基于Bevilacqua模型的乳腺癌保乳术患者术后淋巴水肿风险预测的临床研究

目的验证Bevilacqua乳腺癌术后淋巴水肿风险预测模型的临床适用性及可行性。方法回顾性分析2010年1月至2015年12月203例乳腺癌患者临床资料,临床数据分析使用统计学软件SPSS 24.0。Cox回归模型分析乳腺癌患者术后发生上肢淋巴水肿的危险因素,以P<0.05为有统计学意义;绘制ROC曲线,以曲线下面积检验模型预测效果;应用Hosmere-Lemeshow检验评估预测值与实际值的校准程度,以P>0.05为预测模型校准能力较好,预测与实际没有区别。结果所有患者随访共计62~86个月,中位随访时间70个月。术后5年内共发生上肢淋巴水肿患者45例(22.2%)。Cox回归模型分析结果显示,高身体质量指数(BMI)、接受过新辅助化疗、全腋窝淋巴结清扫、接受过放疗是上肢淋巴水肿的独立危险因素。Becilacqua上肢淋巴水肿风险预测模型ROC曲线分析结果显示,模型AUC值为0.711,95%CI(0.651~0.760),有较好的的预测效果。Hosmer-Lemeshow检验结果显示,风险预测模型预测风险与实际无明显差异(P=0.262),校准能力较好,与实际差别不大。结论Bevilacqua术后6个月淋巴水肿风险预测模型的准确性及适用性较高,可用于临床对乳腺癌保乳术后淋巴水肿的预测,可为预防淋巴水肿的发生制定干预决策提供参考。     

肢体慢性淋巴水肿CDT治疗后低弹力绷带使用时长对远期疗效的影响

目的 探讨肢体慢性淋巴水肿CDT(Complex decongestion therapy)治疗后低弹绷带使用时长对于长期疗效的影响。方法 2016至今,对57例淋巴水肿患者按治疗结束后自我使用低弹绷带包扎时长（t）分为A(>1年)、B(0.5～1年)、C(<0.5年)3组。采用多频生物电阻人体成分分析仪测量组织水分,卷尺测量肢体周径。比较3组患者复诊时与治疗结束时水分和周径的变化。结果 A组在维持肢体周径、水分方面明显优于B组和C组,B组则优于C组（P<0.05）。3组治疗后的丹毒发作频率均有改善,A组改善最为明显（P<0.05）。结论 肢体慢性淋巴水肿患者在CDT治疗结束后应继续使用低弹绷带包扎患肢,坚持使用越久的患者长期疗效越好。     

脂肪抽吸术在治疗慢性晚期淋巴水肿中的应用

随着对淋巴水肿病理生理机制认识的深入与治疗手段的迭代更新,已有的大量证据表明,无论客观测量还是患者的主观感受,脂肪抽吸术均能为慢性晚期淋巴水肿患者带来显著的治疗效果。本文就脂肪抽吸术用于治疗淋巴水肿患者的原理、手术指征、治疗效果及联合应用等方面进行综述。     

Three case studies indicating the effectiveness of manual lymph drainage on patients with primary and secondary lymphedema using objective measuring tools

The superficial lymphatic system is divided into areas called lymphatic territories which are separated by watersheds. When the lymphatic system fails to remove its load either due to surgery, radiotherapy or some congenital malformation of it then the fluid (and the proteins and wastes contained within it) accumulates in that territory. Anastomotic connections exist across the watersheds and while they can work unaided, manual lymph drainage (MLD) can significantly help drainage across them into unaffected lymphatic territories. MLD also can help the movement of extracellular fluids into the lymph vessels and then along them. The purpose of the study is to examine the effectiveness of a manual technique in moving fluids and softening hardened tissues using three non-invasive examination tools. We examined the movement of fluids from the affected limbs of three lymphedema patients who underwent a standardized 45-min treatment using the Dr Vodder method of M L D. We chose a typical cross section of patients with either a primary leg, secondary leg or secondary arm lymphedema. The arm lymphedema patient was also measured for return of edema over a 30-min period after the conclusion of treatment and underwent a follow-up control measurement, 2 months later without treatment. The tools used were tonometry, multi-frequency bioelectrical impedance and perometry. All three evaluation tools indicated a movement of fluid to different and unblocked lymphatic territories as well as a softening of tissues in some of the affected limbs. Fluid movements were also detected in the contralateral, apparently normal limbs, even though they were not treated. MLD thus is an effective means of fluid clearance when it has accumulated as a consequence of a failure of the lymphatic system. It seems likely that MLD has a systemic effect on the lymphatic system and that it can improve flow from otherwise normal tissues. It is hypothesized that a series of treatments (as is the norm) would result in even more significant improvements.     

