So thanks so much for sticking it out for this last lecture of the day. We're gonna make it fun, so that way when you guys finally go get your cafe au lait and your beignets, you'll be in a really, really good mood. So today we're gonna be talking a little bit about some just high-level updates about the field of lymphedema and lymphedema assessment diagnosis and treatment, and then some of my awesome colleagues here are gonna go over some cancer-specific related cases and head and neck lymphedema, scrotal and abdominal lymphedema, and also central lymphatic disorders. So I'm Jasmine Zang, I'm an assistant professor at the University of Pennsylvania, and the director of our Cancer Rehab Fellowship and our Cancer Rehab Program. So no disclosures. So why should you be here? Well, you guys are already here, but why should you stay here for the remainder of this lecture? So many of you are probably building a practice or one day going to be thinking about building a practice, and one of the things is not a lot of people necessarily know what cancer rehab or rehab is, but they know what lymphedema is. They know what lymphedema is, but they don't know how to treat it, and they need people who know how to treat it. And so I think it's a really great way to open the gateway if you introduce yourself as someone who sees lymphedema and can manage lymphedema, and that way, when they come and refer patients to you, you can then showcase all your other amazing skills. And in fact, in this past year, in 2023, the National Comprehensive Cancer Network actually encouraged the early detection diagnosis and early referral for lymphedema in cancer survivors. So they're starting to recognize how important it is. The other thing is there's a growing interest in the lymphatic system. I don't know how many of you recall learning about the lymphatic system when you were in medical school, but I certainly don't remember any lectures on it. But thankfully, the NIH is starting to recognize that this is actually an incredibly important bodily system. And if you think about all the different diseases that occur in our body, it is actually amazing how many are impacted by our lymphatic system, as seen here in this PowerPoint slide. Sorry, the words are tiny. And over the last seven to eight years, there's been some really amazing discoveries in our field. For example, about seven years ago, we discovered meningeal lymphatics, and we discovered that not only are there meningeal lymphatics, but they actually drain into our cervical lymph nodes. And also that they play a role in things like development of neurodegenerative diseases. And when neurodegenerative diseases happen, they can actually impact how our lymphatics function as well. And in fact, there's also roles for maybe stroke recovery, for hepatic cirrhosis, and the list goes on. And finally, in 2022, the NIH actually designated a new research condition and disease categorization term, lymphatic research and lymphedema, finally. And they put together a group of scientists who are now actually responsible for mapping the entire lymphatic system. And we also need to have people who are knowledgeable about this in the field, and be physician leaders in the field. Recently, I gave a lecture on lymphedema at the National Lymphedema Network Conference, and afterward, a plastic surgeon came up to me and said, hey, we need more people like you. And I was like, what, me? And he was like, yes. I mean, you know, I'm a surgeon, I love doing surgeries on lymphatics, and therapists are really wonderful in providing decongestant therapy, but there's no one who's really leading this multidisciplinary group of individuals. And you can be here to do the assessment and to help manage these patients, and we need more people like you. And so that really got me thinking. And so if I haven't convinced you yet, just remember, the lymphatic system is actually really, really cool. I mean, just check out this lymph node with sunglasses, and you'll be convinced. I don't wanna spend too much time going over lymphatic anatomy, except to just remind us that it is connected to our circulatory systems. It moves incredible amounts of fluid. And there's both a superficial and a deep layer. So if you think about it, our superficial layer starts underneath our skin. It's composed of dead-end capillary tube, lymphatic capillary tubes, that form essentially a spiderweb across our entire body. It eventually connects through perforating collectors with our deep lymphatic system. In our leg, the superficial and deep lymphatics meet at the inguinal area. In the arm, they meet in the axillary region. They're complementary, meaning that, so for example, if there's a lymphatic obstruction in the deep lymphatics, it's gonna utilize, for example, the superficial component to then transfer fluid. And that's how we see things like dermal backflow on imaging. Dr. Lee is gonna spend 15 minutes talking about the central lymphatic system, so I don't wanna get too much into it, but just to remind us all that this actually does exist. And we may not typically think about the central lymphatic system when we're talking about lymphedema in our cancer patients, but it is actually quite important. And in fact, patients with peripheral lymphedema can have central lymphatic problems, and central lymphatic problems can lead to peripheral lymphedema. And while the thoracic duct's lymphatic flow is predominantly from the intestines and the liver, about 20% does come from the soft tissue compartments. So depending on what part of the lymphatic system is malfunctioning, we start seeing primary or secondary lymphatic issues. I'm not gonna go too much into the detection, except to say these are historically common ways that we measure or monitor lymphedema. But I really wanted to just give a broader overview about some of the diagnostic options that are available to here. And I specifically didn't put bioimpedance spectroscopy partly because of time, but also because I think it kind of straddles between that detection and diagnosis. So first in terms of lymphocentrography, so this has been around for over 50 years. This is a nuclear medicine test that's probably going to be more readily available at most of your institutions. It involves injection of a radiolabel tracer in between the web spaces of the hands or the feet. And it can be done intradermally, subcutaneously, or subthasially. And depending on what you're looking for, you may be injecting in one layer or multiple layers. Subthasially is gonna give you more information about the deep lymphatics, but it can be more technically difficult. And I rarely ever see this done. It's able to show you, visualize, it's able to give you quantitative and qualitative information about your lymphatic system. So depending on what you are looking for, it might give you information about how quickly the tracer is going to your lymph nodes, or how much of it reaches your lymph nodes, or whether qualitatively you're seeing actual linear lymphatic ducts, or ducts that are engorged, or no ducts at all. Unfortunately, as you can see from the images, sometimes there's poor resolution. And because there's no standardized protocol across systems, I have found in my own experience that this can be a really difficult test to reliably interpret. For example, at my own institution, depending on which of the different hospitals I order this from, or which radiologist reads this, sometimes I get qualitative information, sometimes I get quantitative information. Sometimes I get tests that end at an hour, which doesn't really give me necessarily enough time to ask about dermal backflow or the presence of it. And sometimes the texts have the patients move around versus others where that might not really happen. MRI lymphangiogram, on the other hand, provides much better image resolution for the lymphatics. So, as we all know, MRI is really good for looking at things like edema, fat, and soft tissue composition. And so this is no different. So, specifically with MRI lymphangiogram, if we're looking at the peripheral lymphatic system, we're gonna be injecting, again, in between the web spaces of the hands or the feet. And this is going to be a gadolinium-based contrast that's injected. And sometimes, depending on your institution, they may also provide a IV infusion of an iron-based liquid that can then suppress the venous imaging. So that way you can tell the difference between lymphatic vessels and the veins, because otherwise it can be quite difficult to tell. And what's really wonderful about MRI lymphangiograms is you can then also look at the degree or how progressive the lymphedema is. So, for example, in earlier stages of lymphedema, you should see more fluid versus in later stages where it's gonna be more fat composition. The main thing about, the one big downside is that this is quite time-consuming. It is very technically challenging. For example, at our institution, we have one interventional radiologist who performs this and is able to read this, is trained to read it. And it's definitely much more expensive. And sometimes I've had a little bit of trouble getting insurance companies to approve it because they just have no idea that this exists. I'm gonna kind of skip over this, except just to say with primary lymphedema, we're able to look at the nodal and lymphatic vessel structures. With secondary cancer-related lymphedema, you can definitely see some specific details that might indicate changes to the lymphatic system. For example, with tumor nodes, you might see an afferent lymphatic vessel that's dilated or disrupted. With those who have had asteroid lymph node dissections that have resulted in post-mextectomy lymphedema or lymphedema in the lower extremity after a groin pelvic dissection, you might have more dilated or tortuous lymphatic collectors. And then for those who might have had radiation or surgery to lymph nodes, either you're gonna have reduction in lymph nodes or maybe smaller lymph nodes or nodes that are more irregularly shaped. Now, ICG lymphography is another imaging technique that has been around for a long, long time. And prior to its use for a lymphatic system, it was used for a lot of other things like cardiovascular function. And we probably are more familiar with it because a lot of our surgeons might use it for sentinel lymph node biopsies. But what's really beautiful about ICG lymphography is it can give us real-time information about lymph flow. Unfortunately, it does only allow us