The Lymph-Sparing Quotient: A Retrospective Risk Analysis on Extremity Radiation for Soft Tissue Sarcoma Treatment

Radiation therapy (RT) for extremity soft tissue sarcoma is associated with lymphedema risk. In this study, we analyzed the influence of lymph-sparing volume on the lymphedema occurrence in patients who received adjuvant extremity RT. The lymph-sparing quotient (LSQ) was calculated by dividing the lymph-sparing volume by the total extremity volume with double weightingfor the narrowest lymph-sparing region. A total of 34 patients were enrolled in this analysis. The median applied total radiation dose was 66.3 Gy in 36 fractions. Acute lymphedema appeared in 12 patients (35%). Most of them (n = 8) were lymphedema grade 1 and five patients had grade 2 to 3 lymphedema. Chronic lymphedema appeared in 22 patients (65%). 17 of these patients had at least a grade 2 lymphedema. In 13 of 14 patients with an LSQ ≤ 0.2 and 11 of 20 patients with an LSQ > 0.2, an acute or chronic lymphedema ≥ grade 2 was observed. A Kaplan–Meier Analysis of the two groups with the endpoint of a two-year lymph edema-free survival (=2-YLEFS) was estimated with an univariate, significant result (2-YLEFS LSQ ≤ 0.2 vs. LSQ > 0.2: 0% vs. 39%; p = 0.006; hazard ratio LSQ ≤ 0.2 vs. > 0.2 2-YLEFS 2.822 (p = 0.013); 95% confidence interval (CI): 1.24–6.42). Maximizing the potential oncologically-justifiable lymph-sparing volume should be considered to reduce the risk of high-grade lymphedema when applying RT to extremities.

Theory of active lymph transport: morphofunctional foundations and clinical aspects

Its given significance of lymphangion as a structural-functional unit in the new theory of structure and functions of the lymphatic system. The construction of lymphangion in pathogenesis of lymph edema is represented. Treatment and prophylaxis must be directed at all parts of the lymphatic system.

IL-23 Expression in Stewart-Treves Syndrome: Two Case Reports and Immunohistochemical Investigation

Stewart-Treves syndrome (STS) is a rare cutaneous lymphangiosarcoma developing from chronic lymph edema as a consequence of radical mastectomy or surgical invasion of the groin for the treatment of cervical or penile cancer. Previous reports suggested possible mechanisms in the development of lymphangiosarcoma that correlate with the immunological background of STS patients. In this report, we described two cases of STS developing in patients who underwent radical dissection for cervical cancer, we employed immunohistochemical staining of IL-23 and IL-17.

Correlation between obesity and manual lymphatic drainage in Germany – a retrospective analysis from 2008 to 2016

Summary: Backgrounds: Costs for manual lymphatic drainage (MLD) paid by the Statutory Health Insurances (SHI) have increased disproportionately in Germany in the last decade. There is no obvious reason that this increase is due to an increasing number of patients with lymph edema. We therefore assume that there are large numbers of patients with obesity and obesity-associated dependency syndrome who drive the cost of MLD and did a retrospective analysis of the correlation between hospitalization rates for lymph edema and obesity and MLD prescription rates in outpatients. Patients and methods: Roughly 90 % of the German population is insured by the Statutory Health Insurance. From its reports we extracted data regarding costs and numbers of MLD session prescribed annually. Hospitalization rates for lymph edema (codes I89.*, I97.2 and Q82.0) and for obesity (ICD E66.*) were provided by the Federal Statistical Office after a specific remote analyses. Results: In the years 2008 to 2016, the MLD prescriptions in the individual federal states increased by + 43.5 % in Berlin to + 109.3 % in Mecklenburg-Western Pomerania. Number of hospitalizations with the principal diagnosis (condition, which caused the admission) hereditary and postmastectomy lymph edema are low and decreased in most federal states. Number of hospitalizations with the additional diagnosis (conditions that coexist at the time of admission or develop subsequently) obesity increased with a range from + 4.8 % in Baden-Württemberg to + 86.4 % in Mecklenburg-Western Pomerania. The correlation between the increase in prescribed MLD in the individual federal state and the increase in hospitalization rates per 1000 inhabitants of cases with obesity is greater (R2 0.4696) than with lymph edema (R2 0.0987). Conclusions: Our analysis is in line with the hypothesis that there is a correlation between the increasing prescription rate of MLD and the increasing burden of obesity in Germany.

Surgical Technique can Prevent Arm Lymphoedema After Level III Clearance for Breast Cancer

Clearance of the axillary tissue during operation is still the mainstay of treatment for node positive breast cancer. Level III axillary nodal clearance is supposed to increase the risk of lymph edema of arm, along with other factors. However, preservation of the fascia over the axillary vein during surgery reduces the risk of lymph edema greatly. In this study we measured the incidence of armlymphoedema that occured after Level III axillary clearance for breast cancer. During surgery, dissection over the anterior surface of axillary vein was limited to preserve the fascia covering axillaryvein. Other factors commonly implicated in the development of post-operative arm lymphoedema were also documented and their effect analysed. Forty three patients underwent operation for breast cancer including complete axillary clearance up to Level III. The incidence of lymphoedema was 25.5% (11 out of 43 patients). None of these patients had severe lymphoedema. On multivariate analysis, no other associated factors like BMI, chemotherapy and nodal metastases had any bearing on the development of lymph edema. We conclude that Level III axillary clearance of axilla is safe and not excessively morbid in terms of developing arm lymphoedema provided the fascia over axillary veinis preserved.

Fiddler's Neck: A Review

Fiddler's neck is a common dermatologic condition associated with instrument use in violin and viola players. It typically manifests as a submandibular and/or supraclavicular lesion. It is a benign condition, but it may be mistaken for lymph-edema or a salivary gland malignancy. Otolaryngologists who treat patients with fiddler's neck should be aware of appropriate management protocols and the need to avoid surgical excision. We obtained informed consent from 3 violinists to present their cases as specific examples of fiddler's neck. In addition, we present a literature review based on our PubMed search for articles about this instrument-induced dermatitis. The literature suggests that submandibular fiddler's neck is caused by mechanical pressure and shear stress on the skin and that it can present as erythema, scarring, edema, and lichenification. Supraclavicular fiddler's neck, on the other hand, is caused by allergic contact dermatitis, and it can present as an eczematous, scaly, and/or vesicular lesion. In most cases, a good history (especially of string instrument use), physical examination, and a patch test are sufficient to diagnose this condition. Management of fiddler's neck includes a topical steroid, proper instrument handling, neck padding, changing the instrument's materials, and/or reducing the amount of playing time. Surgical excision is usually not advisable.