Abstract
Zusammenfassung. Das Lymphödem ist eine häufige, chronisch fortschreitende und potenziell invalidisierende Erkrankung. In den entwickelten Ländern ist das Extremitätenlymphödem am häufigsten iatrogen nach Krebstherapien erworben. Meist gehören die radikale Lymphadenektomie sowie die Radiotherapie als essenzielle Bestandteile zum Therapiekonzept bei Krebserkrankungen. Diese sind stark assoziiert mit dem Extremitätenlymphödem. Resezierende Verfahren sollten nur im Endstadium der Erkrankung evaluiert werden, wobei die Liposuktion als Ausnahme und weniger invasives resezierendes Verfahren zu einer effektiven Gewebereduktion führen kann. Lymphovenöse Anastomosen und der mikrovaskuläre Lymphknotentransfer haben das experimentelle Stadium verlassen und stellen für ein korrekt auserwähltes Patientenkollektiv echte therapeutische Optionen dar, um die Hautqualität zu verbessern und das Fortschreiten der Erkrankung aufzuhalten. Die Kosten dafür werden zurzeit nur teilweise auf Antrag von den Krankenkassen übernommen. Für Betroffene eröffnen sich mit den mikrochirurgischen Methoden neue Aussichten auf ein besseres Leben. Um das geeignete Patientenkollektiv noch genauer zu definieren und die guten Resultate zu bestätigen, sind prospektive Studien mit höheren Fallzahlen und Langzeitstudien notwendig.
Abstract. Lymphedema is a chronic progressive and potentially debiliating disease that is frequently observed after cancer treatment. Radical lymphadenectomy and radiotherapy which are strongly associated with development of a lymphedema remain essential components of the therapeutic concept of cancer. Resection of fibrotic tissue should only be evaluated at the end stage of the disease, while liposuction is less invasive and seems to be highly effective in reducing extremity circumferences. Lymphovenous anastomoses and microvascular lymphnode transfers provide valuable therapeutic options for a properly selected patient population and can improve skin quality and limit progression of the disease. In order to further confirm the promising results, scientifically prospective studies with higher numbers of patients as well as long-term follow-up studies are necessary.
Résumé. Le lymphœdème est une maladie chronique progressive et potentiellement débilitante qui est fréquemment observée après un traitement de cancer. La lymphadénectomie radicale et la radiothérapie sont étroitement liées au développement du lymphœdème et restent des composants essentiels du concept thérapeutique du cancer. La résection du tissu fibrotique ne doit être evaluée qu’à la phase finale de la maladie, tandis que la liposuction est moins invasive et semble très efficace à réduire la circonférence des extrémités. Les anastomoses lymphovéneuses et les transferts microvasculaires des ganglions lymphatiques offrent des options thérapeutiques précieuses pour une population de patients bien précise, et peuvent améliorer la qualité de la peau et limiter la progression de la maladie. Afin de mieux confirmer les résultats prometteurs, des études scientifiquement prospectives avec un nombre de patients plus élevé sont nécessaires, ainsi que des études de suivi de longue durée.
Bibliografie
: Lymphedema: anatomy, physiology and pathogenesis. Vasc Med 1997; 2: 321–326.
: Estimating the population burden of lymphedema. Ann N Y Acad Sci 2008; 1131: 147–154.
(Hrsg.): Lehrbuch der Lymphologie. München: Urban & Fischer/Elsevier; 2010.
: Filariasis: diagnosis and treatment. Dermatol Ther 2009; 22: 475–490.
: Lymphedema beyond breast cancer: a systematic review and meta-analysis of cancer-related secondary lymphedema. Cancer 2010; 116: 5138–5149.
: Lymphedema after gynecological cancer treatment: prevalence, correlates, and supportive care needs. Cancer 2007; 109: 2607–2614.
: Lymphedema and bladder-emptying difficulties after radical hysterectomy for early cervical cancer among population controls. Int J Gynecol Cancer 2006; 16: 1130–11339.
: Incidence of unilateral arm lymphedema after breast cancer: A systematic review and meta-analysis. Lancet Ocol 2013; 14: 500–515.
: Lymphedema in a cohort of breast cancer survivors 20 years after diagnosis. Cancer 2001; 92: 1368– .
, : Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial. Ann Surg Oncol 2006; 13: 491–500.
, : Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurements. J Clin Oncol 2008; 26: 5213–5219.
, Moriguchi SM: Arm lymphoscintigraphy after axillary lymph node dissection or sentinel lymph node biopsy in breast cancer. Onco Targets Ther 2017; 10: 1451–1457.
: Imaging of the lymphatic system: new horizons. Contrast Media Mol Imaging 2006; 1: 230–245.
, : The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow stage and concept of subclinical lymphedema. Plast Reconstr Surg 2011; 128: 314e–321e.
, : Comparison of lympho-scintigraphy and indocyanine green lymphography for the diagnosis of extremity lymphoedema. J Plast Reconstr Aesthet Surg 2013; 66: 792–798.
: MR lymphangiography in the treatment of lymphedema. J Surg Oncol 2017; 115: 18–22.
S2k-Leitlinie – Diagnostik und Therapie der Lymphödeme. AWMF Reg.-Nr. 058-001. Februar 2017. http://www.awmf.org/uploads/tx_szleitlinien/058-001l_S2k_Diagnostik_und_Therapie_der_Lymphoedeme_2017-05.pdf Letzter Zugriff 04.10.2017.
: Quality of life of women with lower-limb lymphedema following gynecological cancer. Expert Rev Pharmacoecon Outcome Res 2011; 11: 287–297.
, : Financial costs of lymphedema borne by women with breast cancer. Psychooncology 2017; 26: 849–855.
: Elephantiasis of the leg. In: Latham A, English TC, editors. A system of treatment. Vol. 3. London: Churchill; 1912.
: Contribution to plastic surgery: removal of scars by stages; an open operation for extensive laceration of the anal sphincter; the Kondoleon operation for elephantiasis. Ann surg 1927; 85: 185–193.
: Buried dermal flap operation for chronic lymph-edema of the extremitis: ten-year survey of results in 79 cases. Plast Reconstr Surg 1970; 45: 541–8.
: Liposuction normalizes lymphedema induced adipose tissue hypertrophy in elephantiasis of the leg – a prospective study with a ten-year follow up. Plast Reconstr Surg 2015; 136(4 Suppl): 133–134.
: Complete reduction of arm lymphedema following breast cancer – a prospective twenty-one years’ study. Plast Reconstr Surg 2015; 136(4 Suppl): 134–135.
: SF-36 shows increased quality of life following complete reduction of postmastectomy lymphedema with liposuction. Lymphat Res Biol 2017; 15: 87–98.
, : Lymphaticovenous bypass decreases pathologic skin changes in upper extremity breast cancer-related lymphedema. Lymphatic Res Biol 2015; 13: 46–53.
: Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000; 16: 437–442.
, : Microsurgical lymphaticovenous implantation targeting dermal lymphatic backflow using indocyanine green fluorescence lymphography in the treatment of postmastectomy lymphedema. Plast Reconstr Surg 2011; 127: 1804–1811.
: Lymphaticovenular bypass for lymphedema management in breast cancer patients: A prospective study. Plast Reconstr Surg 2010; 126: 752–758.
: A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema, Plastic Reconst Surg 2013; 132: 1305–1314.
: An algorithmic approach to simultaneous vascularized lymph node transfer with microvascular breast reconstruction. Ann Surg Oncol 2015; 22: 2919–2924.
: Transverse myocutaneous gracilis with vascularized lymph node transfer. In Neligan PC, Masia J, Piller NB (eds.): Lymphedema: Complete Medical and Surgical Management. Boca Raton; CRC Press: 2016. 519–525.
: Vascularized lymph node transfer for treatment of lymphedema: A comprehensive literature review. Ann Surg 2015; 261:1013–1023.
: Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: Flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg 2013; 131: 1286–1298.
: A prospective evaluation of lymph-edema-specific quality-of-life outcomes following vascularized lymph node transfer. Ann Surg Oncol 2015; 22: 2424–2430.
: Complications of autologous lymph-node transplantation for limb lymphoedema. Eur J Vasc Endovasc Surg 2013; 45: 516–520.
: Risk of donor-site lymphatic vessel dysfunction after microvascular lymph node transfer. J Plast Reconstr Aesthet Surg 2015; 68: 551–558.
: Reverse lymphatic mapping: A new technique for maximizing safety in vascularized lymph node transfer. Plast Reconstr Surg 2015; 135: 277–285.