to see the superficial layer, so we're not able to look at the deep lymphatics. And depending on what we're seeing superficially, linear, dermal, or splash patterns, it gives us an indication of the progression of lymphedema and the severity of the lymphedema. And you can see how much clearer on the left ICG is than, for example, a comparison with lymphocentigraphy in the same arm. I just wanted to share a really interesting study that came out by Louise Kohlmeyer in 2021. She utilized ICG lymphography to actually better personalize manual lymphatic drainage in our cancer survivors. So she took 339 cancer survivors with secondary, unilateral, or bilateral lymphedema in the upper or lower extremity, and injected them with ICG. If you've ever gone through complete decongestant therapy training as a certified lymphedema therapist, you'll know that they actually teach that when you have an axillary lymph node dissection, for example, you are going to perform manual lymph drainage, but never drain into the ipsilateral arm where the axillary lymph node dissection happened. Instead, you're gonna be moving that fluid towards a contralateral axilla and spending time moving it to the ipsilateral groin. But what she found that was really interesting was that in the majority of patients, whether it be they had mild lymphedema or more moderate to severe lymphedema, they still drained into the ipsilateral axilla, followed by the clavicular region, then the parasternal nodes, followed by the contralateral axilla, and 0% actually drained into the pelvic lymph nodes. So this was quite a landmark paper, and this has, at least at our institution, changed the way that we perform manual lymph drainage, and our therapists and patients have actually found much better results because of this, and we're no longer wasting time doing manual lymphatic drainage towards the inguinal region. And very similar with the lower extremities, she found that the majority of patients had drainage into the ipsilateral inguinal region rather than into the upper extremity or the contralateral side. Ultrasound, I wanted to mention this quickly as well. It's a really great bedside tool, a rapid evaluation of our lymphatic system if you have it. You don't need an injection into the wet spaces of the hands or the feet, and you don't necessarily need insurance authorization, but what you can see on the ultrasound is any changes in that trilaminar structure of our dermal epidermoid complex, and in cases with even mild lymphedema, you can see dermal edema right away. And that change may not correlate directly with what you might see, or with that change in clinic for that same patient, you may not be actually visibly seeing any volumetric differences, so this can be quite sensitive for mild lymphatic changes. And there's actually also now something called ultra-high frequency ultrasound, which has frequencies about 70 megahertz, so this is about roughly 10 times what we might usually use in our probes for an MSK shoulder injection. And this can help us actually visualize the inner lumen of a lymphatic vessel, so there are some plastic surgeons who are starting to use this in their lymphatic surgeries. Briefly, I wanted to just go over surgical procedures for prevention as well, so axillary reverse mapping is a procedure where we're trying to spare the arm lymphatic drainage when we're performing an axillary lymph node dissection. There's currently a large phase three clinical trial going, multi-center breast trial going, studying whether this really is truly helpful. In a small study that came out in 2023, it does sound like that is particularly hopeful in preventing lymphedema, or at least reducing lymphedema rates in our breast cancer patients. Lympha is another prevention procedure where we're actually performing lymphatic venous anastomosis at the time of an axillary lymph node dissection. I think the verdict is still out here as well, but in a paper published in 2022 and 2023, there's been some conflicting evidence on whether it's truly helpful. And quickly, just three main surgical procedures for lymphatic, for peripheral lymphedema. So I like to separate this out between those that have more mild cases of lymphedema versus those that have more severe progressive lymphedema. So in earlier stages where it's more fluid predominant, the patient may be more a candidate for a lymphatic venous anastomosis, or a vascularized lymph node transfer, or vascularized lymph vessel transfer. So specifically with lymphatic venous anastomosis, you're diverting lymph into the venous system by connecting lymphatic vessels to the veins. And these are with plastic surgeons who are essentially micro, micro plastic surgeons, because the connections that they're making can be less than one millimeter in diameter. And when performed, there's actually been some pretty encouraging results in our cancer population. So at one year post-op, volume reductions with earlier stages of lymphedema have ranged between 75 to 90%, versus in later stages where it might be more, a little bit less, but still encouraging. And in addition to volume reduction, we've seen decreases in rates of cellulitis episodes as well, and also the need for garment use. Similarly, with vascularized lymph node transfer, we have also seen decreases in volume, infection rates, and garment use. There's two ways that this can happen. One, we can actually transfer a vascularized lymph node, or we can actually take the lymphatic vessel. And the idea is, we're not exactly sure how it works, but the thought is, with a lymph node, it can act as a sponge, or promotes lymphangiogenesis, versus a vessel, which can actually act more as a pump to help decongest the limb. Unfortunately, unlike LVA, this requires two surgeries, because you need the donor site, and then also the site, the affected extremity surgery itself. And as you can see in A and B, with a nodal transfer, of course, it's gonna be bulkier, because you're essentially taking this big flap, versus a one VLVT, where it's just the vessel, where it can look a little bit better in terms of cosmesis. And very rarely have there been reports of actual secondary lymphedema from the donor site. And specifically in cancer, treatment-related lymphedema, there have also been fairly encouraging numbers in both upper and lower extremities. And finally, for those with more progressive disease, where now we're looking at more fat-predominant disease in the extremity, unfortunately, a physiologic procedure, like LVA, or VLVT, or VLNT, are really not going to be productive. And in cases like this, we may be looking more at a suction-assisted protein lipectomy, where we're taking out the axis solid tissue with a liposuction-like procedure. This, of course, is gonna result in more rapid reduction of the lymph, but unfortunately, because we're not physiologically changing the lymphatic system, patients are still required to wear lifelong garments. And I'll stop there, thank you. Thanks. Thank you so much. wonderful clinicians here that I admire so I want to do a good job. So my talk is on central lymphedema and it's a relatively new field of study. Unfortunately there isn't much literature out there up until recently and so there's been a lot of new exciting studies that I want to share with you today. And our focus today is on the diagnosis of treatment and special considerations for the cancer patient. So I want to start off with a case. So we have a 54-year-old woman who presents with pain and swelling. She has worsening pain in her lateral chest wall on both sides and her bilateral axilla since having a bilateral mastectomy about seven years ago. And more recently she noticed swelling in both axilla and the proximal thighs. She also noted epigastric and right upper quadrant abdominal pain that started six years ago. She described it as sharp and feels like things are backed up. It's associated with nausea, bloating, abdominal distention and constipation. She described her abdomens feeling swollen, firmer on the left but more fluid on the right. She also had additional complaints of fatigue, joint aches, bruising easily and low-grade fevers and chills. She went to a GI doctor and their impression was irritable bowel syndrome or impaired small bowel transit from adhesions or constipation-related bloating. She sought pain medicine. they prescribed gabapentin for neuropathic pain likely related to surgical history. And during her visit, or during multiple provider visits, she was known to be very tearful and frustrated. One of her major complaints was, it feels like something is wrong and no one is listening. She'd see multiple providers and they'd just send her to someone different. Her past medical history, she's a BRCA1 mutation carrier. She is a survivor of bilateral breast cancer and had bilateral mastectomy with tram-flat reconstruction, central lymph node biopsy and adjuvant, dose-dense adriamycin, cyclophosphamide, and Taxol. She also had questionable history of papillary serous carcinoma of the peritoneum that was found on laparoscopy for endometriosis. The PATH report noted that it was borderline, and so the only treatment she had for it was the resection, no other treatment. She also had bilateral oophorectomy and multiple abdominal surgeries, including cholecystectomy, C-section, and XLAP with lysis of adhesions. And her other significant past medical history, she has OSA and Hashimoto's disease. Family history, grandmother breast cancer, aunt with ovarian cancer. She works as an accounting manager, denies any toxic habits and no known allergies. Additional information about her, she went to lymphatic massage one year ago, which helped with her pain and swelling. She falls closely with oncology and she's had multiple EGDs and colonoscopy with GI with unremarkable results. On physical exam, she has soft abdomen, non-tender but with fullness noted around the tram flap scar. Her mastectomy sites were well-healed, left axilla with palpable nodules that are tender, mild bilateral axillary edema and lateral chest wall edema on both sides, no appreciable swelling anywhere else. So this is a 54-year-old woman with fluctuating abdominal swelling in the setting of multiple abdominal and pelvic surgeries in the past, including removal of lymph nodes. She also has mild bilateral axillary and lateral chest wall edema, no ascites on previous abdominal imaging. We referred her to lymphedema therapy for manual lymph drainage, serial measurements of the abdomen and arms and abdominal