Gluteal lymphoedema associated with lower extremity lymphoedema: A preliminary study with indocyanine green lymphography and magnetic resonance imaging.

INTRODUCTION: Indocyanine green (ICG) lymphography studies have identified that one in three to five patients with cancer-related lower extremity lymphoedema (LEL) demonstrated dermal backflow extending to the gluteal region. This study aimed to further characterize gluteal lymphoedema using contemporaneous magnetic resonance imaging (MRI). PATIENTS AND METHODS: Twenty-eight patients with unilateral advanced LEL who underwent both ICG lymphography and MRI prior to any surgical procedure were included in this study. The patients were divided into two groups with/without gluteal lymphoedema by the presence of dermal backflow on ICG lymphography. MRI was used to evaluate tissue changes. RESULTS: Ten patients demonstrated gluteal lymphoedema on ICG lymphography and had a higher incidence of skin hypertrophy in the gluteal region. However, no difference in excess leg volume was found between the two groups. A trend of increasing gluteal subcutaneous tissue in the affected side was identified in patients with gluteal lymphoedema with a median increase of 20% compared with an 11% increase in the non-gluteal lymphoedema group. The excess gluteal subcutaneous tissue was positively correlated to ipsilateral excess leg volume. CONCLUSION: The gluteal lymphoedema group on ICG lymphography had skin thickening in the gluteal region and was likely identified in the secondary cancer-related group. Surgical and conservative management options for gluteal lymphoedema need to be considered in advanced LEL.

Seven years of preoperative BTA abdominal wall preparation and the Macquarie system for surgical management of complex ventral hernia.

PURPOSE: To assess 7-year outcomes after complex ventral hernia (CVH) repair using pre-operative Botulinum toxin A (BTA) injection and the Macquarie System of management. METHODS: Clinical examination and functional non-contrast abdominal CT scans were used to assess complications and recurrences encountered in a prospective series of 88 consecutive CVH repairs using pre-operative BTA injection (200 or 300 units) between November 2012 and December 2019. Pre-operative progressive pneumoperitoneum (PPP) and/or component separation (CS) were also used in some cases. RESULTS: All hernia defects (mean transverse width 12.9 ± 5.2 cm) were successfully closed using either laparoscopic or laparoscopic-assisted open techniques facilitated by pre-operative BTA injection. The mean pre-operative post-BTA lateral oblique length gain was 4.7 ± 2.2 cm/side (p < 0.001). In 43 patients with defects < 12 cm wide, closure was achieved using BTA-only in 33 (76.7%), BTA + PPP in 2 (4.7%), BTA + CS in 5 (11.6%) and BTA + PPP + CS in 3 (7.0%). In the remaining 45 patients with defects [Formula: see text] 12 cm wide, closure was achieved using BTA-only in 9 (20.0%), BTA + PPP in 11 (24.4%), BTA + CS in 5 (11.1%) and BTA + PPP + CS in 20 (44.4%). There was a significant correlation between increasing defect size and the need for 2 or more CVH closure procedures (χ2 = 25.28, p < 0.0005). There were no BTA complications. Two patients developed midline hernia recurrences. CONCLUSION: Pre-operative BTA injection of the abdominal wall is a safe procedure that facilitates hernia defect closure and reduces the need for CS, especially when defect size is less than 12 cm. BTA may also decrease the rate of hernia recurrence.

The ALERT model of care for the assessment and personalized management of patients with lymphoedema.

BACKGROUND: This study documents the development and evaluation of a comprehensive multidisciplinary model for the assessment and personalized care of patients with lymphoedema. METHODS: The Australian Lymphoedema Education Research and Treatment (ALERT) programme originated as an advanced clinic for patients considering surgery for lymphoedema. The programme commenced liposuction surgery in May 2012 and then introduced lymph node transfer in 2013 and lymphovenous anastomosis (LVA) in 2016. An outpatient conservative treatment clinic was established in 2016. ALERT commenced investigations with indocyanine green (ICG) lymphography in late 2015, leading to the creation of a diagnostic assessment clinic offering ICG in 2017. RESULTS: Since 2012, 1200 new patients have been referred to ALERT for assessment of lymphoedema for a total of 5043 episodes of care. The introduction of ICG lymphography in 2015 initially allowed better screening for LVA, but is now used not only to guide surgical options, but also as a diagnostic tool and to guide manual lymphatic drainage massage. The total number of new patients who attended the surgical assessment clinic to December 2018 was 477, with 162 patients (34·0 per cent) undergoing surgery. CONCLUSION: The ALERT programme has developed a multidisciplinary model of care for personalized lymphoedema treatment options based on clinical, imaging and ICG lymphography. Patients are selected for surgery based on several individual factors.