应用皮瓣桥接治疗阴囊及下肢淋巴水肿的疗效观察

目的 探讨皮瓣桥接法治疗淋巴水肿的疗效。方法 对8例阴囊及下肢淋巴水肿所致严重皮肤病变应用轴型皮瓣和任意型皮瓣(胸腔联合皮管)治疗。切除病变组织、移转皮瓣、桥接引流淋巴液。结果 2年～7年术后随访观察，除1例外伤性小腿淋巴水肿术后3年复发外，其余各例淋巴水肿病变部位术后6月～12月逐渐显效，患肢肿胀均有不同程度的减轻且病情稳定，无丹毒及蜂窝织炎再发，手术效果满意。结论 利用皮瓣修复淋巴水肿所致的严重皮肤病变部位是治疗淋巴水肿的一种有效方法。     

Lymphedema diagnosis and management

PURPOSE: To provide advanced practice nurses with a greater understanding of the pathophysiology, clinical manifestations, diagnosis, and management of lymphedema. DATA SOURCES: Comprehensive literature review of the relevant clinical journals, systematic reviews, and medical textbooks. CONCLUSIONS: Lymphedema is a poorly known and understood condition. If not properly diagnosed and promptly treated, lymphedema can cause significant morbidity and mortality. Diagnosis is based on suggestive history and characteristic findings on physical exam that ideally would be confirmed by lymphoscintigraphy. The primary goal in lymphedema treatment is the removal of excess plasma proteins from the interstitial tissues. The goals of management are to decrease the extremity size, maintain the decreased size, prevent complications, and improve function and overall sense of psychological well-being. IMPLICATIONS FOR PRACTICE: The ability to properly diagnose lymphedema is crucial to prevent the significant morbidity and mortality that is associated with this condition. It is imperative that patients with lymphedema are referred to specially trained healthcare professionals to ensure optimal treatment.     

Association between Number of Retrieved Sentinel Lymph Nodes and Breast Cancer-related Lymphedema

PurposeSentinel lymph node biopsy (SLNB) has become a standard axillary staging surgery for early breast cancer, and the proportion of patients requiring axillary lymph node dissection (ALND) is decreasing. We aimed to evaluate the association between the number of sentinel lymph nodes (SLNs) retrieved and the risk of lymphedema of the ipsilateral arm.MethodsProspectively collected medical records of 910 patients were reviewed. Lymphedema was defined as a difference in circumference > 2 cm compared to the contralateral arm and/or having clinical records of lymphedema treatment in the rehabilitation clinic.ResultsTogether with an objective and subjective assessment of lymphedema, 36 patients (6.1%) had lymphedema in the SLNB group and 85 patients (27.0%) had lymphedema in the ALND group (p < 0.001). In a multivariate analysis of the whole cohort, risk factors significantly associated risk with the development of lymphedema were body mass index, mastectomy (vs. breast-conserving surgery), ALND, and radiation therapy. In logistic regression models in the SLNB group only, there was no correlation between the number of retrieved SLNs and the incidence of lymphedema. In addition, in the Pearson correlation analysis, no correlation was observed between the number of retrieved SLNs and the difference in circumference between the ipsilateral and contralateral upper extremities (correlation coefficients = 0.067, p = 0.111).ConclusionThe risk of lymphedema in breast cancer surgery and adjuvant treatments is multifactorial. The number of retrieved lymph nodes during sentinel biopsy was not associated with the incidence of lymphedema.     

Intra- and Interrater Reliability and Concurrent Validity of a New Tool for Assessment of Breast Cancer–Related Lymphedema of the Upper Extremity

Objective

The goal of this study was to develop and assess intra- and interrater reliability and validity of a clinical evaluation tool for breast cancer–related lymphedema, for use in the context of outcome evaluation in clinical trials.

1例宫颈癌术后双下肢Ⅲ期合并下腹部及外阴部Ⅱ期淋巴水肿患者的护理

总结1例宫颈癌术后双下肢Ⅲ期合并下腹部及外阴部Ⅱ期淋巴水肿患者进行改良式综合消肿治疗的护理经验。治疗期护理要点包括进行皮肤护理,预防和减少感染;改良手法淋巴引流联合空气波压力治疗仪,促进淋巴液定向流动;采用多种方法进行压力包扎,维持消肿效果;制订个体化的饮食及运动管理方案,科学减重。维持期护理要点包括结合凯格尔训练编制自我淋巴引流操,提高锻炼依从性;多学科协作进行随访管理,激发患者自我照护潜能。经过9个月的精心治疗及护理,患者双下肢各部位周径缩小了2.0~14.2 cm,下腹部及会阴部肿胀感消失,BMI降至正常水平。