compression. One month later, she had gone through three weeks of lymphedema therapy with slightly improved pain in her chest and armpits but worsening pain and bloating in her abdomen as the day progresses. She saw a GI doctor about this who wasn't sure what was causing her worsening abdominal symptoms and then she was referred to interventional radiology for evaluation of a possible central lymphatic disorder. Two months later, she had a dynamic contrast enhanced MR lymphangiogram done, which we'll talk about in a little bit. And it demonstrated lymphatic collaterals at the distal part of the thoracic duct, possibly indicating obstruction of the thoracic duct. And you can kind of see here on the picture, you'll see that, you'll see, I don't know if you can see the mouse, but if you see the little two bright spots, oh, okay. Yeah, yeah, right there, right there, yeah. Okay, so those two bright spots right there, that's where the obstruction, or that's where the collaterals were noted. And then three months later, she underwent thoracic duct venous junction lymphoplasty with IR, where they basically took a five millimeter balloon very similar to like a coronary angioplasty to dilate the space. And then she had improvement in her swelling, in her abdominal swelling, and she reported no bloating, pain, or nausea associated with eating. So the central lymphatic system is composed of the cisterna chyle and the thoracic duct. You have four main abdominal lymph trunks that converge to form the cisterna chyle, which are generally found around T12 through L2. The right and left lumbar trunks deliver lymph to the cisterna chyle from the abdominal wall below the level of the navel, pelvis, kidneys, and adrenal glands. And the intestinal trunk delivers lymph and chyle from the GI tract. Chyle is basically lymph fluid and emulsified fats during the digestion of fatty foods. And then you also have the inconsolable trunks that feed into the cisterna chyle. The lymph accumulated in the cisterna chyle then moves approximately toward the thoracic duct, which eventually dumps the fluid into our circulatory system. The thoracic duct is the largest of the body's lymphatic channels. It includes contributions from the cisterna chyle and other lymphatic vessels. And the thoracic drain lymphs, drains lymph from most of the body, as you can see in that diagram. It's the yellow that it drains. And it drains everything except for that purple quadrant, which is the right head and neck, right hemithorax, and the right upper extremity. And it's the right lymphatic duct that drains the quadrant in purple, and it's formed from the union of three lymphatic trunks, the right jugular, the right subclavian, the right bronchomediastinal trunks. So generally, the thoracic duct is around 45 centimeters in length, extending from L2 to the base of the neck, and it's relatively long length makes it very susceptible to injury or trauma. And to give you an idea of its course, it travels superiorly between the aorta and the azygous vein, and it crosses to the left at the T5 level posterior to the aorta and the esophagus. In the superior mediastinum, it courses behind the left internal jugular vein and curves inferiorly to drain into the venous system at the junction of the subclavian vein and the left internal jugular. So basically, with this diagram right here, it's basically, the important takeaway is that everyone's anatomy is different, and the course of the thoracic duct and all the lymphatic tributaries that feed into it are variable from one person to another. The diagram with the pictures of multiple thoracic ducts, that's actually from 1915, and it shows the number of antonic variants that were found in cadavers during a study that was done then. And type six is the most common and was described as conventional anatomy, and that's found in approximately 40 to 60% of patients. There's also a variation in terminations of the thoracic duct as well, with the thoracic duct draining into the left internal jugular vein or into the jugular venous angle as the two most common endings, and that makes about 80% of patients. And although these variations don't have large functional physiological differences, knowing them is extremely important for any type of surgical intervention. Diagnostic imaging is crucial in determining a patient's lymphatic anatomy and any pathologies that can be corrected. And up until recently, there weren't very many ways to clearly image a patient's central lymphatics, but there have been a lot of advancements in the field now that have allowed us to do so. And these different imaging techniques and interventions are really dependent on a hospital's resources, which is why central lymphedema can be kind of hard to formally diagnose and treat in a lot of settings. And I'll be discussing imaging and treatment shortly. The thoracic duct has a lot of volume of lymph that flows through it, and any disruption to this flow can lead to obvious signs and symptoms. The thoracic duct drains about one to two liters of lymph per Kyle per day, 80% from the liver and intestinal compartments, and 20% from soft tissue. The flow of lymph in the thoracic duct can be anywhere from 30 to 190 milliliters per hour, depending on the size of the person. Flow increases after ingestion of food and water and during abdominal massage. Hepatic lymph increases after meals, and the basal intestinal inflow may increase tenfold after fatty meals. Starvation and complete rest decrease the flow through our central lymphatics, and volumes up to 2,500 milliliters of Kyle have been found, or in 24 hours have been found, have been collected from the canal of the human thoracic duct. As mentioned previously, the lengthy course of the thoracic duct predisposes it to injury. There are two main mechanisms. There's direct trauma or laceration lymphatic vessels, or occlusion of the thoracic duct leading to development of leaky collaterals, and traumatic injury is a little more common. Eitrogenically, you have thoracic, cardiac, head and neck surgeries, and even central line placement, which can cause injury. Some studies say that esophageal resection, there's an incidence of 4% traumatic injury to the thoracic duct. Lateral neck dissection, some studies say 4.5 to 8.3%. Non-traumatic occlusion is a lot less common. You have malignancies. For example, lymphoma, esophageal cancer, primary lung malignancies, mesothelioma, metastases. There's also inflammatory infectious diseases, primary lymphatic vessel diseases, and idiopathic causes. And depending on the anatomic location involved, patients suffering from lymph fluid leakage or accumulation of symptoms resulting from where the injury is located, and for this slide, I have to really give credit to Dr. Maxim Bikin, who is an interventional radiologist over at Penn, and he's really one of the leaders in the field of central lymphatic pathology, and this slide is an adaptation from one of his lectures. So if you look at the top of the diagram, that's the type of fluid, lymph fluid, and then the middle is where it's leaking into, and the bottom is the pathology results. For example, if you have chyl leaking into the pleural cavity, you get chylothorax. If you have chyl leaking into the bronchial tree, you can get plastic bronchitis, where basically lymph fluid accumulates in the airways and forms these casts that make it difficult to breathe. And then on the far right, I want to bring your attention to something called protein-losing enteropathy. Basically, here you have leakage of liver lymph into the intestine, and with this, you have these profound losses of protein that are really important for maintaining vast tronchotic pressure. And in normal gut physiology, two to 5% of total body albumin may be leaked to the gastric lumen, and in patients with protein-losing enteropathy, that can be up to 60%. So how can central lymphedema present? So there are a variety of ways that it can present in our patients, and these are some of the complaints that have been documented and unfortunately, there aren't any studies yet, to my knowledge, that really establish percentages for how common these are, as there are only a few centers that really have published literature on central lymphatic disorders. But in our work with central lymphedema, at least anecdotally speaking, these are some of the more common complaints that we've seen, which are bolded here. And again, these complaints really correlate to where the obstruction is located or where the leak might be happening. Complaints can range from things like headache, fatigue, brain fog, cognitive changes, to more common things like shortness of breath, abdominal tension or bloating, weight gain, swelling of the extremities, and GI symptoms can also be present as well, nausea or dyspepsia or pain after eating. So, due to the unfamiliarity with central lymphatic disorders, diagnosis can be tricky, and it's probably under-diagnosed, but although still most likely a rare phenomenon for the general population. For now, while specialized lymphatic imaging is not as widespread, definitive diagnosis can be hard to achieve unless it's done at a specialized lymphatic center. And historically, the major obstacle in visualizing this in central lymphatics has been difficulty in delivering contrast material into the central lymphatics. Now we have much better imaging techniques that are essential for planning treatment. But besides imaging, the important things that aid diagnosis are things like doing detailed history and physical. Is there any past medical history, such as malignancies, infection, trauma, or procedures that might point you towards a central lymphatic issue? Lymphedema can also be the cause of genetic diseases. Does the patient have a family history of any congenital anomalies that make this diagnosis more likely? And one of the more common elements in the history is that the patient will usually complain of a poor response to conservative treatment. And just thinking back to the case at the beginning of my talk, what really made us consider a central lymphatic issue was that our patient developed more abdominal swelling and GI issues after working with a lymphedema therapist, indicating that she had a possible blockage in her central lymphatics. Diagnostic testing can be done to any fluid that has been collected. Usually the fluid is milky white. You can see in the picture there. In the case of chylosocytes or chylothorax, you can see this milky white fluid that's been collected