Conservative treatment of lymphedema: the state of the art.

This article aims to discuss the possibilities of conservative and non-pharmacological treatments for lymphedema. A non-systematic review of the literature was carried out, including studies involving human subjects with different types of lymphedema. Several approaches to lymphedema treatment have been reported and Complex Decongestive Therapy (CDT) has been considered the most effective treatment for limb lymphedema. Other conservative treatments have been proposed such as Taping, Extracorporeal Shock Wave Therapy, Acupuncture, Photobiomodulation Therapy, Endermologie, Intermittent Pneumatic Compression, and Low-frequency, Low-intensity Electrotherapy. The choice of the therapeutic approach to be employed should consider lymphedema characteristics, the therapist's experience, and the patient's wishes. In addition, since this is a chronic condition, the patient must adhere to the treatment. To this end, the therapeutic proposal may be the key to better control of limb volume.

Este artigo tem como objetivo discutir as possibilidades de tratamentos conservadores e não medicamentosos para o linfedema. Foi realizada uma revisão não sistemática da literatura, com a inclusão de estudos realizados em humanos com diferentes tipos de linfedema. Várias abordagens de tratamento foram relatadas, sendo a terapia descongestiva complexa considerada o tratamento mais eficaz para o linfedema de membros. Outros tratamentos conservadores foram propostos, como taping, terapia por ondas de choque extracorpórea, acupuntura, fotobiomodulação, endermologia, compressão pneumática intermitente e eletroterapia de baixa intensidade e baixa frequência. A escolha da abordagem terapêutica a ser empregada deve considerar as características do linfedema, a experiência do terapeuta e os desejos do paciente. Além disso, como é uma condição crônica, o paciente deve aderir ao tratamento. Para isso, a proposta terapêutica pode ser a chave para um melhor controle do volume do membro.

Conservative treatment of lymphedema: the state of the art / Tratamento conservador do linfedema: estado da arte

Abstract This article aims to discuss the possibilities of conservative and non-pharmacological treatments for lymphedema. A non-systematic review of the literature was carried out, including studies involving human subjects with different types of lymphedema. Several approaches to lymphedema treatment have been reported and Complex Decongestive Therapy (CDT) has been considered the most effective treatment for limb lymphedema. Other conservative treatments have been proposed such as Taping, Extracorporeal Shock Wave Therapy, Acupuncture, Photobiomodulation Therapy, Endermologie, Intermittent Pneumatic Compression, and Low-frequency, Low-intensity Electrotherapy. The choice of the therapeutic approach to be employed should consider lymphedema characteristics, the therapist's experience, and the patient's wishes. In addition, since this is a chronic condition, the patient must adhere to the treatment. To this end, the therapeutic proposal may be the key to better control of limb volume.

Resumo Este artigo tem como objetivo discutir as possibilidades de tratamentos conservadores e não medicamentosos para o linfedema. Foi realizada uma revisão não sistemática da literatura, com a inclusão de estudos realizados em humanos com diferentes tipos de linfedema. Várias abordagens de tratamento foram relatadas, sendo a terapia descongestiva complexa considerada o tratamento mais eficaz para o linfedema de membros. Outros tratamentos conservadores foram propostos, como taping, terapia por ondas de choque extracorpórea, acupuntura, fotobiomodulação, endermologia, compressão pneumática intermitente e eletroterapia de baixa intensidade e baixa frequência. A escolha da abordagem terapêutica a ser empregada deve considerar as características do linfedema, a experiência do terapeuta e os desejos do paciente. Além disso, como é uma condição crônica, o paciente deve aderir ao tratamento. Para isso, a proposta terapêutica pode ser a chave para um melhor controle do volume do membro.

Level VI lymph nodes: an anatomic study of lymph nodes located between the recurrent laryngeal nerve and the right common carotid artery. / Linfonodos do nível VI: estudo anatômico dos linfonodos localizados entre o nervo laríngeo recorrente e a artéria carótida comum direita.

