PROGRAMME BOOK ABSTRACT BOOK - Lymphology 2011

PROGRAMME BOOK
ABSTRACT BOOK
www.lymphology2011.com
23RD INTERNATIONAL
CONGRESS OF
LYMPHOLOGY
September 19 - 23 2011
Malmö, Sweden

Congress
Hall
VENUE MAP
East
Room
Room F
Room G
Room E
Speakers
Service
Center
Basement
Room A+B
Room C
Room D
Registration / Info
Main Entrance
Toilets
Wardrobe
Lunch
Exhibition
Posters
Coffee Breaks
www.stadionmassan.se

Dear Colleagues and Lymphologists!
The Department of Plastic and Reconstructive Surgery at
Malmö University Hospital, Sweden, is honored to organize the
23rd International Congress of Lymphology in cooperation with
the International Society of Lymphology, the Swedish Lymphology
Association and the Faculty of Medicine at Lund University.
Problems related to the lymphatic system are central issues for
us, and one of our main focuses is the development of surgical
techniques related to lymphology. Olof Rudbeck (1630-1702),
a Swedish scientist, published his first treatise De Circulatione
Sanguinis in 1652, at the age of 22 years only, and he actually
became the first one to describe the delineation and function
of the lymphatic system in Nova Exercitatio Anatomica, which
he published one year later. With this historical perspective in
mind, we are enthusiastic about hosting the 23rd International
Congress of Lymphology in Sweden. We are also proud of being
entrusted with the task of arranging the prestigious congress in
the city of Malmö. In fact, Malmö connects on to another pioneering
scientific work in the field of lymphology performed by
Thomas Bartholin (1616-1680), who was active in the nearby
capital of Denmark, Copenhagen.
In 2011, from September 19 to 23, the most renowned scientists
from all over the world will gather in Malmö to present and debate
their front line knowledge and experiences in the various
fields of lymphology. This will assure for an interdisciplinary and
all-round illumination of the lymphatic system, its pathophysiology,
and the state-of-the art of different treatment regimes.
Moreover, at the end of the summer but before fall, September
is an excellent time of the year to visit Sweden.
We look forward to seeing you all in Malmö on this very special
occasion. Please contact us for any additional information or
suggestions that can make your stay even more pleasant in our
dynamic and beautiful city.
On behalf of the Organizing Committee
Welcome to Sweden and the 23rd
International Congress of Lymphology!
Håkan Brorson, MD, PhD, Associate Professor
Congress President
23rd International
Congress of
Lymphology
Dear Therapist Colleagues!
Come and join us at the 23rd International Congress of Lymphology,
September 19-23, 2011. Make friends from all over the
world and expand your personal network, as I have enjoyed doing
the past ten years. It is now a network of great knowledge
and wonderful personalities and I am really looking forward to
a reunion in Malmö.
The congress program is now developing from the abstracts
that have been submitted. Those of you who are working with
cancer patients and have special interest in PREVENTION will
find a session with that topic.
If you are involved in TREATMENT of patients with lymphedema,
primary as well as secondary, arms as well as legs, breast or
genitals, you name it, there will be presentations that will interest
you, including different approaches, new as well as already
established. CHILDREN will get a special session.
To get reliable result from our treatments we need good MEAS-
UREMENT METHODS and I am very pleased that not only one
session, but two, will evaluate old methods and introduce new
ones, most of them very useful in clinical work.
What about PHYSICAL ACTIVITY? Can lymphedema patients do
exercises without deterioration of the edema? Do they actually
benefit from exercise? Yes, yes, and yes! Make sure you get all
the latest information on this important topic.
Whenever a lymphedema is diagnosed it will influence QUAL-
ITY OF LIFE for the patient and this issue is very important to
recognize for all care providers. This will be discussed in one
session.
Do different approaches and treatments have promise and
where do they fit in context? The session BEST PRACTICE will
tell.
I think that if this program cannot tickle your lymphedema
senses then nothing can.
Love to see you all in Malmö in September.
Best regards
Karin Johansson, PT, PhD
Congress Vice President
September 19-23, 2011
Malmö, Sweden www.lymphology2011.com

The Organizing committee expresses its thanks and appreciation
to all those who are generously contributing to the success of the
23 rd International Congress of Lymphology, September 19 - 23,
Malmö, Sweden
Platinum Sponsor
Gold Sponsors
Apodan Nordic Healthcare A/S
Bauerfeind AG
Bodystat Ltd
Carl Zeiss AB
Delfin Technologies Ltd
Haddenham Healthcare
Höjmed Medical AB
Intramedic AB
Rolf Davidsen Helseagenturer AS/Jovipak
Juzo GmbH
Lymed Oy
Solaris
Technovital

Content
Committees 5
General Information 7
Overall Congress Evaluation 13
Programme at a Glance 17
Additional Meetings 19
Scientific Programme 21
Keynote Lectures 22
Round Table Sessions 29
Programme Sessions 01-30 39
Industry Sponsored Sessions 54
Social Programme 55
Oral Presentation Abstracts 57
Poster Presentation Abstracts 171
Author Index 193
Exhibition 203
Certificate of Attendance 207

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ORGANIZING COMMITTEE
SCIENTIFIC COMMITTEE
Håkan Brorson, MD, PhD
Karin Johansson, PT, PhD
Leif Perbeck, MD, PhD
ORGANIZING COMMITTEE
Honorary Presidents
Sten Jacobsson, MD, PhD (Malmö)
Torsten Landberg, MD, PhD (Malmö)
Iwona Swedborg, MD, PhD (Stockholm)
Magnus Åberg, MD, PhD (Malmö)
Malmö-Lund
Henry Svensson, MD, PhD
Professor and Head
Department of Plastic and Reconstructive Surgery
Malmö University Hospital
Håkan Brorson, MD, PhD
Carolin Freccero, MD, PhD
Karin Johansson, PT, LT, PhD
Karin Ohlin, OT
Barbro Svensson, PT, LT
Ingrid Tengrup, MD, PhD
Stockholm
Elizabeth Johansson, PT, LT
Leif Perbeck, MD, PhD
Ulla Steen-Zupanc, MD
SCANDINAVIAN GROUP
Denmark
Tony Karlmark, MD, PhD
Susan Nörregaard, RN
Susanne Birkballe, MD
Norway
Kristin Ruder, PT
Hilde Osnes, PT
23 rd ICL Secretariat
Destination Öresund
Fersens väg 18
SE-211 42 Malmö, Sweden
Tel: +46 40 300 665
Fax: +46 40 918 952
lymphology2011@destinationoresund.com
Contact person: Congress Manager Lars Rudbert
5

European Union of Medical Specialists
EACCME - European Accreditation Council for Continuing Medical Education
Institution of the UEMS
Avenue de la Couronne 20, B-1050, Brussels
T: +32 2 649 5164 | F: +32 2 640 37 30 | E: accreditation@uems.net
Department of Clinical Sciences Malmö, Lund University, Plastic and Reconstructive Surgery,
Malmö University Hospital
Entrance 75
SE-205 02 Malmö
SWEDEN
SUBJECT: EACCME accreditation granted EACCME-6047-G
We are pleased to inform you that your application for European accreditation for:
23rd International Congress of Lymphology
Venue: Malmö, Sweden (19.–23.09.2011)
Event code: 6047
was granted 24 European CME credits (ECMEC) by the European Accreditation Council for Continuing
Medical Education (EACCME).
European Accreditation
European Accreditation is granted by the EACCME in order to allow participants who attend the above-mentioned activity to validate their
credits in their own country.
Accreditation Statement
Accreditation by the EACCME confers the right to place the following statement in all communication materials including the registration
website, the event programme and the certificate of attendance. The following statements must be used without revision:
»The 'Department of Clinical Sciences Malmö, Lund University, Plastic and Reconstructive Surgery, Malmö University Hospital' (or) '23rd
International Congress of Lymphology' is accredited by the European Accreditation Council for Continuing Medical Education (EACCME) to
provide the following CME activity for medical specialists. The EACCME is an institution of the European Union of Medical Specialists (UEMS),
www.uems.net.«
»The '23rd International Congress of Lymphology' is designated for a maximum of (or 'for up to') 24 hours of European external CME credits.
Each medical specialist should claim only those hours of credit that he/she actually spent in the educational activity.«
»EACCME credits are recognized by the American Medical Association towards the Physician's Recognition Award (PRA). To convert EACCME
credit to AMA PRA category 1 credit, contact the AMA.«
EACCME credits
Each medical specialist should claim only those hours of credit that he/she actually spent in the educational activity. The EACCME credit system
is based on 1 ECMEC per hour with a maximum of 3 ECMECs for half a day and 6 ECMECs for a full-day event.
Logo
The UEMS – EACCME logo is a service mark of the European Union of Medical Specialists – European Accreditation Council for CME. This
service mark may be used publicly only with the permission of the UEMS – EACCME. The logo may only be used in conjunction with, and in
proximity to, the EACCME accreditation statement. The logo cannot be used in notices, advertising, or promotion of activities other than in
association with the EACCME accreditation statement.
Feedback report
The EACCME requires you to provide a feedback report of the event within four weeks of its completion together with a copy of the list of
participants and the results of the individual feedback assessments by participants.
Brussels, 13. 7. 2011 The UEMS – EACCME Secretariat
UEMS - Union européenne des médecins spécialistes | Avenue de la Couronne 20, B-1050, Bruxelles
IBAN BE28 0001 3283 3820 | BIC (SWIFT) code: BPOTBEB1
The European Accreditation Council for Continuing Medical Education (EACCME) was set up by the UEMS for the purpose of ensuring the international mutual
recognition of quality assesments of CME-CPD activities organised all over the world for the benefit of European physicians

GENERAL
INFORMATION

Banking
Banks are open between 10.00 and 16.00 on weekdays.
Some banks in central Malmö are open 09.00-17.00,
and a few also on Saturdays. Cash machines are often
located along the main streets next to a bank. Credit
cards are accepted everywhere. Some supermarkets in
Malmö are post office agents. Opening hours are usually
08.00-22.00 on weekdays.
Bicycles
Some hotels have bicycles for lending, free of charge.
Ask at the hotel reception.
Certificate of attendance
A certificate of attendance will be issued in the programme
book.
CME information
European Accreditation is granted by the EACCME
(European Accreditation Council for Continuing
Medical Education) in order to allow participants who
attend the congress to validate their credits in their
own country. The EACCME is an institution of the
European Union of Medical Specialists (UEMS), www.
uems.net.
23rd ICL is designated for a maximum of, or up to 24
European CME credits (ECMECs).
Participants who have indicated that they would like
to apply for CME credits will receive a form before
the congress. The form can be submitted to the staff
www.medi.de
at the Congress Information Desk or emailed/faxed to
louise@destinationoresund.com Fax: +46 40-918 952.
A CME certificate will follow by email after the congress.
Coat and luggage
The cloakroom is located at entrance level and will be
open during the congress.
Congress venue
Stadionmässan
Stadiongatan 25, Malmö
Website: www.stadionmassan.se
Congress evaluation
Please fill out the form on page 13 and hand it in
to the staff at the Information Desk.
We kindly ask you to fill the form out, as it is required
by the EACCME as well as future organisers
of the ICL Congresses.
Currency
All official congress prices are indicated in SEK (Swedish
Krona). Exchange rates are approximately:
100 SEK= 15 USD
100 SEK= 11 EUR
All major credit cards are accepted in most hotels, restaurants
and shops.
Lymph therapy
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Delegate badge
Each participant will receive a name badge when checking
in on-site. For security reasons all participants are
requested to wear their badge during all the Congress
activities and social events. The cost of replacing a lost
or mislaid badge is 200 SEK.
Delegate bag
The delegate bag, which includes the programme book,
pad and pen etc. can be collected at the entrance upon
checking in at the registration desks.
Disclaimer & insurance
The Organizing Committee, Destination Öresund and
Stadionmässan accept no liability for any injuries/
losses incurred by participants and/or accompanying
persons, nor loss or damage to any luggage and/or personal
belongings. Participants are advised to take their
own personal insurance. The 23 rd ICL and the organisers
take no responsibility for cancellations or delays for
any causes beyond our reasonable control.
Emergency/First aid
For any emergency or first aid services inside the congress
venue please contact the staff. The emergency
number in Sweden is 112.
Exhibition opening hours
Monday, 19 September 17.30
Tuesday, 20 September 10.00 - 16.30
Wednesday, 21 September 10.00 - 16.30
Thursday, 22 September 10.00 - 16.30
Friday, 23 September 10.00 - 14.00
Guided tours
Participants and accompanying persons should have
registered for the tours by 30 th August. Last minute
registration can also be done online. For detailed info
please refer to: www.hagelborntravel.se/travel/
Accompanying persons are automatically registered
for the tour on Tuesday 20 September.
Information
The Congress Information Desk is located by the entrance.
Our staff will be happy to assist delegates with
their queries. Tel: +46 768 397 936. E-mail: louise@
destinationoresund.com.
Internet spots and wireless internet
We are pleased to provide wireless internet access at
the congress venue. The relevant network name and
password can be found at the message board by the
entrance.
Lost and found
Any lost and found items will be held at the Congress
Information Desk during the congress.
Messages
There will be a message board by the entrance.
Meals and refreshments
Coffee breaks and lunches are included in the delegate
registration fee. For times of service, please refer to the
detailed programme section in this book.
Mobile phones
All delegates are requested to switch off their mobile
phones in the lecture halls and rooms during sessions.
Non-smoking policy
The entire venue is a non-smoking area. Smoking is
only permitted outdoors.
Official congress language
The official congress language is English. No simultaneous
translation will be provided.
Official social events
Welcome reception
Stadionmässan Exhibition Hall, Monday September 19
at 17.30.
Congress dinner:
Malmö Opera, Thursday September 22 at 19.00.
Oral presentations
Please refer to the program in this book.
Photos, filming and recording
Taking photos, filming and audio recording of the scientific
program as well as of sponsor satellite symposia,
partly or in their entirety, is not allowed without
a written approval by the Organising Committee. The
presenters have the intellectual rights and copyrights
of their presentations.
Poster area
The poster area will be located along the left side of the
Exhibition Hall.
Poster presentation
Please see the overview programme in this book.
Public transport
Please consult www.skanetrafiken.se for public transport
in Malmö (click on the British flag at the top for
English), including trains for Copenhagen and other
destinations. Tickets cannot be purchased on the bus/
train.
You can buy your ticket at customer service centers or
ticket machines by the train stations. If you plan to take
the bus/train more than once, purchasing a Jojo discount
card might be advisable.
For a bus map, please see the website above. The information
desk by the entrance can also assist you with
queries regarding buses to and from the congress venue.
9

Registration hours
Monday, 19 Sept 10.00-20.00
Tuesday, 20 Sept 08.00-18.00
Wednesday, 21 Sep 08.00-18.00
Thursday, 22 Sep 08 00-18.00
Friday, 23 Sep 08.00-15.00
Responsibility
The delegate acknowledges that he/she has no right to
lodge damage claims against the organisers, should the
holding of the congress be hindered or prevented by
unexpected political or economical events or generally
by force majeure, or should the non-appearance of
speaker or other reasons necessitate program changes.
With his/her registration, the delegate accepted this
proviso.
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3M and Coban are trademarks of the 3M Company.
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Taxi
The price setting of taxi fares is free in Malmö and we
strongly advise you to use these companies:
Taxi 97, Phone: +46 (0)40 97 97 97
Taxi Skåne, Phone: +46 (0)40 330 330
Taxi Kurir, Phone: +46 (0)40 70 000
You don´t need to take the first taxi in the rank in
Malmö!
Train
The trip from Copenhagen Airport to Station Triangeln/Malmö
Central Station takes approximately 20
minutes and the single fare is 105 SEK (about 11 Euro
or 15 USD, July 2011) if you buy the ticket at the airport.
Ms G, breast cancer survivor,
lymphoedema patient, demonstrates
the flexibility and
function of 3M Coban 2
Compression System.

Turning
Torso
Stora Varvsg
23rd International Congress of Lymphology, Malmö
Malmöhus slott
Malmöhus Castle N. Vallg
Kungsparken
Slottsg
Slottsparken
Stadsbiblioteket
City Library
Regementsg
Congress venue
Stadionmässan
Europaporten
8
Fersens v.
Skeppsbron
Lilla torg
Stadiong
Jörgen Kocksg
Pildammsv
Carlsg
Rådmansg
Stortorget
Malmö Central Station
F
S. Förstadsg
Rådhuset/Town Hall
Baltzarsg
Stora Nyg
Carl Gustafsv
Skånes Universitetssjukhus
University
Hospital
John Ericssons v
Drottn.g
P
Föreningsg
P
Österg
S. Förstadsg
S. Förstadsg
Amiralsg
Dalaplan
Köpenhamn Copenhagen
Köpenhamn Copenhagen
➔
2
Gustav Adolfs torg
1
2
3
Renaissance Malmo Hotel
Hotel Noble House
Scandic S:t Jörgen
6
Triangeln
5
●F
4 Scandic Malmö City
7
5
6
Hotel Plaza
Teaterhotellet
Malmö
Opera Station Triangeln
S:t Johannesg.
7 Hilton Malmö City
8 Ibis Hotel
Pildammsparken
Taxi
F Flygbussar
Airport Coaches
Malmö airport
Walk
Bus
Station
Triangeln
Smedjeg.
Isstadion
34
▲
~2,5 km
➞
1
●
3
➞
4
●F
●F
34
➔
Gågata
Pedestrian street
●F
●F
Bergsg
●
F
Södervärn
N
500 m
Amiralsg
Nobelv
©Destination Öresund
11

Overall Congress Evaluation
Please fill out this form (3 pages) and hand it to the staff at the Information Desk.
1. Registration ID Number (required): _________________
CME credit applicants must complete this.
For others, you may enter a "0" if you want complete anonymity
If you don't remember your registration numbe, ask at the information desk.
2. Your area of specialty (click all that apply)
2a. Physician
2b. Physiotherapist
2c. Occupational therapist
2d. Nurse
2e. Other, please specify: __________________________
3. Please rate the Congress (if applicable)
3a. Overall Opinion of the Congress
Excellent Very Good Good Poor Don’t know
3b. Material Supplied (Final Programme, CD-Rom, Website Content)
Excellent Very Good Good Poor Don’t know
3c. Opportunity for Discussion
Excellent Very Good Good Poor Don’t know
3d. Congress content
Excellent Very Good Good Poor Don’t know
4. Rate the Quality of:
4a. Planning and Organization
Excellent Very Good Good Poor Don’t know
4b.Meeting Rooms
Excellent Very Good Good Poor Don’t know
4c. Registration/Hospitality Desk
Excellent Very Good Good Poor Don’t know
4d. Quality of Catering
Excellent Very Good Good Poor Don’t know
5. How did you hear about the Congress?
I am a past ICL Congress attendee
Email
Website search
From a colleague or friend
Printed material or advertisement
13

14
6. Was this event free of commercial bias? Registration ID: ________________
Yes No
7. Distribution of topics in parallel sessions: How often did you feel that it was urgent for you
to attend more than one parallel session.
Very often Often Seldom Almost never Don’t know
7. Please use the space below to comment on the aspects of the Congress that you enjoyed and
have helped you learn
8. Please use the space below for recommendations or suggestions for improving any aspect
of the Congress

9. General comments or suggestions for the next Congress
Registration ID: ______________
10. What other initiatives would you like the ICL Congress to incorporate in the future?
11. Are you planning to attend the 2013 ICL Congress in Rome?
Yes No Don’t know
15

PROGRAMME AT A GLANCE

18
Congress Hall
Room A+B
East Room
* Congress Hall
Monday 19 Sept Tuesday 20 Sept Wednesday 21 Sept Thursday 22 Sept Friday 23 Sept
Breakfast Workshop - Bauerfeind
07:30 - 08.15
Registration Starts 08:30 - 09.00
Kari Alitalo *
Molecular Mechanisms in Lymphangiongenesis
Keynote
Coffee
10:00
Anne Kärki *
Do We Need MLD? Lymphedema Therapy:
Current Evidence of Best Practise
Keynote
Pierre Bourgeois *
Imaging the Lymphatic System in 2011
Keynote
Terence Ryan *
Adipose Tissue, Fibrosis and Lymphoedema, Mechanisms of Formation and Removal,
What is the Evidence?
Keynote
Session 29
Decongestive Therapy I
Chair: Isabel Forner-Cordero,
Giovanni Moneta,
Jean-Paul Belgrado
Session 27
New Frontiers in
Lymphatic Research I
Keynote
Stan Rockson
Chair: Stan Rockson,
Moirya Ohkuma,
Anatoliy Gashev
Session 24
Genital Lymphedema
Chair: Alexandre Pissas,
Wichai Ekataksin
Session 21
Phlebolymphology
Session 09
Measuring Methods I
09:00 - 10.30
Opening Ceremony
12:00
Chair: Francesco
Boccardo,
Evangelos
Dimakakos
Session 18
Lymphatic Imaging I
Chair: Pierre Bourgeois,
Leif Perbeck,
Pernilla Peterson
Session 15
Lipedema
Chair: Wilfried Schmeller,
Gyozo Szolnoky,
Sandro Michelini
Session 12
New Approaches
- Alternative Therapies
Chair: Miguel Amore,
Wichai Ekataksin,
Alberto Gersman
Round Table
Leigh Ward,
Jane Armer,
Harvey Mayrowitz
Session 06
Prevention
Chair: Neil Piller,
Alex Munnoch,
Ethel Földi
Session 03
Pathophysiology
Chair: Terence Ryan,
Moriya Ohkuma,
Andrzej Szuba
Vice-chancellor Per Eriksson
Repr Skåne Regional Council
City Councillor Kent Andersson
President Håkan Brorson
Vice President Karin Johansson
ISL President Rüdiger Baumeister
Secretary-General Marlys Witte
Prof Emirita Iwona Swedborg
Coffee Break Coffee Break Coffee Break Coffee Break
10:00 - 11.00
Refreshment Break
13:00
Session 30
Decongestive Therapy II
Chair: Ulla Steen-Zupanc,
Waldemar Olszewski,
Elizabeth Johansson
Session 28
New Frontiers in
Lymphatic Research II
Session 10
Measuring Methods II
11:00 - 12.30
Keynotes
Marlys Witte
Lymphology and the ISL in the Real, Virtual and
Imagined World of the Future
13:45
Chair: Stan Rockson,
David Zawieja,
Marlys Witte
Session 25
Compression Treatment I:
Pitfalls and Dangers of
Compression Therapy
Round Table
Hugo Partsch,
Robert Damstra,
Vaughan Keeley
Session 22
Lymphatic Imaging II
Chair: Pierre Bourgeois,
Ningfei Liu,
Emily Iker
Session 19
Surgery I
Chair: Alex Munnoch,
Jaume Masia,
Martin Wald
Session 16
Best Practice for the
Management of
Lymphedema I
Chair: Corradino Campisi,
Jane Armer,
Susanne Birkballe
Session 13
Filariasis and Lymphedema
Keynote
Gurusamy Manokaran
Chair: Gurusamy Manokaran,
Isabel Forner-Cordero
Chair: Leif Perbeck,
Michael Bernas,
Neil Piller
Session 04
Session 07
Pediatric I:
Basic Science
Lymphedema in Children Chair: Mauro Andrade,
Keynote
Gyozo Szolnoky
Cristóbal Papendieck
Keynote
Fiona Connell
Chair: Cristóbal Papendieck,
Fiona Connell,
Carolin Freccero
Katie Schmitz
Balancing Lymphedema Risks: Exercise Versus
Deconditioning
Stanley Leong
Impact of Tumor Burden in the Sentinel Lymph
Nodes on the Outcomes of Cancer Patients
Lunch
Lunch
Lunch
12:30 - 14.00
Peter Mortimer
Breast Cancer Related Lymphedema
Lunch
medi Symposium (13.00 - 13.30) *
Jobst Symposium (13.00 - 13.45) *
3M Symposium (13.00 - 13.30) *
Coffee Break
13.15
Consensus Document
Session 26
Compression Treatment II
Session 20
Surgery II
Chair: Harry Voesten,
Erkki Suominen,
Corrado Campisi
Session 11
Clinic on Lymphedema
14:00 - 15.30
15:30
16:00
14.00
Close of Congress
• Congress President Håkan Brorson
• ISL President Rüdiger Baumeister
• ISL Secretary-General Marlys Witte
• Presentation of 2013 Congress Outline,
Sandro Michelini, San Giovanni Battista
Hospital, Rome, Italy
Chair: Hugo Partsch,
Robert Damstra,
Karin Ohlin
Session 23
Physiology of the
Lymphatic System
Chair: Waldemar Olszewski,
Christen Krag,
Anatoliy Gashev
Session 17
Best Practice for the
Management of
Lymphedema II
Chair: Ethel Földi,
Alexandre Pissas,
Barbro Svensson
Session 14
Cancer and Lymphedema
Chair: Torsten Landberg,
Stanley Leong,
Francesco Boccardo
Chair: Henry Svensson,
Martin Wald,
Marlys Witte
Session 08
Quality of Life
Chair: Jane Armer,
Pia Klenäs,
Sandy Hayes
Session 05
Pediatric II:
Lymphatic Malformations
Keynote
Arin Greene
Session 02
Anatomy of the
Lymphatic System
Keynote
Miguel Amore
Session 01
Exercise and
Lymphedema
Chair: Karin Johansson,
Kathryn Schmitz,
Ethel Földi
Chair: Arin Greene,
Magnus Åberg,
Carolin Freccero
Chair: Miguel Amore,
Eikichi Okada
Welcome Reception Hosted by City of Malmö
17.30
14.30
General Assembly
Coffee Break Coffee Break Coffee Break
15:30 - 16.00
ISL Executive Committee Meeting
Round Table *
Basic Science and the Way to Treatment
Rüdiger Baumeister, Neil Piller,
Anne Saaristo, Håkan Brorson
16:00 - 17.30
Round Table *
Surgical and Non-surgical Treatment: Against Each Other or Together?
Rüdiger Baumeister, Corradino Campisi, Håkan Brorson, Anne Kärki
Round Table *
Lipedema: Diagnostic Tools and Treatment Necessities?
Peter Mortimer, Gyozo Szolnoky, Ilka Meier-Vollrath, Wilfried Schmeller
17.30
Tivoli Copenhagen (optional) Free Evening Congress Dinner (19.00)
* Congress Hall
Poster session Thursday
13.30 – 14.00
P-13.07 – P-29.15
Poster session Tuesday
13.30 – 14.00
P-01.08 – P-11.13

Additional meetings
Swedish Lymphology Association
Date: Thursday, September 22
Time: 12.30-13.00
Room: Congress Venue, Room D (combined with
lunch)
ISL Executive Committee Meeting
Date: Sunday, September 18
Time: 18.00
Room: Meeting Room, Department of Plastic Surgery,
Skåne University Hospital, Entrance 75, 3rd floor
Date: Wednesday, September 21
Time: 12.30-13.00
Room: Congress Venue, Room D (combined with
lunch)
Date: Friday, September 23
Time: afternoon, after General Assembly
Room: Congress Venue, Room D
19

SCIENTIFIC PROGRAMME
KEYNOTE LECTURES
ROUND TABLE SESSIONS
PROGRAMME SESSIONS 01-30
INDUSTRY SPONSORED SESSIONS

22
KEYNOTE LECTURE MONDAY 13.45-14.15 CONGRESS HALL
KN-01
LYMPHOLOGY AND THE ISL IN THE REAL, VIRTUAL AND IMAGINED WORLD OF THE FUTURE
M H Witte, Department of Surgery, University of Arizona College of Medicine, Tucson, UNITED STATES
Since before the official founding of the International Society of Lymphology (ISL), lymphology has transcended the barriers
of medical specialization, language, and geography. In 1966, the First International Congress of Lymphology in Zurich
brought together hundreds of basic scientists (largely anatomists and physiologists) and clinicians (prominent radiologists/
lymphographers and cancer/vascular surgeons) who envisioned the lymphatic system as more than “lymph nodes held
together by strings.” Forty-five years later, we in the “real world” of lymphology still “stand on the shoulders of these giants,”
revisiting neglected threads from earlier times and applying advances in molecular biology, technology, and public health to
bring new understanding to structure-function relationships in the normal and diseased lymphatic system, higher resolution
in multimodal dynamic lymphatic imaging, and improved care to patients afflicted with myriad disorders of the “lymphatics,
lymph, lymph nodes and lymphocytes.” Many key unanswered questions and unquestioned answers persist (true “medical
ignorance”), and many more will doubtless arise de novo in the “imagined world” of bewildering genomes, proteomes,
transcriptomes, metabolomes, organomes, functionomes, diseasomes, phenomes, etc. As we move from “genes to man” – to
translate discoveries into personalized medicine in lymphology – new and better ways to collaborate globally across basic
and clinical disciplines will incorporate sophisticated communication/data networks and remote outreach. Here, the “virtual
world” of our web-based Virtual Clinical Research Center/Questionarium should be a powerful tool to advance molecular,
cellular, systemic, and clinical lymphology and provide a welcome roadmap to our “unimagined” future.
Declaration of interest
None declared
KEYNOTE LECTURE MONDAY 14.15-14.40 CONGRESS HALL
KN-02
BALANCING LYMPHEDEMA RISKS: EXERCISE VERSUS DECONDITIONING
K Schmitz, University of Pennsylvania, Philadelphia, UNITED STATES
Background: Lymphedema is a common and feared adverse clinical sequelae of breast cancer treatment. Our current ability
to predict who will develop lymphedema or who will progress to advanced stages of the condition are poor, at best. Given this
scenario, the clinical advice to women with and at risk for lymphedema has been risk averse, including advice to protect the
affected limb and avoid lifting. Unfortunately, this rational response to the unknown may lead to the very outcome patients
seek to avoid (onset or worsening of lymphedema) as a side effect of the deconditioning resulting from protecting the limb.
Objectives: The objective of this presentation is to present evidence and theory regarding physiologic effects of exercise on the
lymphatic system structure and function, as well as to review the recently published evidence regarding the clinical effects of
exercise on lymphedema outcomes in breast cancer survivors.
Methods: A systematic literature review of the evidence regarding physiologic and clinical effects of exercise on outcomes
related to lymphedema in breast cancer survivors.
Results: Evidence from lymphoscintigraphic studies indicate increased lymphatic clearance during exercise than at rest among
women with lymphedema. Decades of exercise science support the usefulness of site specific exercise to improve circulatory
function, suggesting exercise may improve the ability of the affected limb to respond to infection, inflammation, and trauma.
Exercise training also improves the functional capacity, reducing the relative intensity of work. This may result in avoiding
the overuse often thought to be the cause of lymphedema onset and progression. Results of clinical trials on exercise strongly
support the use of exercise as part of a program to reduce lymphedema onset or progression among breast cancer survivors.
Conclusions: The scientific evidence base regarding the value of exercise for prevention and control of lymphedema in breast
cancer survivors is as compelling as for any therapeutic modality. Further imaging studies will assist with cementing the
mechanisms through which these effects occur. However, it is now clear that rehabilitative weight training exercise should be
standard of care for breast cancer survivors.
Declaration of interest
none declared

KEYNOTE LECTURE MONDAY 14.40-15.05 CONGRESS HALL
KN-03
IMPACT OF TUMOR BURDEN IN THE SENTINEL LYMPH NODES ON THE OUTCOMES OF CANCER
PATIENTS
S Leong, Department of Surgery, California Pacific Medical Center, San Francisco, UNITED STATES
Background: The concept that cancer of a specific anatomical site spreads to its corresponding sentinel lymph nodes (SLNs) in
the regional nodal basin has been extensively validated in melanoma and breast cancer.
Objective: To evaluate the clinical significance of micrometastasis in the SLNs.
Methods: Literature review.
Results: In general, micrometastasis in the SLNs of solid cancers predicts a worse clinical outcome. Cancer metastasis from the
primary site to the SLNs (incubator hypothesis) and then to the non-SLNs prior to systemic spread in melanoma and breast
cancer is consistent with the spectrum theory that cancer metastasis is progressive. However, in about 20% of the time, cancer
cells may spread through the SLNs and vascular system simultaneously (marker hypothesis) or independently to the distant
sites via the vascular system. If the SLNs are negative, a more morbid regional lymph node dissection may be spared in melanoma.
For breast cancer, removal of SLNs with metastasis may be effective during the ‘‘incubator’’ phase, but adjuvant therapy
should be given for patients with microscopic disease in the distant sites. In penile carcinoma, SLN mapping will guide the
appropriate location of the lymph node to avoid a morbid bilateral radical ilioinguinal lymph node dissection. For head and
neck, colorectal, upper GI, other GU and gynecological cancers, the lymphatic pathways are, in general, more complicated and
unpredictable. For head and neck as well as gynecological cancers, the goal is to establish a reliable SLN mapping method to
minimize the degree of lymph node dissection. For colorectal and upper GI cancers, while the extent of lymphadenectomy may
not be altered significantly, the identification of SLNs will increase the accuracy of staging the nodal basins, especially in view
of the fact that the number of lymph nodes being resected for colorectal and gastroesophageal cancer is a significant predictor
of survival.
Conclusion: In conclusion, SLN is the gateway for cancer metastasis in the majority of the time. Further molecular and genomic
studies may define the mechanisms of cancer spread through the lymphovascular system more precisely, thus, allowing us to
develop more rational therapy.
Declaration of interest
None declared
KEYNOTE LECTURE MONDAY 15.05-15.30 CONGRESS HALL
KN-04
BREAST CANCER RELATED LYMPHOEDEMA (BCRL)
P Mortimer, Division of Clinical Science, St George’s, University of London, London, UNITED KINGDOM
Axillary surgery for breast cancer may be followed, weeks to years later, by chronic arm lymphoedema (BCRL). A simple
obstructive “stopcock” mechanism (reduced lymph drainage from the entire limb) does not explain many clinical aspects,
including the delayed onset and selective sparing of some regions eg hand. In a prospective study that investigated patients
following breast cancer treatment, but before the onset of lymphoedema, lymph flow was found to be significantly higher
in the arms of those women who subsequently developed arm swelling.(1) Lymph flow was found significantly higher in
both subcutis and sub-fascial forearm muscle.(1) Furthermore lymph flow was also found to be higher in the contralateral
arm which was unaffected by surgery.(1) BCRL therefore developed in women with higher peripheral lymph flows. These
results indicate that BCRL is not simply an obstructive lymphoedema. We propose that women have a defined, constitutive
predisposition to BCRL by developing high fluid filtration rates in response to cancer and/or its treatment. Higher fluid
filtration overloads lymph drainage which, over time and in the face of increased outflow lymphatic resistance, leads to
lymphatic collector pump failure and the onset of lymphoedema. (2,3)
1. Stanton AW, Modi S, Bennett Britton et al, Lymphatic drainage in the muscle and subcutis of the arm after breast cancer
treatment. Breast Cancer Res Treat. 2009;117:549-57
2. Modi S, Stanton AW, Svensson WE et al. Human lymphatic pumping measured in healthy and lymphoedematous arms by
lymphatic congestion lymphoscintigraphy. J Physiol. 2007;583:271-85
3. Stanton AW, Modi S, Mellor RH et al. Recent advances in breast cancer-related lymphoedema of the arm: lymphatic pump
failure and predisposing factors. Lymphat Res Biology 2009;7:29-45
Declaration of interest
None declared
23