via paracentesis or thoracentesis, or post-surgical drainage catheters. And a fluid analysis usually shows a triglyceride level above 200 milligrams per deciliter, although some sources use a much lower cutoff of 110. And qualitative lab testing of the fluid or urinalysis can also indicate the presence of chelomicrons. So until recently, one of the main imaging techniques to visualize central lymphatics was pedolymphangiography. And without going into too much detail, it can be a pretty involved process. You basically have an indicator dye that's injected intradermally into the first and third web spaces of the foot to facilitate visualization of lymphatic vessels. An incision is then made along the dorsum of the foot, and then a lymphatic duct is identified and cannulated with a lymphangiography needle. You have this ethiodized oil that's infused through the needle, and then fluoroscopic spot images are obtained every 10 to 30 minutes to monitor progression of the oil through the lower extremity. To visualize central lymphatics, at the end of the contrast injection, normal saline is then injected to propel the contrast into the pelvic and abdominal lymphatics, which ultimately helps you visualize the cisterna chyli and the thoracic duct. The introduction of intranodal lymphangiography as an alternative to pedolymphangiography really advanced the field of lymphatic imaging interventions. With this approach, the inguinal nodes are accessed percutaneously via an ultrasound-guided needle, and ethiodized oil is hand-injected, and then you have the serial fluoroscopic spot images that are obtained until the cisterna chylis are pacified. The advantage of the intranodal approach of a transputal is that it's significantly shorter in terms of time because it bypasses the legs, also because it's close proximity to the targeted retroperitoneal lymphatic ducts. Intranodal generally results in better pacification of the thoracic duct. However, due to the viscosity of the oil-based contrast, imaging of the central lymphatic system is not 100% optimal. Out of this need for better imaging came DCMRL, which uses an intranodal injection approach to deliver gadolinium-based contrast agents into the lymphatic system for MRI imaging. And that really allows for really exceptional ability to visualize lymphatics. Although it's considered the reference standard for diagnosing many central lymphatic disorders, there are some logistical challenges. For example, because of the strong manic field of the MRI machine, you obviously have to place the needle outside the MR suite, which increases the risk of the needle moving when you bring the patient back to the MRI for actual visualization. And so MRI also has its usual limitations as well, including the presence of any paramagnetic devices within the patient and then the patient's ability to tolerate the actual exam. And if you look at the picture on your left, A, that is, it's labeled A. That's a really good visualization of a normal thoracic duct, and you can see how nice and bright it lights up with DCMRL. And the picture to the right, labeled B, actually demonstrates abnormal thoracic duct pathology, and you can actually see two thoracic ducts marked with the arrows, and then you see leakage of the contrast where you can imagine lungs would be, and that's leakage of the contrast into the parenchymal space, and this is actually a patient that has plastic bronchitis. CT is much more accessible around the world, and it really has the potential for allowing for wider dissemination of lymphatic imaging. Again, intranodal technique is used, except this time a CT scan is performed. There was a 2021 study that was done that showed that intranodal CT lymphangiography was feasible among these five women that underwent the procedure, and they had successful visualization of the central lymphatic system, allowing for successful surgical treatment. And all three of those pictures are basically a 3D reconstruction of the CT scan obtained after intranodal CT lymphangiography, and the arrowheads where it's sort of lighting up, and it looks a little hazier, that's where the leaks are happening. There are a lot more imaging techniques out there, and they're a little outside the scope of this lecture, and honestly, we could probably have a talk on imaging alone, but here are three other techniques, and basically, their names do a pretty good job of explaining how it's done. There's anti-gray thoracic lymphangiography, retrograde transvenous lymphangiography, and retrograde direct percutaneous lymphangiography. We also have trans-hepatic lymphangiography, which allows for visualization of the liver lymphatic vessels and in the bottom left is a fluoroscopic image of liver lymphangiography performed with a 25-gauge needle, which is marked by the arrow, and then to the right of that, you have CT of liver lymphangiography showing leakage of contrast in the duodenum of a patient with protein-losing enteropathy. Mesenteric lymphangiography looks at the intestinal lymphatic vessels. Basically, it's a very similar process, except mesenteric lymph nodes are very hard to find percutaneously, but it's a lot easier to do under open surgery, and so you might see some clinicians trying to use ultrasound, ultimately failing, and then actually having to do open surgery to find mesenteric lymph nodes. There were a couple case reports where, one in 2018, they talked about where they did an XLAP and basically found mesenteric lymph nodes and were able to visualize the central lymphatics through open surgery, and then in 2022, there was a case report published where they underwent a successful CT-guided percutaneous intranodal mesenteric lymphangiography. So, for the treatment of some of these disorders, so, the management of chi leaks is really guided by the volume of the leak. In low-volume leaks, considered less than a liter per day, management is typically conservative. You have lymphedema therapy, which helps promote physiologic lymph drainage. You have dietary restriction, where patients are advised to consume a low-fat diet, rich in medium-chain triglycerides that are more readily absorbed directly into the portal system. Fasting states and total parenteral nutrition allow for bowel rest with decreased production of intestinal lymph. There's octreotide, which decreases lymph production by reducing splenic blood flow and decreasing GI secretions. And there are other potentially beneficial medical management options, including chemo or radiation in the setting of malignant chylothoraces. And in cases where chylus output exceeds one liter a day, patients will often require thoracic duct embolization or surgical ligation, which we'll be discussing next. So these are a variety of interventional treatments that have been discussed in the literature and are really starting to be used a lot more now. They are thoracic duct embolization, interstitial lymphatic embolization, lymphovenous anastomosis, and thoracic duct venous junction lymphoplasty. And again, this is one of Dr. Itkin's slides that I adapted from one of his lectures, and those are some of the major indications on the right there, and some of the treatments that we have for them. For thoracic duct embolization, that's basically, it's a minimally invasive alternative to surgical ligation of the thoracic duct. You have intranodal lymphangiogram being performed to identify access points in the lymphatic system, and after you have visualization, you inject contrast through a catheter into the thoracic duct to demonstrate the cause of the chylosuffusion. With traumatic chylothoraces, the cause of leak is often a tear of the thoracic duct or leakage from a thoracic duct branch collateral that course through the site of the trauma. With non-traumatic chylothoraces, the cause is usually occlusion of the upper part of the thoracic duct with retrograde flow into the pleural space. This picture right here is basically, with contrast injection, it shows a partially duplicated lower segment of the thoracic duct at the bottom of the picture, and then disruption of the mid-thoracic duct with leakage of contrast near the top marked by the asterisk. So after the cause of chylothorax is identified, embolization of the thoracic duct is performed below the leak point or the abnormality, and then embolization performed using a combination of coils and butyl cyanoacrylate glue. With the picture on the left, with the white arrow, that's showing a coil that's being deployed inferior to the actual leak. And then from the right, from the white arrow to the black arrow, that's actually a picture of the glue that's been injected into the space. And so it's actually going from the level of the leak all the way down to just above the cistern at Kylie. You have interstitial lymphatic embolization, which basically, some lymphatic vessels are very hard to access. And so you can inject embolization material into the interstitial lymph nodes or lymphatic networks and have propagation of glue downstream of the lymphatic system. And I want to be mindful of our other presenter's time, so I'm going to speed through a little bit here. And then you have thoracic duct lymphovenous bypass, where basically a lymphangiogram is performed perioperatively. Once identified via a lymphangiogram, the thoracic duct is cut proximate to the obstruction. The thoracic duct is anastomosed end-to-end to an appropriately sized vein. And then just a little mention here, in 2022, the authors wrote about the success that they had with it. But although they've had some success, there's very little known about the long-term outcomes of these lymphovenous bypasses. And so these early cases should be critically assessed. And just some examples of central lymphatic presentation in cancer patients that we've seen, just some interesting ones. We had a 39-year-old in our clinic with semi-visceral sarcoma of the left hip. She had long-standing unilateral leg lymphedema that was well-controlled with sudden increase in leg swelling, new abdominal distension, rapid weight fluctuations. We worked with IR, and she was found to have a thoracic duct obstruction, 57-year-old with stage 4 non-small cell lung cancer. And they had abdominal swelling, required frequent paracentesis, eventually found to have thoracic duct obstruction as well, 53-year-old with right breast cancer, initially with right arm swelling but then with gradual left arm, bilateral leg abdominal swelling, abdominal pain, found to have a thoracic duct obstruction, and