OBJECTIVE: to describe the presence of lymph nodes and their relationships with demographic and anthropometric characteristics in a specific region, not yet described in anatomy compendiums, called by us Recurrent Carotid Recess (RCR) and located among the right recurrent laryngeal nerve, the right common carotid artery, and the right inferior thyroid artery. METHODS: 32 right cervical regions were harvested from cadavers within 24 hours post-mortem. The fibro-fatty tissue of the RCR was resected and prepared with formalin fixation. It was then subjected to an increasing sequence of alcohols (70%, 80%, and 90%), subsequently to a solution of Xylol, and finally to a solution of Methyl Salicylate, respecting the time required for each step. The macroscopic study was carried out on the diaphanized piece, observing the presence or not of lymph nodes. When present, they were photographed and their measurements were gauged with a digital caliper. In the microscopic study, hematoxylin-eosin staining was used to confirm the lymph node. RESULTS: the presence of lymph nodes was observed in 22 (68.75%) of the 32 specimens. The number of lymph nodes ranged from zero to six (mean of 1.56±0.29), per cadaver, and their mean size was 7.82mmx3.86mm (longitudinal x transversal diameters). CONCLUSION: the relationship between anthropometric data and presence of lymph nodes in the RCR (Fisher's exact test) was significant for medium-height individuals (p=0.03) and also white ones (p=0.04).

OBJETIVO: descrever a presença de linfonodos e suas relações com características demográficas e antropométricas em uma região específica ainda não descrita pelos compêndios de anatomia, por nós denominada de Recesso Carotídeo Recorrencial (RCR), localizada entre o nervo laríngeo recorrente direito, a artéria carótida comum direita e a artéria tireoidea inferior direita. MÉTODOS: foram dissecadas 32 regiões cervicais à direita de cadáveres com até 24 horas de post mortem. O tecido fibrogorduroso do RCR foi ressecado e preparado com fixação em formol. Em seguida, foi submetido a uma sequência crescente de álcoois (70%, 80% e 90%), posteriormente a uma solução de Xilol e, por fim, a uma solução de Salicilato de Metila, respeitando o tempo necessário de cada etapa. O estudo macroscópico foi realizado na peça diafanizada, observando a presença ou não de linfonodos. Quando presentes, foram fotografados e suas medidas foram aferidas com um paquímetro digital. No estudo microscópico, foi utilizada a coloração hematoxilina-eosina para confirmação do linfonodo. RESULTADOS: observou-se a presença de linfonodos em 22 dos 32 espécimes (68,75%), com o número de linfonodos por cadáver variando de zero a seis (média de 1,56±0,29) e tamanho com média de 7,82mmx3,86mm (diâmetros longitudinal x transversal). CONCLUSÃO: a relação entre dados antropométricos e presença de linfonodos no RCR (teste exato de Fischer) foi significante para indivíduos normolíneos (p=0,03) e também significante entre a etnia branca (p=0,04).

Lymph drainage of the upper limb and mammary region to the axilla: anatomical study in stillborns.

PURPOSE: We studied the lymphatic drainage of the upper limb and mammary region directing to the axilla to investigate whether independent pathways can be observed or whether anastomoses and shared drainage occur between them. This analysis aimed to assess the safety of axillary reverse mapping (ARM) in breast cancer treatment and to understand the development of lymphedema after sentinel lymph node biopsy (SLNB) alone. METHODS: Seven unfixed stillborn fetuses were injected with a modified Gerota mass in the peri-areolar area, palm and dorsum of the hands, formalin fixed, and then submerged in 10% hydrogen peroxide solution. Microsurgical dissection was then performed on the subcutaneous cellular tissue of the upper limb, axillary region, and anterior thorax to expose the lymphatic vessels and lymph nodes. RESULTS: The dye injected into the upper limb reached either the lateral axillary group, known to be exclusively responsible for upper limb drainage, or the anterior group, which is typically related to breast drainage. There was great proximity among the pathways and lymph nodes. Communicating lymphatic vessels among these groups of lymph nodes were also found in all studied cases. DISCUSSION: Lymphedema remains a challenging morbidity in breast cancer treatment. ARM and SLNB aim to avoid unnecessary damage to the lymphatic drainage of the upper limb. However, our anatomical study suggests that ARM may have potential oncological risks because preserved lymph nodes may harbor malignant cells due their proximity, overlapping drainage pathways, and connecting lymph vessels among lymph nodes.