24
KEYNOTE LECTURE MONDAY 16.00 - 16.30 ROOM A+B
O-02.01
REVIEW THE LYMPHATIC ANATOMY IN THE SENTINEL NODE ERA
M Amore, Buenos Aires University, Buenos Aires, ARGENTINA
OBJECTIVE:The introduction of the sentinel lymph node biopsy has renewed the interest in regional lymph nodes outside
some organs as a potential site of regional lymph nodes metastases. Detailed gross anatomical information about the lymphatic
system is essential for predicting accurate distant metastatic sites in cancer. The purpose of this study is to carry out a detailed
description of the lymphatic drainage of different organs (mammary gland, colon, stomach, esophagus, thyroid gland, genital
organs and skin, and translation this finding to the clinical experience in lymphatic mapping and sentinel node biopsy.
MATERIAL AND METHODS: Our material comprised 300 specimens 283 of which where from human fetus and 17 from
fresh adult cadavers between 50 to 76 years old of which 226 where women and 74 men. The injection was done with the
modified Gerota’s mass. Dissection is carried out after fixation of the specimen in 40% formaldehyde for 6 days, and then
immersed in an 100 volume hydrogen peroxide solution for 24 hours (Prof. Caplan’s bleaching technique). In 90 fetus
specimens we used the Spalteholz technique for diafanization. Research was carried out at the Lymphatic Research Laboratory
of the III Chair of Anatomy at the University of Buenos Aires.
RESULT: Sentinel lymph node dissections have been shown to be sensitive for the evaluation of nodal basins for metastatic
disease and are associated with decreased short-term and long-term morbidity when compared with complete lymph node
dissection. This study addresses the lymphatic anatomy of some organs in relation of the incidence of cancer. Our finding may
explain the clinical experience in lymphatic mapping and sentinel node biopsy, and also the persistence of a false negative rate
irrespective of experience of the surgeon.
Declaration of interest
NONE DECLARED
KEYNOTE LECTURE TUESDAY 08.30 - 09.00 CONGRESS HALL
KN-05
MOLECULAR MECHANISMS IN LYMPHANGIOGENESIS
K Alitalo, Molecular/Cancer Biology Laboratory, Haartman Institute and Finnish Institute for Molecular Medicine, Helsinki,
FINLAND
Vascular endothelial growth factor (VEGF) stimulates angiogenesis and permeability of blood vessels via its two receptors
VEGFR-1 and VEGFR-2, but it has only little lymphangiogenic activity. The third receptor, VEGFR-3, does not bind VEGF
and its expression becomes restricted mainly to lymphatic endothelia during development. Homozygous VEGFR-3 targeted
mice die around midgestation due to failure of cardiovascular development, whereas transgenic mice expressing the VEGFR-3
ligand VEGF-Cor VEGF-D show evidence of lymphangiogenesis and VEGF-C knockout-mice have defective lymphatic
vessels. VEGF-C overexpression induces lymphangiogenesis and growth of the draining lymphatic vessels, intralymphatic
tumor growth, lymph node lymphangiogenesis and metastasis. Furthermore, soluble VEGFR-3 and antibodies blocking
VEGFR-3 inhibited embryonic and tumor lymphangiogenesis and lymphatic metastasis. These results have indicated that
paracrine signal transduction between tumor cells and the lymphatic endothelium is involved in lymphatic metastasis. We
have recently found that VEGF-C and VEGFR-3 provide also new targets to complement current anti-angiogenic therapies.
Because of their ability to attenuate angiogenic sprouting and inhibit lymphatic metastasis, VEGFR-3 blocking antibodies are
now being tested in phase I clinical (safety) trials. - Furthermore, our studies indicate that antibody combinations may be
used for increased efficacy of inhibition of angiogenic signal transduction pathways.
Preclinical studies of lymphedema treatment have shown that VEGF-C stimulates the formation of new lymphatic capillaries
and, after an initial increase in lymph extravasation, reduces edema. When the growth factor therapy was applied to damaged
collecting lymph vessels, lymphatic capillary growth was followed by intrinsic remodeling, differentiation, and maturation
into functional vessels with normal zipper-like endothelial cell-cell junctions, intraluminal valves and SMC coverage. A
combination of VEGF-C therapy with lymphnode transplantation showed that the growth factor-transduced lymph nodes
formed both afferent and efferent connections with the pre-existing lymphatic vessel network, and could even trap metastatic
tumor cells. In pigs, VEGF-C or VEGF-D therapy proved effective in restoring functional lymphatic vasculature to the site
of surgical damage and greatly increased the survival and functionality of transferred lymph nodes. These studies have
provided a basis for clinical trials in lymphedema patients with non-malignant disease that, after further safety trials, should
be applicable also to cancer patients.
Declaration of interest
None declared

KEYNOTE LECTURES TUESDAY 11.00 - 11.25 CONGRESS HALL
O-04.01
LYMPHEDEMA IN PEDIATRICS. DIALOGUE BETWEEN SCIENCE AND PRIMARY CARE. PROPOSAL
FOR A CONSENSUS DOCUMENT.
C Papendieck, Instituto de Diagnóstico y Tratamiento, Buenos Aires, ARGENTINA, R Martinez, Hospital de Quemados, Buenos
Aires, ARGENTINA, L Barbosa, Angiopediatría, Buenos Aires, ARGENTINA, M A Amore, Hospital Militar Centra, Buenos Aires,
ARGENTINA, E Paltrinieri, Centro Vodder, Buenos Aires, ARGENTINA, D Braun, Angiopediatria, Buenos Aires, ARGENTINA
Lymphedema diagnosis in pediatric patients include as less 140 syndromes or diseases, including the whole universe of primary
lymphedema (PL). There is no reached consensus on its definition. We support the opinion that PL is a sign, and their causes
congenital, and provoke a dysfunction of the lymphatic system. Initially, there is some endothelial, interstitial, precapillary or
capillary disability, or some canalicular or nodal dysplasia (LAD I, LAD II respectively). This dysplasia expresses itself as a deficit
in interstitial fluid protein reabsorption, and other components of lymphatic load too, or in lymph transportation mechanical
obstruction in the way to the venous angle. There are 18 well-known anatomical anomalies in lymph vessels and lymph nodes
design. Stem cells and as less as 12 lymphangiogenic growth factors and their receptors, are involved in the morphogenesis of
lymphatic system and are endothelial function regulators, five of them in the interstice. Interstitial volume/space increased is
constant with or without hypertension in the segments of the circuit. The protocols of international consensus, MEP, ISL and
others, provided the basic tools for rehabilitation. There is no cure. That means a future without specific therapies, for the rest of
life. There is no diagnostic by evidence.
We propose the basis for a Consensus Document on Lymphedema in Pediatric Patients for diagnosis in genetic, molecular,
anatomopathology and image, as well as therapeutic indications considering, when possible, its etiological diagnosis.
A little baby cannot wait for the whole life, it is not satisfactory to propose to use bandage forever, as our unique therapeutic offer.
The ISL Consensus Document completely avoids any mention to pediatric patients. Children are not little adults, their physiology,
anatomy, immune system are peculiar and put the frame for diagnostic and therapeutic interventions.
In a typical secondary lymphedema standard treatment, as established in consensus documents, is indicated. Details for
specific diagnostic and therapeutic procedures must be discussed to guide clinical practice until evidence-based practice
could be well established. Proposals for a consensus document in primary and secondary pediatric lymphedema will be
discussed.
Declaration of interest
None declared
KEYNOTE LECTURES TUESDAY 11.25-11.42 CONGRESS HALL
O-04.02
RECENT ADVANCES IN THE GENETICS OF PRIMARY LYMPHOEDEMA
F Connell, Guy’s and St Thomas’ NHS Trust London, London, UNITED KINGDOM, S Mansour, St George’s University of London,
London, UNITED KINGDOM, P Ostergaard, St George’s University of London, London, UNITED KINGDOM, G Brice, St
George’s University of London, London, UNITED KINGDOM, M Simpson, King’s College London, London, UNITED KINGDOM,
R Trembath, King’s College Hospital, London, UNITED KINGDOM, P Mortimer, St George’s University of London, London,
UNITED KINGDOM, S Jeffery, St George’s University of London, London, UNITED KINGDOM
Background: Primary lymphoedema is a chronic oedema caused by a developmental abnormality of the lymphatic system. In
recent years there has been considerable progress made in understanding the molecular pathways underlying lymphangiogenesis
but knowledge of the genetic causes of human lymphatic disease was limited to VEGFR3, FOXC2 and SOX18. There are many
different phenotypes of primary lymphoedema and with the use of conventional molecular analysis techniques and new next
generation sequencing we have identified two further genes that cause different primary lymphoedema phenotypes; CCBE1 and
GJC2.
Objectives: The aim of our work has been to improve phenotyping of primary lymphoedema patients in order to facilitate the
identification of well defined patient groups for molecular studies that would lead to the discovery of genetic causes of primary
lymphoedema in humans.
Methods: Patients were ascertained from the joint Lymphoedema/Genetics Clinic at St George’s Hospital, London.
Linkage and sequence analysis was carried out to identify the genetic cause of recessively inherited generalised lymphatic
dysplasia/Hennekam syndrome. A large, non-consanguineous family with three affected siblings with generalised lymphatic
dysplasia was studied. Linkage analysis was used to determine a locus in a large multigenerational pedigree in which four-limb
lymphoedema segregates in an autosomal dominant manner. Exome sequencing was employed to look for causative variants
within the predetermined locus.
Results: A homozygous change in CCBE1 was identified as the causative mutation for autosomal recessive generalised lymphatic
dsyplasia/Hennekam syndrome. Mutations in GJC2 were identified to cause autosomal dominantly inherited four-limb/bilateral
lower limb lymphoedema.
Conclusion: Notable advances in the understanding of the genetics of primary lymphoedema have been achieved and the
implications of these discoveries will be discussed. The role of CCBE1 and GJC2 in lymphatic disease has been reported by
Alders et al 2009 and Ferrell et al 2010 respectively, and our work adds supportive evidence to these studies. Understanding the
molecular mechanisms that result in lymphatic disease will hopefully ultimately translate into improved therapies for patients.
Declaration of interest
None declared
25

26
KEYNOTE LECTURE TUESDAY 14.00 - 14.30 CONGRESS HALL
O-05.01
DIFFERENTIAL DIAGNOSIS OF LOWER EXTREMITY ENLARGEMENT IN PEDIATRIC PATIENTS
REFERRED WITH A DIAGNOSIS OF “LYMPHEDEMA”
A Greene, Children’s Hospital Boston/Harvard Medical School, Boston, UNITED STATES
Background: There are many causes for a large lower limb in the pediatric age group. These children are often mislabeled as
having “lymphedema”, and incorrect diagnosis can lead to improper treatment. The purpose of this study was to determine
the differential diagnosis in pediatric patients referred for lower extremity “lymphedema” and to clarify management.
Methods: Our Vascular Anomalies Center database was reviewed between 1999 - 2010 for patients referred with a diagnosis
of “lymphedema” of the lower extremity. Records were studied to determine the correct etiology for the enlarged extremity.
Alternative diagnoses, gender, age-of-onset, and imaging studies also were analyzed.
Results: A referral diagnosis of lower extremity “lymphedema” was given to 170 children; however, the condition was
confirmed in only 72.9% of patients. Forty-six children (27.1%) had another disorder: micro/macrocystic lymphatic
malformation (19.6%), non-eponymous combined vascular malformation (13.0%), capillary malformation (10.9%), Klippel-
Trenaunay syndrome (10.9%), hemi-hypertrophy (8.7%), post-traumatic swelling (8.7%), Parkes Weber syndrome (6.5%),
lipedema (6.5%), venous malformation (4.3%), rheumatologic disorder (4.3%), infantile hemangioma (2.2%), kaposiform
hemangioendothelioma (2.2%), or lipofibromatosis (2.2%). Age-of-onset in children with lymphedema was older than
patients with another diagnosis (p = 0.027).
Conclusion: “Lymphedema” is not a generic term. Approximately one-fourth of pediatric patients with a large lower extremity
are misdiagnosed as having “lymphedema”; the most commonly confused etiologies are other types of vascular anomalies.
History, physical examination, and often radiological studies are required to differentiate lymphedema from other conditions
to ensure the child is managed appropriately.
Declaration of interest
None declared
KEYNOTE LECTURE WEDNESDAY 08.30 - 09.00 CONGRESS HALL
KN-06
ADIPOSE TISSUE, FIBROSIS AND LYMPHOEDEMA, MECHANISMS OF FORMATION AND REMOVAL,
WHAT IS THE EVIDENCE?
T Ryan, Oxford University, Marlborough, UNITED KINGDOM
This paper will describe some of the grossest hypertrophy of the tissues observed in elephantiasis Oedema is a small component
creating mechanical tension and triggering hypertrophy of the collagen component. This is mostly in the dermis and there is
loss of the more elastic tissue component which is elastin.
The dermis affected by lympoedema does acquire new fat containing cells believed to support the locally threatened immunosurveillance
system and secondarily dissipating mechanical forces.
The subcutaneous tissues are normally host to adipose tissue and usually show less hypertrophy when the dermis and epidermis
is most affected by lymphoedema. When the subcutaneous tissues do show gross hypertrophy, the overlying epidermis
and dermis are usually less grossly affected
Reversal of the hypertrophy by therapists is often achieved by simple technologies influencing the lymphatic system such as
washing and massage. How fibrosis is reversed raises many questions. Scandinavia is host to the most impressive effects of
liposuction acting on the subcutaneous issues but sparing the upper dermis in particular. Exactly what mechanisms reverse
elephantiasis requires a review of both
1) the transduction of biochemical signals by mechanical forces and the protective role of elastin, and
2) emphasis on the function of the adipocyte and the effects of its removal from the subcutaneous or lower dermal tissues.
In some respects the deep collecting lymphatic system and the superficial initial lymphatic network are two independent
systems . While the superficial system prefers to exit through the collecting system I regard it as mostly independent and
relying on elastin for support of its function. The collecting system and lymphnodes rely on adipose tissue for some functions,
but when injured the lymph drainage system possibly does better without it. This presentation will discuss the evidence in so
far as it exists in the obscure nomenclature of dermatological disease.
Declaration of interest
None declared

KEYNOTE LECTURE WEDNESDAY 11.00 - 11.30 EAST ROOM
O-13.01
“NEW HOPE FOR LYMPHOEDEMA PATIENTS”
G Manokaran, Apollo Hospitals, Chennai, INDIA
As you all know patients with lymphoedema are so unfortunate that they never get cured irrespective of the etiology, only
lymphatic filarasis in Stage I and Stage II lymphoedema are curable and reverable. Lymphoedema progresses due to secondary
infection, cellulitis, lymphangitis due to injury, intertrigo (fungal infection) and focal sepsis like carries teeth in the patients.
Controlling or eliminating these problems with simple foot hygiene, washing with soap and water, using antifungal cream
or powder, eliminating the focal sepsis by dentist along with Manual Lymph Drainage (MLD) and bandaging with regular
physiotherapy helps in keeping this problem under control.
Only very few congenital, post-surgical lymphoedema patients needs micro-vascular surgery, lymphatico lymphatic anastomosis,
free lymph node or muscle transfers to address this problem, though not cured completely. Liposuction is found to be
very useful in post-mastectomy lymphoedema.
LF lymphadema which loses its shape needs multiple stage reduction surgery followed by physiological operations or MLD.
Our policy of treating these patients by multi-modality therapy will be discussed as an ideal recommendation for these
patients through a power-point presentation, for roughly twenty minutes.
Declaration of interest
None declared
KEYNOTE LECTURE THURSDAY 08.30 - 09.00 CONGRESS HALL
KN-07
IMAGING THE LYMPHATIC SYSTEM IN 2011
P BOURGEOIS, Université Libre de Bruxelles, Institut Jules Bordet, Brussels, BELGIUM
The lymphatic system is a complex network of lymph vessels, lymphatic organs and lymph nodes. Conventional oil-contrast
lymphography has long been the mainstay for lymphatic imaging but is now an all-but-extinct method. Imaging of the lymphatic
system are based -particularly in oncology- on conventional anatomical imaging methods like computed tomography (CT)
and magnetic resonance imaging (MRI), whereby enlargement of lymph nodes is considered the primary diagnostic criterion
for disease. Now, positron emission tomography (PET) can also provide a metabolic assessment of node status. With regard to
lymphatic vessels, heavily T2-weighted MRI has great sensitivity and the Magnetic Resonance Lymphangiographic image has
high legibility for detecting the pathologically modified lymphatic vessels and accompanying complications non-invasively.
However, none of these techniques is capable of detecting flow within the lymphatics. With the intracutaneous injection of
contrast agents such as gadolinium-diethylene-triamine-pentaacetic-acid, MR lymphangiography can provide information
concerning the functional status of lymph flow transport in these lymphatic vessels and lymph nodes. However, MRI methods
are relatively expansive and the reported experiences are relatively limited.
Despite its relatively poor resolution, lymphoscintigraphy is now recognized and widely used as the first investigational step
in the management of most of the lymphatic disorders. It permits (in addition to its use for the sentinel node detections in
oncology) easier imaging of peripheral lymphatic vessels and provides insight into lymph flow dynamics. It is the only method
which allows quantifications and the current “hybrid” equipments (SPECT-CT) allow to obtain three-dimensional imagings
of the lymphatic system-and of its anomalies fused with X ray computed tomographic data. Recently, a new technique was
introduced using indocyanine green and a handheld near-infrared camera to visualize and evaluate lymphatic channels in
real time. The method is very attractive but, in our opinion, presents a major limitation: it allows to study only the very
superficial lymphatic structures. To conclude, the use of these techniques, alone, combined or in an orderly fashion, will have
to be considered taking into account the clinical situations and the (diagnostic and/or therapeutic) questions the clinicians
ask.
Declaration of interest
None declared
27

28
KEYNOTE LECTURE FRIDAY 08.30 - 09.00 CONGRESS HALL
KN-08
DO WE NEED MLD? LYMPHEDEMA THERAPY: CURRENT EVIDENCE OF THE BEST PRACTICE
A Kärki, Satakunta University of Applied Sciences, Pori, FINLAND
Systematic review published 2007 (1) by Finnish Office of Health Technology Assessment and reported 2009 (2) in Acta
Oncologica ended up to conclusions that research results did not support the use of MLD. Literature research yield: 13
systematic reviews, 14 RCTs were included to the final analysis. Two RCTs had moderate and the others high risk of bias.
There was moderate evidence that compression bandages decreased lymphoedema, and that pneumatic pumps had no effect
on lymphoedema.
The available evidence suggests that compression bandages are likely to reduce upper limb lymphedema in breast cancer
patients. Limited or no evidence was found of the effects of other physiotherapy methods and their combinations on
lymphoedema or any other outcome. (1,2)
Recent systematic review by McNeely et al. 2011 (3) concerning conservative interventions for cancer-related lymphedema
concluded that a large clinical benefit was found that supports the use of compression garments and multi-layered compression
bandaging. They pointed out that only a small benefit was found that supports the use of additional MLD. This review also
suggests, that the primary volume reduction benefit from intensive treatment programs, such as DLT, is the results of the
effect of compression therapy component.
Just this moment numerous ongoing clinical trials ( www.controlled-trials.com) are aiming to find out effects of several
treatment options and also manual lymph therapy is studied. Some of the clinical trials are aiming to find out the best
compression treatment for developing more effective and user-friendly methods.
1. Anttila H., Kärki A., Rautakorpi U-M. 2007. LYMPHEDEMA THERAPY IN BREAST CANCER PATIENTS.
EFFECTIVENESS, CURRENT PRACTICES AND COSTS. Finnish Office of Health Technology Assessment, report 30/2007.
2. Kärki A., Anttila H., Tasmuth T., Rautakorpi U-M. 2009. Lymphoedema therapy in breast cancer patients - a systematic
review on effectiveness and a survey of current practices and costs in Finland. Acta Oncologica 2009;48.
3. McNeely M., Peddle C., Yurick J., Dayes I., Mackey J. 2011. Conservative and dietary interventions for cancer-related
lymphedema. Systematic review and meta-analysis. Cancer Mar.15, 117 (6): 1136-48.
Declaration of interest
None declared
KEYNOTE LECTURE FRIDAY 09.00 - 09.30 CONGRESS HALL
O-27.01
NEW FRONTIERS IN LYMPHATIC RESEARCH
S Rockson, Stanford Center for Lymphatic and Venous Disorders, Stanford University School of Medicine, Stanford, UNITED
STATES
The last decade has witnessed an unprecedented explosion of new information that has been accrued about lymphatic vascular
development and genetics, its contractile biology, and the processes of normal, abnormal and therapeutic lymphangionesis.
An overview of these developments will be undertaken, with an eye toward the implications for the diagnosis and treatment
of lymphatic diseases.
Declaration of interest
None declared

ROUND TABLE SESSION TUESDAY 16.00 - 17.30 CONGRESS HALL
BASIC SCIENCE AND THE WAY TO TREATMENT
RT-01.01
TREATMENT OPTIONS, PATHOPHYSIOLOGY AND BASIC SCIENCE
R Baumeister, University of Munich, Munich, GERMANY
Treatment can be based on personal experience, speculation and believes. Treatment options should be based however
on respecting the pathophysiology of the underlying disease and the results given by the basic science. Furthermore they
should take advantage of the latest actual technical possibilities and finally, the results should be controlled by independent
investigators. As an example, the development and scientific follow up protocols of microsurgical reconstructive procedures
is described and future aspects with respect to basic science discussed.
The ISL conferences combine traditionally the different aspects from basic science to treatment in the field of Lymphology.
To intensify the combined efforts, a round table session at this early stage of the congress with basic scientists and therapeutic
practitioners including the opinions of the panel may be the optimal nucleus for further progress on one side and may help
the auditors to form the own opinion of different procedures presented in the treatment sessions at the end of the week on
the other side.
Declaration of interest
None declared
RT-01.02
CONSERVATIVE THERAPY FOR LYMPHOEDEMA: ARE WE DOING IT RIGHT?
N Piller, Lymphoedema Assessment Clinic, Department of Surgery, Flinders Medical Centre, Bedford Park, AUSTRALIA
We do not seem to be gaining significantly better outcomes for our patients despite the plethora of older and new conservative
treatments and patient based management programs. Why is this so? Is this real, or is it because we are not using appropriate
measurement techniques to determine changes related to treatment, or are we not using the right treatment at the right time,
ignoring what we know of anatomy, physiology and patho-physiological changes as lymphoedema progresses.
There are a range of well-evidenced tools available to assess total, limb and local fluid levels using Bio-impedance spectroscopy
and di-electric constants and yet we still do not use them despite the fact that they require less time than circumference
measurement, are more representative of the key changes we are interested in (fluids) and can be easily logged as a measurement
series.
When a health professional does not see a patient frequently the use of circumference and/or plethysmography can be an
invalid indicator ofthe progression of lymphoedema since these measure total limb volume change, which may be increased
with weight gain or musclemass or visaversa. We should concentrate on fluids in the limb or area since these are the best
measure of the status of the lymphatic system.
We also do not use other simple tools such as the tissue tonometer or Indurometer to objectively measure the build up of
fibrotic induration in the lymphatic territories and yet knowing about how its changing is crucial to good lymphatic drainage
and knowing where it is may help better targeting and sequencing of lymphoedema treatment.
This talk will focus on the issues of recognising and responding to structural and functional changes in the tissues as
lymphoedema progresses in terms of selecting the “right” treatment at the “right” time, and what is best or “right” for the
patient, as well as our ability to measure these changes and respond to them with targeted and sequenced conservative
treatment. I hope we can also discuss some of the common errors of assumption that we can make when assessing the
progress of conservative treatment.
Declaration of interest
None declared
29

RT-01.03
LYMPH NODE TRANSFER AND GROWTH FACTOR THERAPY FOR LYMPHEDEMA PATIENTS
A Saaristo, Turku University Central Hospital, Turku, FINLAND, T Tervala, Turku University Central Hospital, Turku, Finland,
K Honkonen, University of Eastern Finland, Kuopio, Finland, K Alitalo, Helsinki University, Helsinki, Finland, E Suominen,
Turku University Central Hospital, Turku, Finland
Background and Objectives: Lymphedema after surgery, infection or radiation therapy is a common and often incurable
problem. Previously application of lymphangiogenic growth factors has been shown to induce lymphangiogenesis and
to reduce tissue edema. The objective of our translational research group has been to develop an effective treatment for
lymphedema, which could be applied in conjunction with surgery.
Methods: We have evaluated the therapeutic effect of autologous lymph node transfer with or without lymphatic growth factors
in lymphedema porcine model. Lymph node grafts and adenovirally delivered vascular endothelial growth factor-C or
VEGF-D were used to reconstruct the lymphatic network in the inguinal area; AdLacZ served as a control.
Results: Results from the porcine lymphedema model demonstrate that lymphatic vasculature does have a tremendous capacity
for spontaneous regeneration. Interestingly we also found that human lymphnodes express endogeneous lymphatic
vessel growth factors. However, without additional growth factor support (AdVEGF-C/D) the incorporation of the transferred
lymph nodes may fail resulting into scarring and fibrosis of the nodes. Both growth factors induced robust growth of
new lymphatic vessels in the defect area, and postoperative lymphatic drainage was significantly improved in the VEGF-C/D
treated pigs as compared to the controls. Interestingly, VEGF-D transiently increased accumulation of seroma fluid in the
operated inguinal region postoperatively, whereas VEGF-C did not have this side effect.
Conclusion: Lymph node transfer technique is still considered experimental surgery. In the future our goal is to combine
lymphatic growth factor therapy (AdVEGF-C) with the lymph node transfer to gain more efficacy for the lymphedema
treatment. By combining the lymphatic vascular growth factor therapy with the lymph node transfer we can fully restore the
normal lymphatic vascular anatomy.
Declaration of interest
Dr Anne Saaristo is a member of the board of directors of OY LX Therapies Ltd.
RT-01.04
FROM LYMPH TO FAT: CONFIRMATORY ANALYSES
H Brorson, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
The occurrence of adipose tissee hypertrophy has been evaluated in various papers. In 1987 we noted an excess of adipose
tissue in the lymphedematous tissues and recommended liposuction in order to remove the excess volume. New ideas and
concepts of treatment, however, require evaluation and confirmation before they are accepted and become the standard of
care.
1. Consecutive analyzes of the content of the aspirate removed under bloodless conditions, using a tourniquet, showed a very
high content of adipose tissue in 44 women (mean 90%, range: 58-100) was found.
2. Analyses with DXA in 18 women with postmastectomy arm lymphedema showed a significant increase of adipose tissue
in the non-pitting swollen arm before surgery. Postoperative analyses showed normalization at 3 months. This effect was seen
also at 12 months. These results paralleled the complete reduction of the excess volume (“edema volume”).
3. Investigation with VR-CT (Volume Rendering Computer Tomography) in 8 patients also showed a significant preoperative
increase of adipose tissue in the swollen arm, followed by a normalization at 3 months paralleling the complete reduction of
the excess volume.
4. The findings of increased adipose tissue in intestinal segments in patients with Crohn’s disease, known as “fat wrapping”,
have clearly shown that inflammation plays an important role.
5. In Graves´ ophthalmopathy a major problem is an increase in the intraorbital adipose tissue volume leading to exopthalmus.
Adipocyte related IEGs (immediate early genes) are overexpressed in active ophthalmopathy and CYR61 (cysteine-rich,
angiogenic inducer, 61) may have a role in both orbital inflammation and adipogenesis.
We now know that patients with chronic, non-pitting, lymphedema develop large amounts of newly formed subcutaneous
adipose tissue, which precludes complete limb reduction utilizing microsurgical reconstruction or conservative treatment.
Although incompletely understood, this adipocyte proliferation has important pathophysiologic and therapeutic implications.
Liposuction can be performed in patients who fail to respond to conservative management because the hypertrophy of the
subcutaneous adipose tissue cannot be removed or reduced by the other techniques available.
Declaration of interest
None declared
30

ROUND TABLE SESSION WEDNESDAY 09.00 - 10.30 CONGRESS HALL
MEASURING METHODS I
O-09.01
BIOELECTRICAL IMPEDANCE SPECTROSCOPY FOR THE EARLY DETECTION OF LYMPHEDEMA.
L C Ward, The University of Queensland, Brisbane, AUSTRALIA
It is now three decades since the measurement of electrical impedance was first proposed for the measurement of edema
(Watanabe et al., 1981) although it was not until 10 years later that it was demonstrated clinically as being diagnostically
informative (Ward et al., 1992). Since then, methods of impedance measurement have been standardised and impedance
instrumentation specifically designed for lymphedema assessment have been produced. Yet the method has still to gain wide
acceptance in a clinical setting (Mohler and Mondry, 2011). The reasons for this are unclear but may relate to the technical
complexity of the method, equipment costs or simply wide-spread acceptance of long-standing use of tape measurements of
limb volume. This instructional session will provide a simple overview of the principles of the technique, review how it may
be used in clinical practice and evaluate the advantages of BIS vis-á-vis other commonly used assessment tools.
Watanabe R. et al. (1981)Trial of application of electrical impedance for measuring leg edema. In Oshima and Kanai (Eds.)
Proc. Vth Int. Conf. on Electrical Bioimpedance, Tokyo, suppl. p. 109.
Ward LC et al. (1992) Multi-frequency bioelectrical impedance augments the diagnosis and management of lymphoedema in
post-mastectomy patients. Eur J Clin Invest. 22: 751-4.
Mohler ER & Mondry TE (2011) Lymphedema: etiology, clinical manifestations and diagnosis. UpToDate http://www.
uptodate.com/contents/lymphedema-etiology-clinical-manifestations-and-diagnosis Accessed 16th April 2011.
Declaration of interest
None declared
O-09.02
CIRCUMFERENCES, PEROMETRY, AND SYMPTOM REPORT IN THE ASSESSMENT OF
LYMPHEDEMA
J Armer, University of Missouri, Sinclair School of Nursing, Columbia, MO, UNITED STATES
A historical overview of assessment of lymphedema by circumference, perometry, and symptom assessment will be provided,
with comparison to the ‘gold standard’ of water displacement. Indications for use, contradictions, advantages and disadvantages,
procedures for measurement, and data generated by circumferences, perometry, and symptom report will be reviewed (1-4).
Comparisons of findings with single and multi-frequency impedance will be reviewed. The summary will include comparisons of
findings among methods, including comparison of advantages and disadvantages, and how to choose the method best suited for
a practice or research setting. National and international clinical guidelines in measurement and assessment will be reviewed (5).
Selected references:
1. Armer, J.M. (2005). The problem of post-breast cancer lymphedema: Impact and measurement issues. Cancer Investigation, 1,
76-83.
2. Armer, J.M., Stewart, B.R. (2005). A Comparison of Four Diagnostic Criteria for Lymphedema in a Post-Breast Cancer Population.
Lymphatic Research and Biology, 3(4).
3. Ridner, S.H., Montgomery, L.D., Armer, J.M., Hepworth, J., & Stewart, B.R. (2007). Comparison of upper limb volume
measurement techniques between healthy volunteers and individuals with known lymphedema. Lymphology, 40, 35-46..
Also: Ridner, S.H., Montgomery, L.D., Hepworth, J.T., Stewart, B.R., & Armer, J.M. (2007). Comparison of upper limb volume
measurement techniques and arm symptoms between healthy volunteers and individuals with known lymphedema. Phlebology
Digest, 21, 23-25. (Invited abstract)
4. Bernas, M., Askew, R., Armer, J.M., & Cormier, J. (2010). Lymphedema: How do we diagnose and reduce the risk of this dreaded
complication of breast cancer treatment?, Current Breast Cancer Reports, Vol.2. 53-58.
5. National Lymphedema Network (2011). THE DIAGNOSIS AND TREATMENT OF LYMPHEDEMA. Position paper of
the National Lymphedema Network Medical Advisory Committee. Updated February 2011. Accessed April 18, 2011 at: http://
lymphnet.org/pdfDocs/nlntreatment.pdf
Objectives
1. Participants can state the protocol, indications, implications, and contraindications for use of circumferences.
2. Participants can state the protocol, indications, implications, and contraindications for use of perometry.
3. Participants can state the protocol, indications, implications, and contraindications for use of symptom assessment.
4. Participants can state the protocol, indications, implications, and contraindications for use of electrical impedance.
5. Participants can identify national and international guidelines for lymphedema assessment and measurement.
Declaration of interest
None Declared
31

O-09.03
SKIN TISSUE DIELECTRIC CONSTANT VALUES IN WOMEN WITH BREAST CANCER:PRE-SURGERY
AND ONE YEAR POST-SURGERY
H MAYROVITZ, COLLEGE OF MEDICAL SCIENCES, FT. LAUDERDALE, UNITED STATES
Background:In breast cancer treatment-related lymphedema (BCRL), tissue dielectric constant (TDC) values, reflecting local
skin water, are greater in affected than contralateral arms. However, the magnitude of side-to-side differences before and
changes after surgery is unclear. Pre-surgery evaluations with follow-ups are the best approach for early BCRL detection, but
pre-surgery values may not be taken. So, it is useful to know if breast cancer or natural variations between affected (at-risk)
and contralateral body sides alter parameter values possibly useful for detecting BCRL.
Objectives:To determine body side differences in lymphedema assessment parameters before and one year after surgery.
Methods: With IRB approval, 71 newly diagnosed breast cancer patients were evaluated before surgery and 32 reevaluated
12 months post-surgery. Bilateral TDC values (Delfin Moisture-Meter-D, 2.5 mm depth probe) were measured at forearm,
biceps, axilla and lateral thorax. Arm volumes and bioimpedance values (Impedimed-DF-50) were also determined and
[affected-side/contralateral-side] ratios determined.
Results: Pre-surgery values (mean±SD) for all (n=71) affected and contralateral side values and [ratios] were as follows;
Arm Volumes (ml): 2263±669 vs. 2289±666 [0.988±0.049]; TDCforearm: 25.2±3.7 vs. 24.9±3.7 [1.015±0.117], TDCbiceps:
22.0±3.2 vs. 21.9±3.7 [1.019±0.138], TDCaxilla: 35.0±7.0 vs. 34.9±8.1 [1.034±0.203], TDCthorax: 26.4±4.6 vs. 26.7±5.2
[0.995±0.107]. Arm bioimpedance values (Ohms) were 290.9±41.6 vs. 290.4±42.8 [1.004±0.052]. All pre-surgery side-to-side
differences were statistically insignificant for the total group and for the 32 patient sub-group. Twelve months after surgery a
significant increase only in thorax TDC values was detected (26.6±4.9 vs. 30.7±6.0, p

ROUND TABLE SESSION WEDNESDAY 16.00 - 17.30 CONGRESS HALL
LIPEDEMA: DIAGNOSTIC TOOLS AND TREATMENT NECESSITIES?
RT-02.01
LIPOEDEMA – AN INHERITED CONDITION
P Mortimer, Division of Clinical Science, St George’s, University of London, London, UNITED KINGDOM
Lipoedema is an under recognised condition either mis-diagnosed as lymphoedema or dismissed as obesity. A positive
family history is not unusual and the publication of a series of pedigrees suggests that lipoedema is a genetic condition [Child
AH, Gordon KD, Sharpe P et al. Lipedema: an inherited condition. Am J Med Genet 2010;152:970-7]. The pure phenotype is
as originally described in 1940 by Allen & Hines namely a regional lipohypertrophy (lipomatosis, lipodystrophy) associated
with pain, tenderness and easy bruising. Pain can be a disabling feature and may locate to joints eg knees, as well as affected
subcutaneous tissues. The inheritance appears to be either x linked dominant or autosomal dominant with sex limitation
hence the almost exclusive involvement with females. Lipoedema is presumably oestrogen-requiring as it usually manifests
at puberty or at times of hormonal change (pregnancy). Male involvement only seems to occur with hormonal abnormalities
[Bano G, Mansour S, Brice G et al. Pit-1 mutation and lipoedema in a family. Exp Clin Endocrinol Diabetes 2010;118:377-80]
Declaration of interest
None declared
RT-02.02
LIPEDEMA: PATHOPHYSIOLOGICAL FEATURES
G Szolnoky, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY, A Nemes, 2nd Department
of Medicine, University of Szeged, Szeged, HUNGARY, É Dósa - Rácz, Department of Dermatology and Allergology, University
of Szeged, Szeged, HUNGARY, M Varga, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY,
E Varga, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY, L Kemény, Department of
Dermatology and Allergology, University of Szeged, Szeged, L Kemény, Department of Dermatology and Allergology, University
of Szeged, Szeged, HUNGARY
Background and Objectives: Most prominent lipedema hallmarks (capillary fragility (CF) and pain) or general perception
(GP) and their response to complex decongestive physiotherapy (CDP) or compression were investigated. We also aimed to
measure large blood vessel characteristics of lipedema patients.
Methods: CDP comprised once daily manual lymph drainage (MLD), intermittent pneumatic compression (IPC)
at 30 Hgmm pressure and multilayered and multicomponent short-stretch bandaging for 5 days. Volumetry was
performed in accordance with Kuhnke’s disc model or optoelectronic measurement, CF was assessed using vacuum
suction method (VSM) and pain was measured with a 10-item questionnaire, Wong Baker Faces and visual
analogue scale (VAS) prior and subsequent to therapy cycles. GP was compared with chronic venous insufficiency
questionnaire (CVIQ) between groups using made-to-measure compression class 2 or 3 stockings. Aortic stiffness
(β) was calculated upon echocardiography.
Results: CDP resulted in a significant reduction of limb volumes in both CDP and CDP+IPC groups, of the number
of petechiae and pain severity (p

