proposed using Mechanical Lymphatic Therapy (RAGodoy®), ManualLymphatic Therapy and compression therapy with a grosgrain stocking for 24 h per day. On the fifth day,there was significant improvement in the volume (right leg 4.45 l and left leg 5.57 l).DISCUSSION: In this case report intensive treatment was used to reduce the volume of leg edema priorto a surgery to replace a hip prosthesis in a patient with grade II leg lymphedema. Small positive andnegative changes, which are common in the evolution of this type of case but the end result was a totalreduction of the edema.
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QUALITY OF LIFE AND PERIPHERAL LYMPHEDEMA
QUALITY OF LIFE AND PERIPHERAL LYMPHEDEMA
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SENSITIVITY AND SPECIFICITY OF COMBINED PERIMETRIC AND VOLUMETRIC EVALUATIONS IN THE DIAGNOSIS OF ARM LYMPHEDEMA
The objective of the current study was to evaluate the sensitivity and the specificity of perimetry combined with volumetry in the treatment of lymphedema. Ninety women, who had been submitted to breast cancer surgery, were randomly selected in the Government Healthcare Clinic for this study. Only patients who underwent surgical treatment of breast cancer with some degree of lymphadenectomy were included in the study cohort. Individuals with activedisease, whether local or otherwise, functional alterations of the upper limbs before breast cancer surgery were not included. The following possibilities were considered: 1 – the perimetry evaluation was considered positive when the difference between the affected and unaffected sides was ³ 2 cm for any one of the seven measurements and volumetry was ³ 100 mL; 2 – perimetry ³ 2 cm and volumetry ³ 200 mL; 3 – a difference > 10% between the two limbs in volumetry and perimetry. Prevalence, sensitivity, specificity, positive predictive value, negative predictive value and accuracy were evaluated statistically with an alpha error of 5% considered acceptable (p-value < 0.05). The mean age of the women was 54.8 ± 11.7 years. The sensitivity, negative predictive value and accuracy were higher using perimetry when a volume ³ 2 cm were considered. The specificity and positive predictive values were better when the difference was greater than 10% between the two limbs by both perimetry and volumetry. Perimetry is a reliable method in the diagnosis of lymphedema when differences > 2 cm between the two limbs should be considered.
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SURGICAL TREATMENT OF ELEPHANTIASIS OF THE FEET IN CONGENITAL LYMPHEDEMA TO FACILITATE THE USE OF A COMPRESSION MECHANISM
The aim of the current study is to report on the minimal surgical treatment of elephantiasis of the feet to facilitate the use of compression mechanisms. The cases of two patients with congenital lymphedema that evolved to elephantiasis involving the feet are reported. Intensive treatment of the lymphedema was performed with a significant reduction in size thus allowing a better identification of the limits of tissue masses for the surgical approach. This reduction enabled primary suturing of the lesions to be carried out and fast healing of the wounds. The surgery greatly improved large deformities of the toes and feet and facilitated further treatment of the lymphedema using bandaging. Thus, the skin was preserved, there was a reduction in the size of the feet, and the patients were able to start wearing shoes.
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