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Commentary on “Factors Associated with Lower Extremity Dysmorphia Caused by Lower Extremity Lymphedema”
Eur J Vasc Endovasc Surg (2017) 54, 78
INVITED COMMENTARY
Commentary on “Factors Associated with Lower Extremity Dysmorphia Caused by Lower Extremity Lymphedema” M.S. Gohel a b
a,b,*
Cambridge Vascular Unit, Addenbrooke’s Hospital, Cambridge, UK Imperial College, London, UK
In this issue, Dr Yamamoto and colleagues1 report the results of a retrospective study to identify independent factors predictive of lower extremity dysmorphia (LED), a surrogate for significant lymphoedema. Patients with a history of pelvic cancer were included and the extent of disease on indocyanine green lymphography (as assessed using leg dermal backflow stage) had the strongest association with LED. The management of patients with primary and secondary lymphoedema remains a major cause of frustration for patients and healthcare providers. Patients may be seen by a range of healthcare specialists including vascular specialists, and there are undoubtedly enormous variations in the assessment and management of these patients. This publication builds on several other lymphoedema studies from the same group. In this report, 268 limbs (in 134 female patients) were retrospectively studied and a variety of demographic, clinical and lymphography based factors were included in the multivariate analysis. The primary assessment of lymphoedema severity was LED, a term used to describe a lower extremity lymphoedema (LEL) index > 250. While the use of novel measures of disease severity may add some confusion (and frustration), the LEL index corrects for patient BMI and therefore offers a more logical assessment of lymphoedema than traditional measures such as limb circumference or volume based assessments which are highly influenced by body physique. The lack of patient reported outcomes in this study is a limitation. It is interesting that the strongest association with disease severity (assessed by LED) was seen with lymphography findings, rather than clinical or demographic factors such as age. This contrasts with many other fields of vascular disease, where radiological and clinical correlations are often poor. This study does highlight the controversy around the optimal imaging strategy for patients with LEL. Although not in widespread use, indocyanine green lymphography is
* Cambridge Vascular Unit, Addenbrooke’s Hospital, Cambridge, UK E-mail address: [email protected] (M.S. Gohel). 1078-5884/Crown Copyright Ó 2017 Published by Elsevier Ltd on behalf of European Society for Vascular Surgery. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2017.04.016
increasingly popular and offers a novel visualisation of conducting lymphatics. However, magnetic resonance lymphangiography, microlymphangiography and even traditional lymphoscintigraphy all have enthusiastic clinical advocates supporting their use.2 The real question not addressed in this study is how imaging can help optimise patient care, particularly as the patient population is so heterogeneous. Many would argue that the diagnosis of lymphoedema is largely clinical and additional expensive investigations or time consuming assessments (such as LEL index) rarely influence clinical management. Much work is needed to improve the overall management of patients with LEL. Tertiary interventions such as liposuction, microvascular lymphovenous surgery, or debulking procedures are only available or suitable for a small minority of patients. Most patients would benefit from decongestive massage therapy and specialist compression garments, but provision of these services is often lacking. Studies from enthusiastic specialist lymphoedema centres are important. However, improvements in the development and dissemination of multidisciplinary care guidelines are needed, with a focus on the nonspecialist and community settings where most of these patients present. Only then can we begin to address the many fundamental challenges in lymphoedema management and improve the overall care of this largely neglected patient group.
REFERENCES 1 Yamamoto T, Yamamoto N, Yoshimatsu H, Narushima M, Koshima I. Factors associated with lower extremity dysmorphia caused by lower extremity lymphoedema. Eur J Vasc Endovasc Surg 2017;54(1):69e77. 2 O’Donnell Jr TF, Rasmussen JC, Sevick-Muraca EM. New diagnostic modalities in the evaluation of lymphedema. J Vasc Surg Venous Lymphat Disord 2017;5(2):261e73.
INVITED COMMENTARY
Commentary on “Factors Associated with Lower Extremity Dysmorphia Caused by Lower Extremity Lymphedema” M.S. Gohel a b
a,b,*
Cambridge Vascular Unit, Addenbrooke’s Hospital, Cambridge, UK Imperial College, London, UK
In this issue, Dr Yamamoto and colleagues1 report the results of a retrospective study to identify independent factors predictive of lower extremity dysmorphia (LED), a surrogate for significant lymphoedema. Patients with a history of pelvic cancer were included and the extent of disease on indocyanine green lymphography (as assessed using leg dermal backflow stage) had the strongest association with LED. The management of patients with primary and secondary lymphoedema remains a major cause of frustration for patients and healthcare providers. Patients may be seen by a range of healthcare specialists including vascular specialists, and there are undoubtedly enormous variations in the assessment and management of these patients. This publication builds on several other lymphoedema studies from the same group. In this report, 268 limbs (in 134 female patients) were retrospectively studied and a variety of demographic, clinical and lymphography based factors were included in the multivariate analysis. The primary assessment of lymphoedema severity was LED, a term used to describe a lower extremity lymphoedema (LEL) index > 250. While the use of novel measures of disease severity may add some confusion (and frustration), the LEL index corrects for patient BMI and therefore offers a more logical assessment of lymphoedema than traditional measures such as limb circumference or volume based assessments which are highly influenced by body physique. The lack of patient reported outcomes in this study is a limitation. It is interesting that the strongest association with disease severity (assessed by LED) was seen with lymphography findings, rather than clinical or demographic factors such as age. This contrasts with many other fields of vascular disease, where radiological and clinical correlations are often poor. This study does highlight the controversy around the optimal imaging strategy for patients with LEL. Although not in widespread use, indocyanine green lymphography is
* Cambridge Vascular Unit, Addenbrooke’s Hospital, Cambridge, UK E-mail address: [email protected] (M.S. Gohel). 1078-5884/Crown Copyright Ó 2017 Published by Elsevier Ltd on behalf of European Society for Vascular Surgery. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2017.04.016
increasingly popular and offers a novel visualisation of conducting lymphatics. However, magnetic resonance lymphangiography, microlymphangiography and even traditional lymphoscintigraphy all have enthusiastic clinical advocates supporting their use.2 The real question not addressed in this study is how imaging can help optimise patient care, particularly as the patient population is so heterogeneous. Many would argue that the diagnosis of lymphoedema is largely clinical and additional expensive investigations or time consuming assessments (such as LEL index) rarely influence clinical management. Much work is needed to improve the overall management of patients with LEL. Tertiary interventions such as liposuction, microvascular lymphovenous surgery, or debulking procedures are only available or suitable for a small minority of patients. Most patients would benefit from decongestive massage therapy and specialist compression garments, but provision of these services is often lacking. Studies from enthusiastic specialist lymphoedema centres are important. However, improvements in the development and dissemination of multidisciplinary care guidelines are needed, with a focus on the nonspecialist and community settings where most of these patients present. Only then can we begin to address the many fundamental challenges in lymphoedema management and improve the overall care of this largely neglected patient group.
REFERENCES 1 Yamamoto T, Yamamoto N, Yoshimatsu H, Narushima M, Koshima I. Factors associated with lower extremity dysmorphia caused by lower extremity lymphoedema. Eur J Vasc Endovasc Surg 2017;54(1):69e77. 2 O’Donnell Jr TF, Rasmussen JC, Sevick-Muraca EM. New diagnostic modalities in the evaluation of lymphedema. J Vasc Surg Venous Lymphat Disord 2017;5(2):261e73.