RT-02.03
LOWER LEGS IN PATIENTS WITH LIPOEDEMA – A CHALLENGE FOR LIPOSUCTION.
I Meier - Vollrath, Hanse-Klinik, Lübeck, GERMANY, W Schmeller, Hanse-Klinik, Lübeck, GERMANY
Lipoedema, a chronic and progressive disease in women, mainly affects thighs and lower legs. In many cases spontaneous
pain, pain due to pressure and feeling of tension are more pronounced in the calves due to stronger oedema in this area. And
in addition the cosmetic impairment is more obvious.
While complex decongestive therapy (CDT) is able to temporarily reduce oedema and pain,the removal of fat of the lower
legs leads to long lasting effects and is therefore crucial. Liposuction is demanding for the surgeon due to the small subcutaneous
layer of the calf and ankle area. Hence there is an increased risk of causing skin irregularities and the surgical procedure
itself can be more painful. The healing period is prolonged compared to the thighs due to a longer period of postoperative
oedema and scar formation and is therefore also a bigger strain for the patients.
Critical evaluation of 112 of our lipoedema patients treated with liposuction in pure tumescent local anesthesia and with
vibrating microcannulas showed good results. There was an improvement of the disproportion with a mean reduction of the
circumference of the calves of 4 (1-11)cm. Beside the amelioration of shape, complaints like swelling and pain were reduced
significantly (p

ROUND TABLE SESSION THURSDAY 11.00 - 12.30 ROOM A+B
COMPRESSION TREATMENT I: PITFALLS AND DANGERS OF COMPRESSION THERAPY
O-25.01
COMPRESSION THERAPY IN MIXED ULCERS: SEARCH FOR AN EFFECTIVE PRESSURE RANGE NOT
AFFECTING ARTERIAL PERFUSION.
H Partsch, Medical University of Vienna, Vienna, AUSTRIA, G Mosti, Medical University of Vienna, Vienna, AUSTRIA,
Objectives: To define bandage pressures which are safe and effective in treating leg ulcers of mixed, arterial-venous, aetiology.
Methods: In 25 patients with mixed aetiology leg ulcers receiving inelastic bandages applied with pressures between 20-30,
31-40 and 41-50 mmHg, the following measurements were performed before and after bandage application to ensure patient
safety throughout the investigation: Laser Doppler Fluxmetry (LDF) close to the ulcer under the bandage and at the great toe,
Transcutaneous Oxygen Pressure (TcPO2) on the dorsum of the foot and toe pressure as safety parameters. Ejection Fraction
(EF) of the venous pump was performed to assess efficacy on venous haemodynamics.
Results: LDF values under the bandages increased by 33% (95% CI 17-48, p < .01), 28% (95% CI 12-45, p

O-25.03
SCREENING FOR PERIPHERAL VASCULAR DISEASE IN CHRONIC OEDEMA. ARE ARTERIAL
DOPPLER WAVE FORMS USEFUL?
V Keeley, Royal Derby Hospital, Derby, UNITED KINGDOM, K Riches, Royal Derby Hospital, Derby, UNITED KINGDOM
Introduction: Peripheral arterial disease is considered a contra-indication to full compression treatment for chronic oedema.
In the UK, in leg ulcer clinics, the ankle brachial pressure index (ABPI) is a commonly used screening tool for peripheral
vascular disease. However, this can be difficult to measure in patients with chronic oedema and indeed the results obtained
may be inaccurate. Recording Doppler wave forms (DWF) in peripheral arteries may be a more practical and reliable tool in
this group of patients.
Objectives: To review the prevalence of abnormal DWF in patients attending a chronic oedema clinic with leg oedema and
to determine the causes of these.
Methods; Doppler wave forms are recorded routinely in new patients using a “vascular Assist” (Huntleigh, UK). Biphasic or
triphasic wave forms in the dorsalis pedis and the posterior tibial arteries are considered to be normal, whereas monophasic
wave forms suggest arterial disease and merit further investigation before compression can be considered.
Results: In 2010 DWF were recorded in 320 new patients with chronic leg oedema in our clinic. Of these, 28 patients (9%)
had at least one monophasic wave form on 44 limbs. 17 (Y%) had two or more monophasic wave forms.
Further investigation, initially with arterial duplex scans revealed significant peripheral vascular disease in the vast majority
of these patients. A number of patients were referred to vascular surgeons and further studies such as MR angiography was
performed.
Conclusions:In this preliminary study, patients with monophasic DWF do seem to have arterial pathology, which may be
asymptomatic. These results have affected our management of patients: in some, where the cause has been reversible e.g. with
angioplasty or stenting, full compression has been possible subsequently. In others, modified (reduced pressure) compression
has been possible. In others with significant irreversible vascular disease, compression has been contra-indicated. Further
studies are required to validate this technique formally in patients with chronic oedema.
Declaration of interest
None Declared
36

ROUND TABLE SESSION THURSDAY 16.00 - 17.30 CONGRESS HALL
SURGICAL AND NON-SURGICAL TREATMENT: AGAINST EACH OTHER OR TOGETHER?
RT-03.01
INTERCONNECTED TREATMENT OPTIONS – A BENEFIT FOR THE PATIENT
R Baumeister, University of Munich, Munich, GERMANY
There is a bunch of suggestions for successful treatment of lymphedema with a wide range starting from simple elevation ,
pharmacological treatment , physical manual drainage , specific exercises, mechanical compression, compression stockings
towards different types of surgical interventions.
Each of these methods may have its specific value. Often however there is a tendency to claim the exclusive usefulness for one
or the other method.
In the view of the patient there is a definite order of desires: cure as the most important one, less invasive treatment , freedom
of continuing treatment, invasive treatment as secondary option with the sequence: reconstruction if possible and resection
if necessary.
With respect to the wishes of the patients each method proposed should be discussed in this order.
To elucidate this, open discussion between the therapist and the patient is necessary and helpful.
This will lead to transitions from one treatment option to the other and possibly to a combination of treatment protocols
supervised jointly by the different specialists.
As an example the procedure is shown using the experiences with conservative treatment, reconstructive microsurgical
options and resection treatment in Germany.
A round table discussion following the presentation of the different methods at the final stage of the congress is the right
occasion to initiate this procedure as a routine in daily praxis.
Declaration of interest
None declared
RT-03.02
LONG-TERM OUTCOME AFTER LYMPHATIC MICROSURGERY FOR PERIPHERAL LYMPHEDEMA.
C Campisi, University of Genoa - University Hospital , Genoa, Italy, P Santi, University of Genoa, Genoa, Italy, C C Campisi,
University of Genoa, Genoa, Italy, R Lavagno, University of Genoa, Genoa, Italy, C S Campisi, University of Genoa, Genoa, Italy,
F Boccardo, University of Genoa, Genoa, Italy
Background: Authors’ wide surgical play in the therapy of both primary and secondary peripheral lymphedema by
microsurgical procedures is mentioned as performed at the Centre of Lymphatic Surgery and Microsurgery of the University
of Genoa, Italy.
Objectives: To report the over 30 years vast clinical experience and the consistent long-lasting outcome concerning the treatment
of peripheral lymphedema by advanced derivative and reconstructive microsurgical techniques.
Methods: Between 1973 and 2011 over 1900 patients underwent microsurgery including derivative lymphatic-venous anastomoses
(LVA technique) and lymphatic reconstruction by interpositioned vein grafted shunts (LVLA technique) with an
average follow-up of more than 10 years. Objective assessment was undertaken by volumetry, venous duplex scan and lymphoscintigraphy.
The outcome obtained in treating lymphedemas at different stages was analyzed in terms of volume reduction,
stability of results with time, reduction of dermatolymphangioadenitis (DLA) attacks, necessity of wearing elastic supports
and use conservative measures post-operatively.
Results: Results were objectively assessed by volumetry and lymphoscintigraphy. Volume changes showed a significant improvement,
till over 84% volume reduction comparing pre-operative conditions. Among patients with lymphedema at earlier
stages (stage I and stage II A), over 86% could progressively give up the use of conservative measures and elastic supports,
and 42% of patients with late stage lymphedema (stage II B and stage III) could decrease the use of physical therapies. Most
considerably, considering lymphedema tertiary prevention in later stage disease, the significant volume reduction diminished
DLA attacks of about 91%. Histological findings showed minor lymphatic and lymph nodal tissue changes in early stage
lymphedemas, whilst significant fibrotic lesions have been demonstrated in late stage lymphedemas.
Conclusion: Microsurgical lymphatic derivative and reconstructive techniques allow to bring about positive results in the
treatment of both primary and secondary peripheral lymphedema, above all in early stages when tissue changes are slight and
allow almost a complete restore of lymphatic drainage.
Declaration of interest
None declared
37

RT-03.03
WHY PERFORM LIPOSUCTION IN PATIENTS WITH CHRONIC NON-PITTING LYMPHEDEMA?
H Brorson, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
The occurrence of adipose tissue hypertrophy in patients with chronic non-pitting lymphedema has been shown in several
papers. We recommend liposuction in patients with chronic non-pitting lymphedema in order to remove the excess volume.
New ideas and concepts of treatment, however, require evaluation and confirmation before they are accepted and become the
standard of care.
Liposuction can thus be performed in patients who fail to respond to conservative management or microsurgical reconstructive
procedures because the hypertrophy of the subcutaneous adipose tissue cannot be removed or reduced by these methods.
A combination of liposuction and reconstructive microsurgery, in order to avoid the wearing of garments, may be an
interesting option but seems not feasible in chronic late stage lymphedema since the delicate anatomy and intrinsic transport
capacity of the lymph vessels is destroyed.
Declaration of interest
None declared
RT-03.04
NEXT STEP – HOW TO ENHANCE THE BEST TREATMENT OPTION OF THE CLIENT?
A Kärki, Satakunta University of Applied Sciences, Pori, FINLAND
Systematic reviews of the clinical trials concerning conservative lymphedema treatments systematically support the use of
compression in different forms. The therapist should be able to critically read existing studies, but the basic education has not
enough supported this scientific reading skills. The lack of awareness of the existing evidence of best practice raises some
concerns. If the therapists are not aware of the evidence base for the treatments they use, they will not be able to explain
and discuss the treatment options with their patients. The lymph therapists should seriously think about increasing their
awareness and also take their own steps to build the evidence base through rigorous and well-designed research settings.
If the evidence do not support the methods used – the methods should be developed. The professional practice of therapist
should be evolving by the study results. It is not enough anymore to rely on old regimes if the study results do not support
their use. The next step in therapeutic practices should be user-centered studies of enhancing best practices among altered
user groups.
Declaration of interest
None declared
38

PROGRAMME
Programme Oral Presentations
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
2011-09-19 MONDAY
SESSION 00 PLENAR
13.45-14.15 KN-01 LYMPHOLOGY AND THE ISL IN THE REAL, VIRTUAL AND IMAGINED
WORLD OF THE FUTURE
M H Witte
14.15-14.40 KN-02 BALANCING LYMPHEDEMA RISKS: EXERCISE VERSUS DECONDITIONING
K Schmitz
14.40-15.05 KN-03 IMPACT OF TUMOR BURDEN IN THE SENTINEL LYMPH NODES ON THE
OUTCOMES OF CANCER PATIENTS
S Leong
15.05-15.30 KN-04 BREAST CANCER RELATED LYMPHOEDEMA (BCRL)
P Mortimer
SESSION 01 EXERCISE AND LYMPHEDEMA
16.00-16.12 O-01.01 EFFECT OF WEIGHT LIFTING ON BREAST CANCER-RELATED
LYMPHEDEMA – DOES EFFECT DIFFER BY DIAGNOSTIC METHOD?
S Hayes, R Speck, K Schmitz
16.12-16.24 O-01.02 THE USE OF CLINIMETRIC INSTRUMENTS ACCORDING TO THE
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND
HEALTH
A Hendrickx, R J Damstra
16.24-16.36 O-01.03 USING WEIGHT-LIFTING TO CONTROL LYMPHEDEMA ONSET OR FLARE-
UPS: THE PAL TRIAL
K Schmitz
16.36-16.48 O-01.04 IMPACT OF SPORTING COMPRESSION CLOTHING ON LYMPH FLOW
DURING EXERCISE; MIGHT IT PREVENT EARLY LYMPHOEDEMA?
K Sierakowski, N Piller
16.48-17.00 O-01.05 RESISTANCE TRAINING IN THE SUB-ACUTE POST-OPERATIVE PERIOD
DOES NOT CAUSE LYMPHOEDEMA: A RANDOMISED CONTROL TRIAL
L Ward, J Beith, K Refshauge, M J Lee, S Kilbreath
17.00-17.12 O-01.06 POLE WALKING FOR WOMEN WITH BREAST CANCER RELATED ARM
LYMPHEDEMA
C Jönsson, K Johansson
17.12-17.24 O-01.07 A RANDOMIZED STUDY OF THE EFFECT OF SWIMMING AND WATER
AEROBIC EXERCISE ON BREAST-CANCER-RELATED ARMLYMPHEDEMA.
K Johansson, S Hayes, R Speck, K Schmitz
SESSION 02 ANATOMY OF THE LYMPHATIC SYSTEM
16.00-16.30 O-02.01 REVIEW THE LYMPHATIC ANATOMY IN THE SENTINEL NODE ERA
M Amore
16.30-16.42 O-02.02 SIGNIFICANCE OF D2-40 IMMUNOHISTOCHEMISTRY IN EVALUATION OF
LYMPHATIC INVASION BY CANCER CELLS IN GASTRIC
ADENOCARCINOMA
E OKADA
16.42-16.54 O-02.03 EFFECT OF NEGATIVE PRESSURE IN PHARYNGO-ORAL CAVITY ON
LYMPHATIC CIRCULATION OF EYES
C Guoling, W Luwan
16.54-17.06 O-02.04 OLOF RUDBECK AND THE DISCOVERY OF THE LYMPHATIC SYSTEM
E Hansson, H Svensson, H Brorson
17.06-17.18 O-02.05 LYMPHATIC DRAINAGE OF MAMMARY GLAND: TRANSLATING FROM
ANATOMY TO SURGERY TO MICROSURGERY.
C Campisi, M Amore
17.18-17.30 O-02.06 VERSATILITY OF A CANINE FORELIMB MODEL FOR INVESTIGATING THE
LYMPHATIC SYSTEM
H Suami, D Chang
2011-09-20 TUESDAY
SESSION 01 KEYNOTE
08.30-09.00 KN-05 MOLECULAR MECHANISMS IN LYMPHANGIOGENESIS
K Alitalo
SESSION 03 PATHOPHYSIOLOGY
Oral presentations
CONGRESS HALL
CONGRESS HALL
ROOM A+B
CONGRESS HALL
CONGRESS HALL
39

40
PROGRAMME
Oral presentations
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
09.00-09.15 O-03.01 OVERGROWTH AND ITS REVERSAL IN WOUND HEALING AND
LYMPHOEDEMA.
T J Ryan
09.15-09.30 O-03.02 THE MECHANISM HOW LYMPHEDEMA GETS WORSE.
M Ohkuma
09.30-09.40 O-03.03 INTERLEUKIN-6 IN THE SECONDARY LYMPHEDEMA AND IN NORMAL
VOLUNTEERS
M Ohkuma
09.40-09.50 O-03.04 STUDY OF INTERLEUKIN1, INTERLEUKIN6 AND TNFΑ IN LYMPH
COMPOSITION IN POST-SURGICAL LYMPHOCEL.
S Michelini, m Cardone, a Failla, g Moneta, m Todini, r Todisco, a Fiorentino, f Cappelino
09.50-10.00 O-03.05 DEVELOPMENT OF UPPER EXTREMITY LYMPHEDEMA AFTER AXILLARY
LYMPHNODE DISSECTION. PROSPECTIVE LYMPHOSCINTIGRAPHIC
EVALUATION.
A Szuba, A Chachaj, M Koba - Wszedybyl, R Hawro, R Jasinski, R Tarkowski, K Szewczyk,
A Jodkowska, U Pilch, M Wozniewski
10.00-10.10 O-03.06 BLOCKADING MESENTERIC LYMPH RETURN CAN PROMOTE THE
VASCULAR REACTIVITY AND CALCIUM SENSITIVITY AFTER
HEMORRHAGIC SHOCK
Z Zhao, C Niu, Y Wei, J Zhang, Y Zhang
10.10-10.20 O-03.07 THE RELATIONSHIP BETWEEN MESOTHELIAL CELLS AND LYMPHATIC
ENDOTHELIAL CELLS IN AN ADJUVANT-INDUCED LYMPHANGIOMA
T Ezaki, K Shimizu, S Morikawa, S Kitahara, J Desaki
10.20-10.30 O-03.08 ROLE OF NITRIC OXIDE ON ISOLATED LYMPHATIC CONTRACTILE
ACTIVITY IN HEMORRHAGIC SHOCK RATS
C Niu, Z Zhao, L Qin, J Zhang, Y Zhang
SESSION 04 PEDIATRIC I - LYMPHEDEMA IN CHILDREN
11.00-11.25 O-04.01 LYMPHEDEMA IN PEDIATRICS. DIALOGUE BETWEEN SCIENCE AND
PRIMARY CARE. PROPOSAL FOR A CONSENSUS DOCUMENT.
C Papendieck, R Martinez, L Barbosa, M A Amore, E Paltrinieri, D Braun
11.25-11.42 O-04.02 RECENT ADVANCES IN THE GENETICS OF PRIMARY LYMPHOEDEMA
F Connell, S Mansour, P Ostergaard, G Brice, M Simpson, R Trembath, P Mortimer, S
Jeffery
11.42-11.54 O-04.03 MANAGEMENT OF LYMPHEDEMA IN CHILDREN AND ADOLESCENTS.
A Failla, S Michelini, M Cardone, F Cappelino, L Michelotti, M Haag o Agga
11.54-12.06 O-04.04 THE CHALLENGE OF PAEDIATRIC LYMPHOEDEMA AND VASCULAR
ANOMALIES
J Phillips
12.06-12.18 O-04.05 CASEREPORT.ADJUSTMENT IN SEATING POSTURE OF A YOUNG WOMAN
WITH HYPERTROFIC TISSUE IN LOWER LIMB
Å Gruvsved Andersson
12.18-12.30 O-04.06 EXPERIENCE FROM REHABILITATION OF YOUTHS WITH LYMPHOEDEMA
AT THE RED CROSS HOSPITAL IN STOCKHOLM
Å Gruvsved Andersson
SESSION 05 PEDIATRIC II – LYMPHATIC MALFORMATIONS
14.00-14.30 O-05.01 DIFFERENTIAL DIAGNOSIS OF LOWER EXTREMITY ENLARGEMENT IN
PEDIATRIC PATIENTS REFERRED WITH A DIAGNOSIS OF “LYMPHEDEMA”
A Greene
14.30-14.42 O-05.02 DIFFUSE LIPOFIBROMATOSIS OF THE LOWER EXTREMITY
MASQUERADING AS A VASCULAR ANOMALY
A Greene
14.42-14.54 O-05.03 LYMPHATIC MALFORMATIONS IN KLIPPEL-TRENAUNAY SYNDROME
N Liu
14.54-15.06 O-05.04 LYMPHEDEMA AND MALFORMATIONS: PERSONAL EXPERIENCE.
S Michelini, A Failla, G Moneta, M Cardone, F Cappelino, C Salusri
15.06-15.18 O-05.05 THE ROLE OF C-ARM CT IN THE TREATMENT OF COMPLEX HEAD AND
NECK LYMPHATIC MALFORMATIONS
D Ballah, X Zhu, J Edgar, A Cahill
15.18-15.30 O-05.06 CONGENITAL LARGE MICROCYSTIC LYMPHATIC MALFORMATION – A
CASE REPORT
M Åberg, M Becker, K Ivanchev
SESSION 06 PREVENTION
CONGRESS HALL
CONGRESS HALL
ROOM A+B

PROGRAMME
Oral presentations
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
09.00-09.13 O-06.01 INCREASED FLUID ACCUMULATION (OEDEMA/LYMPHOEDEMA) AND
HARDENING IN THE BREASTS ASSOCIATED WITH POORLY FITTED BRAS
N Piller, B Heidenreich, J Douglass, J Smith, J Rice, S Birrell, A Moseley
09.13-09.24 O-06.02 INCIDENCE OF UPPER LIMB LYMPHOEDEMA FOLLOWING FREE FLAP
BREAST RECONSTRUCTION
M Schaverien, A Munnoch
09.24-09.35 O-06.03 EARLY DIAGNOSTICS OF LYMPHEDEMA AND SELF MANAGEMENT AFTER
ONCOLOGICAL SURGERY
E Brouwer, R J Damstra
09.35-09.46 O-06.04 LYMPHEDEMA RISK FACTORS IN BREAST CANCER PATIENTS
S Haghighat, A Akbari, M Ansari, F Homaei, M Najafi, M Ebrahimi, M Yunesian, HR Mirzaei,
M E Akbari
09.46-09.57 O-06.05 EFFECTIVENESS OF MANUAL LYMPH DRAINAGE ON THE PREVENTION
OF BREAST CANCER- RELATED ARM LYMPHOEDEMA
N Devoogdt, M R Christiaens, I Geraerts, S Truijen, A Smeets, K Leunen, P Neven, M Van
Kampen
09.57-10.08 O-06.06 LY.M.P.H.A.: A NEW STRATEGIC APPROACH TO PREVENT BREAST
CANCER RELATED LYMPHEDEMA.
C C Campisi, F Casabona, D Friedman, M Puglisi, F De Cian, C S Campisi, M Adami, P
Santi, C Campisi, F Boccardo
10.08-10.19 O-06.07 PREVENTIVE INTERVENTION FOR LOWER- LIMB LYMPHEDEMA AT EARLY
POSTOPERATIVE PERIOD IN GYNECOLOGICAL CANCER
N Kobayashi, T Fujino, N Sakuragi
10.19-10.30 O-06.08 THE USE OF PRE-OPERATIVE MEASUREMENTS IN THE DETECTION OF
LYMPHOEDEMA FOLLOWING TREATMENT FOR BREAST CANCER.
K Riches, V Keeley
SESSION 07 BASIC SCIENCE
11.00-11.15 O-07.01 ADIPOSE TISSUE EXPRESSES SPECIFIC LYMPHANGIOGENESIS
MEMBRANE RECEPTORS
M ANDRADE, A L JACOMO, F E AKAMATSU, A Q SILVA, D A MARIA
11.15-11.30 O-07.02 HEALING OF ACUTE WOUNDS: LYMPHATICS MATTER
G Szolnoky, G Erős, K Szentner, I B Németh, L Kemény
11.30-11.45 O-07.03 DIFFERENTIATION OF LYMPHATIC ENDOTHELIAL CELLS FROM BONE
MARROW MESENCHYMAL STEM CELLS WITH VEGF
W Luwan, L Yanli
11.45-12.00 O-07.04 THE MEDICAL MECHANISM OF SUCTION BASED NEGATIVE PRESSURE
ON VITAL POWER ELEMENTS
L Zhiyu, D Zhaoxi
12.00-12.15 O-07.05 EXPRESSION AND SIGNIFICANCE OF CHEMOKINE RECEPTOR CCR7 IN
THYROID PAPILLARY CARCINOMA
H Tian, H Tian, H Zhang
12.15-12.30 O-07.06 GRAIN MEASURES IN THE EXTRACELLULAR MATRIX
F Passariello
SESSION 08 QUALITY OF LIFE
14.00-14.15 O-08.01 ASSESSMENT OF QUALITY OF LIFE IN LYMPHEDEMA PATIENTS IN
SWEDEN
P Klernäs, K Johansson, L Kristjanson
14.15-14.30 O-08.02 ROLE OF PROBLEM SOLVING IN COPING SUCCESSFULLY WITH
LYMPHEDEMA
J Armer, B Stewart, P Heppner, A Wanchai
14.30-14.45 O-08.03 QUALITY OF LIFE OF WOMEN WITH LOWER-LIMB LYMPHOEDEMA
FOLLOWING GYNAECOLOGICAL CANCER
A Finnane, M Janda, S C Hayes, A Obermair
14.45-15.00 O-08.04 RELATIONSHIP BETWEEN PHYSICAL ACTIVITY AND LYMPHOEDEMA IN
THE CONTEXT OF EVERYDAY LIFE
J Meiklejohn, S Hayes
15.00-15.15 O-08.05 YOUNG WOMEN’S EXPERIENCES OF LYMPHOEDEMA
P Sanderson
15.15-15.30 O-08.06 QUALITY OF LIFE IN PATIENTS WHO SELF-REPORT LOWER LIMB
SWELLING AFTER TREATMENT FOR GYNAECOLOGICAL CANCER
S Hayes, M Janda, H Reul - Hirche, L Ward, A Obermair
S ROUND TABLE: BASIC SCIENCE AND THE WAY TO TREATMENT
ROOM A+B
ROOM A+B
CONGRESS HALL
41

42
PROGRAMME
Oral presentations
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
16.00-17.30 RT-01.01 TREATMENT OPTIONS, PATHOPHYSIOLOGY AND BASIC SCIENCE
R Baumeister
16.00-17.30 RT-01.02 CONSERVATIVE THERAPY FOR LYMPHOEDEMA: ARE WE DOING IT
RIGHT?
N Piller
16.00-17.30 RT-01.03 LYMPH NODE TRANSFER AND GROWTH FACTOR THERAPY FOR
LYMPHEDEMA PATIENTS
A Saaristo, T Tervala, K Honkonen, K Alitalo, E Suominen
16.00-17.30 RT-01.04 FROM LYMPH TO FAT: CONFIRMATORY ANALYSES
H Brorson
2011-09-21 WEDNESDAY
SESSION 02 KEYNOTE
08.30-09.00 KN-06 ADIPOSE TISSUE, FIBROSIS AND LYMPHOEDEMA, MECHANISMS OF
FORMATION AND REMOVAL, WHAT IS THE EVIDENCE?
T Ryan
SESSION 09 MEASURING METHODS I
09.00-09.30 O-09.01 BIOELECTRICAL IMPEDANCE SPECTROSCOPY FOR THE EARLY
DETECTION OF LYMPHEDEMA.
L C Ward
09.30-10.00 O-09.02 CIRCUMFERENCES, PEROMETRY, AND SYMPTOM REPORT IN THE
ASSESSMENT OF LYMPHEDEMA
J Armer
10.00-10.30 O-09.03 SKIN TISSUE DIELECTRIC CONSTANT VALUES IN WOMEN WITH BREAST
CANCER:PRE-SURGERY AND ONE YEAR POST-SURGERY
H MAYROVITZ
SESSION 10 MEASURING METHODS II
11.00-11.12 O-10.01 INFRARED OPTOELECTRONIC VOLUMETER (PEROMETER®)AS A
STANDARD MEASUREMENT TOOL FOR BREAST CANCER RELATED
LYMPHEDEMA.
N Adriaenssens, R Buyl, P Lievens, J Lamote
11.12-11.24 O-10.02 THE USE OF ICF CORE SETS FOR LYMPHEDEMA IN DAILY CLINICAL
PRACTICE
P Viehoff, Y Heerkens, D van Ravensberg, M Martino
11.24-11.36 O-10.03 TRAINING OF A NOVICE LYMPHOEDEMA CLINICIAN IN UPPER LIMB
CIRCUMFERENTIAL MEASUREMENT
M Matthews, S Gordon
11.36-11.48 O-10.04 LIMB VOLUMETRY: COMPARISON OF MAGNETIC RESONANCE IMAGING
WITH OPTOELECTRONIC MEASUREMENT
G Szolnoky, A Palkó, M Varga, E Varga, L Kemény
11.48-12.00 O-10.05 LOWER LIMB LYMPHEDEMA FOLLOWING TREATMENT FOR
GYNAECOLOGICAL CANCER
T Lahtinen, J Pyykönen, M Komulainen, J Nuutinen, M Anttila, M Tuppurainen
12.00-12.12 O-10.06 A NON-INVASIVE, LOW COST, PORTABLE PHOTOGRAPHIC APPLICATION
FOR LIMB VOLUME CALCULATIONS IN LYMPHOEDEMA
L Mc Fetridge, O J Pallotta, N B Piller
12.12-12.24 O-10.07 A NEW TOOL, THE INDUROMETER, FOR ASSESSING SUPERFICIAL
CHANGES AS LYMPHOEDEMA PROGRESSES
N Piller, M McEwen, O Pallotta, S Tilley, T Wonders, M Waters
12.24-12.30 O-10.08 POST-OPERATIVE LYMPHOEDEMA: THE EFFECT OF LIMB DOMINANCE
L Ward, K Refshauge, J Beith, L Koelmeyer, J Lee, J French, O Ung, S Kilbreath
SESSION 11 CLINIC ON LYMPHEDEMA
14.00-14.10 O-11.01 CORRECT SEMANTICS IN LYMPHOLOGY AND CONSEQUENT CORRECT
GUIDELINES
S Michelini, A Failla, G Moneta, M Cardone, F Cappelino, A Fiorentino
14.10-14.20 O-11.02 LYMPHEDEMA ASSOCIATED SKIN MANIFESTATIONS: A CLINICAL
OVERVIEW
R Damstra
14.20-14.30 O-11.03
USING MULTISPIRAL COMPUTED TOMOGRAPHY IN DIAGNOSIS OF
LYMPHEDEMA OF LOWER EXTREMITIES.
T V Apkhanova, V A Badtieva, V G Bardakov
CONGRESS HALL
CONGRESS HALL
CONGRESS HALL
CONGRESS HALL

PROGRAMME
Oral presentations
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
14.30-14.40 O-11.04 POST-MASTECTOMY SYNDROME AND ITS RELATIONSHIP TO
LYMPHOEDEMA.
M Wald, J Adámek, H Váchová
14.40-14.50 O-11.05 DIAGNOSIS AND MANAGEMENT OF SECONDARY LYMPHEDEMA DUE TO
METASTASIS
K F van Duinen, C C W Theunissen, R J Damstra
14.50-15.00 O-11.06 DEFINING A THRESHOLD FOR INTERVENTION IN BREAST CANCER-
RELATED LYMPHEDEMA: IS 3% VOLUME CHANGE TOO LOW?
A Taghian, M N Skolny, C L MIller, T A Russell, J O' Toole,, M Ancukiewicz, M Specht, S J
Isakoff, B L Smith
15.00-15.10 O-11.07 ARM MORBIDITY AFTER BREAST CONSERVING THERAPY FOR BREAST
CANCER. OBJECTIVE FINDINGS AND SELF-ESTEEMED SYMTOMS
I Tengrup, L Tennvall - Nittby, I Christiansson
15.10-15.20 O-11.08 CHARACTERISTIC INDOCYANINE GREEN (ICG)-ENHANCED
LYMPHOGRAPHY FINDINGS: A NOVEL LOWER EXTREMITY LYMPHEDEMA
SEVERITY STAGING SYSTEM
T Yamamoto, M Narushima, N Yamamoto, K Doi, A Oshima, M Mihara, M Gerhard, T Iida, I
Koshima
15.20-15.30 O-11.09 THAILAND LYMPHEDEMA DAY CARE CENTER: PROPOSING A FORMAT
FOR MANAGING LYMPHEDEMA UNDER LIMITED RESOURCES
W Ekataksin, W Ekataksin, N Chanwimalueang, P Suebtrakul, P Piyaman, P Wongwat, W
Khajornsaksumeth, B K Hanboon
SESSION 12 NEW APPROACHES – ALTERNATIVE THERAPIES
09.00-09.10 O-12.01 THE EFFECT OF LYMPH TAPING ON SEROMA FORMATION AFTER
BREAST CANCER SURGERY
J Bosman, N B Piller
09.10-09.20 O-12.02 EFFECT OF ORIENTAL DRUGS ON CALCITONIN GENE-RELATED PEPTIDE
IN LYMPHEDEMA TREATED BY PHYSIOTHERAPY
H Hasegawa
09.20-09.30 O-12.03 A PRIMARY LYMPHODEMA OF UPER LIMB WAS CURED BY COMBINATION
OF TCM WITH WESTERN MEDICINE
L Zhiyu, D Zhaoxi
09.30-09.40 O-12.04 LYMPHOTROPIC THERAPY OF ACUTE INFECTIOUS PULMONARY
DISEASES
I Kurnikova, Y Levin, F Kurieva
09.40-09.50 O-12.05 FOOD AGGRAVATION: EFFECT OF DIETARY HABITS STUDIED IN 2300
PATIENTS WITH LYMPHEDEMA AND THE LIKE
W Ekataksin, N Chanwimalueang, M Teerachaisakul
09.50-10.00 O-12.06 LYMPHEDEMA, PAIN AND THE USE OF TAPING
M Amore, P Yanes Chandia, J L Ciucci, L Marcovecchio, A Mendoza
10.00-10.10 O-12.07 AN INNOVATIVE APPROACH TO TREATING LYMPHATIC ASSOCIATED
PATHOLOGIES USING OSTEOPATHIC SPINAL MANIPULATIONS
S Merrett, N Piller
10.10-10.20 O-12.08 A YOGA INTERVENTION FOR BREAST CANCER-RELATED LYMPHOEDEMA
J Douglass, M Immink, N Piller
10.20-10.30 O-12.09 LYMPHEDEMA PROFUNDA: A NEW CLINICAL ENTITY, A NEW ROLE
ADDED FOR LYMPHOLOGISTS
W Ekataksin
SESSION 13 FILARIASIS AND LYMPHEDEMA
11.00-11.30 O-13.01 "NEW HOPE FOR LYMPHOEDEMA PATIENTS"
G Manokaran
11.30-11.42 O-13.02 "GENITAL MANIFESTATION OF LYMPHATIC FILARASIS"
G Manokaran
11.42-11.54 O-13.03 PRECLINICAL LYMPHOEDEMA - A LYMPHOSCINTIGRAPHIC
CORRELATION
G Manokaran
11.54-12.06 O-13.04 LYMPHATIC FILARIASIS: A METHOD TO IDENTIFY SUBCLINICAL LOWER
LIMB CHANGE IN PNG ADOLESCENTS
S Gordon, W Melrose, J Warner, P Buttner, L Ward
12.06-12.18 O-13.05
SURGERY OF ELEPHANTIASIS NOSTRAS VERRUCOSA OF THE FOOT IN
CHRONIC LYMPHEDEMA OF THE LEG
D A. A. Lamprou, P. Klinkert, O. R M. Wikkeling, R.J. Damstra, H. G. J. Voesten
EAST ROOM
EAST ROOM
43

