림프부종 (Lymphedema) 서울 성모병원 완화의학과 이 용주
Goal of palliative care QoL Physical spiritual emotional Socioeconomical
Introduction Definition : Pathological conditions in which protein-rich fluid accumulates in soft tissue of the affected body part resulting from lymphatic system disruption Affect physical and psychological well-being
Prevalence, cause, symptoms Prevalence : not exactly known, 0~56% Most common cause Surgery, radiation Common malignancy : breast, ovary, prostate, cervix, m. melanoma, lymphoma Symptom : heaviness, tight sensation of the skin, decreased flexibility of the affected joint. Itching or burning sensation functional problem : walking, wearing, handling
Risk factor High Risk Factors Axillary LN dissection Sentinel node biopsy Obesity Other Risk Factors Surgery Local radiation Delayed wound healing Lymphatic obstruction Scarring of lymphatic duct d/t RT, surgery Pelvic, peritoneal mass Genetic predisposition
Pathophysiology 1. Changes in lymphatic system lymphatic flow 2. Interstitial fluid accumulation dilatation of lymphatic duct, valve insufficiency 3. Fibrosis of lymphatic wall 4. High protein fluid accumulation Inflammatory change 5. macrophage activation fibrosis of soft tissue 6. Fibroblast movement into interstitial tissue colagen accumulation 7. Pitting edema as a inflammatory effect 8. Chronic infection, malignancy potential
Lymphagionsarcoma
Stage and grade Clinical staging(중등도에 따름) Stage I 부종이 있고 피부를 누르면 들어가며 부종부위를 높게 유지하면 부종이 감소 Stage II 섬유경화증이 생겨 조직이 단단하며 피부를 눌러도 들어가지 않고 감염 될 위험이 높은 경우 Stage III 부종이 매우 심하고 피부에 변화가 온 경우로 일명 상피증(lymphostatic elephantiasis)이라고 함 Common Terminology Criteria for Adverse Events v3.0 (CTCAE) Grade I 림프 부종이 있는 사지 중 가장 눈에 띄는 부위에서 반대측과 5~10%의 차이(부피 혹은 둘레): 팽대, 함요부종, 해부학적 구조물이 모호해짐. Grade II 림프 부종이 있는 사지 중 가장 눈에 띄는 부위에서 반대측과 10~30% 의 차이(부피 혹은 둘레): 피부주름의 소실, 해부학적 구조물의 명백한 소실 등 Grade III 림프 부종이 있는 사지 중 가장 눈에 띄는 부위에서 반대측과 30% 이상 의 차이(부피 혹은 둘레): 임파 유출(lymphorrhea), 해부학적 구조의 육 안적인 변형 : 일상생활 활동의 방해 Grade IV 악성으로의 진행(lymphangiosarcoma), 사지 절단 고려, 기능상실
Diagnosis Diameter Volume estimation Routine exam : CXR, ECG, blood test Lymphoscintigraphy lymphangiography : X
Diameter 15cm 10cm
Lymphoscintigraphy
lymphedema management Prevention Correct underlying cause Exercise Low stretch bandage Compression Garments Pneumatic compression Medication
Level of evidence Level 1 : exercise improves lymphedema symptoms of pain and quality of life Level 2 : compression garmet improves lymphedema volume Level 3 : dietary MCT improves lymphedema volume but no diff. in symptom Level 4 : self massage, elevation Controversy : LLL(low level laser)
Prevention 1.작은 상처라도 입지 않도록 주의한다 : 칼로 베임, 벌레 물림, 동물에게 할큄, 벌에 쏘임 2.무거운 것을 들지 않는다. 3.사지를 항상 청결하고 건조하게 유지한다. 4.충분한 보습제를 바르고 자외선차단제를 사용한다. 5.열기에 15분 이상 노출되지 않도록 한다. 목욕물은 38.9 C 이하로 한다. 6.장갑을 착용하여 가사일이나 기타 작업으로부터 손을 보호한다. 7.손톱을 자를 때 각별히 조심하고 가위보다는 손톱 깎기를 사용한다. 8.제모가 필요하면 전기면도기를 사용한다. 9.부종이 생긴 사지에서 혈액채취나 주사를 피한다. 10. 부종부위가 붉어지거나 부어 오르고 통증이 생기면 진료를 받는다. 11. 부종부위에 작은 상처나 갈라짐이 생겨도 진료를 받는다. 12. 항공 여행시 압박 스타킹을 착용하고 기내에서 자주 움직인다.