Linfonodos do nível VI: estudo anatômico dos linfonodos localizados entre o nervo laríngeo recorrente e a artéria carótida comum direita / Level VI lymph nodes: an anatomic study of lymph nodes located between the recurrent laryngeal nerve and the right common carotid artery

RESUMO Objetivo: descrever a presença de linfonodos e suas relações com características demográficas e antropométricas em uma região específica ainda não descrita pelos compêndios de anatomia, por nós denominada de Recesso Carotídeo Recorrencial (RCR), localizada entre o nervo laríngeo recorrente direito, a artéria carótida comum direita e a artéria tireoidea inferior direita. Métodos: foram dissecadas 32 regiões cervicais à direita de cadáveres com até 24 horas de post mortem. O tecido fibrogorduroso do RCR foi ressecado e preparado com fixação em formol. Em seguida, foi submetido a uma sequência crescente de álcoois (70%, 80% e 90%), posteriormente a uma solução de Xilol e, por fim, a uma solução de Salicilato de Metila, respeitando o tempo necessário de cada etapa. O estudo macroscópico foi realizado na peça diafanizada, observando a presença ou não de linfonodos. Quando presentes, foram fotografados e suas medidas foram aferidas com um paquímetro digital. No estudo microscópico, foi utilizada a coloração hematoxilina-eosina para confirmação do linfonodo. Resultados: observou-se a presença de linfonodos em 22 dos 32 espécimes (68,75%), com o número de linfonodos por cadáver variando de zero a seis (média de 1,56±0,29) e tamanho com média de 7,82mmx3,86mm (diâmetros longitudinal x transversal). Conclusão: a relação entre dados antropométricos e presença de linfonodos no RCR (teste exato de Fischer) foi significante para indivíduos normolíneos (p=0,03) e também significante entre a etnia branca (p=0,04).

ABSTRACT Objective: to describe the presence of lymph nodes and their relationships with demographic and anthropometric characteristics in a specific region, not yet described in anatomy compendiums, called by us Recurrent Carotid Recess (RCR) and located among the right recurrent laryngeal nerve, the right common carotid artery, and the right inferior thyroid artery. Methods: 32 right cervical regions were harvested from cadavers within 24 hours post-mortem. The fibro-fatty tissue of the RCR was resected and prepared with formalin fixation. It was then subjected to an increasing sequence of alcohols (70%, 80%, and 90%), subsequently to a solution of Xylol, and finally to a solution of Methyl Salicylate, respecting the time required for each step. The macroscopic study was carried out on the diaphanized piece, observing the presence or not of lymph nodes. When present, they were photographed and their measurements were gauged with a digital caliper. In the microscopic study, hematoxylin-eosin staining was used to confirm the lymph node. Results: the presence of lymph nodes was observed in 22 (68.75%) of the 32 specimens. The number of lymph nodes ranged from zero to six (mean of 1.56±0.29), per cadaver, and their mean size was 7.82mmx3.86mm (longitudinal x transversal diameters). Conclusion: the relationship between anthropometric data and presence of lymph nodes in the RCR (Fisher's exact test) was significant for medium-height individuals (p=0.03) and also white ones (p=0.04).

Translation and Cross-Cultural Adaptation of the Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema into Portuguese Language.

OBJECTIVE: The objective of the study is to describe the process of translation and cross-cultural adaptation of the Lymphoedema Functioning, Disability, and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL) into (Brazilian) Portuguese. METHODS: The process was comprised of five steps - translation, back translation, revision by an expert panel, pretest, and final translation. The first translation was performed by two professionals of the healthcare area, and the back translation was performed by two translators. An expert panel assessed the questions for semantics and idiomatic, cultural, and conceptual equivalence. The pretest was conducted on 10 patients with lymphedema. RESULTS: Small differences were identified between the translated and back-translated versions, which were revised by the expert panel. The patients included in the pretest found 10 questions difficult to understand; these questions were reassessed by the same expert panel. CONCLUSION: The results of the translation and cross-cultural adaptation of the Lymph-ICF-LL resulted in a Brazilian Portuguese version, which still requires validation with various samples of the local population.