44
PROGRAMME
Oral presentations
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
12.18-12.30 O-13.06 PODOCONIOSIS IN ETHIOPIA. A PILOT STUDY TO IMPROVE THE
MANAGEMENT OF LYMPHEDEMA.
M LOPEZ - AGUSTIN, M GUTIERREZ - DELGADO, I FORNER - CORDERO
SESSION 14 CANCER AND LYMPHEDEMA
14.00-14.10 O-14.01 MICROSURGERY IN PREVENTING AND TREATING LYMPHEDEMA AFTER
SKIN MELANOMA TREATMENT
F Boccardo, C Campisi, C Campisi, R Lavagno, S Accogli, F De Cian, P L Santi, C Campisi
14.10-14.20 O-14.02 SHOULDER-ARM MORBIDITY IN EARLY BREAST CANCER PATIENTS
TREATED WITH TWO DIFFERENT RADIATION TECHNIQUES
N Adriaenssens, H Van Parijs, V Vinh - Hung, T Reynders, M De Ridder, J Lamote, P
Lievens
14.20-14.30 O-14.03 LYMPHEDEMA OF THE BREAST IN BREAST CANCER PATIENTS
FOLLOWING BREAST CONSERVING SURGERY WITH RADIATION
THERAPY
N Adriaenssens, H Verbelen, J Lamote, P Lievens
14.30-14.40 O-14.04 ARM LYMPHOEDEMA AND IMPAIRED SHOULDER MOBILITY AFTER
TREATMENT FOR PRIMARY BREAST CANCER BY ELDERLY WOMEN
I Christiansson
14.40-14.50 O-14.05 PROSPECTIVE ASSESSMENT OF LYMPHEDEMA FOLLOWING LYMPH
NODE SURGERY FOR MELANOMA
J Cormier, Y J Chiang, J Hyngstrom, Y Xing, K Mungovan, S Taylor, J Lee, J Gershenwald,
J Armer, M Ross
14.50-15.00 O-14.06 IS THERE A LINK BETWEEN LYMPHOEDEMA TREATMENT AND BREAST
CANCER REOCCURENCE?
R Dawson, D de Vries, N Piller, J Rice
15.00-15.10 O-14.07 AXILLARY LYMPH NODES BEFORE AND AFTER COMPLETE AXILLARY
CLEARANCE IN WOMEN UNDERGOING BREAST CANCER SURGERY
A Szuba, A Chachaj, M Koba - Wszędybył, R Hawro, R Jasiński, R Tarkowski, K Szewczyk,
A Jodkowska, U Pilch, M Woźniewski
15.10-15.20 O-14.08 CORDING IN THE PRESENCE OF BREAST CANCER RELATED
LYMPHEDEMA: A PROSPECTIVE STUDY ON NATURAL HISTORY
J O' Toole, M N Skolny, C L MIller, T A Russell, M Specht, M Ancukiewicz, R Schainfeld, S J
Isakoff, B L Smith, A G Taghian, A G Taghian
SESSION 15 LIPEDEMA
09.00-09.15 O-15.01 THE LIPO-LYMPHEDEMA: DEFINITION OF DISABILITY BY INTERNATIONAL
CLASSIFICATION OF FUNCTIONING.
M Cardone, S Michelini, A Failla, G Moneta, F Cappelino, A Fiorentino
09.15-09.30 O-15.03 LONG-TERM OUTCOME AFTER SURGICAL TREATMENT OF LIPEDEMA
H Brorson, A Warren Peled, S Slavin
09.30-09.45 O-15.02 COMPLEX DECONGESTIVE THERAPY IN LIPEDEMA
G Szolnoky, S Diana, L Kemény
09.45-10.00 O-15.04 PAIN IN LIPOEDEMA
I Meier - Vollrath
10.00-10.15 O-15.05 LIPOEDEMA AND ASSOCIATED COMPLAINTS (OBESITY, ORTHOPAEDIC
PROBLEMS)
W Schmeller
10.15-10.30 O-15.06 LIPEDEMA AND QUALITY OF LIFE
S Michelini, M Cardone, A Failla, G Moneta, F Cappellino, A Fiorentino
SESSION 16 BEST PRACTICE FOR THE MANAGEMENT OF LYMPHEDEMA I
11.00-11.18 O-16.01 ASSOCIATION BETWEEN MEASUREMENT DATA AND LYMPHEDEMA
PATIENT INFORMATION USING TEMPORAL MINING TECHNIQUE
S Xu, C Shyu, J Armer
11.18-11.30 O-16.02 DEVELOPMENT OF A MINIMUM DATA SET TO ASSIST IN INTERNATIONAL
COLLABORATIVE LYMPHEDEMA STUDIES
J Reneker, J Armer, B Stewart, C Shyu
11.30-11.42 O-16.03 ALFP THERAPISTS SURVEY: PATIENT CHARACTERISTICS AND
TREATMENT OPTIONS FOR THERAPISTS MANAGING LYMPHEDEMA IN
UNITED STATES
J Armer, J Feldman, J Cormier, M Austin, B Stewart
11.42-11.54 O-16.04
DISCOVERING DISTRIBUTIONS OF TRAINED LYMPHEDEMA THERAPISTS,
TREATMENT CENTERS, AND LYMPHEDEMA PATIENTS USING
GEOGRAPHIC INFORMATION SYSTEM
S Xu, C Shyu, B Stewart, J Armer
EAST ROOM
ROOM A+B
ROOM A+B

PROGRAMME
Oral presentations
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
11.54-12.06 O-16.05 DEVELOPMENT OF ICF CORE SETS FOR LYMPHEDEMA: LITERATURE
REVIEW
P Viehoff, Y Heerkens, D van Ravensberg, J Hidding, M Martino
12.06-12.18 O-16.06 NEW MULTIDISCIPLINARY CENTRE FOR MANAGEMENT OF CHRONIC
OEDEMA WITH EXPERT FUNCTION OF DIAGNOSES AND TREATMENT
S Birkballe, T Karlsmark, S Nørregaard, F Gottrup
12.18-12.30 O-16.07 CANCER-RELATED LYMPHEDEMA: AN EDUCATIONAL INTERVENTION
FOR GENITOURINARY AND GYNECOLOGIC ONCOLOGY OUTPATIENT
NURSES
K Smalky, H Saez, R Martin, J Leflor, R Askew, M Kallen, R Tintner, J Cormier
SESSION 17 BEST PRACTICE FOR THE MANAGEMENT OF LYMPHEDEMA II
14.00-14.15 O-17.01 THE INCIDENCE OF LYMPHOEDEMA IN PARTIAL VERSUS TOTAL
MASTECTOMIES
H Saeed, M Samarin, N Piller
14.15-14.30 O-17.02 A RISK FACTOR-BASED CLINICAL DECISION TOOL TO IDENTIFY
LYMPHEDEMA IN WOMEN WITH EARLY BREAST CANCER
N Stout, L Pfalzer, E Levy, C Mc Garvey, B Springer, L Gerber, P Soballe
14.30-14.45 O-17.03 BREAST CANCER RELATED LYMPHEDEMA: COST OF PROSPECTIVE
SURVEILLANCE COMPARED TO STANDARD CARE
N Stout, L Pfalzer, B Springer, E Levy, C McGarvey, J Danoff, L Gerber, P Soballe
14.45-15.00 O-17.04 LONG-TERM FOLLOW UP PROCEDURES FOR LYMPHEDEMA PATIENTS
FOLLOWING LIPOSUCTION OF ARM AND/OR LEG LYMPHEDEMA.
B Svensson, K Ohlin, C Freccero, H Brorson
15.00-15.15 O-17.05 THE EFFECT OF SEASONAL VARIATION ON UPPER LIMB SIZE AND
VOLUME: AN AUSTRALIAN STUDY
M Matthews, S Gordon
15.15-15.30 O-17.06 DIET AND LYPHOEDEMA: FACTS AND FALLACIES IN THE GREY AND
POPULAR INTERNET LITERATURE
R Dawson, N Piller
ROOM A+B
S ROUND TABLE: LIPEDEMA - DIAGNOSTIC TOOLS AND TREATMENT NECESSITIES? CONGRESS HALL
16.00-17.30 RT-02.01 LIPOEDEMA – AN INHERITED CONDITION
P Mortimer
16.00-17.30 RT-02.02 LIPEDEMA: PATHOPHYSIOLOGICAL FEATURES
G Szolnoky, A Nemes, É Dósa - Rácz, M Varga, E Varga, L Kemény, L Kemény
16.00-17.30 RT-02.03 LOWER LEGS IN PATIENTS WITH LIPOEDEMA – A CHALLENGE FOR
LIPOSUCTION.
I Meier - Vollrath, W Schmeller
16.00-17.30 RT-02.04 LONG-TERM RESULTS FOLLOWING LIPOSUCTION IN LIPOEDEMA
W Schmeller, I Meier - Vollrath
2011-09-22 THURSDAY
SESSION 03 KEYNOTE
08.30-09.00 KN-07 IMAGING THE LYMPHATIC SYSTEM IN 2011
P BOURGEOIS
SESSION 18 LYMPHATIC IMAGING I
09.00-09.10 O-18.01 THE ROLE OF HIGH-RESOLUTION ULTRASOUND IN THE DIAGNOSICS,
THERAPY-PLANNING AND MONITORING OF LYMPHEDEMA.
K Martin, E Föeldi
09.10-09.20 O-18.02 NEAR-INFRARED FLUORESCENCE IMAGING OF TUMOR-INDUCED
LYMPHANGIOGENESIS IN MELANOMA PATIENTS
J Rasmussen, I Tan, M Marshall, B Zhu, J Cormier, E Sevick - Muraca
09.20-09.30 O-18.03 USE OF INDOCYANINE GREEN FLUORESCENT LYMPHOGRARPHY FOR
DEMONSTRATING DYNAMIC LYMPH FLOW
H Suami, D Chang, K Yamada, Y Kimata
09.30-09.40 O-18.04 FLUORESCENT LYMPHOGRAPHY IN VISUALIZATION OF LYMPHATIC
SYSTEM
O. V. Danilevskaya, V. I. Polsachev, B. M. Urtaev, A. I. Marchenko, N. Y u. Mushnikova, N.
A. Khananyan, A. R. Tsarapkina, V. V. Yakubson, I. V. Yarema
09.40-09.50 O-18.05
MANUAL LYMPHATIC DRAINAGE VISUALIZED BY LYMPHO-
FLUOROSCOPY
J P Belgrado
CONGRESS HALL
CONGRESS HALL
45

46
PROGRAMME
Oral presentations
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
09.50-10.00 O-18.06 INVESTIGATION OF SUBFASCIAL FAT IN ARM LYMPHEDEMA USING MRI-
BASED FAT QUANTIFICATION
P Peterson, H Brorson, S Månsson
10.00-10.10 O-18.07 DIAGNOSING LYMPHEDEMA WITH MRI: A REDEFINITION FOR
THERAPEUTIC PURPOSES
W Ekataksin, N Chanwimalueang, W Nitiwarangkul
10.10-10.20 O-18.08 LYMPH DRAINAGE STUDIED BY LYMPHOSCINTIGRAPHY IN THE BREAST
AFTER REDUCTION MAMMAPLASTY AFTER 5 YEARS FOLLOW-UP
L Perbeck, R Axelsson, L Svensson
SESSION 19 SURGERY I
11.00-11.10 O-19.01 LYMPHATICOVENOUS SIDE TO END ANASTOMOSIS FOR TREATMENT OF
PERIPHERAL LYMPHEDEMA
J Maegawa, H Tomoeda, M Hosono
11.10-11.20 O-19.02 SURGICAL TREATMENT OF SECONDARY LYMPHOEDEMAS BY
MICROSURGICAL LYMPH VESSEL TRANSPLANTATION
D Tobbia, G Felmerer
11.20-11.30 O-19.03 SURGICAL TREATMENT FOR LYMPHOEDEMA AFTER BREAST CANCER: 4
YEARS OF EXPERIENCE
J MASIA, G PONS
11.30-11.40 O-19.04 5 YEAR EXPERIENCE OF LIPOSUCTION FOR CHRONIC LYMPHOEDEMA
OF THE UPPER LIMB IN DUNDEE, SCOTLAND
N Kandamany, K Munro, D Munnoch
11.40-11.50 O-19.05 DOES LIPOSUCTION FOR UPER-EXTREMITY LYMPHOEDEMA HAVE A
LONG-LASTING EFFECT?
M Wald, D Tomášek, H Houdová, J Adámek, J Hoch
11.50-12.00 O-19.06 END-STAGE BREAST CANCER RELATED ARM LYMPHEDEMA SURGICAL
TREATMENT: A PROSPECTIVE STUDY OF 100 PATIENTS
P. Klinkert, O. R. M. Wikkeling, D A. A. Lamprou, R. J. Damstra, H. G. J. Voesten
12.00-12.10 O-19.07 LIPOSUCTION IN THE MANAGEMENT OF LEG LYMPHOEDEMA – THE
DUNDEE EXPERIENCE.
P Baker, A Munnoch
12.10-12.20 O-19.08 SEVENTEEN YEARS’ EXPERIENCE OF COMPLETE REDUCTION OF ARM
LYMPHEDEMA FOLLOWING BREAST CANCER
H Brorson, C Freccero, K Ohlin, B Svensson, M Åberg, H Svensson
12.20-12.30 O-19.09 THE SIMULTANEOUS TWO-PHASE DEBULKING PROCEDURE IN PATIENTS
WITH LATE STAGE OF BREAST CANCER RELATED LYMPHEDEMA
V Nimaev, M Shumkov, M Soluyanov, E Kombantsev, D Habarov, M Lubarsky
SESSION 20 SURGERY II
14.00-14.10 O-20.01 PROSPECTIVE RANDOMIZED TRIAL ON THE EFFECTS OF PERIPHERAL
LYMPHEDEMA PHYSICAL-MICROSURGICAL TREATMENT VS. COMBINED
PHYSICAL THERAPY.
C C Campisi, F Boccardo, M Adami, C S Campisi, R Lavagno, C Campisi, P Santi
14.10-14.20 O-20.02 LONG TERM RESULTS AFTER RECONSTRUCTIVE MICROSURGERY USING
LYMPHATIC AUTOGRAFTS, PROVED BY RADIOLOGY AND NUCLEAR
MEDICINE
R Baumeister, M Notohamiprodjo, M Weiss, J Wallmichrath, S Springer, A Frick
14.20-14.30 O-20.03 MICROVASCULAR BREAST RECONSTRUCTION AND LYMPH NODE
TRANSFER FOR POSTMASTECTOMY LYMPHEDEMA PATIENTS
E Suominen, A Saarikko, T Niemi, T Viitanen, T Tervala, K Alitalo
14.30-14.40 O-20.04 EARLY AUSTRALIAN EXPERIENCE OF LIPOSUCTION TREATMENT FOR
NON-PITTING CHRONIC LYMPHOEDEMA.
J Tiong, H Mackie, K Shanley, K Poon
14.40-14.50 O-20.05 LIPOSUCTION NORMALIZES ELEPHANTIASIS OF THE LEG – A
PROSPECTIVE STUDY WITH AN EIGHT-YEAR FOLLOW-UP
H Brorson, C Freccero, K Ohlin, B Svensson, M Åberg, H Svensson
14.50-15.00 O-20.06 LIPOSUCTION WITH COMPRESSIVE THERAPY FOR TREATMENT OF
LOWER EXTREMITY LYMPHEDEMA AND LIPOLYMPHEDEMA
M Topalan, Y Demirtas
15.00-15.10 O-20.07
CIRCUMFERENTIAL SUCTION-ASSISTED LIPECTOMY IN END STAGE LEG
LYMPHEDEMA: A PROSPECTIVE STUDY IN 60 PATIENTS
H. G. J. Voesten, D A. A. Lamprou, O. R. M. Wikkeling, R. J. Damstra, P. Klinkert
CONGRESS HALL
CONGRESS HALL

PROGRAMME
Oral presentations
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
15.10-15.20 O-20.08 TREATMENT OF LOWER LIMB ELEPHANTIASIS WITH COMBINATION OF
CONSERVATIVE TREATMENT, SURGICAL EXCISION AND LIPOSUCTION
K Dalen, M Veske, M Johansen, W van de Veen, H Brorson
15.20-15.30 O-20.09 DIFERENT RESULTS OF LIPOSUCTION FOR PRIMARY AND SECONDARY
LOWER-EXTREMITY LYMPHOEDEMA.
M Wald, J Adámek
SESSION 21 PHLEBOLYMPHOLOGY
09.00-09.15 O-21.01 PREVENTION AND TREATMENT OF LYMPHATIC COMPLICATIONS DURING
VENOUS SURGERY
F Boccardo, C Campisi, S Accogli, C Campisi, R Lavagno, P L Santi, C Campisi
09.15-09.30 O-21.02 MANAGEMENT OF HIGH EXUDATION OF THE ULCERS IN PATIENTS WITH
LYMPHEDEMA (FINAL RESULTS)
E. Dimakakos, J. Kalemikerakis, Z. Vardaki, G. Fouka, K. Syrigos
09.30-09.45 O-21.03 INSUFFICIENT LYMPH DRAINAGE CAUSES ABNORMAL LIPID
ACCUMULATION AND DEGENERATES VEIN WALL.
H Tanaka, N Yamamoto, M Suzuki, Y Mano, M Sano, T Saito, N Zaima, H Konno, M Setou,
N Unno
09.45-10.00 O-21.04 TREATMENT OF PHLEBEDEMA OF THE FACE : 14 CASES
A Hamadé, C Krieger, T Samkharadzé, P Michel, G Obringer, J C Stoessel, M Lehn - Hogg
10.00-10.15 O-21.05 ESTIMATION OF BIOMECHANICAL ABNORMALITIES OF PATIENTS WITH
CHRONIC LYMPHOVENOUS INSUFFICIENCY OF LOWER EXTREMITIES.
S Katorkin, G Yarovenko
10.15-10.30 O-21.06 REVISITING "VENOUS OBSTRUCTION IN THE ETIOLOGY OF
LYMPHEDEMA PRAECOX"
W Hsu, T Chang, T Tsai
SESSION 22 LYMPHATIC IMAGING II
11.00-11.10 O-22.01 MR LYMPHAMGIOGRAPHY: WHAT IS THE VALUE IN DIAGNOSIS OF
PERIPHERAL LYMPHATIC SYSTEM DISORDERS
N Liu
11.10-11.20 O-22.02 THE LYMPHATIC DRAINAGES OF MAMMARY EDEMAS AND/OR AFTER
MAMMARY RECONSTRUCTION DEMONSTRATED BY
LYMPHOSCINTIGRAPHY
P BOURGEOIS, J P BELGRADO, J DEWILDE, N KINDT, P BRACALE, M HARDY, F
URBAIN
11.20-11.30 O-22.03 ROLE OF LYMPHOSCINTIGRAPHY OF LOWER EXTREMITIES IN PATIENTS
WITH INCREASED BODY MASS
E Iker, E lGlass
11.30-11.40 O-22.04 CLINICAL ASPECTS OF LYMPHEDEMA AND LYMPHOSCINTIGRAPHY
M Cardone, S Michelini, A Failla, F Cappelino, F Romaldini, D Puglisi, A Semprebene
11.40-11.50 O-22.05 LYMPHEDEMA OF THE PROSTHESIS-RECONSTRUCTED BREAST AFTER
TRAUMA OR EXERCISE.
L Vandermeeren, P Bourgeois, G Andry, F C Urbain
11.50-12.00 O-22.06 LYMPHATIC DRAINAGE IN DIEP FLAPS AFTER BREAST
RECONSTRUCTION
L Vandermeeren, P Bourgeois, G Andry, F C Urbain
12.00-12.10 O-22.07 A COMPARISON OF PHYSICAL AND FUNCTIONAL ASSESSMENT USING
LYMPHOSCINTIGRAPHY IN PRIMARY AND SECONDARY LYMPHEDEMA
M Hosono, J Maegawa, H Tomoeda
12.10-12.20 O-22.08 LYMPHOSCINTIGRAPHY IN VIZUALIZING PATHWAYS OF LYMPH AND
TISSUE FLUID FLOW DURING PNEUMATIC COMPRESSION THERAPY
W L Olszewski, M Zaleska, A Domaszewska - Szostek, J Cwikla
SESSION 23 PHYSIOLOGY OF THE LYMPHATIC SYSTEM
14.00-14.12 O-23.01 AGING AND LYMPH FLOW: STATUS, RESERVES, MECHANISMS
A Gashev, S Thangaswamy, T Nagai, T Akl, V Chatterjee, G Cote
14.12-14.24 O-23.02 EXTRACELLULAR FLUID MOVEMENT IN ELEVATED LYMPHOEDEMATOUS
AND HEALTHY UPPER LIMBS: A STUDY USING BIOIMPEDANCE
SPECTROSCOPY.
O Meddings - Blaskett, C Galbraith, N Piller
14.24-14.36 O-23.03
MITOGENIC EFFECT OF HUMAN TISSUE FLUID/ LYMPH ON
KERATINOCYTE PROLIFERATION
A Domaszewska - Szostek, M Zaleska, W L Olszewski
EAST ROOM
EAST ROOM
EAST ROOM
47

48
PROGRAMME
Oral presentations
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
14.36-14.48 O-23.04 PHYSIOLOGICAL PARAMETERS FOR EFFECTIVE COMPRESSION
THERAPY OF SWOLLEN LOWER LIMBS
W Olszewski, M Zaleska, M Cakala, M Durlik
14.48-15.00 O-23.05 QUANTIFYING THE MOLECULAR MECHANISMS IN VITRO OF LYMPHATIC
UPTAKE OF LIPOPROTEINS FROM THE INTESTINE
J Dixon, M Faulkner
15.00-15.12 O-23.06 THOMAS BARTHOLIN AND THE DISCOVERY OF THE LYMPHATIC SYSTEM
C KRAG
15.12-15.24 O-23.07 EFFECT OF AGING ON LYMPHATIC PUMPING IN HUMAN LOWER
EXTREMITIES
N Unno, M Suzuki, H Tanaka, N Yamamoto, M Nishiyama, Y Mano, M Sano, T Saito, H
Konno
SESSION 24 GENITAL LYMPHEDEMA
09.00-09.15 O-24.01 A NEW CLASSIFICATION OF GENITAL LYMPHOEDEMA AND ITS
SURGICAL TREATMENT
G Felmerer, D Tobbia, M Zvonik
09.15-09.30 O-24.02 LYMPHEDEMA WITH GENITAL COMPLICATIONS, SO FAR DESPERATE
AND EMBARRASSING, BUT NOW PREVENTABLE: FOUR CASE REPORTS
W Ekataksin, N Chanwimalueang, P Suebtrakul, P Piyaman
09.30-09.45 O-24.03 CASEREPORT:TREATMENT WITH URIDOME FOR PENILE LYMPHOEDEMA
M Dahl, K Johansson
09.45-10.00 O-24.04 THREE CASES OF PENO-SCROTAL LYMPHEDEMA OPERATED BY
PLASTIC PROCEDURE
A PISSAS, L SOUSTELLE, A GEVORGYAN
10.00-10.15 O-24.05 SURGERY FOR EXTERNAL GENITALIA LYMPHOEDEMA
M Wald, L Jarolím, J Adánek
10.15-10.30 O-24.06 SURGERY OF MALE GENITAL LYMPHEDEMA
W Olszewski, S Gogia, P Jain, M Zaleska, M Durlik
SESSION 25 COMPRESSION TREATMENT I: PITFALLS AND DANGERS OF
11.00-11.25 O-25.01 COMPRESSION THERAPY IN MIXED ULCERS: SEARCH FOR AN
EFFECTIVE PRESSURE RANGE NOT AFFECTING ARTERIAL PERFUSION.
G Mosti, H Partsch
11.25-11.50 O-25.02 CUTANEOUS WOUNDS, EDEMA AND COMPRESSION: “CONDITIONING OF
THE SKIN”
R J Damstra
11.50-12.00 O-25.03 SCREENING FOR PERIPHERAL VASCULAR DISEASE IN CHRONIC
OEDEMA. ARE ARTERIAL DOPPLER WAVE FORMS USEFUL?
V Keeley, K Riches
12.00-12.10 O-25.04 EVALUATION OF A 2-LAYER COMPRESSION SYSTEM IN TREATMENT OF
A LYMPHOEDEMA PATIENT WITH ARTERIAL STENOSIS
T Zee
12.10-12.20 O-25.05 USE OF 2-LAYER COMPRESSION SYSTEM IN TREATMENT OF A PATIENT
WITH FONTAINE STAGE IV
M Lauret - Roemers
12.20-12.30 O-25.06 COMPRESSION MAY CAUSE PROBLEMS IN PATIENTS WITH CARDIAC
OEDEMA
K Riches
SESSION 26 COMPRESSION TREATMENT II
14.00-14.12 O-26.01 PROSPECTIVE TRIAL COMPARING A NEW 2 LAYER COMPRESSION
VERSUS INELASTIC MULTICOMPONENT BANDAGING IN LEG
LYMPHEDEMA
R J Damstra, D A A Lamprou, H Partsch
14.12-14.24 O-26.02 A MODEL APPROACH FOR ASSESSING OPTIMUM COMPRESSION FOR AN
IRREVERSIBLE LOWER LIMB LYMPHOEDEMA
S THEYS, J C Schoevaerdts, J F r Thirot, T h Deltombe
14.24-14.36 O-26.03 INTERNATIONAL COMPRESSION CLUB- PRACTICAL IMPLICATIONS
H Partsch
14.36-14.48 O-26.04
SEARCH FOR AN OPTIMAL COMPRESSION PRESSURE TO REDUCE
EXTREMITY OEDEMA
H Partsch, R Damstra, H Mosti
ROOM A+B
ROOM A+B
ROOM A+B

PROGRAMME
Oral presentations
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
14.48-15.00 O-26.05 CONTROLLED COMPRESSION THERAPY AFTER LIPOSUCTION OF LEG
LYMPHEDEMA – HOW TO KEEP CONTROL OVER TIME
K Ohlin, B Svensson, C Freccero, H Brorson
15.00-15.12 O-26.06 STANDARIZATION OF A PRESSURE-MEASURING DEVICE FOR
OPTIMIZING LYMPHEDEMA TREATMENT WITH COMPRESSION
GARMENTS
C Freccero, E Jense, K Ohlin, B Svensson, H Brorson
15.12-15.24 O-26.07 PROSPECTIVE TRIAL COMPARING THE EFFECT OF JUXTA-FIT VERSUS
TRICO BANDAGES IN TREATING LEG LYMPHOEDEMA
R Damstra, D- A A Lamprou, H Partsch
S ROUND TABLE: SURGICAL AND NON-SURGICAL TREATMENT
16.00-17.30 RT-03.01 INTERCONNECTED TREATMENT OPTIONS – A BENEFIT FOR THE PATIENT
R Baumeister
16.00-17.30 RT-03.02 LONG-TERM OUTCOME AFTER LYMPHATIC MICROSURGERY FOR
PERIPHERAL LYMPHEDEMA.
C Campisi, P Santi, C C Campisi, R Lavagno, C S Campisi, F Boccardo
16.00-17.30 RT-03.03 WHY PERFORM LIPOSUCTION IN PATIENTS WITH CHRONIC NON-PITTING
LYMPHEDEMA?
H Brorson
16.00-17.30 RT-03.04 NEXT STEP – HOW TO ENHANCE THE BEST TREATMENT OPTION OF THE
CLIENT?
A Kärki
2011-09-23 FRIDAY
SESSION 04 KEYNOTE
08.30-09.00 KN-08 DO WE NEED MLD? LYMPHEDEMA THERAPY: CURRENT EVIDENCE OF
THE BEST PRACTICE
A Kärki
SESSION 27 NEW FRONTIERS IN LYMPHATIC RESEARCH I
09.00-09.30 O-27.01 NEW FRONTIERS IN LYMPHATIC RESEARCH
S Rockson
09.30-09.45 O-27.02 PDGF (PLATELET DERICVED GROWTH FACTOR) IN THE PRIMARY
LYMPHEDEMA.
M Ohkuma
09.45-10.00 O-27.03 CLINICAL AND GENETIC STUDY OF ITALIAN FAMILIES WITH PRIMARY
LYMPHEDEMA
S Michelini, M Bertelli, M Cardone, S Cecchin, L Pinelli, F Cappelino, A Guerrini, F Agostini,
A Fiorentino
10.00-10.15 O-27.04 SOME CASES OF FAMILIAL LOW-LIMB LYMPHEDEMA IN SIBERIAN
REGION (PRELIMINARY REPORT)
V Nimaev, M Gubina, M Lubarsky, I Kulikov, A Povestchenko, V Maksimov, V Konenkov
10.15-10.30 O-27.05 A RAT MODEL FOR EXPERIMENTAL SUPERMICROSURGICAL
LYMPHATICOVENULER ANASTOMOSIS
Y Demirtas, M Topalan
SESSION 28 NEW FRONTIERS IN LYMPHATIC RESEARCH II
11.00-11.15 O-28.01 TREATMENT OF SECONDARY LYMPHOEDEMA WITH MICROSURGICAL
LYMPH NODE AUTOTRANSPLANTATON
D Tobbia, M Johnston, J Semple
11.15-11.30 O-28.02 MICROSURGICAL TECHNIQUE AND FUNCTION OF LYMPHO-
LYMPHONODULAR ANASTOMOSES IN THE RAT MODEL.
J Wallmichrath, A Frick, R G H Baumeister
11.30-11.45 O-28.03 MONOCYTIC RESOURCE OF LYMPHATIC ENDOTHELIAL LIKE CELLS
Z Zou, Z Zou, T Tian
11.45-12.00 O-28.04 ANTIGEN-PRESENTING CELL FUNCTION WITHIN RAT MUSCULAR
LYMPHATICS
D Zawieja, W Wang, E Childs, E Bridenbaugh
12.00-12.15 O-28.05 CONFERRING TO WATER THE CHARACTERISTICS OF STRENGTHENING
LYMPH OUTFLOW FROM ORGANS AND TISSUES.
M PIKALOV, Y LEVIN
12.15-12.30 O-28.06 THE REGULATION OF TISSUE HUMORAL TRANSPORT,
LYMPHATICDRAINAGE AND LYMPHATIC SYSTEM FUNCTIONS IN
GENERAL PATHOLOGY
Y Levin, O Rodionova, E Artamonova, F Kurieva, I Panova, V Milov, I Kurnikova, G
Kukushkin, Y Sharikov, K Syzdykova
SESSION 29 DECONGESTIVE THERAPY I
CONGRESS HALL
CONGRESS HALL
CONGRESS HALL
CONGRESS HALL
ROOM A+B
49

50
PROGRAMME
Oral presentations
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
09.00-09.12 O-29.01 COMPARISON OF THREE DRAINAGE OPTIONS IN IRREVERSIBLE LOWER
LIMB LYMPHOEDEMA
S Theys, J F r Thirot, A Genette, J C Schoevaerdts, T h Deltombe
09.12-09.24 O-29.02 PREDICTIVE FACTORS OF RESPONSE TO COMPLETE DECONGESTIVE
THERAPY IN UPPER EXTREMITY LYMPHEDEMA FOLLOWING BREAST
CARCINOMA
S Haghighat, M Lotfi - Tokaldany, A A Khadem Maboudi, M Karami, A Bahadori, J Weiss
09.24-09.36 O-29.03 INTEGRATED TREATMENT APPROACHES IN LYMPHEDEMA.
G Moneta, S Michelini, A Failla, M Cardone, F Cappelino, V Zinicola
09.36-09.48 O-29.04 PREVENTING POSTOPERATIVE LIMB OEDEMA WITH FARROWWRAP®
COMPRESSION.
A Munnoch, J Wigg
09.48-10.00 O-29.05 INFECTION RECURRENCE IN POSTMASTECTOMY LYMPHEDEMA
PATIENTS TREATED BY COMPLETE DECONGESTIVE TREATMENT
S Haghighat, F Haji Mollahoseini, F Zayeri, M Habibi
10.00-10.12 O-29.06 EFFECTIVENESS OF TWISTING TOURNIQUET TECHNIQUE® FOR
LYMPHEDEMA TREATMENT
N Chanwimalueang, W Ekataksin, P Piyaman
10.12-10.24 O-29.07 COMPRESSION THERAPY OF SWOLLEN LOWER LIMBS- TISSUE FLUID
HYDRAULICS, CLINICAL EFFECTS
M Zaleska, W Olszewski, M Cakala, P Jain
SESSION 30 DECONGESTIVE THERAPY II
11.00-11.10 O-30.01 PRACTICAL LYMPHEDEMA SELF-MANAGEMENT: AN ASSESSMENT OF
PATIENT SATISFACTION AND PERCEIVED EFFECTIVENESS OF
TREATMENT MODALITIES
K Ashforth, J Cosentino
11.10-11.20 O-30.02 COMPARING TWO TREATMENT METHODS FOR POST MASTECTOMY
LYMPHEDEMA: CDT ALONE AND IN COMBINATION WITH IPC
S Haghighat, M Lotfi - Tokaldany, M Yunesian, M E Akbari, F Nazemi, J Weiss
11.20-11.30 O-30.03 A NEW TREATMENT OF LYMPHEDEMA BY SEQUENTIAL COMPRESSION
COMBINED WITH THE OTHER PHYSIOTHERAPY
M Ohkuma
11.30-11.40 O-30.04 PHYSICAL THERAPIES IN THE DECONGESTIVE TREATMENT OF
LYMPHEDEMA: A PHASE III, MULTICENTER, RANDOMIZED, CONTROLLED
STUDY.
I FORNER - CORDERO, J MUNOZ - LANGA, J M DEMIGUEL - JIMENO, P REL - MONZO
11.40-11.50 O-30.05 PRINCIPLES OF PNEUMATIC COMPRESSION THERAPY
W Olszewski, P Jain, M Zaleska, M Cakala
11.50-12.00 O-30.06 FORMATION OF TISSUE FLUID CHANNELS IN LYMPHEDEMATOUS
SUBCUTANEOUS TISSUE DURING INTERMITTENT PNEUMATIC
COMPRESSION THERAPY
W Olszewski, M Zaleska, M Cakala, P Jain
12.00-12.10 O-30.07 MANUAL AND PNEUMATIC MASSAGE - TISSUE FLUID AND LYMPH
TRANSFER TO THE NON-LYMPHEDEMATOUS TISSUES
W Olszewski, P Jain, M Zaleska, M Cakala, E Stelmach
12.10-12.20 O-30.08
THE GIANTS. TREATMENT OF BIG LYMPHEDEMAS WITH CDT.
A GERSMAN, A GERSMAN
ROOM A+B

THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
PROGRAMME
Poster presentations
Page 1
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SESSION SWEDEN
01 EXERCISE AND LYMPHEDEMA
TIME NUMBER
TITLE ROOM
P-01.08 MUSCLE ACTIVITY AND MECHANICAL LOAD IN THE SHOULDERS OF
PROGRAMME
Poster presentations
WOMEN WITH BREAST CANCER RELATED LYMPHEDEMA.
Page 1
THE 23RD INTERNATIONAL K Johansson, CONGRESS J Linnell, A Sandsborg, OF LYMPHOLOGY E Horneij 19-23 SEPTEMBER 2011,
MALMÖ, SESSION SWEDEN 01 02 01 EXERCISE ANATOMY EXERCISE OF AND THE LYMPHEDEMA
LYMPHATIC SYSTEM
TIME NUMBER TITLE ROOM
P-01.08 P-02.07 P-01.08 MUSCLE MICROARCHITECTURE MUSCLE ACTIVITY AND OF MECHANICAL PRELYMPHATIC LOAD SYSTEM IN THE SHOULDERS IN RAT LIVER OF
AND
WOMEN INTERFACE WOMEN WITH TO BREAST LYMPHATICS CANCER REVEALED RELATED BY LYMPHEDEMA.
THREE-DIMENSIONAL
K RECONSTRUCTION
K Johansson, J Linnell, A Sandsborg, E Horneij
P Piyaman, W Ekataksin, K Kaneda
SESSION SESSION 02 01 02 ANATOMY EXERCISE ANATOMY OF AND THE LYMPHEDEMA
LYMPHATIC SYSTEM
SESSION 03 PATHOPHYSIOLOGY
P-02.07
P-01.08 MICROARCHITECTURE MUSCLE ACTIVITY AND OF MECHANICAL PRELYMPHATIC LOAD SYSTEM IN THE SHOULDERS IN RAT LIVER OF AND
P-03.09 INTERFACE THE INTERFACE WOMEN LYMPHATIC WITH TO BREAST LYMPHATICS HYPO-REACTIVITY CANCER REVEALED RELATED AND BY CALCIUM LYMPHEDEMA.
THREE-DIMENSIONAL
DESENSITIZATION
RECONSTRUCTION
FOLLOWING RECONSTRUCTION
K Johansson, J HEMORRHAGIC Linnell, A Sandsborg, SHOCK E Horneij
P C P Piyaman, Niu, Z Zhao, W Ekataksin, Y Zhang, Z K Liu, Kaneda
J Zhang
SESSION 02 ANATOMY OF THE LYMPHATIC SYSTEM
P-03.10
SESSION 03 PATHOPHYSIOLOGY
ROLE OF NITRIC OXIDE ON ISOLATED LYMPHATIC REACTIVITY DURING
P-02.07 HEMORRHAGIC MICROARCHITECTURE SHOCKOF
PRELYMPHATIC SYSTEM IN RAT LIVER AND
P-03.09
THE Z THE INTERFACE Zhao, LYMPHATIC C Niu, TO L Qin, LYMPHATICS HYPO-REACTIVITY Y Zhang, Y Si, REVEALED L Zhang, AND J Zhang BY CALCIUM THREE-DIMENSIONAL
DESENSITIZATION
P-03.11 MESENTERIC FOLLOWING RECONSTRUCTION HEMORRHAGIC LYMPH DUCT LIGATION SHOCK
IMPROVES HYPO-VISCOSAEMIA
AND C P Piyaman, Niu, ABNORMAL Z Zhao, W Ekataksin, Y Zhang, ERYTHROCYTE Z K Liu, Kaneda J Zhang
RHEOLOGY IN ACUTE BLOOD LOSSING
P-03.10
ROLE RATS
SESSION 03 PATHOPHYSIOLOGY
ROLE OF NITRIC OXIDE ON ISOLATED LYMPHATIC REACTIVITY DURING
HEMORRHAGIC C HEMORRHAGIC Niu, Z Zhang SHOCK
P-03.12 P-03.09 HUMAN Z THE Zhao, LYMPHATIC C SKIN Niu, L TISSUE Qin, HYPO-REACTIVITY Y Zhang, FLUID/LYMPH Y Si, L Zhang, CYTOKINES AND J Zhang
CALCIUM AND DESENSITIZATION
GROWTH FACTORS
P-03.11
MESENTERIC - MESENTERIC FOLLOWING THEIR ROLE HEMORRHAGIC LYMPH IN LYMPHEDEMA DUCT LIGATION SHOCK SKIN CHANGES IMPROVES HYPO-VISCOSAEMIA
AND M AND C Niu, Zaleska, ABNORMAL Z Zhao, A Domaszewska Y Zhang, ERYTHROCYTE Z Liu, - Szostek, J ZhangM
RHEOLOGY Cakala, W Olszewski, IN ACUTE M Durlik, BLOOD M Zaleska, LOSSING
A
RATS Domaszewska RATS - Szostek, M Cakala, W Olszewski, M Durlik
P-03.10 ROLE OF NITRIC OXIDE ON ISOLATED LYMPHATIC REACTIVITY DURING
C Niu, Z Zhang
SESSION 07 PEDIATRIC HEMORRHAGIC I - LYMPHEDEMA SHOCK IN CHILDREN
P-03.12
HUMAN Z Zhao, C SKIN Niu, L TISSUE Qin, Y Zhang, FLUID/LYMPH Y Si, L Zhang, CYTOKINES J Zhang AND GROWTH FACTORS
P-07.07
P-03.11 - FLUORESCENCE-BASED - MESENTERIC THEIR ROLE LYMPH IN LYMPHEDEMA DUCT
MEASUREMENTS
LIGATION SKIN CHANGES
IMPROVES
OF NITRIC
HYPO-VISCOSAEMIA
OXIDE IN ISOLATED
M LYMPHATICS
AND M Zaleska, ABNORMAL A Domaszewska ERYTHROCYTE - Szostek, M RHEOLOGY Cakala, W Olszewski, IN ACUTE M Durlik, BLOOD M Zaleska, LOSSING A
Domaszewska O RATS Domaszewska Gasheva, J Wilson, - Szostek, E Rahbar, M Cakala, J Moore, W Olszewski, H G Bohlen, M Durlik
D Zawieja
C Niu, Z Zhang
SESSION 07 06 07 PEDIATRIC PREVENTION
PEDIATRIC I - LYMPHEDEMA IN CHILDREN
P-03.12 HUMAN SKIN TISSUE FLUID/LYMPH CYTOKINES AND GROWTH FACTORS
P-07.07 P-06.09 P-07.07 FLUORESCENCE-BASED WHETHER - FLUORESCENCE-BASED THEIR ROLE OR IN NOT LYMPHEDEMA PUNCTURING MEASUREMENTS SKIN THE CHANGES IPSILATERAL OF NITRIC ARM OXIDE AFTER IN ISOLATED
LYMPHATICS
AXILLARY LYMPHATICS
M Zaleska, A NODE Domaszewska DISSECTION. - Szostek, A M REVIEW. Cakala, W Olszewski, M Durlik, M Zaleska, A
O P O Domaszewska van Gasheva, Gulick J - Wilson, Gielink, - Szostek, E J Rahbar, Hidding M Cakala, J Moore, W Olszewski, H G Bohlen, M Durlik D Zawieja
Programme Poster Presentations
SESSION SESSION 06 08 06 07 PREVENTION
QUALITY PREVENTION
PEDIATRIC OF I - LIFE LYMPHEDEMA IN CHILDREN
P-06.09 P-08.07 P-06.09 P-07.07
WHETHER THE WHETHER FLUORESCENCE-BASED USE OF OR PATIENT NOT PUNCTURING INFORMATION MEASUREMENTS THE TO IPSILATERAL PREVENT OF NITRIC LATE ARM OXIDE AND AFTER
IN LONG-TERM ISOLATED
AXILLARY IMPAIRMENTS AXILLARY LYMPHATICS NODE AFTER DISSECTION. BREAST A CANCER REVIEW.
TREATMENT
P A P O van Skördåker, Gasheva, Gulick J - U Wilson, Gielink, Steen E - J Zupanc, Rahbar, Hidding
L J Pettersson, Moore, H G A Bohlen, Jonsson, D Zawieja K Johansson
SESSION SESSION 09 08 06 08 MEASURING QUALITY PREVENTION
QUALITY OF LIFE
METHODS I
P-08.07 P-09.04 P-08.07 P-06.09 THE MEASUREMENT THE WHETHER USE OF OR PATIENT NOT OF PUNCTURING RESISTANCE INFORMATION TO THE TO COMPRESSION TO IPSILATERAL PREVENT LATE ARM USING AND AFTER LONG-TERM
IMPAIRMENTS ULTRASONOGRAPHY IMPAIRMENTS AXILLARY NODE AFTER DISSECTION. BREAST WITH BREAST REAL-TIME A CANCER REVIEW. PRESSURE TREATMENT
MONITORING
A J A P Park, van Skördåker, Gulick K S Seo - U Gielink, Steen - J Zupanc, HiddingL
L Pettersson, A Jonsson, K Johansson
SESSION SESSION
P-09.05
09 08 MEASURING QUALITY
PREDICTION
OF LIFE METHODS OF TREATMENT
I
OUTCOME WITH BIOIMPEDANCE MEASURE
IN BREAST CANCER RELATED LYMPHEDEMA(BCRL) PATIENTS
P-09.04
P-08.07 MEASUREMENT G MEASUREMENT THE J Yun, USE S J OF Lee, PATIENT Y OF J OF Sim, RESISTANCE J INFORMATION Y Jeon TO COMPRESSION TO COMPRESSION PREVENT LATE USING
AND LONG-TERM
P-09.06 THE ULTRASONOGRAPHY IMPAIRMENTS ULTRASOUND AFTER INTERNAL WITH BREAST WITH REAL-TIME VOLUMETRY CANCER PRESSURE TREATMENT IN THE ASSESSMENT MONITORING
OF
LYMPHEDEMA
J A Park, Skördåker, K S Seo
U Steen - Zupanc, L Pettersson, A Jonsson, K Johansson
P-09.05
PREDICTION F PREDICTION Passariello
SESSION 09 MEASURING METHODS
OF TREATMENT I
OUTCOME WITH BIOIMPEDANCE MEASURE
P-09.07 IN MEASUREMENTS IN BREAST CANCER OF RELATED LOWER EXTREMITY LYMPHEDEMA(BCRL) LOCAL TISSUE PATIENTS
WATER IN
P-09.04 HEALTHY G MEASUREMENT J Yun, S J WOMEN Lee, Y J OF J Sim, VOLUNTEERS RESISTANCE J Y Jeon
– TO VALIDATION COMPRESSION AND REPRODUCIBILITY.
USING
P-09.06
THE M THE ULTRASONOGRAPHY Radmer ULTRASOUND Jensen, S Birkballe, INTERNAL WITH S Nørregaard, REAL-TIME VOLUMETRY T Karlsmark PRESSURE IN THE ASSESSMENT MONITORING OF
P-09.08 LYMPHEDEMA
PREDICTION LYMPHEDEMA
J Park, K S Seo
OF TREATMENT OUTCOME WITH BIOIMPEDANCE
P-09.05 MEASUREMENT F PREDICTION F Passariello
OF IN TREATMENT LOWER-EXTREMITY OUTCOME LYMPHEDEMA WITH BIOIMPEDANCE PATIENTS MEASURE
P-09.07
MEASUREMENTS G MEASUREMENTS IN J BREAST Yun, S J Lee, CANCER J Y OF Jeong, RELATED LOWER Y J Sim EXTREMITY LYMPHEDEMA(BCRL) LOCAL TISSUE PATIENTS WATER IN
HEALTHY G J Yun, S J WOMEN Lee, Y J Sim, VOLUNTEERS J Y Jeon – VALIDATION AND REPRODUCIBILITY.
SESSION 10 MEASURING M Radmer METHODS Jensen, S Birkballe, II
P-09.06 THE ULTRASOUND INTERNAL S Nørregaard, VOLUMETRY T Karlsmark
IN THE ASSESSMENT OF
P-09.08 P-10.09 P-09.08 PREDICTION AN PREDICTION LYMPHEDEMA
INNOVATIVE OF APPROACH TREATMENT TO OUTCOME EXAMINING WITH LYMPHEDEMA
BIOIMPEDANCE
MEASUREMENT OCCURRENCE: MEASUREMENT F Passariello TRAJECTORIES IN LOWER-EXTREMITY AND AREA LYMPHEDEMA UNDER THE PATIENTS
CURVE
P-09.07 G J MEASUREMENTS G Armer, J Yun, S B S Stewart J Lee, J Y OF Jeong, LOWER Y J Sim
EXTREMITY LOCAL TISSUE WATER IN
HEALTHY WOMEN VOLUNTEERS – VALIDATION AND REPRODUCIBILITY.
SESSION 10 11 10 MEASURING CLINIC MEASURING M ON Radmer LYMPHEDEMA
METHODS Jensen, S Birkballe, II
S Nørregaard, T Karlsmark
P-10.09
P-09.08 AN PREDICTION AN INNOVATIVE OF APPROACH TREATMENT TO OUTCOME EXAMINING WITH LYMPHEDEMA
BIOIMPEDANCE
OCCURRENCE: MEASUREMENT OCCURRENCE: TRAJECTORIES IN LOWER-EXTREMITY AND AREA LYMPHEDEMA UNDER THE PATIENTS CURVE
J G Armer, J Yun, B S Stewart
J Lee, J Y Jeong, Y J Sim
SESSION SESSION 11 10 CLINIC MEASURING ON LYMPHEDEMA
METHODS II
P-10.09
AN INNOVATIVE APPROACH TO EXAMINING LYMPHEDEMA
OCCURRENCE: TRAJECTORIES AND AREA UNDER THE CURVE
J Armer, B Stewart
SESSION 11 CLINIC ON LYMPHEDEMA
51

52
PROGRAMME
Poster presentations
Page 2
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
P-11.10
P-11.11
P-11.12
P-11.13
CHRONIC PERIPHERAL LYMPHEDEMA: CLINICAL, ETIOPATHOGENETIC,
AND DIAGNOSTIC ANALYSES A SINGLE-CENTER EXPERIENCE
Y Akcali, M Kula, E Mavili
DEVELOPMENT OF LIPODERMATOSCLEROSIS OBSERVED IN
LYMPHEDEMA PATIENTS IS ACTUALLY A SLAENGH TO PORK
W Ekataksin
SHOULD BREAST CANCER-RELATED LYMPHEDEMA BE DIAGNOSED
BASED ON ABSOLUTE OR RELATIVE (PERCENT) ARM VOLUME CHANGE?
A G Taghian, C L Miller, M N Skolny, L E Warren, T A Russell, J O' Toole, M Ancukiewicz
THE INCIDENCE OF LYMPHEDEMA RELATED TO BREAST CANCER THAT
RESOLVES WITHOUT INTERVENTION
J O' Toole, T A Russell, M N Skolny, C L MIller, M Specht, M Ancukiewicz, R A Raad, S J
Isakoff, B L Smith, A G Taghian
SESSION 13 FILARIASIS AND LYMPHEDEMA
P-13.07
NONMEDICINAL, NONSURGICAL MANAGEMENT OF CUTANEOUS
COMPLICATIONS IN PATIENTS WITH LYMPHEDEMA: FOUR CASE
REPORTS
K Oyama, M Mitsuda, N Chanwimalueang, M Ohkuma, W Ekataksin
SESSION 14 CANCER AND LYMPHEDEMA
P-14.09
P-14.10
P-14.11
P-14.12
P-14.13
P-14.14
SESSION 19 SURGERY I
P-19.10
SESSION 20 SURGERY II
P-20.10
THE EFFECT OF A THORAX BANDAGE ON SEROMA FORMATION
POSTOPERATIVE IN A BREAST CANCER PATIENT
A T M Nieuwenhuijsen
EFFECT OF MAGNETIC STIMULATION IN SPINAL CORD ON LIMB
ANGIOGENESIS AND IMPLICATION FOR LYMPHEDEMA
J Beom, B M Oh, K S Seo
THE EFFECT OF COMPLEX DECONGESTIVE PHYSIOTHERAPY FOR
MALIGNANT LYMPHEDEMA : PILOT STUDY
Y J Sim, B H Kim, E H Kong
MALIGNANT PLEURAL EFFUSION AND ASCITES OCCURRING IN
CONJUNCTION WITH CANCER METASTASIS TO THE LYMPHATIC
STOMATA
H Oshiro, M Miura, O Ohtani, A Kudo, Y Shimazu, T Aoba, K Okudela, K Nagahama, Y
Inayama, T Nagao
DIFFERENTIAL DIAGNOSIS OF LYMPHEDEMA IN A PATIENT WITH A LUNG
CANCER AND A HUMERAL FRACTURE.
I FORNER - CORDERO, C RUBIO - MAICAS, E DUARTE - ALFONSO, R GARCIA - SAEZ
FOXC2 DEFICIENCY AND MELANOMA SPREAD IN A MOUSE MODEL
S Daley, E Bastidas, J Washington, M Bernas, M Witte
MICROSURGICAL LYMPHOVENOUS ANASTOMOSES AFTER 45 YEARS-
INDICATIONS, TECHNIQUES AND FOLLOW-UP EVALUATION METHODS
W L Olszewski
SURGICAL DEBULKING PROCEDURES IN VERY ADVANCED
LYMPHEDEMA OF LOWER LIMBS
W Olszewski, P Jain, J Victor
SESSION 24 GENITAL LYMPHEDEMA
P-24.07
EFFECTS OF REDUCTION OPERATION WITH GENITAL LYMPHOEDEMA ON
THE FREQUENCY OF ERYSIPELAS AND LIFE QUALITY
G Felmerer, E Földi,
SESSION 26 COMPRESSION TREATMENT II
P-26.08
EFFECT OF SHORT-STRETCH MULTILAYER BANDAGING WITH PADDING
IN BREAST CANCER-RELATED LYMPHEDEMA PATIENTS
S J Lee, G J Yun, H J Kim, Y J Sim, J Y Jeon
SESSION 27 NEW FRONTIERS IN LYMPHATIC RESEARCH I
P-27.06
POSSIBLE ROLES OF PODOPLANIN POSITIVE CELLS IN LYMPHATIC
VESSEL REGENERATION DURING THE WOUND HEALING
K Shimizu, T Ezaki
SESSION 29 DECONGESTIVE THERAPY I

PROGRAMME
Poster presentations
Page 3
THE 23RD INTERNATIONAL CONGRESS OF LYMPHOLOGY 19-23 SEPTEMBER 2011,
MALMÖ, SWEDEN
TIME NUMBER TITLE ROOM
P-29.08
P-29.09
P-29.10
P-29.11
P-29.12
P-29.13
P-29.14
P-29.15
LONGER TERM CHANGES IN BIOIMPEDENCE FOLLOWING LIPOSUCTION
FOR CHRONIC ARM LYMPHOEDEMA RELATED ADIPOSITY
H Mackie, J Tiong, K Shanley
COMPARATIVE STUDY OF THE EFFICIENCY OF METHODS CRYOTHERAPY
OF LYMPHEDEMA OF LOWER EXTREMITIES
T Apkhanova
STATISTICAL EXAMINATION OF LYMPHATICOVENOUS ANASTOMOSIS
AND PREOPERATIVE COMPLEX DECONGESTIVE PHYSIOTHERAPY FOR
TREATMENT OF PERIPHERAL LYMPHEDEMA
J Maegawa, H Tomoeda, M Hosono, A Tosaki
ENDOLYMPHATIC PHARMACOKINETICS OF MEROPENEM AT LOCAL
PYOINFLAMMATORY PROCESS OF ABDOMINAL CAVITY –
EXPERIMENTAL RESEARCHES RESULTS
I. V. Yarema, B. M. Urtaev, A. I. Marchenko, A. A. Akopyan, R. A. Simanin, O. V.
Danilevskaya, R. I. Yarema, P. S. Neklyudova
SUBSTANTIATION OF ENDOLYMPHATIC ANTIBIOTIC THERAPY OF
POLYNEURITIS
A. I. Marchenko, I. D. Stulin, E. Y u. Demidova, R. I. Yarema, E. Y u. Ponomareva, O. V.
Danilevskaya, N. D. Postriganova, A. R. Tsarapkina
LYMPHOEDEMA AND HEALTH RELATED QUALITY OF LIFE BY EARLY
TREATMENT IN LONGTERM SURVIVORS OF BREASTCANCER.
K Karlsson, I Wallenius, L Nilsson Wikmar, H Lindman, B Johansson
MANUAL LYMPHATIC DRAINAGE INFLUENCE IN THE EVOLUTION OF
POST-SURGERY IN PATIENTS SUBMITTED TO ABDOMINAL
LIPOASPIRATION
M Lacerda
SUCCESSFUL EVIDENCE FROM TWISTING TOURNIQUET TECHNIQUE®
FOR LYMPHEDEMA TREATMENT
N Chanwimalueang, W Ekataksin, P Piyaman
53

Industry Sponsored Sessions
3M Satellite Symposium
Date: Tuesday Sept 20.
Time: 13:00-13:30
Room: Congress Hall
Chair: Bart Maene, Scientific Affairs & Education
Specialist - Western Europe
3M Skin & Wound Care Division
Less is More in Intensive Compression Therapy?
13:00-13:15 Bandage Frequency, Efficacy and
Quality of Life?
Speaker: Bart Maene
13:15-13:20 Bandaging Frequency and Health
Economics?
Speaker: Bart Maene
13:20-13:30 Case Histories
Speaker: TBD
Bauerfeind Breakfast session
Date: Wednesday Sept 21.
Time: 07.30-08.15
Room: Room D
Chair: Bart Maene
VOLUME MEASUREMENT FOR CONTROLLING
LYMPHEDEMA
1. Limb Volume Assessments Based on
Circumference
Measurements:
Possibilities and Limitations
Speaker: Harvey Mayrovitz
2. Inverse Water Plethysmography for Arm Volume
Measurements"
Speaker: Robert Damstra
3. Photogrammetry for Treatment-Controlling of
Edema
Speakers: HJ Thomä, A Basson
4. Volumetry by Computer Tomography
Speaker: JF Uhl
5. Volumetry by MRI
Speaker: Gyozo Szolnoky
6. Discussion
54
Jobst Satellite Symposium
Date: Wednesday Sept 21.
Time: 13:00-13:45
Room: Congress Hall
Effects of compression therapy on lymphedema:
pressure and temperature
Speaker: Ethel Földi
medi Satellite Symposium
Date: Thursday Sept. 22
Time: 13:00-13:30
Room: Congress Hall
Chair: Hugo Partsch
Compression in decongestive lymphatic therapy.
Speaker: Franz Schingale
Compression after liposuction.
Robert Damstra

SOCIAL PROGRAMME

Photo: Charlotte Strömwall
Social Programme
Welcome Reception
Monday September 19, 17.30 at Stadionmässan
(Exhibition Hall)
The Welcome Reception evening is hosted
by the City of Malmö.
Meet the exhibitors and talk about the latest
news, make new friends, mingle with
colleagues and enjoy a buffet dinner with
drinks. During the evening there will be entertainment.
Dress code: Business-casual
NB! You must register for the Welcome
Reception (free of charge) to obtain a ticket.
Otherwise you will not have access.
Malmö Opera House
56
Congress Dinner
Thursday September 22, 19.00 at Malmö
Opera
Situated in the city centre, Malmö Opera is
southern Sweden’s own opera house.
The Opera House is one of the largest auditoriums
in Scandinavia with 1508 seats,
created in the form of an enclosed amphitheatre
to allow for the greatest viewing
possibility.
Join us at Malmö Opera House and enjoy
a three course dinner with wine, entertainment,
and a dance floor that will open after
the dinner.
Dress code: Business-casual
NB! You must register for the Congress Dinner
(free of charge) to obtain a ticket. Otherwise
you will not have access.
Please bring your ticket!
Photo: Jimmy Wahlstedt

ORAL PRESENTATION
ABSTRACTS
SESSIONS 01-30

KN-01
LYMPHOLOGY AND THE ISL IN THE REAL, VIRTUAL AND IMAGINED WORLD OF THE FUTURE
M H Witte, Department of Surgery, University of Arizona College of Medicine, Tucson, UNITED STATES
Since before the official founding of the International Society of Lymphology (ISL), lymphology has transcended the barriers
of medical specialization, language, and geography. In 1966, the First International Congress of Lymphology in Zurich
brought together hundreds of basic scientists (largely anatomists and physiologists) and clinicians (prominent radiologists/
lymphographers and cancer/vascular surgeons) who envisioned the lymphatic system as more than “lymph nodes held
together by strings.” Forty-five years later, we in the “real world” of lymphology still “stand on the shoulders of these giants,”
revisiting neglected threads from earlier times and applying advances in molecular biology, technology, and public health to
bring new understanding to structure-function relationships in the normal and diseased lymphatic system, higher resolution
in multimodal dynamic lymphatic imaging, and improved care to patients afflicted with myriad disorders of the “lymphatics,
lymph, lymph nodes and lymphocytes.” Many key unanswered questions and unquestioned answers persist (true “medical
ignorance”), and many more will doubtless arise de novo in the “imagined world” of bewildering genomes, proteomes,
transcriptomes, metabolomes, organomes, functionomes, diseasomes, phenomes, etc. As we move from “genes to man” – to
translate discoveries into personalized medicine in lymphology – new and better ways to collaborate globally across basic
and clinical disciplines will incorporate sophisticated communication/data networks and remote outreach. Here, the “virtual
world” of our web-based Virtual Clinical Research Center/Questionarium should be a powerful tool to advance molecular,
cellular, systemic, and clinical lymphology and provide a welcome roadmap to our “unimagined” future.
Declaration of interest
None declared
KN-02
BALANCING LYMPHEDEMA RISKS: EXERCISE VERSUS DECONDITIONING
K Schmitz, University of Pennsylvania, Philadelphia, UNITED STATES
Background: Lymphedema is a common and feared adverse clinical sequelae of breast cancer treatment. Our current ability
to predict who will develop lymphedema or who will progress to advanced stages of the condition are poor, at best. Given this
scenario, the clinical advice to women with and at risk for lymphedema has been risk averse, including advice to protect the
affected limb and avoid lifting. Unfortunately, this rational response to the unknown may lead to the very outcome patients
seek to avoid (onset or worsening of lymphedema) as a side effect of the deconditioning resulting from protecting the limb.
Objectives: The objective of this presentation is to present evidence and theory regarding physiologic effects of exercise on the
lymphatic system structure and function, as well as to review the recently published evidence regarding the clinical effects of
exercise on lymphedema outcomes in breast cancer survivors.
Methods: A systematic literature review of the evidence regarding physiologic and clinical effects of exercise on outcomes
related to lymphedema in breast cancer survivors.
Results: Evidence from lymphoscintigraphic studies indicate increased lymphatic clearance during exercise than at rest among
women with lymphedema. Decades of exercise science support the usefulness of site specific exercise to improve circulatory
function, suggesting exercise may improve the ability of the affected limb to respond to infection, inflammation, and trauma.
Exercise training also improves the functional capacity, reducing the relative intensity of work. This may result in avoiding
the overuse often thought to be the cause of lymphedema onset and progression. Results of clinical trials on exercise strongly
support the use of exercise as part of a program to reduce lymphedema onset or progression among breast cancer survivors.
Conclusions: The scientific evidence base regarding the value of exercise for prevention and control of lymphedema in breast
cancer survivors is as compelling as for any therapeutic modality. Further imaging studies will assist with cementing the
mechanisms through which these effects occur. However, it is now clear that rehabilitative weight training exercise should be
standard of care for breast cancer survivors.
Declaration of interest
None declared
58

KN-03
IMPACT OF TUMOR BURDEN IN THE SENTINEL LYMPH NODES ON THE OUTCOMES OF CANCER
PATIENTS
S Leong, Department of Surgery, California Pacific Medical Center, San Francisco, UNITED STATES
Background: The concept that cancer of a specific anatomical site spreads to its corresponding sentinel lymph nodes (SLNs)
in the regional nodal basin has been extensively validated in melanoma and breast cancer.
Objective: To evaluate the clinical significance of micrometastasis in the SLNs.
Methods: Literature review.
Results: In general, micrometastasis in the SLNs of solid cancers predicts a worse clinical outcome. Cancer metastasis from
the primary site to the SLNs (incubator hypothesis) and then to the non-SLNs prior to systemic spread in melanoma and
breast cancer is consistent with the spectrum theory that cancer metastasis is progressive. However, in about 20% of the
time, cancer cells may spread through the SLNs and vascular system simultaneously (marker hypothesis) or independently
to the distant sites via the vascular system. If the SLNs are negative, a more morbid regional lymph node dissection may be
spared in melanoma. For breast cancer, removal of SLNs with metastasis may be effective during the ‘‘incubator’’ phase, but
adjuvant therapy should be given for patients with microscopic disease in the distant sites. In penile carcinoma, SLN mapping
will guide the appropriate location of the lymph node to avoid a morbid bilateral radical ilioinguinal lymph node dissection.
For head and neck, colorectal, upper GI, other GU and gynecological cancers, the lymphatic pathways are, in general, more
complicated and unpredictable. For head and neck as well as gynecological cancers, the goal is to establish a reliable SLN
mapping method to minimize the degree of lymph node dissection. For colorectal and upper GI cancers, while the extent of
lymphadenectomy may not be altered significantly, the identification of SLNs will increase the accuracy of staging the nodal
basins, especially in view of the fact that the number of lymph nodes being resected for colorectal and gastroesophageal
cancer is a significant predictor of survival.
Conclusion: In conclusion, SLN is the gateway for cancer metastasis in the majority of the time. Further molecular and
genomic studies may define the mechanisms of cancer spread through the lymphovascular system more precisely, thus,
allowing us to develop more rational therapy.
Declaration of interest
None declared
KN-04
BREAST CANCER RELATED LYMPHOEDEMA (BCRL)
P Mortimer, Division of Clinical Science, St George’s, University of London, London, UNITED KINGDOM
Axillary surgery for breast cancer may be followed, weeks to years later, by chronic arm lymphoedema (BCRL). A simple
obstructive “stopcock” mechanism (reduced lymph drainage from the entire limb) does not explain many clinical aspects,
including the delayed onset and selective sparing of some regions eg hand. In a prospective study that investigated patients
following breast cancer treatment, but before the onset of lymphoedema, lymph flow was found to be significantly higher
in the arms of those women who subsequently developed arm swelling.(1) Lymph flow was found significantly higher in
both subcutis and sub-fascial forearm muscle.(1) Furthermore lymph flow was also found to be higher in the contralateral
arm which was unaffected by surgery.(1) BCRL therefore developed in women with higher peripheral lymph flows. These
results indicate that BCRL is not simply an obstructive lymphoedema. We propose that women have a defined, constitutive
predisposition to BCRL by developing high fluid filtration rates in response to cancer and/or its treatment. Higher fluid
filtration overloads lymph drainage which, over time and in the face of increased outflow lymphatic resistance, leads to
lymphatic collector pump failure and the onset of lymphoedema. (2,3)
1. Stanton AW, Modi S, Bennett Britton et al, Lymphatic drainage in the muscle and subcutis of the arm after breast cancer
treatment. Breast Cancer Res Treat. 2009;117:549-57
2. Modi S, Stanton AW, Svensson WE et al. Human lymphatic pumping measured in healthy and lymphoedematous arms by
lymphatic congestion lymphoscintigraphy. J Physiol. 2007;583:271-85
3. Stanton AW, Modi S, Mellor RH et al. Recent advances in breast cancer-related lymphoedema of the arm: lymphatic pump
failure and predisposing factors. Lymphat Res Biology 2009;7:29-45
Declaration of interest
None declared
59

O-01.01
EFFECT OF WEIGHT LIFTING ON BREAST CANCER-RELATED LYMPHEDEMA – DOES EFFECT
DIFFER BY DIAGNOSTIC METHOD?
S Hayes, Queensland University of Technology, Brisbane, AUSTRALIA, R Speck, University of Pennsylvania, Philadelphia,
United States of America, K Schmitz, University of Pennslyvania, Philadelphia, United States of America
Background: Several objective and self-report methods for assessing lymphedema exist, and it is well-established that the
diagnostic method used in observational or intervention studies may influence results found.
Objectives: The purposes of this work were to compare baseline lymphedema prevalence in the Physical Activity and
Lymphedema (PAL) trial cohort according to three standard diagnostic methods, and to subsequently compare the effect of
the weight lifting intervention on lymphedema.
Methods: The PAL trial was a randomized, controlled intervention study, involving 295 women who had previously been
treated for breast cancer, and evaluated the effect of 12 months of weight lifting on lymphedema status. Three diagnostic
methods were used to evaluate lymphedema outcomes: interlimb volume difference via water displacement, interlimb
impedance ratio using bioimpedance spectroscopy and a validated self-report survey.
Results: Of the 295 women who participated in the PAL trial, between 26-47% were considered to have lymphedema at
baseline according to the three diagnostic criteria used. No between group differences were noted in the proportion of women
who had a change in interlimb swelling, interlimb ratio, or survey score of >5% (Cumulative incidence ratio, CIR, 95% CI: 0.8,
0.4-1.4), >10% (CIR, 95%: 0.8, 0.2, 2.9) and 1 unit (CIR, 95% CI: 0.6, 0.2-1.9), respectively.
Conclusion: The variation in proportions of women within the PAL trial considered to have lymphedema at baseline highlights
the potential impact of the diagnostic criteria on population surveillance regarding prevalence of this common morbidity of
treatment. Importantly though, progressive weight lifting was shown to be safe for women following breast cancer, even for
those at risk- or with lymphedema, irrespective of the diagnostic criteria used.
Declaration of interest
None declared
O-01.02
THE USE OF CLINIMETRIC INSTRUMENTS ACCORDING TO THE INTERNATIONAL
CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH
A Hendrickx, Nij Smellinghe hospital, Drachten, NETHERLANDS, R J Damstra, Nij Smellinghe hospital, Drachten,
NETHERLANDS
Background: Patients with lymphedema suffer from varying degrees swelling, limited range of motion, pain, loss
of muscle strength and fatigue. Related to these problems, activities of daily living are limited, e.g. personal care,
walking, housekeeping, sports activities and working. Subsequently, the overall quality of life for people with
lymphedema is often significantly affected.
With the utilization of the ICF, based on the bio-psycho-social model, influences upon a patient’s functioning, including body
functions and structures, activities and participation in relation to personal and environmental factors, can be described.
In the management of lymphedema monitoring of activity of disease parameters as well as results of treatment and follow up
is mandatory. Health care professionals and the patient perform monitoring. Such checks require validated measurements, in
a protocolled schedule on all domains of the ICF.
Objective: Present an overview clinical measurements and reasoning on all domains of the ICF in the expertise centre for
lymphedema Drachten, The Netherlands.
Methods / Results: We use several clinical instruments for all the phases of treatment for the patient with or at risk for
developing lymphedema. The phase after oncological surgery, when the lymph system is impaired, secondary prevention
consists of volumetry and Body Mass Index and is regular measured during oncological follow-up.
When a patient has been diagnosed with lymphedema and the treatment has started, the initial measurements are aimed at
the edema itself, but also at the presence of risk factors, pain, loss of joint mobility, strength, physical capacity and emotional
distress. In this phase, the frequency of measurement is high.
In the maintenance phase the desired level of activity and participation are leading for the therapy itself, but also for the
instruments and the frequency of measuring. For example, the DASH (Disabilities of the Arm, Shoulder and Hand) and
objective questionnaires regarding Health Related Quality of Life are utilized.
The frequency of measuring decreases and the role of self-monitoring becomes more important.
Conclusion: Clinimatric instruments according the ICF provide tools for objective measuring the various domains of func- functioning
in relation to prevention, treatment and follow-up of lymphedema.
Declaration of interest
None declared
60

O-01.03
USING WEIGHT-LIFTING TO CONTROL LYMPHEDEMA ONSET OR FLARE-UPS: THE PAL TRIAL
K Schmitz, University of Pennsylvania, Philadelphia, UNITED STATES
Background: Lymph node dissection forever alters the area served by those nodes with regard to response to injury, infection,
inflammation and trauma. Exercise improves body responses to these challenges.
Objectives: To determine the effect of one year of twice-weekly strength training on lymphedema outcomes among breast
cancer survivors with and at risk for lymphedema.
Methods: Breast cancer survivors (N=295) were recruited, including 141 with and 154 at risk for lymphedema. Randomization
was stratified by baseline lymphedema status, number of nodes removed, age, time since breast cancer diagnosis, body mass
index (BMI), and history of radiation therapy. Treatment group participants were provided with 13 weeks of supervised twice
weekly strength training instruction, followed by 9 months of unsupervised strength training intervention. Measurements at
baseline and 12 months included water volume, arm circumferences, need for therapist delivered treatment (onset or flareup),
BMI, body composition (DEXA scans), muscle strength and body image.
Results: No differences were noted across treatment versus control group participants with regard to changes in arm swelling,
with the exception of 70% reduction of the likelihood of increased interlimb water volume differences in the treatment versus
control group women who had five or more lymph nodes removed (p=0.05). The likelihood of needing therapist delivered
treatment among women who entered the study with lymphedema was reduced by 53% among treatment versus control
participants (p=0.03). No significant changes were noted in BMI or body composition. Muscle strength and body image
both improved significantly more among treatment than control group participants, regardless of baseline lymphedema
status (p