then a 67-year-old with a diffuse large B cell lymphoma, developed abdominal pain and swelling one year after completing chemo, and then found to have chylosocytes, and then she was found to have a tortuous thoracic duct obstruction on imaging. And between 2021 and 2023, we had 53 patients that our institution underwent or planned for intervention by our IR team to address this central lymphatic issue. And 14 out of 53 of them, 26% had some sort of malignancy. And so it's hard to extrapolate that to the general population out there. So we have no idea if these numbers would hold up if we looked at everyone that has central lymphedema, but this is what we've found so far, and hopefully new studies in the future will give us an idea of how common these issues really are. So, all right, thank you. Thank you. Okay, hello everybody. I'm Diana Molinares from University of Miami. I'm going to talk a little bit about abdominal and genital lymphedema. So Dr. Tseng and Dr. Lee did a wonderful job explaining all the pathophysiology and the images that we use to diagnose lymphedema. This presentation is going to be a little bit more about how the lymphedema can affect the patient, quality of life, and body image issues, especially when the lymphedema is related to the genital area. Nothing to disclose. Okay, a little bit of the anatomy, just as a reminder. So we have the lymph nodes, and then we can divide them into the inguinal, and then we can have them also in the iliac, internal iliac and external iliac, and then the parietal lymph nodes. So these are the pathways for several type of cancers to go into the lymphatic system, and depending where that, what cancer is, is where they are going to go. So superficial pathway, it's more about perineal tumors. Pelvic pathway, it's more about pelvic tumors, and parietal pathways are usually related to gonadal vessels. So this is very important for us to understand because it's going to kind of like determine what kind of studies we need to use, and also to have an idea of the risk that the patient has for developing genital lymphedema. So genital lymphedema is defined as an increased volume in the genital area, so for men, penis, for skin and scrotum, and labia and vaginal lymphedema for female patients. So as you can imagine, this is going to really affect the sexual aspect and the quality of life of these patients, and we already know that lymphedema in general has a lot of effects in body image issues, even when it's an upper extremity or lower extremity lymphedema, but a little bit of talk about how much of the genital lymphedema can affect even normal functions like urination or especially sexual intercourse. So it's frequently associated with lower lymphedema, so if you have a patient in clinic that presents with significant lymphedema of the lower extremity, they may not want to feel comfortable telling you that the genital area is also affecting, or that they have issues with the sexual intercourse unless you ask them. So this is important for all of us to be aware of, so that when we have these patients, we ask these questions that are sometimes a little bit difficult, but it's difficult for them to bring it up to you. They are focused on the part that everybody can see, and that's the part that they are going to be coming to you for, but very little of them are going to feel comfortable telling you this. The other thing is that even for gait or ambulation, it's going to affect them because the fact that the genitals are so swollen interferes with the gait, so they may come with also musculoskeletal issues related to trying to walk with their legs separated or more a broader base gait. Like I said, body image and sexual, and there is a problem with the fact that there is very minimal garments that can help these patients, so the time that you come and see them, their genital lymphedema is very advanced, especially because they probably have seen other doctors that may not be familiar with genital lymphedema and basically tell them that there is no treatments for this. Again, the most common cancers are cervical, uterine, ovarian, melanoma, prostate, and anus, and then you can see the fibrosis of the skin adipose tissue, which is related to all the lymphedemas. Risk factors, of course, the cancer itself can cause the lymphedema, especially you have to keep in mind when a patient presents with cancer-free for several years and then all of a sudden have lymphedema, I have to think about recurrence into those regional lymph nodes, so please keep that in mind. The surgery, of course, is a big risk factor, but radiation is one of the main reasons why these patients have lymphedema, because there is a lot of fibrosis tissue around that area that include the lymphatic vessels. If the patient gains weight, then obesity is also a contributing factor that, with appropriate education and nutrition, patients can control to some degree. These are some reasons for non-cancer-related lymphedema. Most commonly is for genetic reasons, patients with primarily lymphedema of the genital area, but we can also find other causes, such as infection and fibrosis. Even sexual behaviors can cause lymphedema. Excessive or rough masturbation can cause lymphedema, and injections in the pineal area. Sometimes reconstruction of the vaginal area for cosmetic reasons can also cause lymphedema, since there is a disruption of vessels there, or can cause an infection that ultimately results in lymphedema. Oops, sorry. I did something wrong. There you go. Okay, so this is a picture of a patient with lymphedema. It's a male, of course, and you can see how difficult it will be for this patient to even go to the restroom and urinate. So it causes discomfort with rubbing between the thighs and have the heaviness sensation. The sensitivity on the scrotum is very significant, so the fact that you have a very heavy weight in the scrotum can cause a lot of discomfort that even may limit their ability to just get up and walk and do their exercises. The penis can become, with this particular shape that is called a saxophone shape, and can cause also entrapment in the foreskin, and this can cause infection. There are high risks for cellulitis because it is very hard to clean and there is fluid accumulated in that area. The fluid accumulation eventually, like Dr. Seng explained, will become fat or fibrotic tissue and will make the skin very, very thick, which is also prone to have cracks or infection or like erythema around the area. So this is for female lymphedema. You can see in the labia, so in this one you don't see it that swollen, right? So you will think, okay, there is no that significant lymphedema, but if you are checking, you see these papillary areas right there. Sorry, I'm very shaky. These are caused by lymphedema. They appear like they are papillomatosis, but actually they are cysts that are caused by the excessive fluid that is in that area. They can cause discomfort. They can cause a lot of arthritis and the lymphatic vessels that I mentioned. And in some cases, it can be confused as like an infection or a viral infection that is causing this. Some physicians that may not be familiar with lymphedema and genital lymphedema may try to cut this or catheterize these lesions, which is not the treatment that the patient needs at that moment and can make things a little bit worse. So the way that you diagnose this in cases like I'm going to present later is very obvious the diagnosis, but you still want to do some testing to check the degree or the severity of the lymphedema, but also the structure of the lymphatic vessels so that can guide the treatment options for the patient. So the most important part is the clinical findings. Examine your patient. Ask for the history. Like I said, they are not going to volunteer a lot of this information, so you have to really ask these questions for them. You can start with the ultrasound. In the ultrasound, you can see, like Dr. Seng was explaining, the different layers of the skin, and then you can see the fibrotic tissue as well. But also, 40% of the patients are associated with hydrocele, so it's important to make that distinction as well. ICG lymphography, I'm going to talk a little bit about how important this is, and lymphocytography is another option for these patients. I'm not going to go into details about the test because my co-presenters did an amazing job explaining that, but I want to just highlight that it is also used for patients with genital lymphedema and that they can be injected in the penis, on the foreskin, in the inguinal vessels, to see how this dive is flowing in the lymphatic system. This is a study that Hara et al. did and determined a score for genital pathways, so it goes from zero to three. Honestly, I haven't seen it being used that often. I'm going to talk a little bit about other ways to score these patients, but zero, of course, is the one that it's no significant changes in the pattern of the ICG, but when you go up, then it starts with the changes in the genital area, and then it's more severe if you see changes in the groin area, and then more severe if those changes are in both areas going down to the leg. That kind of gives you an idea of the region that is affected and how severe this lymphedema is going to be. Lymphocytography, you can also use it, but it's not as sensitive as is ICG, and that's the point that I wanted to highlight here because Dr. Sen was explaining how it depends on the interventional radiologist that feels comfortable doing the lymphocytography. At University of Miami, we are doing it more and more often these days, but still there is not a good availability. It used to be like two or three months waiting in areas where you don't have an interventional radiologist that specialize in this type of testing, it may be hard for the patient to get tested. In doing the lymphocytography in the genital area, it's even a little bit more difficult to achieve. This is a case of one of my patients. He's 61 years old, lovely gentleman. He unfortunately developed an anal carcinoma, and he was initially diagnosed in 2019, but then he had a recurrence in 2020. In 2019, he did chemo radiation, and that included some of the inguinal area, but then with 2020 recurrence, they also included the perineum area as well, in addition to parathylic lymph nodes as well in 2022. This poor gentleman also had a septic joint and had to get hip replacement. All of the treatments have gone back and forth, and he didn't really get to get