Translation and Cross-Cultural Adaptation of the Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema into Portuguese Language / Tradução e adaptação transcultural do Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema para o português brasileiro

Objective The objective of the study is to describe the process of translation and cross-cultural adaptation of the Lymphoedema Functioning, Disability, and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL) into (Brazilian) Portuguese. Methods The process was comprised of five steps - translation, back translation, revision by an expert panel, pretest, and final translation. The first translation was performed by two professionals of the healthcare area, and the back translation was performed by two translators. An expert panel assessed the questions for semantics and idiomatic, cultural, and conceptual equivalence. The pretest was conducted on 10 patients with lymphedema. Results Small differences were identified between the translated and back-translated versions, which were revised by the expert panel. The patients included in the pretest found 10 questions difficult to understand; these questions were reassessed by the same expert panel. Conclusion The results of the translation and cross-cultural adaptation of the Lymph- ICF-LL resulted in a Brazilian Portuguese version, which still requires validation with various samples of the local population.

Objetivo Descrever o processo de tradução e adaptação transcultural para o português (Brasil) do instrumento Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL). Métodos O processo foi realizado em cinco fases: tradução, retro-tradução, revisão por um comitê de especialistas, pré-teste e tradução final. A tradução inicial foi realizada por dois profissionais e a retro-tradução por dois tradutores. Um comitê de especialistas avaliou a semântica, equivalências idiomática, cultural, e conceitual das questões. Foi realizado um pré-teste em 10 pacientes com linfedema. Resultados Durante o processo de tradução e retro-tradução, foram identificadas pequenas diferenças que foram revisadas pelo comitê. Os pacientes incluídos no préteste identificaram 10 questões como sendo de difícil compreensão, as quais foram reavaliadas pelo mesmo comitê de especialistas. Conclusão Os resultados obtidos após o processo de tradução e adaptação transcultural permitiram a criação de uminstrumento que necessita ser validado emdiferentes populações brasileiras.

Safety and tolerability of Kinesio Taping in patients with arm lymphedema: medical device clinical study.

PURPOSE: The aim of this study is to assess the safety and tolerability of Kinesio Taping (KT) in patients with arm lymphedema. METHOD: Medical device clinical study in women with arm lymphedema. Kinesio Tex Gold bandage was applied by the KT technique. Assessments and interviews were carried out both at the beginning and 4 days after intervention. Skin disorders, reported tolerance and modification of limb volume and function after intervention were assessed. Changes in limb volume and functionality before and after intervention were compared by the Student's t test and the Wilcoxon Signed-Rank test, considering significant p value <0.05. RESULTS: Twenty-four women were studied. After intervention, no patient had cutaneous lesions, vesicle or limb hyperthermia, and 4.2% presented skin peeling and redness. Most patients reported no change in social life and that they felt safer in the daily activity and were very pleased with the treatment. The patients presented improvement of upper limb functionality after intervention (p < 0.001). No difference of limb volume was found after intervention (p = 0.639). CONCLUSIONS: Kinesio Tex Gold bandage by the KT technique proved to be safe and tolerable in patients with lymphedema, with improved functionality and no change of the affected limb volume.

Quality of Life and Volume Reduction in Women with Secondary Lymphoedema Related to Breast Cancer.

Purpose. To assess the quality of life (QOL) as a predictor of volume reduction in women undergoing complex physical therapy (CPT) for lymphoedema following breast cancer. Methods. Clinical trial in 57 women undergoing CPT. Results. At baseline, in measuring quality of life for the EORTC QLQ-C30 questionnaire subscale of functionality, the worst scores for emotional function (55 points) and better social function (89 points) were observed. The symptom scales showed the worst pain averaged (66 points). The overall quality of life showed a low score (40 points). In the BR 23 module, low scores were observed in the field of future perspective (47 points). After treatment of lymphoedema, absolute reduction of excess volume between the upper limbs of 282 mL was observed, representing a reduction of 15%. No association was observed between the domains of quality of life and response to treatment of lymphoedema. Conclusion. This study included 57 women with advanced and chronic lymphoedema in early treatment with CPT and low scores for quality of life. The lymphoedema therapeutic response was not influenced by the QOL at the beginning of treatment.