O-01.05
RESISTANCE TRAINING IN THE SUB-ACUTE POST-OPERATIVE PERIOD DOES NOT CAUSE
LYMPHOEDEMA: A RANDOMISED CONTROL TRIAL
L Ward, The University of Queensland, Brisbane, AUSTRALIA, J Beith, Sydney Cancer Centre, Sydney, Australia, K Refshauge,
University of Sydney, Sydney, Australia, M J Lee, University of Sydney, Sydney, Australia, S Kilbreath, University of Sydney,
Sydney, Australia
Introduction: As part of a single-blinded randomised trial, we investigated whether progressive resistance training,
commencing 4-6 weeks post-breast cancer surgery was associated with a higher incidence of lymphoedema (LE).
Methods: Women (n=160) who had undergone either axillary node dissection or sentinel node biopsy in combination with
breast surgery within the previous 4 – 6 weeks for unilateral breast cancer were stratified for axillary surgery, and randomised
to an exercise (EX: 79) or control group (CONTROL: n=77). EX received progressive resistance training using free weights
and Thera-Band®. This program targeted the shoulder flexors, abductors, external rotators and horizontal flexors in the
range of 90 degrees and above-shoulder elevation. Exercise progression was monitored weekly. The median commencing
weight for each exercise on the affected side was 1 to 1.5kg. However, by 8 weeks, the median weight was 3 kg for shoulder
abduction and flexion, and 4 kg for horizontal flexion and extension. CONTROL received advice regarding active stretching.
Presence of swelling in both groups was assessed by self-report, by arm circumferential measurements and by bioimpedance
spectroscopy.
Results: Following the 8-week program, EX did not have greater incidence of LE or changes suggestive of LE than CONTROL.
At 6 m follow-up, 13% of women in CONTROL and 8% in EX exceeded the published boimpedance thresholds indicative of
lymphoedema, and 85% of both groups were within 2 cm differences at all 5 inter-limb arm circumference comparisons. BIS
identified more women as having LE than either circumference or volume measures but not necessarily the same individuals.
This discrepancy was particularly noticeable when the non-dominant limb was identified as having LE with BIS.
Conclusion: Resistance training commencing within 4-6 weeks of surgery for breast cancer did not result in higher incidence
of LE compared to women receiving usual care. Resistance training to address post-operative shoulder weakness can
commence early as 4 weeks post-operatively. For early detection of lymphoedema, BIS is the preferred tool as it has greater
sensitivity and specificity than measures related to arm volume.
Declaration of interest
Author Ward consults to Impedimed Ltd.
Other authors state no conflict of interests.
O-01.06
POLE WALKING FOR WOMEN WITH BREAST CANCER RELATED ARM LYMPHEDEMA
C Jönsson, University hospital in Lund, Lund, SWEDEN, K Johansson, University hospital, Lund, Sweden
Background and objectives: The positive effects of exercise are well documented for breast cancer treated women. However,
there are few studies of the effects of exercise in breast cancer treated women with arm lymphedema. The purpose of this
study was to determine the effects of pole walking as a cardiovascular exercise on arm lymphedema, fitness, body weight and
subjective assessments in women with arm lymphedema after breast cancer treatment.
Methods: Twenty-three women with unilateral arm lymphedema took part in an eight week intervention study consisting
of pole walking for at least 30 minutes, 3 to 5 times per week, at 70-80% of maximum heart rate, preceded by a two week
control period. Measurements of arm lymphedema (water displacement method), body weight, fitness (submaximal bicycle
ergometer test) and subjective assessments (the disability of arm, shoulder and hand questionnaire (DASH), rating of
heaviness and tightness in the edema arm on the VAS and general well-being) were performed before control period, before
and after exercise intervention.
Results: No augmentation in arm lymphedema was caused by the intervention. On the contrary we found a significant
reduction in total arm volume in the edema arm (p=.001), in lymphedema absolute volume (p=.014) and in lymphedema
relative volume (p=.015) after exercise intervention compared to before intervention. After intervention we also found a
significant decrease in heart rate (p=.004), in DASH score (p=.04) and in rating of tightness in the edema arm (p=.027)
compare to before. No changes in body weight or in rating of heaviness were found after intervention. Both positive and
negative influences on well-being were reported by the women.
Conclusion:Pole walking can be performed as a cardiovascular exercise in women with breast cancer related arm lymphedema
without increasing the arm lymphedema. However, there is a need for more and larger prospective studies on the effects of
pole walking.
Declaration of interest
None declared
62

O-01.07
A RANDOMIZED STUDY OF THE EFFECT OF SWIMMING AND WATER AEROBIC EXERCISE ON
BREAST-CANCER-RELATED ARMLYMPHEDEMA.
K Johansson, Lund University, Lund, SWEDEN, S Hayes, Queensland University, Brisbane, AUSTARLIA, R Speck, Pennsylvania
University, Philadelphia, USA, K Schmitz, Pennsylvania University, Philadelphia, USA
Background: Swimming and water aerobic exercises are often used in breast cancer rehabilitation.
Objectives: The purpose of this study was to determine the impact of swimming and water aerobic exercise on changes in arm
volume and shoulder range of motion and perceptions of body image in women with breast cancer related arm lymphedema.
Patients and methods: Twenty-nine women with unilateral breast cancer and arm lymphedema clinically verified for at least
six months have been included in the study. They were randomized either to a control group with no intervention or an
intervention group performing swimming and water aerobic exercise for 30 minutes 3 times per week for 8 weeks. The
participants were free to choose whether they wanted to swim or do exercises or both but register in a diary. Arm volume
were measured by perometer, arm fluids by bioimpedance spectroscopy (BIS), local tissue water by Tissue dielectric constant
(TDC) and shoulder range of motion by goniometer
Results: Preliminary results show no differences between the groups, however, a significant increase of outward rotation was
found in the intervention group.
Declaration of interest
None declared
O-02.01
REVIEW THE LYMPHATIC ANATOMY IN THE SENTINEL NODE ERA
M Amore, Buenos Aires University, Buenos Aires, ARGENTINA
OBJECTIVE: The introduction of the sentinel lymph node biopsy has renewed the interest in regional lymph nodes outside
some organs as a potential site of regional lymph nodes metastases. Detailed gross anatomical information about the lymphatic
system is essential for predicting accurate distant metastatic sites in cancer. The purpose of this study is to carry out a detailed
description of the lymphatic drainage of different organs (mammary gland, colon, stomach, esophagus, thyroid gland, genital
organs and skin, and translation this finding to the clinical experience in lymphatic mapping and sentinel node biopsy.
MATERIAL AND METHODS: Our material comprised 300 specimens 283 of which where from human fetus and 17 from
fresh adult cadavers between 50 to 76 years old of which 226 where women and 74 men. The injection was done with the
modified Gerota’s mass. Dissection is carried out after fixation of the specimen in 40% formaldehyde for 6 days, and then
immersed in an 100 volume hydrogen peroxide solution for 24 hours (Prof. Caplan’s bleaching technique). In 90 fetus
specimens we used the Spalteholz technique for diafanization. Research was carried out at the Lymphatic Research Laboratory
of the III Chair of Anatomy at the University of Buenos Aires.
RESULT: Sentinel lymph node dissections have been shown to be sensitive for the evaluation of nodal basins for metastatic
disease and are associated with decreased short-term and long-term morbidity when compared with complete lymph node
dissection. This study addresses the lymphatic anatomy of some organs in relation of the incidence of cancer. Our finding may
explain the clinical experience in lymphatic mapping and sentinel node biopsy, and also the persistence of a false negative rate
irrespective of experience of the surgeon.
Declaration of interest
NONE DECLARED
63

O-02.02
SIGNIFICANCE OF D2-40 IMMUNOHISTOCHEMISTRY IN EVALUATION OF LYMPHATIC INVASION
BY CANCER CELLS IN GASTRIC ADENOCARCINOMA
E OKADA, TAKAOKA CITY HOSPITAL, TAKAOKA, JAPAN
Background: Although lymphatic invasion by cancer cells has been expected to be an important prognostic factor, the accurate
evaluation of the lymphatic invasion has been difficult. By advent of D2-40 immunohistochemistry, correct identification of
the lymphatic vessels in histological sections became possible.
Objectives: To demonstrate significance of D2-40 immunohistochemistry in evaluation of the lymphatic invasion
Methods: An investigation with surgically resected stomachs and their regional lymph nodes from cases of primary gastric
adenocarcinoma was performed. The histological sections of the stomachs were subjected to immunohistochemistry using
monoclonal antibody of D2-40 (DakoCytomation M3619) to detect lymphatic invasion by the tumor cells. The relations
between extent of lymphatic invasion, extent of lymph node metastasis, and life prognosis was analyzed.
Results: With D2-40 immunohistochemistry, lymphatic endothelial cells always gave clear positive signals along its contours,
and endothelial cells of the blood vessels never revealed positive signals with D2-40 antiserum. So that, we could make
accurate assessment of extent of lymphatic invasion by the tumor cells. Lymphatic invasion by the tumor cells were principally
observed in pre-existent submucosal lymphatic vessels and lymphatic vessels in adjacent to cancer nests. By nonparametric
multifactorial test, we analyzed whether the extent of lymphatic invasion is an independent prognostic factor.
Declaration of interest
None declared
O-02.03
EFFECT OF NEGATIVE PRESSURE IN PHARYNGO-ORAL CAVITY ON LYMPHATIC CIRCULATION
OF EYES
C Guoling, the Second Hospital of Shandong University, Jinan, CHINA, W Luwan, Shandong University School of Medicine,
Jinan, CHINA
Background: Altered aqueous humor flow from the eye can lead to high intraocular pressure (IOP) and irreversible blindness
from glaucoma. Aqueous humor is drained from the eye via two pathways: conventional outflow via trabecular meshwork,
and unconventional outflow via the ciliary body.Previous studies have indicated that the presence of distinct lymphatic
channels in the human ciliary body and that fluid and solutes flow at least partially through this system. It had been reported
that negative pressure in pharyngo-oral cavity was helpful in the treatment of lymphedema and related disorders.
Objective: To investigate the signification and effect of negative pressure in pharyngo-oral cavity on lymphatic circulation
of eyes in rabbits and the dynamics influence of aqueous humor circulation in patients who were suffering from glaucoma.
Methods: Part I, 0.2ml of 10% Patent Blue V was injected into the anterior chamber of eyes in 24 New-Zealand rabbits,12
rabbits were treated with negative pressure in pharyngo-oral cavity, and other 12 rabbits were not received this treatment. After
that, the time of lymphatic circulation were counted. ParII, 32 patients suffering from glaucoma were randomly divided into
control group (n=16) and treatment group (n=16) according to whether they were received negative pressure of pharyngooral
cavity or not, the IOP and visual function of patients were observed.
Results: After treatment with negative pressure of pharyngo-oral cavity in rabbits, times of lymphatic circulation (from
anterior chamber to preauricular lymph nodes) of eyes were less than those without this therapy (P

O-02.04
OLOF RUDBECK AND THE DISCOVERY OF THE LYMPHATIC SYSTEM
E Hansson, Lund University/Skåne University Hospital, Malmö, SWEDEN, H Svensson, Lund University/Skåne University
Hospital, Malmö, SWEDEN, H Brorson, Lund University/Skåne University Hospital, Malmö, Sweden,
In 1653 Olof Rudbeck (1630-1702) presented a thesis, “Nova exercitatio anatomica”, in which the lymphatic system for the
first time was described as a functional unit of the human body, in analogy with the venous circulation. Later the same year,
the Danish anatomist Thomas Bartholin (1616-1680) published an anatomical description of the lymphatic system in “Vasa
lymphatica”. He claimed that the lymphatic vessels drain chyle to the liver for the production of blood. This was in contrast
to Rudbeck findings. The discovery of the lymphatic system resulted in a battle between Rudbeck and Bartholin, regarding
who actually made the discovery. In brief, Bartholin published his results about one month before Rudbeck, but Rudbeck had
described the thoracic duct and noted that the lymphatic vessels contain serous fluid that drain into cisterna chyli already in
1650. Furthermore, Rudbeck had performed a public vivisection of a dog for Queen Kristina, in 1952. During the vivisection
he called the lymphatic vessels vasa serosa. The Queen’s physician, Pierre Bourdelot, wrote to Bartholin about the vivisection,
but did not state who had performed it. Bartholin wrote that the vessels have been named as vasa serosa “by others” in
his work “Vasa lymphatica”, thus he used the same terminology as Rudbeck had in his thesis. In summary, both Rudbeck
and Bartholin deserve praise for their discoveries but Rudbeck has to be considered the discoverer of the function of the
lymphatic system.
Declaration of interest
None of the authors have any conflict of interest including affiliations with sponsoring companies
O-02.05
LYMPHATIC DRAINAGE OF MAMMARY GLAND: TRANSLATING FROM ANATOMY TO SURGERY
TO MICROSURGERY.
C Campisi, University of Genoa - University Hospital , Genoa, Italy, M Amore, University of Buenos Aires, Buenos Aires,
Argentina
Background: The predominant breast lymphatic drainage pathway is towards the axilla. The incidence of secondary arm
lymphedema varies from 7 to 77 % in patients following axillary lymph node dissection (ALND). On the other hand, the
incidence of arm lymphedema after sentinel lymph node biopsy (SLNB) varies from 0 to 13 %.
Objectives: To carry out a detailed description of the breast area lymphatic drainage remarking the importance of upper limb
derivative lymphatic pathways. Translating this anatomical findings into current surgical practice, microsurgical primary
prevention of secondary arm lymphedema acquires a leading role in the advanced management of breast cancer patients.
Methods: In this study, 350 mammary glands and upper limbs together with 80 sections of anterior pectoral skin of deceased
fetuses and of 20 adults were injected. The injection had been performed with the modified Gerota’s mass. Dissection had
been carried out after appropriate fixation of the specimens in 40% formaldehyde for 6 days, and then immersed in a 100
volume hydrogen peroxide solution for 24 hours. In 90 fetus specimens we used the Spalteholz technique for diafanization.
Results: Breast lymph flows through the perilobular lymphatics and the interlobar spaces that initiate the lymphatic capillaries,
which, on the other hand, give origin to secondary pedicles. These lymphatic vessels exit the mammary gland at specific sites
(external, internal and posterior), thus constituting the following draining pedicles: external or axillary pedicle (95,33 %),
internal or mediastinal pedicle (36,6 %) and posterior or retromammary pedicle (17,1%). Regarding the skin lymphatic
drainage of breast area, there are two main lymphatic pathways, the homolateral and the contralateral. In addition, we can
observe three different derivative lymphatic pathways of the upper limb: anterior external superficial pathway, posterior
external superficial way and anterior internal deep pathway.
Conclusion: Microsurgery has a key role regarding primary prevention of secondary arm lymphedema at the same time
of ALND/SLNB. Planning breast cancer surgery, patients should undergo an appropriate clinical assessment together with
lymphoscintigraphy in order to evaluate their lymphedema low-moderate-high risk.
Declaration of interest
None declared
65

O-02.06
VERSATILITY OF A CANINE FORELIMB MODEL FOR INVESTIGATING THE LYMPHATIC SYSTEM
H Suami, The University of Texas M. D. Anderson Cancer Center, Houston, UNITED STATES, D Chang, The University of Texas
M. D. Anderson Cancer Center, Houston, UNITED STATES
Introduction: Despite a critical need for better understanding of lymphedema and evaluating efficacy of various surgical
treatments for lymphedema, there is no accepted animal model for investigating the lymphatic system.
Objectives: The aim of this study is to investigate the lymphatic system of the forelimb in canine and to compare with our
previous studies of human lymphatic system in the upper extremity.
Methods: Six upper extremities from three mongrel dogs were investigated. After animals were euthanized, our novel
microsurgical injection technique was applied for demonstrating the lymphatic vessels. Hydrogen peroxide (3 %) was injected
into the dermis and subcutaneous tissue in the searching area. The lymphatic vessels were inflated by fine oxygen bubbles and
identified under the microscope. Individual lymph channels were cannulated with 30 gauge needle or 24 gauge cannula and
filled with a radio-opaque lead oxide suspension. Each injected vessel was dissected and traced antegradely to find its course
until the vessel reached the corresponding lymph nodes. Each vessel was then traced retrogradely to define the lymphatic
territory of each lymph node.
Results: Using our injection technique, the superficial and deep lymphatic vessels could be demonstrated. The calibers of
canine lymphatic vessels varied from 0.3 mm to 1.2 mm. These were similar to human lymphatic vessels and were sizable for
demonstrating on radiographs. The radiographs revealed that major difference between human and canine lymphatic system
was the size of the supraclavicular lymph node territory. The territory in canine was much larger than that in human and most
of the lymphatic vessels from the lateral aspect connected to the node.
Conclusions: We succeeded to map the lymphatic vessels in the canine forelimb. Our studies revealed that the dog forelimb
contains three lymphatic pathways: the lateral, medial, and deep lymphatic pathways. We concluded that the canine model is
versatile enough to mimic the human lymphatic system because of composition of the superficial and deep lymphatic system
and readiness for manipulating the lymphatic vessels.
Declaration of interest
None declared
KN-05
MOLECULAR MECHANISMS IN LYMPHANGIOGENESIS
K Alitalo, Molecular/Cancer Biology Laboratory, Haartman Institute and Finnish Institute for Molecular Medicine, Helsinki,
FINLAND
Vascular endothelial growth factor (VEGF) stimulates angiogenesis and permeability of blood vessels via its two receptors
VEGFR-1 and VEGFR-2, but it has only little lymphangiogenic activity. The third receptor, VEGFR-3, does not bind VEGF
and its expression becomes restricted mainly to lymphatic endothelia during development. Homozygous VEGFR-3 targeted
mice die around midgestation due to failure of cardiovascular development, whereas transgenic mice expressing the VEGFR-3
ligand VEGF-Cor VEGF-D show evidence of lymphangiogenesis and VEGF-C knockout-mice have defective lymphatic
vessels. VEGF-C overexpression induces lymphangiogenesis and growth of the draining lymphatic vessels, intralymphatic
tumor growth, lymph node lymphangiogenesis and metastasis. Furthermore, soluble VEGFR-3 and antibodies blocking
VEGFR-3 inhibited embryonic and tumor lymphangiogenesis and lymphatic metastasis. These results have indicated that
paracrine signal transduction between tumor cells and the lymphatic endothelium is involved in lymphatic metastasis. We
have recently found that VEGF-C and VEGFR-3 provide also new targets to complement current anti-angiogenic therapies.
Because of their ability to attenuate angiogenic sprouting and inhibit lymphatic metastasis, VEGFR-3 blocking antibodies are
now being tested in phase I clinical (safety) trials. - Furthermore, our studies indicate that antibody combinations may be
used for increased efficacy of inhibition of angiogenic signal transduction pathways.
Preclinical studies of lymphedema treatment have shown that VEGF-C stimulates the formation of new lymphatic capillaries
and, after an initial increase in lymph extravasation, reduces edema. When the growth factor therapy was applied to damaged
collecting lymph vessels, lymphatic capillary growth was followed by intrinsic remodeling, differentiation, and maturation
into functional vessels with normal zipper-like endothelial cell-cell junctions, intraluminal valves and SMC coverage. A
combination of VEGF-C therapy with lymphnode transplantation showed that the growth factor-transduced lymph nodes
formed both afferent and efferent connections with the pre-existing lymphatic vessel network, and could even trap metastatic
tumor cells. In pigs, VEGF-C or VEGF-D therapy proved effective in restoring functional lymphatic vasculature to the site
of surgical damage and greatly increased the survival and functionality of transferred lymph nodes. These studies have
provided a basis for clinical trials in lymphedema patients with non-malignant disease that, after further safety trials, should
be applicable also to cancer patients.
Declaration of interest
None declared
66

O-03.01
OVERGROWTH AND ITS REVERSAL IN WOUND HEALING AND LYMPHOEDEMA.
T J Ryan, Oxford University, Oxford, UNITED KINGDOM
Collagen in lymphoedema is greatly increased while water accumulation is only slightly so.
In common with wound healing,the later phases are inflammation and organisation which is inclusive of fibrosis. Hebra and
Kaposi in the 19th century emphasised that fibrosis was stimulated by repair of damage done by venous disease .
The reticular elastin is inextricably interwoven with the superficial lymphatic system. Replacement by an endogenous stocking
of fibrosis limits swelling and may be hypertrophic ,even keloidal though unevenly distributed.
A little oedema stretches the fibroblast which responds by laying down collagen to different degrees at different stages of life.
Experiments in our laboratory on fibroblasts of different ages concerned protease inhibition when subjected to centrifugal
forces.
Tangential elastin fibres help the epidermis to respond to the mechanical forces of expansion and they dampen mechanical
signals to the epidermis. What happens when collagen fibresreplace elastin ?
Fat cells also increase in lymphoedema. When subjected to mechanical stress they dissipate such signals and dampen the
response.
Reversibility of overgrowth in lymphatic filariasis is demonstable using Ayurveda and Yoga and in Podoconiosis using
footwear and washing.. The mechanism of such effects by breathing includes suppressing sympathetic vasoconstriction and
dispersal of even a little tissue fluid which thereby reduces tension on collagen.
The initial lymphatic drainage system is superficial at the interface of the body with the environment . The collecting
lymphatics are deep and genetically different . When the deep system is damaged the superficial system usually continues
to work very well,unless damaged by inflammation when fibrosis replaces elastin .
In the majority of cases in which the deep system is damaged there is an increase in adiposity and dispersing oedema
becomes more difficult . Liposuction of the subcutaneous tissues spares the upper dermis, increasing its responsiveness to
tissue movement.
Declaration of interest
none declared
O-03.02
THE MECHANISM HOW LYMPHEDEMA GETS WORSE.
M Ohkuma, Univ. Kinki, Sakai, Kazo, Saitama, JAPAN, H. Hasegawa and Moriya Ohkuma#, Department of Nephrology and
# of Dermatology, Sakai Hospital, Kinki University, School of Medicine, Osaka, Japan
Background:It has often been said lymphedema is an uncurable disease. Is it true? It is well known that after acute inflammatory
complication, lymphedema gets worse with extremity’s volume increased. On the contrary some patients gets worse even
without such a complication. How does it come?
Methods:Lymphedema with Lymphedema-related acute dermatitis(Ohkuma,2001)(acute cellulitis, erysipelas or acute
dermato- lymphangioadenitis) and lymphedema appearantly free from this complication are compared after examinations
of clinical symptoms, laboratory & histological findings.
Results:The inflammations of lymphedema-related acute dermatitis are very similar to those of lymphedema without clinical
signs of inflammation in laboratory data as well as histological findings. However clinical symptoms are a little bit different in
two groups with the less extent in the lymphedema without recognized inflammatory complications.
Discussion and Conclusion: If lymphedema shows inflammatory reactions even without clinically recognized dermatitis, it
causes fibrosis and acanthosis. Thus proliferation, anastomosis and function of the lymphatics are impaired. This is the one
which makes the lymphedema worse. If the patients have become edema free after the treatment and are kept away from this
inflammatory complication, they are completely healed. A new treatment of lymphedema should be carried out from this
point of view.
Declaration of interest
None declared if there is no conflict to declare.
67

O-03.03
INTERLEUKIN-6 IN THE SECONDARY LYMPHEDEMA AND IN NORMAL VOLUNTEERS
M Ohkuma, Univ. Kinki, Sakai, Sakai, Osaka, JAPAN, H.Hasegawa and M. Ohkuma*, Department of Nephrology and *
Dermatology, Sakai Hospital, Kinki University, School of Medicine, Osaka, Japan
Background:In the past the authors have shown Il-6 is high in the lymphedema patients during lymphedema-related acute
dermatitis, a serious inflammatory complication. It is well known that after the complication the edema of the patients become
worse. Even though the patients do not show any such an inflammation, the edema gets worse and worse.
Objectives:In order to explain how it happens, this investigation has been performed.
Materials and Methods: Il-6 in sera of each 5 patients of secondary lymphedema and of 5 normal volunteers are evaluated
for interleukin-6 by means of ELISA.
Results:the secondary lymphedema shows higher value of Il-6 than the normal volunteers.
Discussion: Il-6 is one of the inflammatory cytokins. This inflammation increases acanthosis and fibrosis which make
lymphedematous tissue rigid.The lymphedema patients show inflammatory reaction even though they are free from
clinical complication.It may explain how lympheema patients get worse and worse even though they are clinically free from
complication. A good treatment and management of lymphedema must be done from this point of view.
Conclusion:The secondary lymphedema patients show elevated Il-6 even though they are free from clinical complication.
Declaration of interest
None declared if there is no conflict to declare.
O-03.04
STUDY OF INTERLEUKIN1, INTERLEUKIN6 AND TNFΑ IN LYMPH COMPOSITION IN POST-
SURGICAL LYMPHOCEL.
s Michelini, San Giovanni Battista Hospital, Roma, ITALY, m Cardone, San Giovanni Battista Hospital, Roma, ITALY, a Failla,
San Giovanni Battista Hospital, Roma, ITALY, g Moneta, San Giovanni Battista Hospital, Roma, ITALY, m Todini, San Giovanni
Battista Hospital, Roma, ITALY, r Todisco, San Giovanni Battista Hospital, Roma, ITALY, a Fiorentino, San Giovanni Battista
Hospital, Roma, ITALY, f Cappelino, San Giovanni Battista Hospital, Roma, ITALY
INTRODUCTION: The post-operative lymphocele can be considered a source of informations about the lymph composition.
The lymphocele is lasting (from 2 weeks to more than 1 year) and is supplied by the lymph collectors coming from the natural
corresponding anatomical area. The lymph carried by the collectors is the same produced by the tissues and collected by the
initial lymphatic vessels at microvasculotissutal level.
AIMS: Studying the behavior of interleukins in the lymph produced in the postoperative period in both subjects with
Secondary lymphedema and in subjects with non edematous limb.
METHODS: The authors studied 18 patients undergoing lymphadenectomy at the root of the limb for cancer with secondary
lymphocele. In particolar were researched at the time 0, after 1 week (T1), after 2 weeks (T2) and after 3 weeks (T3) the
following components of the lymph (of subjects with and without associated lymphedema) :
- Interleukin 1
- Interleukin 6
- TNF α
RESULTS:The Authors observed:
A medium concentration so composed : Interleukin 1 (with lymphoedema 89 pg/ml and without 65 pg/ml), Interleukin 6
(with lymphoedema 78pg/ml and without 46 pg/ml), TNF α (with 31 pg/ml and without 22 pg/ml). After three weeks of
combined physical treatment the most important modifications were the medium decrease of the Interleukin 1 (21 and 12)
and of Interleukin 6 (19 and 10). There weren’t significant modifications of the concentrations of TNF α.
CONCLUSIONS: This preliminary study demonstrates that the lymph concentration of interleukin 1 and Interleukin 6
is caracterized by low concentration in health limb than in the affected limbs. In particular the precox tissular fibrosis is
proportional to the Interleukin 1 initial concentration. The TNFα is constant and non significant. The composition can
change in function of the pharmachological and/or physical treatment.
Declaration of interest
None declared
68

O-03.05
DEVELOPMENT OF UPPER EXTREMITY LYMPHEDEMA AFTER AXILLARY LYMPHNODE
DISSECTION. PROSPECTIVE LYMPHOSCINTIGRAPHIC EVALUATION.
A Szuba, Wroclaw Medical University, Wroclaw, POLAND, A Chachaj, Wroclaw Medical University, Wroclaw, Poland,
M Koba - Wszedybyl, Wroclaw Medical University, Wroclaw, Poland, R Hawro, School of Physical Education, Wroclaw, Poland,
R Jasinski, School of Physical Education, Wroclaw, Poland, R Tarkowski, Wroclaw Medical University, Wroclaw, Poland,
K Szewczyk, Wroclaw Medical University, Wroclaw, Poland, A Jodkowska, Wroclaw Medical University, Wroclaw, Poland,
U Pilch, School of Physical Education, Wroclaw, Poland, M Wozniewski, School of Physical Education, Wroclaw, Poland
Background: Upper limb lymphedema is one of the most common complications after breast cancer surgery, considerably
decreasing a quality of life in affected women. The pathology of it remains still unclear. The aim of this study was to compare
lymphoscyntygraphy patterns (LSG) in breast cancer women before and after surgical breast treatment and to determine
characteristic changes of LSG patterns connected with the appearance of lymphedema.
Methods: We have prospectively investigated 32 women with breast cancer who underwent breast cancer surgery with
auxiliary lymph nodes dissection (ALND). The study protocol included physical examination, measurements of of both
upper limbs circumferences in 4 cm intervals and LSG before surgery and repeated after 1-2 months (32 women), 1 year (32
women) and 2 years (9 women). The upper limb edema was defined as at least 2,0 cm circumference difference in at least 2
arm levels.
Results: Upper extremity lymphedema was diagnosed in 10 of 32 women. Characteristic lymphoscintigraphic features
included: disappearance of previously functional lymphnodes (2 of 10 women with lymphedema) and appearance of dermal
backflow (4 of 10 women with lymphedema). In women who did not developed lymphedema 6 of 22 had no change in
visualized axillary lymphnodes comparing to preoperative status.
Conclusion: Destruction of lymphatic pathways spared during ALND may represent an important mechanism of lymphedema
development. We will present complete analysis of arm volume changes and quantitative and qualitative lymphoscintigraphy
analysis in the studied group of women.
Declaration of interest
None declared
O-03.06
BLOCKADING MESENTERIC LYMPH RETURN CAN PROMOTE THE VASCULAR REACTIVITY AND
CALCIUM SENSITIVITY AFTER HEMORRHAGIC SHOCK
Z Zhao, Hebei North University, Zhangjiakou, CHINA, C Niu, Hebei North University, Zhangjiakou, CHINA, Y Wei, Hebei
North University, Zhangjiakou, CHINA, J Zhang, Hebei North University, Zhangjiakou, CHINA, Y Zhang, Hebei North
University, Zhangjiakou, CHINA
Background: Vascular hyporeactivity is an important mechanism of irreversible shock, and the intestinal lymph pathway play
an important role on multiple organ injury after severe hemorrhagic shock. Objectives: To observe the effects of mesenteric
lymph duct ligation (MLDL) and mesenteric lymph drainage (MLD) on vascular reactivity and calcium sensitivity in
hemorrhagic shock rats. Methods: Seventy-two male Wistar rats were randomly divided into Sham, Shock, Shock+MLDL,
Shock+MLD groups. The changes of mean artery pressure (MAP) after norepinephrine (NE, 3μg/kg) at different time points
were recorded. After the hypotension (40mmHg) for three hours, the superior mesenteric artery (SMA) vascular ring was
made for assaying the vascular reactivity and calcium sensitivity by observing the contraction initiated by NE and Ca2+ under
depolarizing conditions (120 mmol/L K+) with isolated organ perfusion system. RESULTS: Compared with Sham group, the
∆MAP of Shock group was increased at shock 0h and 0.5h and decreased at shock 1.5h, 2h, 2.5h and 3h, that of Shock+MLDL
and Shock+MLD groups were increased at shock 0h, 0.5h, 1h, and decreased at shock 2.5h and 3h, respectively; but the
∆MAP of Shock+MLDL and Shock+MLD groups were higher than Shock group at multiple time points after shock 0.5h.
The SMA reactivity to NE and sensibility to Ca2+ of Shock, Shock+MLDL and Shock+MLD groups were lower markedly
than that of Sham group, and that of Shock+MLDL and Shock+MLD groups were higher compared with Shock group.
Meanwhile, the vascular reactivity and calcium sensitivity of shocked SMA were signficantly increased after incubating
with calcium sensitizer angiotensin II, that of Shock+MLDL and Shock+MLD groups were decreased after incubating with
calcium sensitivity inhibitor insulin. Conclusion: Blockading mesenteric lymph return with the methods of MLDL and MLD
could promote the vascular reactivity of rats after HS, and its mechanism was related to improving the calcium sensitivity
(This work is supported by National Natural Science Foundation of China No. 30971203).
Declaration of interest
None declared
69

O-03.07
THE RELATIONSHIP BETWEEN MESOTHELIAL CELLS AND LYMPHATIC ENDOTHELIAL CELLS IN
AN ADJUVANT-INDUCED LYMPHANGIOMA
T Ezaki, Tokyo Women's Medical University, Tokyo, JAPAN, K Shimizu, Tokyo Women's Medical University, Tokyo, Japan,
S Morikawa, Tokyo Women's Medical University, Tokyo, Japan, S Kitahara, Tokyo Women's Medical University, Tokyo, Japan,
J Desaki, Ehime University, Matsuyama, Japan
[Background] Besides sharing the same mesenchymal origin, both endothelial cells and mesothelial cells have several
similarities in their structure and function. Furthermore, the two cell types have some ability to transform into various
interstitial cells under pathological conditions or in vitro. In vivo, however, there has been no clear evidence to show the
interrelationship between the two cell types.
[Objectives] The aim of this study is, therefore, to investigate the relationship between mesothelial cells of the abdominal
cavity and lymphatic endothelial cells under the pathological condition using an adjuvant-induced benign lymphangioma
model.
[Methods] Benign lymphangiomas were induced in C57BL/6 mice by the intraperitoneal injection(s) of Freund’s incomplete
adjuvant (FIA). Lymphatic vessels were identified with specific markers, such as LYVE-1, podoplanin and LA102 (Ezaki et
al., 2006). Blood vessels were visualized either by the immunostaining of CD31 or by perfusing fluorescent tomato lectin
after the intravenous injection. The animals were perfused with 2% paraformaldehyde in PBS for 5 min and washed with
PBS. Cryosections of tissue samples were made and immunostained with various antibodies. Three-dimensional images were
obtained using a Leica TCS-SL confocal laser-scanning microscope. Some tissues were prepared for both transmission and
scanning electron microscopy.
[Results & Conclusions] One to 2 weeks after FIA injection, we found peritoneal mesothelial cells became tall in height and
lost their polarity, and gradually formed thick stratified cell masses all over the peritoneal membranes. Some mesothelial cells,
interstitial cells including fat-stored cells expressed early pregnancy factor (EPF or HSP-10). At 1~2 months, they formed
typical honeycomb-like lymphangiomas consisted of various sizes of fat storing cells. At 3 months or longer periods, the
fat storing tumor cells fused with each other and gradually formed tubular structures like lymphatic vessels. Although the
tumors were podoplanin-positive, only the typical lymphatic vessel-like structures expressed LYVE-1 and LA102. The results
may suggest a sequential changes from mesothelial cells to lymphatic endothelial cells via fat-storing lymphangioma cells
after FIA stimulations. The phenomena may be interpreted as one of biological defense mechanisms to drain the extrinsic
FIA out of the peritoneal cavity.
Declaration of interest
None declared.
O-03.08
ROLE OF NITRIC OXIDE ON ISOLATED LYMPHATIC CONTRACTILE ACTIVITY IN HEMORRHAGIC
SHOCK RATS
C Niu, Hebei North University, Zhangjiakou , CHINA, Z Zhao, Hebei North University, Zhangjiakou , CHINA, L Qin, Hebei
North University, Zhangjiakou , CHINA, J Zhang, Hebei North University, Zhangjiakou , CHINA, Y Zhang, Hebei North
University, Zhangjiakou , CHINA
Background: The lymphatic contraction is the dynamical foundation of lymph circulation, which play important roles in
circulation system homeostasis, lymphatic contraction disturbance play an important role on progress of severe shock.
Objective: To observe the changes of isolated lymphatic contractile activity during hemorrhagic shock, and probe the role
of nitric oxide (NO). Methods: To evaluate the lymphatic contractile activity, we determined contraction frequency (CF),
end systolic diameter, end diastolic diameter and passive diameter of isolated lymphatics in different transmural pressure
(1, 3, 5, 7, 9 cmH2O) during hemorrhagic shock (0h, 0.5h, 1h, 2h, 3h) using pressure myograph system, and calculated the
contraction amplitude (CA), tonic index (TI) and fractional pump flow (FPF). At transmural pressure of 3 cmH2O, the
lymphatics of shock 0.5h and shock 2h were incubated with the different drugs of NO/nitric oxide synthase, respectively.
Results: The results showed that in several transmural pressure, lymphatic CF, TI, FPF were significantly higher in shock
0h and shock 0.5h groups than control group, but with the development of shock, the CF, TI, FPF decreased significantly in
shock 2h and shock 3h groups. Meanwhile, the NO donor L-Arg reduced the CF, TI and FPF of shock 0.5h lymphatics to the
control levels, the ODQ which is soluble guanylate cyclase inhibitor suppressed the effect of L-Arg. Moreover, NOS inhibitor
L-NAME elevated the CF, TI and FPF of 2h- shocked lymphatics to the control levels, and the phosphodiesterase inhibitor
aminophylline suppressed the effect of L-NAME. Conclusion: The results suggested that the lymphatics contractile activity
appeared a biphasic change during hemorrhagic shock: the lymphatic contractility is increased in early phase and declined
in later stage. And NO plays a major regulating role in the biphasic change of shocked lymphatic contraction. (This work is
supported by National Natural Science Foundation of China No. 30770845, 30971203).
Declaration of interest
None declared
70