treatment for the lymphedema until it was a little bit very advanced, a little bit late for him. He also had DVT and had to get an IVC filter, which probably didn't help with the whole swelling situation, and the hip surgery that he had required revisions, because he had also infections of that hip. The whole storm happened to this poor gentleman. This is how he presented to the clinic. He had already seen other physicians that, again, told him that there is no treatment for this, and he tried to figure out a way to get any compression. For upper extremity, we order sleeve. For lower extremity, we order stockings, but what do we do with this genital area? There are things in the market that you're going to find, but if you ask your patients, they are not very comfortable to wear, and it's very difficult for them to be compliant with them. This patient, when I asked him, hey, can I just examine you and maybe take a picture for the records and for the presentation, he was like, you know, doctor, do whatever you want. This doesn't belong to me. I made my mind in order for me to survive that this is not part of my body. It doesn't belong to me. So it just tells you about the psychological process that this has an impact on this patient. Of course, no intercourse, at least no penetration, and also very difficult to urinate, because if you see in this picture, he cannot point his penis down and all the urine just goes up. So he came up with ideas of how to put the urinal, how to wear his clothing, and how to be functional at the same time thinking that this is not a part of his body, so he doesn't want to even recognize that. So we did some wrapping and getting creative, and, you know, it got some improvement. But ultimately, this is already very, very fibrotic tissue, and it's very hard to touch. You have papillary lesions also in the scrotum, and there is not much of fluid that can also be drained with manual lymphatic drainage at this point. So we did the ICG lymphography. Our plastic surgeon is the one that does it in our institution. And they injected in the contrast or the ICG in the groin, in the central scrotum and in the dorsal penis. The groin, thankfully, shows some normal linear lymphatics. So when you see that in the reports, that you see linear lymphatics, that's good news. That means that it's preserved. But then the scrotum shows dermal backflow. And the dermal backflow really shows that there is a lot of problems with the ICG like moving into the lymphatic system. So MD Anderson has an ICG scoring. So this is stage four. The scoring goes from zero to five. Five, basically, there is no movement of the contrast. But for four, it's going, but it's so diffused, there is like no, any structure of lymphatic there. He hasn't gone through the surgery yet, but this is the surgical plan. So there is treatment for these patients. There is gonna be a lymphatic reconstruction with a lymphovenous bypass. And there is gonna be a vascularized lymph node transplant like Dr. Zeng was explaining earlier on. But because of the fibrotic tissue, there's not gonna be a lot of fluid movement there. So liposuction had to be part of the treatment in order to make sure that we have a reduction in the volume and an improvement in the quality of the skin that at this point is very fibrotic. They go into more details about the type of surgery. So for those that are very interested in the surgical description, it's right there about the plan. But it requires a lot of transplants and grafts, and it's gonna be a very, very involved surgery in this gentleman. But the point that I wanna drive home and what I want you to remember when you are practicing back home is that these patients have genital lymphedema. They're not going to tell you, please ask your patient, examine your patient. And when they have it, they are going to have an option for treatment. So just explore. If you don't have a lymphatic surgeon at your institution, you know, just contact one of us or whoever you have around that there are gonna be other lymphatic surgeons that maybe have to travel, but that can give solutions to these patients that have a very significant affection in their quality of life, and especially in the sexual aspect of that. Gracias. Thank you. Hi, everyone. Thanks for still being here. We have a few minutes left, so I will be speaking quickly. I'm Jessica Chang from City of Hope, Orange County. That's in Southern California. So without further ado, I'll be talking about head and neck cancer associated lymphedema. So quick review of anatomy. It's the, there's lots of lymph nodes in the head and neck region, roughly categorized by several different methods. You can categorize them anatomically and correlating with the anatomy is the radiation oncology version with different levels from one through six. This encompasses both superficial and deep lymphatic systems, which is yet another way to classify the lymphatic system here. The drainage pattern is from medial to lateral, as opposed to straight down the middle, and superficial to deep. Here, you can see in tiny words here, the jugulodigastric node is important clinically because it is the first drainage point of the face, mouth, pharynx, and tonsils. So you want to evaluate that if you find that lymph node enlarged in a head and neck cancer patient. Those are the areas you want to think about. The other node to know about is the jugulomohyoid node, also known as the tongue node because it drains the tongue. Here's a case showing the progression of complete decongestive therapy, CDT, for head and neck lymphedema. Can anyone see where the swelling is? Yeah, everyone's motioning. So it's under the neck right here, some mental area. And you can see how the neck becomes more and more defined with CDT. So the presentation, as you know, for lymphedema would be swelling. In head and neck specifically, you want to think about the effects of gravity. So upon awakening, it's worse, been lying down all night, and it's better after some time being upright and mobile. There's two basic categories of head and neck lymphedema. There's external and internal. External, unlike some of our other areas of lymphedema, cannot easily be hidden. It shows up in the face and neck as tightness, heaviness, decreased neck and shoulder range of motion, posture changes, and it can affect some of the sense organs like vision, hearing, and obviously, because people can see it, it can contribute heavily to poor body image. Internal lymphedema can involve the internal structure, so the mouth, the oral cavity, the pharynx, the larynx. So as you would think, voice, speech, swallowing, eating, those can all be affected. The red flags to look out for are things related to recurrence, infection, and potential emergency situations requiring tracheostomy if some breathing and voice changes are occurring rapidly. The short for diagnosis is that there is no gold standard. The prevalence is that anyone with prior radiation or surgical damage to the lymphatic system, almost everyone gets head and neck lymphedema. The short phrase I will give you is nearly all of them get both and get it bad. And so specifics are there. I'm not going to read it to you. But external lymphedema in this graph, you can see it peaks around nine months and you have two trajectories of more severe versus less severe. And then the next is internal lymphedema with a similar trajectory and time course. And as you would expect, the fibrosis settles in a little later and is more evenly split in terms of how common the severe trajectory and the mild trajectory is. So this is a systematic review paper published earlier this year, thanks to the CRPC research subgroup that collaborated with me. We found 23 interventional studies on rehab interventions for head and neck cancer associated lymphedema, six of which were RCTs and 17 were observational studies. So a large part of the rest of this is based off of the findings of the study, starting with diagnosis, then intervention. So measures for external lymphedema, the most common ones were composite face and neck measures. About half the studies had this very complicated face measurement, tape measurement system and neck composite measures. Half of that half had the MD Anderson cancer head and neck lymphedema rating scale. The key points here to remember are whether there's swelling or not, whether it's reversible or not, whether there's pitting and whether there's tissue changes, the firmness of the tissue. Other ways to measure external lymphedema, you could take a photo from the exact same spot and get the front view and the side view. CT is the one that's recommended in literature for diagnosis for external and internal lymphedema and ultrasound for monitoring of external lymphedema. In my systematic review, there was only one study that used ultrasound skin to bone distance and no studies that used the CT. Tissue dielectric constant is that little gizmo you see there, it measures the skin tissue water and gives a percentage. That takes about one second per spot. There was one study that used this. All right, NERFLI or ICG lymphography. Here you can see normal lymphatics and then on the right side you see dermal backflow which is diagnostic of lymphedema. And so in the systematic review, only one study in advanced pneumatic compression device used the ICG lymphography. This is a 3D scanner. It takes about one minute to scan, four minutes to compile and it measures volume in two studies to use the 3D analysis. For internal lymphedema, the gold standard is modified Patterson scale or some version of the Patterson scale that involves endoscopy or laryngoscopy and it's graded from normal to severe. So here's an example of one of the 11 anatomic sites from normal here to severe here of the epiglottis and for the true vocal folds, you can see how swollen the vocal folds can get here. And so nearly all studies that looked at internal lymphedema looked at some version of the Patterson score. Function and quality of life measures are always important to us rehab doctors. The highest quality tool is the head and neck lymphedema and fibrosis symptom inventory from a recent systematic review and there was only one study that used this. Overall, there's rapidly growing evidence for the treatment of head and neck cancer associated lymphedema. Five of the six RCTs were since 2020. Most of the observational studies were recent and almost all of the advanced pneumatic compression device studies were recent as well. Gold standard treatment