Experimental model of Achilles tendon injury in rats.

PURPOSE: To describe an effective experimental model to study the Achilles tendon healing. METHODS: Forty male Rattus norvegicus albinus, Wistar lineage adult male weighing 250 to 300g were used for this experiment and thirty were surgically submitted to bilateral partial transverse section of the Achilles tendon. The right tendon was treated with radio waves (RF) whereas the left tendon served as control. On the third postoperative day, the rats were divided into four experimental groups consisting of ten rats each which were treated with monopolar RF adjusted to 650 kHz and 2w, for two minutes twice a week and a group of normal animals without any intervention, until they were sacrificed on the 7th, 14th and 28th days, respectively. Tendons were weighed and collagen quantification was evaluated by hydroxyprolin content. RESULTS: Significant reduction in collagen content on day 7, 14 and 28 was related to control experiment to normal tendon (7 days, p<0.01; 14 e 28 days, p<0.05). CONCLUSION: The experimental model has been effective and available to be used to study Achilles tendon healing.

Experimental model of Achilles tendon injury in rats

PURPOSE: To describe an effective experimental model to study the Achilles tendon healing. METHODS: Forty male Rattus norvegicus albinus, Wistar lineage adult male weighing 250 to 300g were used for this experiment and thirty were surgically submitted to bilateral partial transverse section of the Achilles tendon. The right tendon was treated with radio waves (RF) whereas the left tendon served as control. On the third postoperative day, the rats were divided into four experimental groups consisting of ten rats each which were treated with monopolar RF adjusted to 650 kHz and 2w, for two minutes twice a week and a group of normal animals without any intervention, until they were sacrificed on the 7th, 14th and 28th days, respectively. Tendons were weighed and collagen quantification was evaluated by hydroxyprolin content. RESULTS: Significant reduction in collagen content on day 7, 14 and 28 was related to control experiment to normal tendon (7 days, p<0.01; 14 e 28 days, p<0.05). CONCLUSION: The experimental model has been effective and available to be used to study Achilles tendon healing.(AU)

Experimental model of Achilles tendon injury in rats

PURPOSE: To describe an effective experimental model to study the Achilles tendon healing. METHODS: Forty male Rattus norvegicus albinus, Wistar lineage adult male weighing 250 to 300g were used for this experiment and thirty were surgically submitted to bilateral partial transverse section of the Achilles tendon. The right tendon was treated with radio waves (RF) whereas the left tendon served as control. On the third postoperative day, the rats were divided into four experimental groups consisting of ten rats each which were treated with monopolar RF adjusted to 650 kHz and 2w, for two minutes twice a week and a group of normal animals without any intervention, until they were sacrificed on the 7th, 14th and 28th days, respectively. Tendons were weighed and collagen quantification was evaluated by hydroxyprolin content. RESULTS: Significant reduction in collagen content on day 7, 14 and 28 was related to control experiment to normal tendon (7 days, p<0.01; 14 e 28 days, p<0.05). CONCLUSION: The experimental model has been effective and available to be used to study Achilles tendon healing. .

Prognostic impact of the lymph node metastatic ratio on 5-year survival of patients with rectal cancer not submitted to preoperative chemoradiation

Lymph node metastases are a major prognostic factor in colorectal cancer. Inadequate lymph node resection is related to shorter survival. The lymph nodes ratio (LNR) has been used as a prognostic factor in patients with colon cancer. Few studies have evaluated the impact of LNR on the 5-year survival of patients with rectal cancer. OBJECTIVE: To evaluate the impact of LNR on the survival of patients with rectal cancer not submitted to preoperative chemoradiotherapy. METHODS: Ninety patients with rectal cancer excluding colon tumors, synchronous tumors, hereditary colorectal cancer and those undergoing preoperative chemoradiation. The patients were divided into three groups according t < 0.05). RESULTS: The 5-year survival was related to the Dukes classification, TNM, number of metastatic lymph nodes and LNR. A difference was observed in 5-year survival between the different classes of LNR. Patients classified as LNR-0 had a survival rate of 85%, while classes LNR-1 and LNR-2, 73 and 19%, respectively (p=0.0001). CONCLUSIONS: The results showed that the LNR has an impact on 5-year survival of patients with rectal cancer not submitted to neoadjuvant therapy. (AU)