O-04.01
LYMPHEDEMA IN PEDIATRICS. DIALOGUE BETWEEN SCIENCE AND PRIMARY CARE. PROPOSAL
FOR A CONSENSUS DOCUMENT.
C Papendieck, Instituto de Diagnóstico y Tratamiento, Buenos Aires, ARGENTINA, R Martinez, Hospital de Quemados, Buenos
Aires, ARGENTINA, L Barbosa, Angiopediatría, Buenos Aires, ARGENTINA, M A Amore, Hospital Militar Centra, Buenos
Aires, ARGENTINA, E Paltrinieri, Centro Vodder, Buenos Aires, ARGENTINA, D Braun, Angiopediatria, Buenos Aires,
ARGENTINA
Lymphedema diagnosis in pediatric patients include as less 140 syndromes or diseases, including the whole universe of
primary lymphedema (PL). There is no reached consensus on its definition.
We support the opinion that PL is a sign, and their causes congenital, and provoke a dysfunction of the lymphatic system.
Initially, there is some endothelial, interstitial, precapillary or capillary disability, or some canalicular or nodal dysplasia
(LAD I, LAD II respectively). This dysplasia expresses itself as a deficit in interstitial fluid protein reabsorption, and other
components of lymphatic load too, or in lymph transportation mechanical obstruction in the way to the venous angle.
There are 18 well-known anatomical anomalies in lymph vessels and lymph nodes design. Stem cells and as less as 12
lymphangiogenic growth factors and their receptors, are involved in the morphogenesis of lymphatic system and are
endothelial function regulators, five of them in the interstice.
Interstitial volume/space increased is constant with or without hypertension in the segments of the circuit. The protocols of
international consensus, MEP, ISL and others, provided the basic tools for rehabilitation. There is no cure. That means a future
without specific therapies, for the rest of life.
There is no diagnostic by evidence.
We propose the basis for a Consensus Document on Lymphedema in Pediatric Patients for diagnosis in genetic, molecular,
anatomopathology and image, as well as therapeutic indications considering, when possible, its etiological diagnosis.
A little baby cannot wait for the whole life, it is not satisfactory to propose to use bandage forever, as our unique therapeutic
offer.
The ISL Consensus Document completely avoids any mention to pediatric patients. Children are not little adults, their
physiology, anatomy, immune system are peculiar and put the frame for diagnostic and therapeutic interventions.
In a typical secondary lymphedema standard treatment, as established in consensus documents, is indicated. Details for
specific diagnostic and therapeutic procedures must be discussed to guide clinical practice until evidence-based practice
could be well established.
Proposals for a consensus document in primary and secondary pediatric lymphedema will be discussed.
Declaration of interest
None declared
O-04.02
RECENT ADVANCES IN THE GENETICS OF PRIMARY LYMPHOEDEMA
F Connell, Guy's and St Thomas' NHS Trust London, London, UNITED KINGDOM, S Mansour, St George's University of
London, London, UNITED KINGDOM, P Ostergaard, St George's University of London, London, UNITED KINGDOM, G
Brice, St George's University of London, London, UNITED KINGDOM, M Simpson, King's College London, London, UNITED
KINGDOM, R Trembath, King's College Hospital, London, UNITED KINGDOM, P Mortimer, St George's University of London,
London, UNITED KINGDOM, S Jeffery, St George's University of London, London, UNITED KINGDOM
Background: Primary lymphoedema is a chronic oedema caused by a developmental abnormality of the lymphatic
system. In recent years there has been considerable progress made in understanding the molecular pathways underlying
lymphangiogenesis but knowledge of the genetic causes of human lymphatic disease was limited to VEGFR3, FOXC2
and SOX18. There are many different phenotypes of primary lymphoedema and with the use of conventional molecular
analysis techniques and new next generation sequencing we have identified two further genes that cause different primary
lymphoedema phenotypes; CCBE1 and GJC2.
Objectives: The aim of our work has been to improve phenotyping of primary lymphoedema patients in order to facilitate
the identification of well defined patient groups for molecular studies that would lead to the discovery of genetic causes of
primary lymphoedema in humans.
Methods: Patients were ascertained from the joint Lymphoedema/Genetics Clinic at St George’s Hospital, London.
Linkage and sequence analysis was carried out to identify the genetic cause of recessively inherited generalised lymphatic
dysplasia/Hennekam syndrome. A large, non-consanguineous family with three affected siblings with generalised lymphatic
dysplasia was studied. Linkage analysis was used to determine a locus in a large multigenerational pedigree in which fourlimb
lymphoedema segregates in an autosomal dominant manner. Exome sequencing was employed to look for causative
variants within the predetermined locus.
Results: A homozygous change in CCBE1 was identified as the causative mutation for autosomal recessive generalised
lymphatic dsyplasia/Hennekam syndrome. Mutations in GJC2 were identified to cause autosomal dominantly inherited fourlimb/bilateral
lower limb lymphoedema.
Conclusion: Notable advances in the understanding of the genetics of primary lymphoedema have been achieved and the
implications of these discoveries will be discussed. The role of CCBE1 and GJC2 in lymphatic disease has been reported by
Alders et al 2009 and Ferrell et al 2010 respectively, and our work adds supportive evidence to these studies. Understanding
the molecular mechanisms that result in lymphatic disease will hopefully ultimately translate into improved therapies for
patients.
Declaration of interest
None declared
71

O-04.03
MANAGEMENT OF LYMPHEDEMA IN CHILDREN AND ADOLESCENTS.
A Failla, San Giovanni Battista Hospital, Roma, ITALY, S Michelini, San Giovanni Battista Hospital, Roma, ITALY, M Cardone,
San Giovanni Battista Hospital, Roma, ITALY, F Cappelino, San Giovanni Battista Hospital, Roma, ITALY, L Michelotti, San
Giovanni Battista Hospital, Roma, ITALY, M Haag o Agga, San Giovanni Battista Hospital, Roma, ITALY
INTRODUCTION: The primary connatal lymphedema is a pathology of difficult therapeutic approach also due to the
involvement of the family of the young patient who is often unprepared to deal with chronic care needs that the clinical case
requires.
AIMS: The authors have examined the problems most frequently encountered in clinical practice in the management of
patients with connatal lymphedema.
METHODS: We studied 65 patients with primary connatal lymphedema (42 females and 23 males) aged between 0 and 16
years. All patients showed no associated malformations. 31 of them had a history of familiarity of the condition. We have
been studied for a period of 12 months, in collaboration with the psychology service, the factors that opposed the continuous
monitoring of the disease and the management of it as a whole by involving the young patient and the family.
RESULTS: The study helped to identify the strengths and weaknesses affecting results. Among the first: better economic
conditions of the household; best level of medium culture, proximity to specialized centers; strength of the marital relationship
of parents and availability of time in relation to work commitments. Among the second: poor compliance to elastic garement
or ortho-elastic shoes; prescribing errors in 'tailored' garments or neglect in replacement (with more rapid turnover than in
adults), school performance problems or relationships with same aged; treatment of chronic treatment.
CONCLUSIONS: The study demonstrates the importance of a number of economic, relationships and social factors that
influence the therapeutic management of lymphedema in children and adolescents, considering the role of the patient, but
(or above) of the family to which he belongs.
Declaration of interest
None declared
O-04.04
THE CHALLENGE OF PAEDIATRIC LYMPHOEDEMA AND VASCULAR ANOMALIES
J Phillips, Mercy Health Lymphoedema Clinic, Melbourne , AUSTRALIA
A joint clinic in the management of paediatric lymphoedema has been set up between an adult lymphoedema service
and a paediatric hospital, in Melbourne, Australia. This collaborative care clinic, set up to recognise and manage primary
lymphoedema in childhood, has seen a significant proportion of children with vascular anomalies present for management of
swelling. Deformities associated with primary lymphoedema may present with orthopaedic distortion and may be managed
by surgery. Deformities presented by vascular anomalies are frequently managed by plastic surgery. There are significant
challenges for the successful outcome of surgery against the background of oedema impeding healing. Lack of awareness of
best practice for lymphoedema management may lead to variable management post-operatively and consequently, mixed
outcomes of surgery. The impact on the child and family is considerable as they attempt to navigate a health system with
complex and inconsistent messages, whilst they deal with different hospital departments.
A summary of some of the challenges for good functional outcome will be presented.
Declaration of interest
None declared
72

O-04.05
CASEREPORT.ADJUSTMENT IN SEATING POSTURE OF A YOUNG WOMAN WITH HYPERTROFIC
TISSUE IN LOWER LIMB
Å Gruvsved Andersson, Red Cross Hospital Stockholm, Solna, SWEDEN
Klippel Trénaunay syndrome (KTS) is a congenital disorder of varicose or malformed veins, cutaneous capillary malformations
of veins(portwinestains) and lymphatics, and bony or soft tissue hyperplasia of usually one lower limb. Symptoms of KTS
effects activities of everyday life in various degrees. This case report presents an analysis of seating, guided by body pressure
measuring, and describes adjustment in the seating posture of a young woman with KTS including hypertrophic tissue of the
leg and pelvic girdle.
Declaration of interest
None declared
O-04.06
EXPERIENCE FROM REHABILITATION OF YOUTHS WITH LYMPHOEDEMA AT THE RED CROSS
HOSPITAL IN STOCKHOLM
Å Gruvsved Andersson, Red Cross Hospital, Solna, SWEDEN
Rehabilitation and complete decongestive therapy in a multi professional setting, for children and young adults with
lymhpoedema during specific youth weeks is provided for at the Red Cross Hospital in Stockholm. A summary of 6 years
experience of these youth weeks will be presented. The participants have been in ages 2 – 24 years. Diagnosis besides
lymphoedema has been Turner or Noonan syndrome, Klippel Trénaunay syndrome, juvenile arthritis and others. Focus
of the program is to strengthen coping skills in our young patients by teaching them more about their own diagnose and
treatment options, sharing experiences of living with lymphoedema with other patients and giving their families a chance
to meet others in a similar situation. The program strives to broaden the conception of what physical exercise might be and
encourage engagement in new activities. Individual, sometimes diagnose specific, interventions are made. Cooperation with
the lymphoedema patient organization is valuable and has made some of the activities possible
Declaration of interest
None declared
73

O-05.01
DIFFERENTIAL DIAGNOSIS OF LOWER EXTREMITY ENLARGEMENT IN PEDIATRIC PATIENTS
REFERRED WITH A DIAGNOSIS OF “LYMPHEDEMA”
A Greene, Children's Hospital Boston/Harvard Medical School, Boston, UNITED STATES
Background: There are many causes for a large lower limb in the pediatric age group. These children are often mislabeled as
having “lymphedema”, and incorrect diagnosis can lead to improper treatment. The purpose of this study was to determine
the differential diagnosis in pediatric patients referred for lower extremity “lymphedema” and to clarify management.
Methods: Our Vascular Anomalies Center database was reviewed between 1999 - 2010 for patients referred with a diagnosis
of “lymphedema” of the lower extremity. Records were studied to determine the correct etiology for the enlarged extremity.
Alternative diagnoses, gender, age-of-onset, and imaging studies also were analyzed.
Results: A referral diagnosis of lower extremity “lymphedema” was given to 170 children; however, the condition was
confirmed in only 72.9% of patients. Forty-six children (27.1%) had another disorder: micro/macrocystic lymphatic
malformation (19.6%), non-eponymous combined vascular malformation (13.0%), capillary malformation (10.9%), Klippel-
Trenaunay syndrome (10.9%), hemi-hypertrophy (8.7%), post-traumatic swelling (8.7%), Parkes Weber syndrome (6.5%),
lipedema (6.5%), venous malformation (4.3%), rheumatologic disorder (4.3%), infantile hemangioma (2.2%), kaposiform
hemangioendothelioma (2.2%), or lipofibromatosis (2.2%). Age-of-onset in children with lymphedema was older than
patients with another diagnosis (p = 0.027).
Conclusion: “Lymphedema” is not a generic term. Approximately one-fourth of pediatric patients with a large lower extremity
are misdiagnosed as having “lymphedema”; the most commonly confused etiologies are other types of vascular anomalies.
History, physical examination, and often radiological studies are required to differentiate lymphedema from other conditions
to ensure the child is managed appropriately.
Declaration of interest
None declared
O-05.02
DIFFUSE LIPOFIBROMATOSIS OF THE LOWER EXTREMITY MASQUERADING AS A VASCULAR
ANOMALY
A Greene, Children's Hospital Boston/Harvard Medical School, Boston, UNITED STATES
Lipofibromatosis is a slow-growing, childhood soft-tissue neoplasm that is often confused with other conditions. We report
a patient with lipofibromatosis causing extremity enlargement at birth. The lesion initially was thought to be a vascular
anomaly or lipedema on clinical and MRI examination. When involving the lower extremity, diffuse lipofibromatosis must
be differentiated from more common causes of lower limb enlargement in children: lymphatic malformation, lymphedema,
or lipedema. Compared to these more frequent conditions, lipofibromatosis usually has less morbidity. Management of the
tumor includes observation or excision. Because complete extirpation of the lesion is often difficult, recurrence after excision
is common.
Declaration of interest
None declared
74

O-05.03
LYMPHATIC MALFORMATIONS IN KLIPPEL-TRENAUNAY SYNDROME
N Liu, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai , CHINA
Objectives: Fewer previous studies have focused on the involvement of the lymphatic system in KTS, although some evidence
suggests that lymphatic abnormalities are associated with the disease. The aim of the study was to investigate the involvement
of lymphatic system in Klippel-Trenaunay syndrome (KTS).
Methods: Magnetic resonant lymphangiography (MRL) with use of Gadobenate Dimeglumine as the contrast was performed
on 51 patients with KTS involving the extremities, to evaluate lymphatic vessels, lymph nodes and veins.
Results Forty-eight of 51 patients exhibited lymphatic vessel and /or lymph node anomalies, including hyperplasia (18/48),
hypoplasia (22/48) or aplasia (4/48) of lymphatic vessels and lymphedema (48/48) of the affected limbs. Twenty-seven patients
showed asymmetry of inguinal node as increase or decrease in number and size or absence. Venous dysplasia was found in 49
patients in superficial and/or deep veins. The results showed a high concomitance of malformations of the lymphatic system
and veins in the affected limbs of patients with KTS.
Conclusions: Lymphatic system abnormalities as examined with MRL are commonly associated with KTS and are likely to
play a significant role in the disorder.
Declaration of interest
None declared
O-05.04
LYMPHEDEMA AND MALFORMATIONS: PERSONAL EXPERIENCE.
S Michelini, San Giovanni Battista Hospital, Roma, ITALY, A Failla, San Giovanni Battista Hospital, Roma, ITALY, G Moneta,
San Giovanni Battista Hospital, Roma, ITALY, M Cardone, San Giovanni Battista Hospital, Roma, ITALY, F Cappelino, San
Giovanni Battista Hospital, Roma, ITALY, C Salusri, San Giovanni Battista Hospital, Roma, ITALY
INTRODUCTION: Lymphedema is associated with many complex malformative diseases occurring at birth or in childhood
and consists, in this sense, in a diagnostic and therapeutic aspect of the overall clinical picture.
AIMS: This study evaluated the importance of specific diagnosis and of therapeutic approach in malformative diseases that
also involve the lymphatic system.
METHODS: We studied 35 patients with rare malformative diseases (19 Prader Willi Syndrome, 7 Noonan Syndrome,
4 Klippel Trenaunay, 2 Maffucci Weber Syndrome, 2 Petreus Syndrome, 1 Gorham Stout Syndrome). All subjects had
Lymphedema of the lower limbs in developmental stages ranging from I to III, evaluated with high-resolution ultrasound
examination and lymphoscintigraphy. They were treated with physical decongestive treatment which includes manual and
mechanical drainage and multilayer bandaging.
RESULTS: The most advanced clinical stages of lymphedema were found in Prader Willi Syndrome (which is associated with
early obesity). All subjects obtained clinical improvement with the treatment (found with the parameters of the International
Classification of Functioning) and maintained the results through the use of standard or 'tailored' elastic garments. Recurrence
(27) were determined either by infectious complications (14 cases) or poor patient compliance (often linked to the cognitive
conditions of the same).
CONCLUSIONS: The study shows that the lymphedema is associated with variable clinical entity in various malformative
diseases involving children and adolescents. Continuous monitoring of the disease and of lymphology aspects are essential to
control the lymphedema and for the prevention of secondary complications.
Declaration of interest
None declared
75

O-05.05
THE ROLE OF C-ARM CT IN THE TREATMENT OF COMPLEX HEAD AND NECK LYMPHATIC
MALFORMATIONS
D Ballah, Children's Hospital of Philadelphia/University of Pennsylvania, Philadelphia, PA , UNITED STATES, X Zhu, Children's
Hospital of Philadelphia/University of Pennsylvania, Philadelphia, PA , UNITED STATES, J Edgar, Children's Hospital of
Philadelphia/University of Pennsylvania, Philadelphia, PA , UNITED STATES, A Cahill, Children's Hospital of Philadelphia/
University of Pennsylvania, Philadelphia, PA , UNITED STATES
Objective: This study evaluates the efficacy of C-Arm CT for the assessment of sclerotherapy agent distribution within
lymphatic malformations (LM) and to note its clinical implications.
Methods: Over a 2 year period, 22 children (11M, 11F, mean age 6.0 Years) with LM underwent 30 sclerotherapy procedures
with additional novel low dose C-Arm CT imaging. Imaging and clinical records were reviewed for each patient. Pretreatment
imaging with MRI or CT were compared to intra-procedural C-Arm CT imaging in three dimensions by two
reader consensus, to assess the volume of lesion treated. Percent of lesion coverage was calculated.
Results: 30 C-Arm CT imaging studies were analyzed. The median lesion volume treated was 79%, (range 5.2%-388%). In
five procedures, lesions measured greater than 100% due to interval growth. In nine procedures, less than 50% of the lesion
was treated due to elective partial lesion treatment secondary to lesion extent.
Periprocedural management was altered with 10 procedures necessitating intubation (mean 6.9 days, range 4-21days) due to
lesion sclerotherapy agent proximity to airway noted on C-Arm CT. One patient with sclerotherapy agent

O-06.01
INCREASED FLUID ACCUMULATION (OEDEMA/LYMPHOEDEMA) AND HARDENING IN THE
BREASTS ASSOCIATED WITH POORLY FITTED BRAS
N Piller, Flinders Medical Centre, Bedford Park , SOUTH AUSTRALIA, B Heidenreich, Flinders Medical Centre, Bedford Park
, SOUTH AUSTRALIA, J Douglass, Flinders Medical Centre, Bedford Park , SOUTH AUSTRALIA, J Smith, Flinders Medical
Centre, Bedford Park , SOUTH AUSTRALIA, J Rice, Flinders Medical Centre, Bedford Park , SOUTH AUSTRALIA, S Birrell,
Flinders Medical Centre, Bedford Park , SOUTH AUSTRALIA, A Moseley, Flinders Medical Centre, Bedford Park , SOUTH
AUSTRALIA
Background: The exact incidence and prevalence of breast oedema and lymphoedema is still a relative unknown, however, it
may be as high as or higher than arm lymphoedema. Current evidence suggests lymphatic pumping ability is poor in those
with lymphoedema thus we should take better care of the pressure exerted by a bra on the lymphatic drainage pathways of
the arm, chest and breast.
Objectives: To discover the impact of the type of bra on operated and normal breast fluids and fibrotic induration.
Methods: Tonometry (tissue hardness), bio-impedance (tissue fluids) and pressure sensors (external pressures)changes were
followed over a 12 month period in patients wearing either an off the shelf or Made to Measure bra.
Results: The level of breast induration fluctuated in both groups over the course of the trial not only in the surgical breast but
the un-operated breast. Those who wore off the shelf bras displayed increased tissue hardness in all four breast quadrants.
Hardening was statistically significant in all 4 quadrants, in the post op to new bra time period, and 3 and 9 months. The bra's
increased pressures on lymphatic territories was highest under the shoulder strap in both groups. Pressures were higher in off
the shelf group. Breast fluid levels showed increases in both groups with the made to measure group showing a statistically
significant improvement in the lower outer quadrant at 6mo. The made to measure bra group showed either no change or
an improvement in symptoms and like the off the shelf group, the perceived hardness of the breast tissue reduced, reaching
statistical significance at 6 months. The 12 month follow-up showed a trend to reduced fluids in the made to measure group
suggesting better lymphatic drainage. This was associated with reduced fibrotic induration.
Conclusion: A made to measure bra is better than an off the shelf one for comfort and minimising changes to the breast tissue
over the 12 month period after breast cancer surgery.
Declaration of interest
This trial was funded by the National Breast Cancer Foundation and Flinders Medical Centre Foundation
O-06.02
INCIDENCE OF UPPER LIMB LYMPHOEDEMA FOLLOWING FREE FLAP BREAST
RECONSTRUCTION
M Schaverien, Ninewells Hospital, Dundee, UNITED KINGDOM, A Munnoch, Ninewells Hospital, Dundee, UNITED
KINGDOM
Background: Lymphoedema of the upper extremity is a well-recognised complication of axillary lymph node surgery for breast
cancer and leads to significant physical and psychological sequelae. Recent reports have suggested that breast reconstruction
following mastectomy may lead to decreased rates of lymphoedema.
Objectives: This prospective study investigated the incidence of lymphoedema up to 24 months following mastectomy,
axillary node surgery, and immediate free flap breast reconstruction using four measures.
Methods: Patients with preoperative circumferential measurements of both upper limbs were included in the study. Patients
with evidence of lymphoedema preoperatively were excluded. Demographic information was recorded and at each follow-up
appointment measurements were repeated. Evidence of lymphoedema included patient reported symptoms of swelling or
heaviness, 2cm circumferential difference from the contralateral measurement at any measurement point, 200ml calculated
volume difference, and 10% difference in calculated volume difference.
Results: 184 patients underwent immediate breast reconstruction following mastectomy and axillary surgery within the study
period. 54 patients underwent free flap reconstruction and had complete measurement data. 8 patients were excluded for
meeting any criteria for preoperative lymphoedema (14.8%). 13 patients met at least one criterion for lymphoedema on at
least one occasion during the study period (28.3%). There was no relationship with time from surgery, type of axillary surgery
(lymph node clearance or sample), or chemo or radiotherapy, or both. Depending on the method used, the mean incidence
of lymphoedema ranged from 21.7% (patient reported symptoms) to 8.7% (10% volume difference)
Conclusions: This study provides preliminary evidence that immediate free flap surgery following mastectomy and axillary
surgery is associated with a low rate of upper limb lymphoedema.
Declaration of interest
None declared
77

O-06.03
EARLY DIAGNOSTICS OF LYMPHEDEMA AND SELF MANAGEMENT AFTER ONCOLOGICAL
SURGERY
E Brouwer, Nij Smellinghe Hospital, Drachten, NETHERLANDS, R J Damstra, Nij Smellinghe Hospital, Drachten,
NETHERLANDS
Breast cancer patients in general,those having an axillary lymph dissection and patients receiving an inguinal/abdominal
dissection in particular, have a legitimate concern for developing LE in arm, leg or midline. Healthcare providers should
keep in mind that LE involves more than just a swollen limb, associated symptoms such as psychological distress, fatigue, and
altered arm/leg sensations should also be assessed and treated when needed. Until true prevention strategies are developed or
a cure is found, early identification of swelling and prompt referral for treatment remain the best hope for achieving optimal
patient outcomes. In this process the patients play an important role themselves .
In this process two stages can be distinguished: primary prevention in those who don’t have LE yet but are at risk and secondary
prevention in those who already experiencing LE or just found a small swelling. In this second group self-assessment and
self-treatment is very important.
Many articles have been published about patient independence, encompassing the concepts of the expert patient and selfmanagement
in which the nurse-patient relationship is based on partnership . Bogan et al described 7 patients with noncancer
related LE who where instructed during an inpatient treatment in self-exercise, self-management and advices about
awareness. These results meet the conclusions from Brouwer et al about 50 courses of self-management training in patients
with BCRL and LE on the legs
Well designed, quality pretreatment lymphedema education in a manner that is tolerable to patients must be offered to breast
cancer survivor’s to reduce dissatisfaction with educational information about LE. It may also serve as the foundation from
which coping decisions and strategies are generated should LE develop later . This awareness education exists of knowledge
and practical skills, that is designed to stimulate lymphatic flow. The psychological issues on LE and cancer are being discusses
in the course, but are not the main topic, because it is all about prevention and awareness. When possible, family members or
friends are included in the training in order to help encourage compliance with this part of the home program .
Declaration of interest
None declared
O-06.04
LYMPHEDEMA RISK FACTORS IN BREAST CANCER PATIENTS
S Haghighat, ACECR/ICBC, Tehran, IRAN (ISLAMIC REPUBLIC OF), A Akbari, SBMU/CRC, Tehran, IRAN (ISLAMIC
REPUBLIC OF), M Ansari, ACECR/ICBC, Tehran, IRAN (ISLAMIC REPUBLIC OF), F Homaei, MUMS, Mashad, IRAN
(ISLAMIC REPUBLIC OF), M Najafi, ACECR/ICBC, Tehran, IRAN (ISLAMIC REPUBLIC OF), M Ebrahimi, ACECR/ICBC,
Tehran, IRAN (ISLAMIC REPUBLIC OF), M Yunesian, TUMS, Tehran, IRAN (ISLAMIC REPUBLIC OF), HR Mirzaei,
SBMU/CRC, Tehran, IRAN (ISLAMIC REPUBLIC OF), M E Akbari, SBMU/CRC, Tehran, IRAN (ISLAMIC REPUBLIC OF)
Background: lymphedema secondry to breast cancer treatment is a common and serious problem for breast cancer survivors.
The objective of the current study was to identify the risk factors for secondary lymphedema after breast carcinoma treatment.
Materials & Methods: The breast cancer patients who were followed up in three centers in Tehran and Mashad in 2008 were
included in the study. The circumference measurement was used for defining lymphedema.
Results: Among 410 breast cancer patients, 123 cases (30%) developed lymphedema. Variables such as low educational level,
Body Mass Index (BMI), higher stage of disease, number of involved lymph node, co-morbid diseases, trauma, infection and
the time after surgery showed significant correlation with the development of lymphedema. In logistic regression analysis,
increase of 1 kg/m2 in BMI (OR = 1.09; 95%CI 1.05-1.15), each number increase in lymph node involvement (OR = 1.15;
95%CI 1.08-1.21) and the increase of every 1 year after surgery (OR = 1.01; 95%CI 1.01-1.02) significantly increased the risk
of lymphedema.
Conclusion: The results of this study demonstrated that preserving a fitted BMI, emphasis on self-care and educating
preventive activities may have important roles in decreasing the lymphedema incidence and improving the patients’ quality
of life.
Declaration of interest
Academic Center for Education, Culture and Research (ACECR),Grant research support
Shahid Beheshti Medical University (SBMU),Grant research support
78

O-06.05
EFFECTIVENESS OF MANUAL LYMPH DRAINAGE ON THE PREVENTION OF BREAST CANCER-
RELATED ARM LYMPHOEDEMA
N Devoogdt, Katholieke Universiteit Leuven, Heverlee, BELGIUM, M R Christiaens, University Hospitals Leuven, Leuven,
BELGIUM, I Geraerts, University Hospitals Leuven, Leuven, BELGIUM, S Truijen, Artesis University College Antwerp,
Antwerp, BELGIUM, A Smeets, University Hospitals Leuven, Leuven, BELGIUM, K Leunen, University Hospitals Leuven,
Leuven, BELGIUM, P Neven, University Hospitals Leuven, Leuven, BELGIUM, M Van Kampen, Katholieke Universiteit Leuven,
Leuven, BELGIUM
Background: The combination of guidelines about the prevention of lymphoedema, exercise therapy and manual lymph
drainage (MLD) is more effective to prevent arm lymphoedema than alone guidelines. The preventive effect of MLD on the
development of lymphoedema has never been investigated in a peer-reviewed randomised controlled trial.
Objective: This single-blinded randomised controlled trial aimed to compare the effect of a treatment programme consisting
of guidelines, exercise therapy and MLD (experimental group) and the same programme without MLD (control group) on
the development of breast cancer- related lymphoedema.
Methods: We included 160 breast cancer patients with a unilateral axillary dissection. All patients were randomised into an
experimental (N=79) or control group (N=81). Treatment started five weeks after the axillary dissection on average. Patients
were treated during 20 weeks. The experimental group received 29 exercise therapy sessions and 34 MLD sessions and the
control group received 28 exercise therapy sessions. The assessors were blinded for the allocation to the groups. Primary
endpoint was incidence of arm lymphoedema at 6 and 12 months, defined as an increase of 200 ml or more of the pre-surgical
value. Secondary outcome parameters were time to develop lymphoedema, lymphoedema volume and patient’s quality life at
3, 6 and 12 months post-surgery.
Results: Four patients of the experimental group and 2 patients of the control group were lost to follow-up. Overall incidence
rates for lymphoedema were comparable between the experimental and control group both at 6 months (14% vs 15%, odds
ratio 0.9 [95% CI 0.4 to 2.3]; p=0.93) and at 12 months (24% vs 19%, odds ratio 1.3 [95% CI 0.6 to 2.9]; p=0.45). Time to
develop lymphoedema was comparable in the experimental and control group (log rank p>0.05). Both groups had 3, 6 and
12 months post-surgery, a similar increase of the arm volume compared to the pre-surgical level (p>0.05) and a comparable
mental and physical health-related quality of life (p>0.05).
Conclusion: MLD additional to guidelines and exercise therapy is unlikely to have a medium to large effect in the reduction
on the number of breast cancer- related arm lymphoedema at short-term.
Declaration of interest
None declared
O-06.06
LY.M.P.H.A.: A NEW STRATEGIC APPROACH TO PREVENT BREAST CANCER RELATED
LYMPHEDEMA.
C C Campisi, University of Genoa - University Hospital , Genoa, Italy, F Casabona, University of Genoa, Genoa, Italy,
D Friedman, University of Genoa, Genoa, Italy, M Puglisi, University of Genoa, Genoa, Italy F De Cian, University of Genoa,
Genoa, Italy, C S Campisi, University of Genoa, Genoa, Italy, M Adami, University of Genoa, Genoa, Italy, P Santi, University
of Genoa, Genoa, Italy, C Campisi, University of Genoa, Genoa, Italy, F Boccardo, University of Genoa, Genoa, Italy
Background: The prevention of lymphatic complications caused by breast cancer treatment is a central topic concerning the
high incidence of secondary lymphedema. Following sentinel lymph node (SLN) biopsy, lymphedema incidence varies from
0% to 13% and after axillary lymph node dissection incidence range varies from 7 to 77%. This wide variability is due to the
definition and method to determine lymphedema, the different length of follow-up, the different number of positive lymph
nodes, postoperative irradiation and body habitus.
Objectives: The purpose of this manuscript is to prospectively assess the efficacy of LYMPHA (Lymphatic Microsurgical
Preventive Healing Approach) to prevent secondary lymphedema following axillary dissection (AD) for breast cancer
treatment.
Methods: Among 49 consecutive women from March 2008 to September 2009 addressed to complete AD, 46 were randomly
divided in two groups. Twenty-three patients underwent LYMPHA technique for the prevention of arm lymphedema
(LYMPHA group – LG). The other 23 patients had no preventive surgical approach (control group – CG). LYMPHA procedure
consisted in performing lymphatic-venous anastomoses (LVA) at the same time of AD. All patients underwent pre-operative
lymphoscintigraphy (LS). Patients were followed up clinically at 1, 3, 6, 12 and 18 months by volumetry. Lymphedema was
diagnosed when a difference in the excess volume was of at least 100 ml. Post-operatively LS was performed after 18 months
in 41 patients (21 LG and 20 CG). Arm volume and LS alterations were assessed.
Results: Lymphedema appeared in 1 patient in the LG after 6 months from the operation (4,34 %). In the CG lymphedema
occurred in 7 patients (30,43 %). No significant difference in the arm volume were observed in LG during follow-up, while
the arm volume in CG showed a significant increase after 1, 3 and 6 months from operation. There was significant difference
between the two groups in the volume changes with respect to baseline after 1, 3, 6, 12 and 18 months from surgery (every
timing p-value

O-06.07
PREVENTIVE INTERVENTION FOR LOWER- LIMB LYMPHEDEMA AT EARLY POSTOPERATIVE
PERIOD IN GYNECOLOGICAL CANCER
N Kobayashi, Hokkaido University Hospital, Sapporo, JAPAN, T Fujino, Teine Keijinkai Hospital, Sapporo, JAPAN, N Sakuragi,
Hokkaido University Hospital, Sapporo, JAPAN
Background: The treatment of the lower-limb lymphedema (LLL) is not easy because of various factors such as the age, the
complication, the patient background, and so on. Therefore, the management of LLL at the early period after gynecological
surgery is very important for patients to improve the quality of life.
Objectives: The aim of this study was to examine the effect of early preventive intervention for the LLL after lymphadenectomy
in patients with gynecological cancer.
Methods: From June, 2002, 623 LLL patients after lymphadenectomy for gynecological cancer were diagnosed lymphedema
stage according to the criteria of the International Society of Lymphology. Self-management techniques based on Complete
decongestive physiotherapy (manual lymphatic drainage, compression, exercises, and skin care) were guided for the
postoperative patients with gynecological cancer in hospital
Results: 1) Ninety of 623 patients (14.4%) were diagnosed stage I of lymphedema, and 533 (85.6%) were more than stage II.
Although 55.7% was aware of the edema within 1 year after the operation, patients took 5.0 ± 6.7 years (M ± SD) to a diagnosis
of LLL. 2) In stage I, 81 of 90 patients (90.0%) didn’t turn worse of LLL (non-progress group), while 9 of 90 patients (10.0%)
had a progression to stage II from stage I (progress group) in treatment follow up period 4.3±2.1 years.3) The occurence of
cellulitis were 6/9 (33.3%), 5/81 (6.2%) in the progress group and non- progress group, respectively. In the progress group,
cellulitis occurred significantly higher than the non- progress group (p10% may be considered to represent lymphoedema, although this definition is debated.
An absolute “L-dex” >10 or a change in “L-dex” of >10 indicates lymphoedema using bioimpedance.
Results:To date 413 patients have undergone pre-treatment assessments (Uptake rate =100%). 14 (3%) have declined follow
up assessment. 101 (24%) patients had an axillary node clearance (ANC), 287 (69%) had a sentinel node biopsy (SNB) and
25 (6%) had other surgery.
85% of ANC patients and 46% of SNB/other patients have been reviewed and re-measured at least once.
Abnormal results have been demonstrated in 19 (5%) patients pre or post treatment. 10 patients have been referred to the
lymphoedema service. 3 patients had undergone a SNB and 7 ANC.
Conclusions: Pre and post-treatment assessments seem to be acceptable to women.
Some abnormal results have already been detected.
A more detailed evaluation of these methods and the results will be undertaken.
These assessment techniques are being used in a randomised trial of early intervention / treatment with the aim of reducing
the development of long term symptomatic lymphoedem
Declaration of interest
none declared
80