is complete decongestive therapy. Over half of the studies in the systematic review were on CDT or some component of CDT. The quality of the evidence was overall low quality and it was mostly studied in mild to moderate lymphedema. The ideal timing, duration, intensity, the components is still unclear, but there were a few studies that looked at adherence, that partial adherence is better than no adherence as you would imagine, and outpatient supervised therapy guided by a lymphedema therapist is more effective than home-based therapy. So CDT components gets interesting here. For bandaging and compression pads that oftentimes is before manual lymphatic drainage when there's some firm pitting edema. There are off-the-shelf ones, but they can have very different shape from the cancer surgery. And so usually custom is recommended and that's a example of a compression pad used before MLD. Manual lymphatic drainage, like we said, is usually medial to lateral. Decongesting the trunk is important, then followed by the face, then back to the trunk. And compared to other lymphedema populations, this can be more challenging to do self-MLD. Compression garment, how many of you guys would wear this? So same for the patients. It's adherence is difficult, but it is recommended to use the compression garment as well. And again, custom compression garments rather than the off-the-shelf because of shape uniqueness. All right, exercises can consist of, as you would think, range of motion in the shoulder or the neck region, but also face and jaw exercise and swallowing exercise, coughing exercise, breathing exercises. What was notable in the systematic review was that there was one study that looked at exercise specifically and it was not shown to be feasible. And there were no studies on whole body exercise or weight loss or prehabilitation that you might find in some of the rest of the lymphedema literature. The next section that we looked at in our systematic review are treatment adjuncts, so the ones that are not CDT specifically. And so advanced pneumatic compression therapy was a major aspect. I have a picture here. This is the FlexiTouch Plus by TactileMed. It's the only one on the market. And so five studies recently. What is that? Not a proof of insurance lady. Okay. Kinesio taping had the best quality evidence, one RCT of good quality, meaning low risk of bias. And generally the idea is to drain the lymph towards the nodes. So you can see the wider part of the, it's hard to see, of the K-tape is where the nodes are. So some practical tips that was not found in literature that can help your patients is the importance of ergonomic sitting, posture, decreasing stress. Because as you would imagine, as you all know, that can increase the tightness of your neck musculature and that can impact the lymphatic drainage. For the men with, or anyone with facial hair, and they are wanting to shave and they have history of head and neck cancer, head and neck lymphedema, using an electric razor can be safer than using a manual razor because skincare is important. You want to decrease the risk of infection. And another one goes back to gravity. When they're lying down, they can sleep more elevated. So instead of waking up super swollen with a changed voice, they can have less swelling when they wake up. So the takeaway here, the evidence review, is outpatient standard CDT, complete decongestive therapy with adherence, which is the really hard part. Kinesios taping has one RCT with high quality evidence and advanced pneumatic compression device, a FlexiTouch specifically, has a growing evidence base. Thank you. And it's five. Okay, it is late, but I just wanted to drive this point home that lymphedema needs a multidisciplinary team to be treated, and there are different pathways, different institutions have different ways to approach this. And I just wanted to say that I'm not a physician, I'm not a doctor, I'm not a nurse, I'm not a nurse, I'm not a nurse, I'm not a doctor, to approach this. Some of them, the oncologists or surgeons send the patients directly to therapy. When there is not a physiatrist, they are to assist with the management. But some other centers have developed kind of like a pathway or algorithm of how to help these patients navigate. So this is for University of Miami-Sylvester Comprehensive Cancer Center. So this is our pathway. I know it's a lot to see there, but I just basically wanted to show you that something that it may be like clear to us about where this patient need to go, the surgeons or the oncologists may not know. So this is a tip sheet that we give them to know when to refer the patient to surgery versus when to refer the patient to rehab or to cancer rehab. So in these cases, patients with functional limitation, BMI greater than 35, also patients that are not in remission or they have active cancer are patients that should go into cancer rehabilitation instead of going directly to plastic surgery in our institution. Also patients that have never done conservative treatment should not go directly to surgery, and especially when the lymphedema is advanced and not controlled. I'm not gonna bore you with all these arrows and boxes, but basically this is our pathways or where the patient goes in terms of seeing the plastic surgeon and the physical therapist or occupational therapy, lymphedema therapist, or the cancer rehabilitation team. It's a comprehensive, multidisciplinary, integrative group of providers that these patients need in order to make sure that the lymphedema is not only well managed, but also monitored during the survivorship period. And I won't take up too much time either, but this is just an example of our pathway at University of Pennsylvania. So very similar to University of Miami, we have a multidisciplinary team and we have an initial phone call or chart screening process that then allows the patient to be shuttled either to our lymphatic rehab clinic, which I would say the majority of our patients go to, before then being shuttled to our lymphedema IR clinic or the lymphedema surgery clinic. And the lymphedema rehab clinic is made up of our physiatry team and then also our physical therapy, occupational therapy, lymphedema partners. So thank you so much. Thank you. Oh, yeah. Does anyone have any questions? Yeah, I think, or you can stand up and talk, or I think there's a microphone in the aisle. Great. I would say for the obvious ones where, like a breast cancer patient who's had a clear axillary lymph node dissection and then comes in with the standard lymphedema presentation, I don't start out with diagnostic imaging. I might rule out blood clots if I'm suspicious of something else or vascular abnormality. But when it comes time to say we've maximized non-surgical management and they're still interested in potential lymphatic surgical procedures, then that's when I'm going to order our MRI lymphangiogram if I think they might be a surgical candidate. And then what happens is once the MRI lymphangiogram is done, we have a multidisciplinary lymphatic meeting once to twice a month with our IR folks, plastic surgery, therapists, PM&R, and where we review the cases and discuss each patient and decide if they should then be referred to a different specialist like our plastic surgery colleagues. Very similar at University of Miami, especially upper extremity lymphedema with the history of breast cancer and surgery. Very rarely we do the imaging except for surgery. Lower extremity, we do it a little bit more frequently, especially when it's bilateral because we want to make sure that it's more lymphatic related versus vascular related. So we do the lymphocytography kind of like as part of our initial plan. Also that helps the surgeon when we refer the patient over there. So for lower extremity, we do it way more frequently and also discuss the patients in a monthly multidisciplinary like we call it the lymphedema board or something like that. So, in our cancer rehab clinic, in our lymphedema clinic, in the PM&R component of it, we only see secondary lymphedema. The plastic surgeons see a little bit more, and it's not interesting, it's just because of volume in our institution when it's related to the cancer. So the oncologists are very involved, and we have a direct connection there, and also they come to our meetings to discuss the treatment, because a lot of times if they have active cancer and they need to stop the immunotherapy or the chemotherapy prior to the surgery, then it's a decision that they need to be part of. If I'm suspicious of any progression of the disease, and this being the cause of the lymphedema, then definitely they are invited also to discuss those cases, and we go ahead and order the necessarily diagnostic test, but always like communicating with them, but it's a very tight group, so the communication is very easy with the oncology team. It is a really difficult presentation, and I think I've seen it go both ways, folks who have malignant lymphedema who end up actually doing really well and respond to their cancer treatment and their lymphedema improves, and then those who end up being treated with going home with hospice, right? And so I think it is a little bit dependent, I agree with Dr. Molinaris that you absolutely have oncology involved to get a sense of prognosis, and then talk with the patient about expectations and helping them understand why they're having this painful swelling, that this is a little bit different from your typical secondary lymphedema after a lymph node dissection. And then depending on the goals of care, I think there can be a role for things like palliative manual lymphatic drainage from a pain relieving perspective. It's a little bit dependent on resources that are available. Sometimes I get home care involved, and we're lucky enough to have some certified lymphedema therapists at Penn Medicine at home who's able to offer palliative manual lymphatic drainage. And then we do talk about compression. Some of the patients find compression helpful, some of them do not. Another thing I do find really important is to do some vascular imaging, because there's been a variety of times when they're presenting with this particular presentation where it turns out they also have concomitant DVTs or vascular involvement. And so I have gotten IR involved in the past for vascular interventions, which has also helped with reducing the painful edema. Sorry. No, it just reminds me of a patient I had not too long ago that passed away. He had