ANTECEDENTES: Este estudio presenta el desarrollo y valoración de un modelo multidisciplinario integral para la evaluación y atención personalizada de pacientes con linfedema. MÉTODOS: El programa australiano de educación en investigación y tratamiento del linfedema (Australian Lymphoedema Education Research and Treatment, ALERT) se originó como un centro clínico avanzado para pacientes que consideran la cirugía como tratamiento para el linfedema. El programa se inició en mayo del 2012 con la cirugía de liposucción, introduciendo la cirugía de transferencia ganglionar (lymph node transfer, LNT) en 2013 y la anastomosis linfovenosa (lymphovenous anastomosis, LVA) en 2016. En 2016 se estableció una clínica de tratamiento conservador ambulatorio. ALERT comenzó las investigaciones con la linfografía con verde de indocianina (indocyanine green, ICG) a fines del 2015, lo que se siguió de la creación de una clínica de evaluación diagnóstica que ofrece ICG en 2017. RESULTADOS: Desde el 2012, 1.200 pacientes nuevos han sido referidos a ALERT para la evaluación de un linfedema, con un total de 5.043 episodios atendidos. La introducción inicialmente de linfografía con ICG en 2015 permitió un mejor cribaje para LVA, pero actualmente se utiliza no solo como guía de las opciones quirúrgicas, sino también como herramienta diagnóstica y como guía del masaje de drenaje linfático manual (manual lymphatic drainage, MLD). El número total de pacientes nuevos atendidos en la clínica de evaluación quirúrgica hasta diciembre de 2018 fue de 477, con 122 pacientes (34%) tratados quirúrgicamente. El modelo tal como se ha descrito, ha atraído a pacientes de toda Australia y Nueva Zelanda. CONCLUSIÓN: El programa ALERT ha desarrollado un modelo multidisciplinario de atención para las opciones de tratamiento personalizado del linfedema basado en la evaluación clínica, por imagen (MRI y LSG) y linfografía con ICG. Los pacientes se seleccionan cuidadosamente para el tratamiento quirúrgico en función de varios factores relacionados con el paciente, el tumor, los linfáticos y las opciones terapéuticas, y se someten a una evaluación detallada después de cualquier procedimiento.

The integration of pharmacology and pathophysiology into locoregional chemotherapy delivery via mass fluid transfer.

The prevailing paradigm of locoregional chemotherapy has been centred around delivering chemotherapy as close to the tumour as possible and in some cases incorporating vascular isolation techniques. Strategically, the development of these techniques has been rudimentary without consideration for the interdependencies between macrovascular manipulation and the microvascular effects. This review focuses on how new capabilities offered by recent advances in vascular access technology could be exploited to facilitate the mass fluid transfer (MFT) of anticancer agents to solid tumours. A haemodynamic model of MFT is proposed using the physical laws of fluid flow, flux, and diffusion that describe the microvascular effects anticancer agents may have upon tumours through the manipulation of macrovascular blood flow control. Finally, the possible applications of this technique for several organs are discussed.

Optimized sampling and parameter estimation for quantification in whole body PET.

Whole-body positron emission tomography (PET) has recently emerged as an important imaging tool for cancer detection and staging. Initial applications of the technique have been primarily qualitative. One of the major reasons is the limits imposed by kinetically undersampled data over the whole body, as opposed to the standard method of continuous dynamic sampling in one body location. In this paper, a new estimation method using weighted nonlinear least squares (WNLS) for the first bed position and Bayesian regression (BR) for subsequent positions is proposed. A general criterion for designing optimal sampling schedules which maximizes the measurement information with multiple bed positions is developed. The overall approach is illustrated with the problem of estimating the metabolic rate of glucose (MRGLu) in tumors at different axial positions (image bed positions) in the body by using computer simulations and patient data. The results show that estimates of MRGLu using sparse data and the optimized Bayesian approach are comparable with those obtained by standard methods and fully sampled data. This study demonstrates the potential of the technique described for quantification where several bed positions have to be used to image all the regions of interest (ROI).