Differential diagonosis Vascular cause : DVT Senile edema Heart failure Myxedema : hypothyroidism Lipoedema : hormone
Exercise Prevention and treatment for lymphedema Good exercise : walking, swimming, yoga, ballet Rationale : muscle contraction moves lymph flow from tissue into lymphatic system increase protein absorption Aerobic exercise : increase sympathetic tone Slowly progressive weight lifting Isometric exercise : not recommended
Compressive Bandages
Compression Garments(lymphedema sleeves or stockings)
Compression garmet vs. compression bandage Garment Bandage Disability vs volume reduction Support Care Cancer (2012) 20:1031 1036
Intermittent external pneumatic compression Provide additional effect Volume reduction, joint motion Cancer 95 (11): 2260-7, 2002 Iran Red Crescent Med J. 2012; 14: 210-7. Limited availability in palliative setting
Pharmacologic therapy NLN : lymphedema should not be exclusively treated with drugs or dietary supplements Vitis vinifera(entelon) : regulation of extracellular matrix, angioprotector for venous insufficiency Benzopyrones : stimulate macrophage activity and promote the breakdown of proteins in the lymph fluid. Diuretics : These promote excess fluid in the body to be excreted, not recommended for long term use
Combined decongestive therapy(cdt) Manual lymphedema drainage skin care CDT low-stretch bandaging exercises
CDT(Combined decongestive therapy) Goal Return to a latent stage Maintain near normal limb size Prevention and elimination of infections Reduction and removal of fibrotic tissues
CDT(Combined decongestive therapy) Primary treatment when unresponsive to standard elastic compression therapy Divided in two phase 1 st phase(working phase) : intensive treatment for volume reduction 2 nd phase(resting phase) : maintenance treatment at home(elastic sleeve and lowstretch bandage )
Manual lymphedema drainage Effect Stimulate the intake of lymphatic loads Increase in lymphangiomotoricity Reverse of lymph flow Increase in venous return Increase parasymphathetic response Analgesics
Manual massage light superficial massage with gentle, rhythmic skin distention, ideally limited to pressures of approximately 30 mmhg to 45 mmhg Abdominal breathing Lymphnode massage distal to proximal superficial massage
Skin care Meticulous hygiene Low ph moisturizers Complication Superinfection : impetigo, cellulitis, erysipelas, lymphangitis Elephantiasis lymphangiosarcoma
Limitation of CDT Multidisciplinary approach Doctor, nurse, therapist, volunteer Time and cost consuming Device Insurance system
Other Physical Therapy Thermal therapy Low Level Laser therapy Hyperbaric oxygen therapy TENS
Palliative Care for Cancer-Related Lymphedema: A Systematic Review Joint project of the American Lymphedema Framework Project (ALFP) and the international Lymphoedema Framework (ILF) Aim : to provide Evidence-based clinical practice guidelines for all aspects of LE diagnosis and management A systematic review of 2004 2010 literature on LE management in palliative care : 11 articles from 5927 Putting Evidence into Practice (PEP) classification Towers et al
<4 categories> Result 1. Closed-controlled subcutaneous drainage 2. Manual lymphatic drainage (MLD) 3. Compression therapy : Multi-layer bandaging, Kinesio taping 4. Complete decongestive therapy (CDT) Small sample size, lack of objective tool Effectiveness not established
Case M/70 Prostate cancer DM/HTN/A-fib PSKT(2007) Grade III
Treatment Hx Not effective Stocking apply and manual massage Medication : Entelon 150mg bid Effective Leg elevation : only half day Needle lymphatic drainage : small drainage volume
Needle aspiration US : fluid collection Consider position, gravity Image from google
Lymphatic drainage Procedure Scalf Needle puncture and drainage Multiple Scalf Needle puncture and urostomy apply
유용한 사이트 대한 림프부종 학회 : www.kslymph.or.kr/ National Lymphedema Network(NLN) : http://www.lymphnet.org/ www.cancersupportivecare.com/rc600.html#rc646 NCI(National Cancer Institute) : www.cancer.gov/cancertopics/pdq/supportivecare/ lymphedema