had a neck lymphedema after he's had a really, like, you know, he's done with treatment, given less than six months to live, and suddenly it was swollen, it was starting to cover his trach. He was concerned about breathing, and, you know, we were having hospice conversations during the procedure visits for trigger point injections, and he wanted to continue with the lymphedema therapist because he found that it was helpful. So it was very tricky in terms of, like, he's thinking about hospice, but he needs therapy that can help his quality of life. And so, yeah, he had a lot of other pain issues as well, but that was my experience with malignant head and neck lymphedema. Hi. Can you hear me? I just talked without... Okay. Thank you all for your presentations. I want to commend all of you and Dr. Melaneres, especially for tackling the challenging topic of genital lymphedema and sexuality in our oncology patients. So from the practical standpoint, how in a busy cancer rehab clinic would you address screening for genital lymphedema? Do all patients who receive, who come in with complaints of lower lymphedema, do you address them? Yes, for the ones, especially with gynecological or anal cancers. Those that are more like melanomas that may have lower extremity lymphedema, then I don't... I ask the questions about if their genitals are swelling, but I don't necessarily go and examine them. For the ones that are gynecological or anal cancers, yes, we examine them, making sure that they are not signs of lymphedema in the genital area. So I do inpatient rehab, so I kind of like encounter that often. I work a lot with administration of the hospital to show them that if we address the lymphedema while they are in acute inpatient rehab, they are gonna have better functional outcomes and shorter length of stay, because the limb is less heavy and they have less pain, better participation to therapy. Probably there is a study there to do. But so they, with this conversation, I was able to get them to have the necessary materials to do bandaging in the hospital, and we have in the inpatient side also a lymphedema certified therapist. So when I encounter these patients, we do the bandaging and the drainage as part of the therapy as well, and also teach them and provide them with those when they're gonna go home, and then we see them outpatient, of course, to do the continuation of care. Sometimes when they don't have access to therapy or they don't know how to wrap themselves, because that's very difficult, I relied a lot in the Velcro wraps, not to use any brand. I personally really like them, because I find that the patients are more compliant with them. The problem with that is that 90% of the time the insurance won't cover it, so it's a little bit costly for the patient, but I get very good results with that. But in the inpatient setting, if you talk to your institution and explain how that is going to improve their numbers, then they may be willing to make an investment. You're not gonna have them all the time, so it's not like you need tons of material there, but just have it available when they need it. Yeah, I think this is definitely an ongoing struggle. I'm not on the inpatient side either, but I know historically in the past our therapy team has tried to get Velcro wraps just because they are adjustable and can be used in a variety of patients. I've spoken with therapy as well about just temporary options that they would recommend for our patients who may have lymphedema but may also have edema for other reasons. Is there something safe? Because a lot of times you go into a room and you see someone in ACE bandages and you're like, no, long stretch bandages, so bad, take them off. I have had folks who've recommended TubaGrip and also EdemaWear. So I would say those are the two more readily available, but even with those I would be careful because sometimes just poor sizing can also lead to problems. I guess the general rule of thumb is if it's not preventing, if it's not a barrier to discharge and it's not so severe, then perhaps waiting until the outpatient side when you can have adequate resources, but make sure they have that follow-up appointment. But as I said, bringing an important point, sometimes it's better to do nothing rather than give them the wide compression stockings regular that you have in the hospital just because those can cause more harm. So if you don't have the right materials or the therapies with the skills to do the wrapping, it's better just to leave them alone. Hi, I just had a question about if you've had any patients that have had different surgical procedures afterwards, like lymphovenous bypasses, that unfortunately have then become infected and then what you do after that, because that is a big challenge and it's almost worse than before they had the surgery. We have had, and sorry, the question is just whether we've had, we've seen patients who've had it done and they look like ideal surgical candidates. Right, right. We've had, frankly, our plastic surgery team is quite conservative about the patients that they pick. So of all the patients I've referred, I can think of like two people who've actually ended up getting surgery and one of them was a poor outcome, unfortunately because she had an allergic reaction to the methylene blue that was injected during the surgical procedure. So unfortunately, and she was an LVA patient, so unfortunately she ended up having increased hand swelling afterwards from the allergic reaction. And so, and we hadn't seen enough arm improvement yet for that reason, so yeah. No infections so far that I've seen, at least no significant enough to cause worsening of the symptoms. There are some cases that haven't been successful and I've seen cases that weren't done in our institution but somewhere else that cause a lot of scar tissue that can worsen the lymphedema. So you can see that and there's a lot of patients also, I should say, that don't want to do the surgery. I mean, they have dealt with so much, so many surgeries for the cancer treatment that if they are well-controlled and there is not really interfering with a lot of activities, even though they are great surgical candidates, they just may defer. And there's like, I'm just counting my blessings and don't want to go on their other surgical procedure. I've seen that a lot. Yeah, I just, I don't, there's one patient where that unfortunately had a very poor surgical outcome and you have to be on the antibiotics for a long time afterwards if it gets infected. Yeah, so. Yeah, I think the struggle is still identifying the right patient population for all these procedures. And in, you know, at Boston Lymphatic Center, they've started doing both LVA or VLNT with SAPL, with the suction-assisted protein lipectomy because they found better outcomes with that rather than just doing one or the other. All right, it looks we have one more, sorry. It looks like we have one more question. Sorry, thanks y'all for your talk. This is more of a comment than a question. But, so I think, you know, this is obviously a bit of a complex thing and it's not as straightforward. But this being said, the NCCN guidelines panel for the subcommittee for under their survivorship at lymphedema group actually does not involve one CLT or physiatrist on that panel. It's two surgeons, one, two breast oncologists and a head and neck surgeon and one researcher. So I just always highly encourage people to get involved. I happen to know that because the person that leads that happens to be at my institution. Or he's the second in command and he had to lead a meeting because the first person was out. He's a head and neck surgeon and he told me, I don't really know anything about lymphedema management. He's like, I see a lot of lymphedema because I cut people's necks open and they swell. But like that guideline is basically created by people that have no idea how to treat lymphedema. And he told me after a week talking to our team, he was like, I just learned two thirds of what I know about lymphedema in the last week talking to you all. Why are you guys not on this panel? And like, yeah, we should change that. So I'm on a separate NCCN panel for fatigue. So I think there's a real opportunity there where there are a lot of very rehab appropriate and rehab adjacent things that we see and we have opportunities to be established in the guidelines of treatment. So thank you all for what you're doing. And I encourage people to get involved on that level because I think it's really necessary and I think we can make a bigger impact there. And these algorithms and things are great. And I think they'd be really useful to people. And I find that the people in those rooms are not unwilling to listen. They actually are very grateful to actually talk about it and hear about it because they don't know a lot of this stuff. Thank you. Yeah, thank you. I think this is a quick question. Saw a lot of MRI images today and Dr. Zhang, you spoke about the limitations of lymphocentrography, but that is the historical gold standard of imaging. So are you still doing lymphocentrography as the first pass or it looked like at your institution right to MRI? Yeah, I mean, again, with specifically cancer patients, unless I really am unsure about the diagnosis, I try not to do imaging unless I really need to. So more I'm ordering the MRL when we think, hey, maybe this might be a surgical candidate. Let's take a look at the degree of fibrosis, the DEMA, where the lymphatics are, what's engorged or dilated. I sometimes still order lymphocentrographies. I would say the majority of those are actually for my non-cancer patients who are coming in for the first time with swelling and it's unclear what the reason is. I have just found that I have to be very specific about what I'm looking for with a lymphocentrography because there have been times where the radiologist will come back and say, we stopped the study after 15 minutes because we visualized a tracer in the groins and there's so much more to it than just that. And so I think that's been helpful in directing them because there's been a few times where I'm pretty sure they were false negatives and then I go back and I have to order something else. Well, thank you so much for staying this late. Thank you. Yes.

lymphedema

assessment

diagnosis

treatment

early detection

referral

imaging techniques

central lymphedema

symptoms

thoracic duct embolization

abdominal lymphedema

genital lymphedema

head and neck lymphedema