Metástases linfonodais representam um dos principais fatores prognósticos no câncer colorretal. A ressecção linfonodal inadequada relaciona-se à menor sobrevida. A proporção entre linfonodos metastáticos (PLM) vem sendo utilizada como fator prognóstico em doentes com câncer de cólon. Poucos estudos avaliaram o impacto da PLM na sobrevida de doentes com câncer retal. OBJETIVO: Avaliar o impacto da PLM na sobrevida de doentes com câncer de reto não submetidos à quimioradioterapia pré-operatória. MÉTODOS: Foram incluídos 90 doentes com adenocarcinoma retal excluindo-se tumores de cólon, tumores sincrônicos, câncer colorretal hereditário e aqueles submetidos a tratamento radioquimioterápico pré-operatório. Os doentes foram divididos em três grupos segundo a PLM: PLM-0, sem linfonodos comprometidos; PLM-1, 1 a 20% dos linfonodos comprometidos; e PLM-2, mais de 21% dos linfonodos comprometidos. A identificação do ponto de corte da amostra selecionada foi obtida a partir da curva de características de operação do receptor (curva ROC). A sobrevida foi avaliada pelo teste de Kaplan-Meier, a diferença entre os grupos pelo teste de Cox-Mantel e a correlação entre as variáveis pelo teste de Pearson, adotando-se um nível de significância de 5% (p<0,05). RESULTADOS: A sobrevida em cinco anos relacionou-se à classificação de Dukes, TNM, número de linfonodos metastáticos e PLM. Houve diferença na sobrevida ao compararem-se as diferentes classes de PLM. Doentes classificados como PLM-0 apresentaram sobrevida de 85%, enquanto os pertencentes às classes PLM-1 e PLM-2, de 73 e 19%, respectivamente (p=0,0001). CONCLUSÃO: Os resultados encontrados mostraram que a PLM tem impacto na sobrevida de doentes com câncer de reto não submetidos à neoadjuvância. (AU)

Intertrigo em pacientes com linfedema de membro inferior: correlacao clinico-laboratorial / Intertrigo in patients with lower limb lymphedema: clinical and laboratorial correlation

Lesoes cutaneas interdigitais sao frequentes em pacientes com linfedema de membros e sua prevencao e tratamento sao importantes no controle da doenca e prevencao de complicacoes infecciosas. Material colhido da regiao interpododigital de 21 pacientes com linfedema dos membros inferiores do Ambulatorio da Unidade de Linfedema do Servico de Cirurgia Vascular do Hospital das Clinicas da FMUSP foram estudados atraves de exame micologico direto, cultura para fungos e exame direto por luz fluorescente. Treze dos pacientes apresentaram lesoes clinicas sugestivas de intertrigo (61,9 por cento). Em 11 destes pacientes, demonstrou-se presenca exclusiva de fungos em sete pacientes, Corynebacterium minutissimum em dois e associacao de fungos e bacterias em outros dois pacientes...

Complicaçöes raras em hérnias: relato de um caso de apendicite aguda em hérnia incisional / Rare complications in hernias: report of a case of acute appendicitis in incisional hernia

Descreve-se um caso de apendicite aguda ocorrido em uma hérnia incisional de longa duraçäo. Faz-se uma revisäo da literatura, encontrando-se apenas um caso semelhante. Comenta-se a dificuldade do diagnóstico diferencial com estrangulamento de hérnia

Sífilis gástrica: apresentaçäo de dois casos / Gastric syphilis: report of 2 cases

Apresentam-se dois casos típicos de gastropatia sifilítica, comparando-se seus resultados com os dados encontrados na literatura, advertindo-se sobre a necessidade de se fazer o diagnóstico diferencial com neoplasia