O-07.01
ADIPOSE TISSUE EXPRESSES SPECIFIC LYMPHANGIOGENESIS MEMBRANE RECEPTORS
M ANDRADE, UNIVERSITY OF SÃO PAULO, SÃO PAULO, BRAZIL, A L JACOMO, UNIVERSITY OF SÃO PAULO, SÃO
PAULO, BRAZIL, F E AKAMATSU, UNIVERSITY OF SÃO PAULO, SÃO PAULO, BRAZIL, A Q SILVA, UNIVERSITY OF
SÃO PAULO, SÃO PAULO, BRAZIL, D A MARIA, BUTANTAN INSTITUTE, SÃO PAULO, BRAZIL
BACKGROUND: Lymphedema results from impaired lymphatic drainage and subcutaneous tissue modifications have long
been recognized.
One of the most striking features in affected limbs is fat tissue hypertrophy and the mechanisms by which lymph stasis
promotes fat overgrowth are still unclear. Increase in blood levels of VEGF-D, a specific growth factor to lymphatic endothelial
cells, has been reported in patients with lymphedema and interpreted as a compensatory mechanism secondary to lymph
stasis.
OBJECTIVES: Our aim was to identify any possible target in the subcutaneous fat tissue which could be secondarily activated
by lymphatic growth factors besides lymphatic endothelial cells in the tissue.
METHODS: Normal subcutaneous fat was obtained under sterile conditions from human surgical specimens and immersed
and washed in a phosphate buffer and then submitted to enzymatic digestion in a Dulbecco´s Modified Eagle Medium
(DMEM), 2 mg/ml type A collagenase, 20 mg/ml bovine serum albumin, penicillin, gentamycin, and streptomycin. The cell
suspension was centrifuged and the pellet was transferred and cultured in a medium containing DMEM, 10% Fetal Bovine
Serum, penicillin, gentamycin and streptomycin.
The cells in culture were tested for different markers using flow citometry and their characteristics are those of multi potential
mesenchymal stem cells.
Cells were then submitted to indirect immunofluorescence. Flt-4 (C-20): SC-321 (Santa Cruz Biotechnology, Inc.), a purified
rabbit polyclonal antibody against a peptide mapping at the C-terminus of human VEGFR-3, was used as the primary
antibody. Diluted Alexa fluoride 488 was employed as secondary antibody.
RESULTS: Cells stained with immunofluorescent marked antibodies against VEGFR-3 receptors.
DISCUSSION: In lymphedema, current therapeutic approaches focus on removal of stagnant lymph in order to keep epifascial
tissues from progressive degenerative changes or surgical debulking to improve limb format and function. Though further
studies to ascertain the real role of those multi potential mesenchymal cells under local and systemic lymphangiogenic stimuli
are needed, it seems to be a promising possibility to explain one possible causative mechanism for fat hyperplasia in lymph
stasis conditions.
Declaration of interest
none declared
O-07.02
HEALING OF ACUTE WOUNDS: LYMPHATICS MATTER
G Szolnoky, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY, G Erős, Institute of Surgical
Research, University of Szeged, Szeged, HUNGARY, K Szentner, Department of Dermatology and Allergology, University of
Szeged, Szeged, HUNGARY, I B Németh, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY,
L Kemény, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY
Background: Wound healing is assumed to be predominantly determined by blood vasculature development. Several clinical
observations and histological examinations suggest that lymph stasis may also be responsible for the maintenance of chronic
wounds. The role of lymphatics in acute wound healing is likewise poorly studied.
Objectives: We aimed to measure acute wound healing of mice using PBS as control and lymph- or blood angiogenesis
inhibitors.
Methods: 6 SKH-1 hairless mice were included into each group receiving periwound intracutaneous injections with sterile
phosphate buffer saline (PBS) as control and vascular endothelial growth factor receptor-2 (VEGFR-2) or -3 (VEGFR-3)
neutralizing antibodies and wound size measurements with photodocumentation were carried out every second day for
20 days. Intravital microscopy was performed every 4th day. By the end of study period animals were sacrificed and biopsy
specimen were taken from the wound area.
Results: Between days 8 and 18 mean wound surfaces, between days 4 and 18 relative vascular densities and between days
8 and 18 vascular diameters of each group significantly (p

O-07.03
DIFFERENTIATION OF LYMPHATIC ENDOTHELIAL CELLS FROM BONE MARROW MESENCHYMAL
STEM CELLS WITH VEGF
W Luwan, Shandong University School of Medicine of China, Jinan, CHINA, L Yanli, Shandong University School of Medicine
of China, Jinan, CHINA
Background: Although secondary lymphedema is a common clinical condition, treatment for this disabling condition remains
limited and largely ineffective. Although many researches have demonstrated that bone marrow-derived mesenchymal stem
cells (MSCs) have the potential to differentiate into mesenchymal tissues like osteocytes, chondrocytes, and adipocytes in
vivo and in vitro, little information is available regarding its potential to differentiate into lymphatic endothelial cell. Thus, we
investigated the differentiation of MSCs into cells of the lymphatic endothelial lineage.
Objective: in order to study the differentiation of lymphatic endothelial cells from bone marrow mesenchymal stem cells with
VEGF.
Methods: Rat MSCs were isolated from bone marrow aspirate of Sprague-Dawley rats, and flow cytometry to detect the
surface markers: CD31, CD29 and CD90. Purified MSCs were then plated onto dishes at cell density of 1 to 1.5×104 cells/
cm2 in the presence of VEGF (20 ng/mL) and / or VEGF-C (50 ng/mL) cultured in differentiation medium for 10 days to
media containing 2% FBS. The immunocytochemistry, RT-PCR, Western Blot demonstrated that compared to control group,
the groups of VEGF-A, VEGF-C and VEGF-A +VEGF-C express prox-1 and LYVE-1. Our results demonstrated that in
differentiation medium, MSCs treating with VEGF-A, VEGF-C and VEGF-A + VEGF-C individually promote lymphatic
endothelial cell formation in vitro, and express the marks of Prox-1and LYVE-1.
Results: According to the Immunohistochemical staining, the result of RT-PCR and Western blot analysis were similar with
Immunohistochemical staining that the prox-1 and LYVE-1 was chosen for the basal characterization of lymphatic endotheliallike
cells and the results demonstrated: after 10 days of cultivation the prox-1 and LYVE-1 were expressed in differentiated
MSCs, not only in endothelial cell cuture medium with VEGF-C, but also with VEGF-A and VEGF-A/ VEGF–C,
Conclusion: Our study shows for the first time that rat bone marrow-derived MSCs are capable of differentiating into
lymphatic endothelial like cells in vitro, which make them attractive candidates for the development of autologous tissue
grafts.
Declaration of interest
None declared
O-07.04
THE MEDICAL MECHANISM OF SUCTION BASED NEGATIVE PRESSURE ON VITAL POWER
ELEMENTS
L Zhiyu, Shandong University School of Medicine of China, Jinan, CHINA, D Zhaoxi, Shandong University School of Medicine
of China, Jinan, CHINA
Background: The 21st century is the biotic century. It is the new era of returning to nature, green environmental protection,
health caring, emphasizing prevention and the revival of the health medicine. This article presents a new theory introducing
present chemical and physical theory to medical field. It describes the theory of meridian-blood-lymphology, Traditional
Chinese Medicine (TCM) meridian theory and Qi-blood body fluid and its metabolism by studying the vital power elements
and the complex ion which is soluble in water. We establish the negative pressure in oral cavity to activate the medicine,
hemolymph circulation and form the pressure gradient in coelom, which can significantly increase the oxygen concentration
in blood and distance of oxygen diffusion to activate the human meridian channel. The method is simple, reliable and has no
side effects through repeated clinical tests.
Objective. inorder to explore the medical mechanism of suction based negative pressure on vital power elements. Methods:
Establish the negative pressure in oral cavity to activate the function of the meridian-hemolymph circulation and increase
the microcirculation. Results: According to the new theory of “the lymphatic system is the self-caring system, which has
three functions of immune defence, depuratory and reparation, we form the gradient in intracoelomic cavity system by
establishing negative pressure to increase the gradient pressure between the two ends of tissue channel. That will be helpful
to wash away the metabolic deposit in vivo and activate the meridian-blood-lymph microcirculation. Diseases caused by
stagnation of qi and blood will be treated with smoothened channel of meridian. This kind of medical equipment has great
effect especially for prevention and recovery of illness. It provides a convenient method to health caring and prlonging life.
Declaration of interest
None declared
82

O-07.05
EXPRESSION AND SIGNIFICANCE OF CHEMOKINE RECEPTOR CCR7 IN THYROID PAPILLARY
CARCINOMA
H Tian, Shandong University, Jinan, CHINA, H Tian, Shandong University, Jinan, CHINA, H Zhang, Shandong University,
Jinan, CHINA
Background: Chemokine receptor 7 (CCR7) has been detected in tumor cells and reported to play a role in the process of
lymphatic metastasis. Objective: To investigate the expression of chemokine receptor CCR7 in thyroid papillary carcinoma
and discuss its relationship with lymphatic metastasis. Methods: The expression of CCR7 in thyroid papillary carcinoma
tissues from 60 patients undergoing curative surgery was examined by immunohistochemistry. Results: CCR7 was positively
expressed in 56.7% (34/60) of the patients. The expression rate of CCR7 in lymph node metastasis and non-lymph node
metastasis was 92.3% (24/26) and 29.4% ( 10/34) respectively. The expression of CCR7 was not proportional to age, gender or
tumor size(P>0.05). Conclusions: The expression of CCR7 is closely related to the lymph node metastasis of capillary thyroid
cancer(P= 10 MHz
linear probe is used, with a “small parts” configuration and a near focalization.Definitions are given of axes in the limb and
angles between them.
In addition, lengths can be related to the height and standardised according to the weight and to the body mass index (BMI)
or to the standard length of limb segments.
The clinical assessment is effected using the CEAP-L classification, using an extension of venous CEAP.
The Ultrasound Internal Volumetry (UIV) measures the volumes of the coutaneous, subcoutaneous and musculo-skeletal
compartments. Standard limb reference points are used to get more stable measures.
Results: Grain calibre in the EM and the angle grain/segment axis correlate with the clinical severity score and with the UIV
measures.
Discussion: Axes and grain measures are useful in the assessment of lymph diseases.
Declaration of interest
None declared
83

O-08.01
ASSESSMENT OF QUALITY OF LIFE IN LYMPHEDEMA PATIENTS IN SWEDEN
P Klernäs, Red Cross Hospital, Solna, SWEDEN, K Johansson, Lund University, Lund, SWEDEN, L Kristjanson, Curtin
University, Perth, Western Australia
Background: The purpose of this study was to measure the quality of life in patients with different types of lymphedema.
Material and Methods: An instrument for assessment of quality of life has been developed in Australia, the Lymphedema
Quality of Life Inventory (LQOLI) and has been adapted to Swedish conditions. The Swedish version of the LQOLI (SLQOLI)
consists of 61 items and was found valid with a moderate reliability (kappa rang 0.25-0.83) in the physical, emotional, social
and practical dimensions. It can be used in the clinic to describe quality of life in patients with lymphedema. The responses in
the reliability test, from 58 patients with lymphedema, were analyzed and are presented in descriptive statistics.
Results: The mean score in the physical dimension was 62.1, in the emotional dimension 56.2, in the social dimension 49.0 and
in the practical dimension 50.7. The highest scored items were found in the physical dimension concerning swelling (score
103) and heaviness (score 94) followed by the emotional dimension concerning anxiety of whether or not the lymphedema
would get worse.
Conclusion: The quality of life in lymphedema patients are more influenced in the physical and emotional dimensions than
in the social and practical dimensions.
Declaration of interest
None declared
O-08.02
ROLE OF PROBLEM SOLVING IN COPING SUCCESSFULLY WITH LYMPHEDEMA
J Armer, University of Missouri, Columbia, MO, UNITED STATES, B Stewart, University of Missouri, Columbia, MO, United
States, P Heppner, University of Missouri, Columbia, MO, United States, A Wanchai, University of Missouri, Columbia, MO,
United States
Background: Breast cancer (BC) survivors (BCS) are faced with numerous life-changing issues including a lifetime risk for
developing lymphedema (LE), a chronic condition that impacts quality of life.
Objectives: The research goal was to examine the role of problem solving in coping successfully with LE one year after
diagnosis and initial BC surgery.
Methods: Participants were enrolled following diagnosis of BC but before surgical treatment and followed every 3 months up
to 12 months (n = 54). Psychosocial data were collected at baseline and 12 months later, using the Problem Solving Inventory
(PSI), Coping Efficacy with Lymphedema (CEL), the Psychological Adjustment to Illness Scale Self-Report (PAIS-SR), and
Global Severity Index (GSI) of the Brief Symptom Inventory (BSI).
Results and Conclusions: Preliminary analysis indicated that the CEL was significantly predictive of the GSI but not the PAIS
at 12 months. Moreover, the PSI was significantly predictive of the CEL as well as psychological adjustment (both PAIS and
GSI) 12 months later. As in an earlier study, the Personal Control factor of the PSI was the most predictive of psychological
adjustment.
These preliminary findings provide evidence that women’s self-reported efficacy to cope with LE was predictive of some
dimension of psychological adjustment. Moreover, BC survivors’ problem solving was predictive of their perceived ability
to cope with the difficult LE symptoms as early as 12 months after BC intervention. Thus, BC survivors’ problem solving is
an important predictor of overall psychological adjustment over time, and also a good predictor of women’s perceived ability
to cope with LE 12 months after diagnosis. These results underscore the importance of the need for more focus on problemsolving
interventions with BCS.
Declaration of interest
None declared
84

O-08.03
QUALITY OF LIFE OF WOMEN WITH LOWER-LIMB LYMPHOEDEMA FOLLOWING
GYNAECOLOGICAL CANCER
A Finnane, Queensland University of Technology, Brisbane, AUSTRALIA, M Janda, Queensland University of Technology,
Brisbane, AUSTRALIA, S C Hayes, Queensland University of Technology, Brisbane, AUSTRALIA, A Obermair, Royal Brisbane
and Women's Hospital, Brisbane, AUSTRALIA
Background: Secondary lymphoedema has been associated with impairments in physical functioning and reduced quality of
life (QoL). However, much of what is understood about the impact of lymphoedema following cancer is derived from studies
involving women with upper-limb lymphoedema following breast cancer.
Objectives: The aim of this review was to summarise results of studies assessing the impact of lower-limb lymphoedema
(LLL) on QoL of women with gynaecological cancer, evaluate their methodologies, and discuss limitations and priorities for
future research.
Methods: Electronic databases were searched for articles published between 2001 and 2011. Studies were included if they
involved women with LLL following treatment for gynaecological cancers. To be eligible, studies needed to evaluate the
relationship between lymphoedema and any aspect of QoL. QoL could be measured using validated tools or qualitatively
explored. Only articles published in English in peer-reviewed journals were eligible for inclusion.
Results: Of the ten eligible papers, seven were descriptive papers, of which four (including one case study) used qualitative
research methods, and three (two using data from the same patient population) used quantitative methods. The remaining
three papers reported the results from intervention trials. Despite differences in methodology and study samples, findings
are largely consistent and indicate patients with LLL following treatment for gynaecological cancers experience reductions
in physical, psychological and emotional functioning, and significant reductions in QoL. Women’s ability to perform daily
tasks (e.g., grocery shopping, exercise, social activities) was adversely affected and they faced additional difficulties in finding
suitable clothing and completing self-management tasks required for treatment of their LLL. Living with LLL affected social,
work and personal relationships and severe sexual difficulties and the loss of intimacy were also reported.
Conclusion: Despite limited research involving women with LLL, it is clear that the condition adversely impacts all aspects of
life. Future research investigating strategies to minimise the impact of lymphoedema on quality of life is needed.
Declaration of interest
None declared
O-08.04
RELATIONSHIP BETWEEN PHYSICAL ACTIVITY AND LYMPHOEDEMA IN THE CONTEXT OF
EVERYDAY LIFE
J Meiklejohn, Queensland University of Technology, Brisbane, AUSTRALIA, S Hayes, Queensland University of Technology,
Brisbane, AUSTRALIA
Background: Studies of exercise interventions among women with breast cancer, with or without lymphoedema, clearly
demonstrate that exercise during and following treatment optimizes function and quality of life. While exercise does not
increase risk nor exacerbate existing lymphoedema, reductions in incidence of lymphoedema exacerbations and associated
symptoms have been observed in those participating in regular weight lifting. Despite these benefits, lymphoedema prevention
and management advice cautions women against ‘repetitive use’ or ‘overuse’ of their affected arm. It is plausible that this
advice creates a barrier to exercise participation, however, little is known about the relationship between physical activity and
lymphoedema from the perspective of women following breast cancer treatment.
Objectives: To explore the relationship between lymphoedema and physical activity among women following treatment for
breast cancer.
Methods: Four focus groups, involving a total of thirteen women, and eight individual telephone interviews (women n=20),
recruited using purposive sampling techniques, have been conducted. Qualitative data analysis has been undertaken using a
social constructionist grounded theory approach.
Results: Participants were aged 40-75 years and were experiencing mild to severe lymphoedema following treatment for
breast cancer. Differences in how people perceived physical activity were found and confusion about acceptable forms and
levels of physical activity were described. Significant impacts on one’s ability to be physically active were reported, however
some participants undertook physical activity to cope with lymphoedema and to regain a sense of normality.
Conclusions: There is a clear need for lymphoedema guidelines to reflect evidence derived from well-designed studies regarding
the benefits of physical activity and to better define and clarify the role of physical activity with respect to lymphoedema
prevention and/or management.
Declaration of interest
None declared
85

O-08.05
YOUNG WOMEN’S EXPERIENCES OF LYMPHOEDEMA
P Sanderson, Mercy Health Lymphoedema Clinic, East Melbourne, AUSTRALIA
Background: Young women diagnosed with lymphoedema in their adolescent years or younger, often struggle to make
sense of the impact it has on their lives. Life issues including education, employment, social acceptance and identity are of
paramount importance during these years, and the way they negotiate these issues, either successfully or not, is predictive of
their future wellness and integration into social and vocational networks. The skills required for them to approach care of
lymphoedema seem elusive, and are often not implemented until they are approaching their twenties.
Objectives: The objective of the study was to identify the range of issues for young women with lymphoedema and to define
the barriers that exist for them in embracing self care. The research was aimed at identifying the successful strategies that
have been adopted to improve self management and what influenced an improvement in the capacity to show resilience.
Methods: A small group of young women ranging in age from 18 - 28, who are current clients of the lymphoedema clinic,
participated in both semi structured interviews and a focus group exploring their experiences of lymphoedema.
Results: Key themes will be identified for these women in terms of the challenges they encountered in dealing with the
diagnosis and treatment, and the impact this had and continues to have on their lifestyle. This will provide valuable information
in developing and improving the young people’s programs currently available which can enhance capacity to manage the
physical and emotional aspects of lymphoedema.
Conclusion: Psycho-social support and program development can be targeted more effectively by understanding the factors
which improve young women’s capacity to engage with treatment and self management programs.
Declaration of interest
None Declared
O-08.06
QUALITY OF LIFE IN PATIENTS WHO SELF-REPORT LOWER LIMB SWELLING AFTER TREATMENT
FOR GYNAECOLOGICAL CANCER
S Hayes, Queensland University of Technology, Brisbane, AUSTRALIA, M Janda, Queensland University of Technology, Brisbane,
Australia, H Reul - Hirche, Royal Brisbane and Women's Hospital, Brisbane, Australia, L Ward, University of Queensland,
Brisbane, Australia, A Obermair, Royal Brisbane and Women's Hospital, Queensland Centre of Gynaecological Research,
Brisbane, Australia
Background and objectives: Lower limb lymphoedema is a serious and feared sequelae after treatment for gynaecological
cancer. Given the limited prospective data on incidence of and risk factors for lymphoedema after treatment for gynaecological
cancer we initiated a prospective cohort study in 2008.
Methods: Overall, 378 women were assessed before treatment and at regular intervals after treatment for two years. Followup
visits were grouped into time periods of 6 week - 3 months (time 1), 6 months – 12 months (time 2), and 15 months - 24
months (time 3). Preliminary data analysis was undertaken using generalised estimating equations to model the repeated
measures data of Functional Assessment of Cancer Therapy-General (FACT-G) quality of life (QoL) scores and self-reported
swelling at each follow-up visit period (best-fitting covariance structure).
Results: The QOL of those with self-reported swelling was clinically lower at all time periods, compared with those who did
not have swelling (Mean (SD) FACTG scores at time 1, 2 and 3 were 83 (15), 82 (17) and 85 (15), respectively, for those with
swelling and 88 (15), 93 (13), 91 (15), respectively, for those without swelling, p

RT-01.01
TREATMENT OPTIONS, PATHOPHYSIOLOGY AND BASIC SCIENCE
R Baumeister, University of Munich, Munich, GERMANY
Treatment can be based on personal experience, speculation and believes.
Treatment options should be based however on respecting the pathophysiology of the underlying disease and the results
given by the basic science.
Furthermore they should take advantage of the latest actual technical possibilities and finally, the results should be controlled
by independent investigators.
As an example, the development and scientific follow up protocols of microsurgical reconstructive procedures is described
and future aspects with respect to basic science discussed.
The ISL conferences combine traditionally the different aspects from basic science to treatment in the field of Lymphology.
To intensify the combined efforts, a round table session at this early stage of the congress with basic scientists and therapeutic
practitioners including the opinions of the panel may be the optimal nucleus for further progress on one side and may help
the auditors to form the own opinion of different procedures presented in the treatment sessions at the end of the week on
the other side.
Declaration of interest
None declared
RT-01.02
CONSERVATIVE THERAPY FOR LYMPHOEDEMA: ARE WE DOING IT RIGHT?
N Piller, Lymphoedema Assessment Clinic, Department of Surgery, Flinders Medical Centre, Bedford Park, AUSTRALIA
We do not seem to be gaining significantly better outcomes for our patients despite the plethora of older and new conservative
treatments and patient based management programs. Why is this so? Is this real, or is it because we are not using appropriate
measurement techniques to determine changes related to treatment, or are we not using the right treatment at the right time,
ignoring what we know of anatomy, physiology and patho-physiological changes as lymphoedema progresses.
There are a range of well-evidenced tools available to assess total, limb and local fluid levels using Bio-impedance
spectroscopy and di-electric constants and yet we still do not use them despite the fact that they require less time than
circumference measurement, are more representative of the key changes we are interested in (fluids) and can be easily logged
as a measurement series.
When a health professional does not see a patient frequently the use of circumference and/or plethysmography can be an
invalid indicator ofthe progression of lymphoedema since these measure total limb volume change, which may be increased
with weight gain or musclemass or visaversa. We should concentrate on fluids in the limb or area since these are the best
measure of the status of the lymphatic system.
We also do not use other simple tools such as the tissue tonometer or Indurometer to objectively measure the build up of
fibrotic induration in the lymphatic territories and yet knowing about how its changing is crucial to good lymphatic drainage
and knowing where it is may help better targeting and sequencing of lymphoedema treatment.
This talk will focus on the issues of recognising and responding to structural and functional changes in the tissues as
lymphoedema progresses in terms of selecting the “right” treatment at the “right” time, and what is best or “right” for the
patient, as well as our ability to measure these changes and respond to them with targeted and sequenced conservative
treatment. I hope we can also discuss some of the common errors of assumption that we can make when assessing the
progress of conservative treatment.
Declaration of interest
None declared
87

RT-01.03
LYMPH NODE TRANSFER AND GROWTH FACTOR THERAPY FOR LYMPHEDEMA PATIENTS
A Saaristo, Turku University Central Hospital, Turku, FINLAND, T Tervala, Turku University Central Hospital, Turku, Finland,
K Honkonen, University of Eastern Finland, Kuopio, Finland, K Alitalo, Helsinki University, Helsinki, Finland, E Suominen,
Turku University Central Hospital, Turku, Finland
Background and Objectives: Lymphedema after surgery, infection or radiation therapy is a common and often incurable
problem. Previously application of lymphangiogenic growth factors has been shown to induce lymphangiogenesis and
to reduce tissue edema. The objective of our translational research group has been to develop an effective treatment for
lymphedema, which could be applied in conjunction with surgery.
Methods: We have evaluated the therapeutic effect of autologous lymph node transfer with or without lymphatic growth
factors in lymphedema porcine model. Lymph node grafts and adenovirally delivered vascular endothelial growth factor-C
or VEGF-D were used to reconstruct the lymphatic network in the inguinal area; AdLacZ served as a control.
Results: Results from the porcine lymphedema model demonstrate that lymphatic vasculature does have a tremendous
capacity for spontaneous regeneration. Interestingly we also found that human lymphnodes express endogeneous lymphatic
vessel growth factors. However, without additional growth factor support (AdVEGF-C/D) the incorporation of the transferred
lymph nodes may fail resulting into scarring and fibrosis of the nodes. Both growth factors induced robust growth of new
lymphatic vessels in the defect area, and postoperative lymphatic drainage was significantly improved in the VEGF-C/D
treated pigs as compared to the controls. Interestingly, VEGF-D transiently increased accumulation of seroma fluid in the
operated inguinal region postoperatively, whereas VEGF-C did not have this side effect.
Conclusion: Lymph node transfer technique is still considered experimental surgery. In the future our goal is to combine
lymphatic growth factor therapy (AdVEGF-C) with the lymph node transfer to gain more efficacy for the lymphedema
treatment. By combining the lymphatic vascular growth factor therapy with the lymph node transfer we can fully restore the
normal lymphatic vascular anatomy.
Declaration of interest
Dr Anne Saaristo is a member of the board of directors of OY LX Therapies Ltd.
RT-01.04
FROM LYMPH TO FAT: CONFIRMATORY ANALYSES
H Brorson, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
The occurrence of adipose tissee hypertrophy has been evaluated in various papers. In 1987 we noted an excess of adipose
tissue in the lymphedematous tissues and recommended liposuction in order to remove the excess volume. New ideas and
concepts of treatment, however, require evaluation and confirmation before they are accepted and become the standard of
care.
1. Consecutive analyzes of the content of the aspirate removed under bloodless conditions, using a tourniquet, showed a
very high content of adipose tissue in 44 women (mean 90%, range: 58-100) was found.
2. Analyses with DXA in 18 women with postmastectomy arm lymphedema showed a significant increase of adipose tissue
in the non-pitting swollen arm before surgery. Postoperative analyses showed normalization at 3 months. This effect was seen
also at 12 months. These results paralleled the complete reduction of the excess volume (“edema volume”).
3. Investigation with VR-CT (Volume Rendering Computer Tomography) in 8 patients also showed a significant preoperative
increase of adipose tissue in the swollen arm, followed by a normalization at 3 months paralleling the complete reduction of
the excess volume.
4. The findings of increased adipose tissue in intestinal segments in patients with Crohn’s disease, known as “fat wrapping”,
have clearly shown that inflammation plays an important role.
5. In Graves´ ophthalmopathy a major problem is an increase in the intraorbital adipose tissue volume leading to
exopthalmus. Adipocyte related IEGs (immediate early genes) are overexpressed in active ophthalmopathy and CYR61
(cysteine-rich, angiogenic inducer, 61) may have a role in both orbital inflammation and adipogenesis.
We now know that patients with chronic, non-pitting, lymphedema develop large amounts of newly formed subcutaneous
adipose tissue, which precludes complete limb reduction utilizing microsurgical reconstruction or conservative treatment.
Although incompletely understood, this adipocyte proliferation has important pathophysiologic and therapeutic implications.
Liposuction can be performed in patients who fail to respond to conservative management because the hypertrophy of the
subcutaneous adipose tissue cannot be removed or reduced by the other techniques available.
Declaration of interest
None declared
88

O-09.01
BIOELECTRICAL IMPEDANCE SPECTROSCOPY FOR THE EARLY DETECTION OF LYMPHEDEMA.
L C Ward, The University of Queensland, Brisbane, AUSTRALIA
It is now three decades since the measurement of electrical impedance was first proposed for the measurement of edema
(Watanabe et al., 1981) although it was not until 10 years later that it was demonstrated clinically as being diagnostically
informative (Ward et al., 1992). Since then, methods of impedance measurement have been standardised and impedance
instrumentation specifically designed for lymphedema assessment have been produced. Yet the method has still to gain wide
acceptance in a clinical setting (Mohler and Mondry, 2011). The reasons for this are unclear but may relate to the technical
complexity of the method, equipment costs or simply wide-spread acceptance of long-standing use of tape measurements of
limb volume. This instructional session will provide a simple overview of the principles of the technique, review how it may
be used in clinical practice and evaluate the advantages of BIS vis-á-vis other commonly used assessment tools.
Watanabe R. et al. (1981)Trial of application of electrical impedance for measuring leg edema. In Oshima and Kanai (Eds.)
Proc. Vth Int. Conf. on Electrical Bioimpedance, Tokyo, suppl. p. 109.
Ward LC et al. (1992) Multi-frequency bioelectrical impedance augments the diagnosis and management of lymphoedema in
post-mastectomy patients. Eur J Clin Invest. 22: 751-4.
Mohler ER & Mondry TE (2011) Lymphedema: etiology, clinical manifestations and diagnosis. UpToDate http://www.
uptodate.com/contents/lymphedema-etiology-clinical-manifestations-and-diagnosis Accessed 16th April 2011.
Declaration of interest
None declared
O-09.02
CIRCUMFERENCES, PEROMETRY, AND SYMPTOM REPORT IN THE ASSESSMENT OF
LYMPHEDEMA
J Armer, University of Missouri, Sinclair School of Nursing, Columbia, MO, UNITED STATES
A historical overview of assessment of lymphedema by circumference, perometry, and symptom assessment will be
provided, with comparison to the ‘gold standard’ of water displacement. Indications for use, contradictions, advantages and
disadvantages, procedures for measurement, and data generated by circumferences, perometry, and symptom report will be
reviewed (1-4). Comparisons of findings with single and multi-frequency impedance will be reviewed. The summary will
include comparisons of findings among methods, including comparison of advantages and disadvantages, and how to choose
the method best suited for a practice or research setting. National and international clinical guidelines in measurement and
assessment will be reviewed (5).
Selected references:
1. Armer, J.M. (2005). The problem of post-breast cancer lymphedema: Impact and measurement issues. Cancer Investigation, 1, 76-83.
2. Armer, J.M., Stewart, B.R. (2005). A Comparison of Four Diagnostic Criteria for Lymphedema in a Post-Breast Cancer Population. Lymphatic Research
and Biology, 3(4).
3. Ridner, S.H., Montgomery, L.D., Armer, J.M., Hepworth, J., & Stewart, B.R. (2007). Comparison of upper limb volume measurement techniques between
healthy volunteers and individuals with known lymphedema. Lymphology, 40, 35-46..Also: Ridner, S.H., Montgomery, L.D., Hepworth, J.T., Stewart, B.R., &
Armer, J.M. (2007). Comparison of upper limb volume measurement techniques and arm symptoms between healthy volunteers and individuals with known
lymphedema. Phlebology Digest, 21, 23-25. (Invited abstract)
4. Bernas, M., Askew, R., Armer, J.M., & Cormier, J. (2010). Lymphedema: How do we diagnose and reduce the risk of this dreaded complication of breast
cancer treatment?, Current Breast Cancer Reports, Vol.2. 53-58.
5. National Lymphedema Network (2011). THE DIAGNOSIS AND TREATMENT OF LYMPHEDEMA. Position paper of the National Lymphedema
Network Medical Advisory Committee. Updated February 2011. Accessed April 18, 2011 at: http://lymphnet.org/pdfDocs/nlntreatment.pdf
Objectives
1. Participants can state the protocol, indications, implications, and contraindications for use of circumferences.
2. Participants can state the protocol, indications, implications, and contraindications for use of perometry.
3. Participants can state the protocol, indications, implications, and contraindications for use of symptom assessment.
4. Participants can state the protocol, indications, implications, and contraindications for use of electrical impedance.
5. Participants can identify national and international guidelines for lymphedema assessment and measurement.
Declaration of interest
None Declared
89

O-09.03
SKIN TISSUE DIELECTRIC CONSTANT VALUES IN WOMEN WITH BREAST CANCER:PRE-SURGERY
AND ONE YEAR POST-SURGERY
H MAYROVITZ, COLLEGE OF MEDICAL SCIENCES, FT. LAUDERDALE, UNITED STATES
Background:In breast cancer treatment-related lymphedema (BCRL), tissue dielectric constant (TDC) values, reflecting local
skin water, are greater in affected than contralateral arms. However, the magnitude of side-to-side differences before and
changes after surgery is unclear. Pre-surgery evaluations with follow-ups are the best approach for early BCRL detection, but
pre-surgery values may not be taken. So, it is useful to know if breast cancer or natural variations between affected (at-risk)
and contralateral body sides alter parameter values possibly useful for detecting BCRL.
Objectives:To determine body side differences in lymphedema assessment parameters before and one year after surgery.
Methods: With IRB approval, 71 newly diagnosed breast cancer patients were evaluated before surgery and 32 reevaluated
12 months post-surgery. Bilateral TDC values (Delfin Moisture-Meter-D, 2.5 mm depth probe) were measured at forearm,
biceps, axilla and lateral thorax. Arm volumes and bioimpedance values (Impedimed-DF-50) were also determined and
[affected-side/contralateral-side] ratios determined.
Results: Pre-surgery values (mean±SD) for all (n=71) affected and contralateral side values and [ratios] were as follows;
Arm Volumes (ml): 2263±669 vs. 2289±666 [0.988±0.049]; TDCforearm: 25.2±3.7 vs. 24.9±3.7 [1.015±0.117], TDCbiceps:
22.0±3.2 vs. 21.9±3.7 [1.019±0.138], TDCaxilla: 35.0±7.0 vs. 34.9±8.1 [1.034±0.203], TDCthorax: 26.4±4.6 vs. 26.7±5.2
[0.995±0.107]. Arm bioimpedance values (Ohms) were 290.9±41.6 vs. 290.4±42.8 [1.004±0.052]. All pre-surgery side-to-side
differences were statistically insignificant for the total group and for the 32 patient sub-group. Twelve months after surgery a
significant increase only in thorax TDC values was detected (26.6±4.9 vs. 30.7±6.0, p

O-10.02
THE USE OF ICF CORE SETS FOR LYMPHEDEMA IN DAILY CLINICAL PRACTICE
P Viehoff, Erasmus Medical Centre, Rotterdam, NETHERLANDS
Y Heerkens, Dutch Institute of Allied Health Care, Amersfoort, NETHERLANDS
D van Ravensberg, Dutch Institute of Allied Health Care, Amersfoort, NETHERLANDS
M Martino, Erasmus Medical Centre, Rotterdam, NETHERLANDS
BACKGROUND The International Classification of Functioning, Disability and Health (ICF) offers a system to describe
the functioning of the patient complementary to the medical problems described with the ICD-10. Since the ICF is too
comprehensive for daily practice, Core Sets can be composed for easier use.
OBJECTIVES The purpose of the presentation is to make the audience more familiar with the practical use of the ICF Core
Sets for Lymphedema and to make clear the benefits of its use.
With ICF Core Sets for lymphedema the health care professional can work faster (no need to describe the patient in words)
and gets a better overview of the patient with lymphedema.
METHODS An oral presentation will be given with explications and examples of the use of Core Sets for patients with
lymphedema.
RESULTS Not applicable
CONCLUSION The Core sets can give direction to treatment goals. The codes of the ICF can also be used to formulate
outcome measures. Once there are ICF Core Sets digital registration in terms of the ICF of the patient with lymphedema can
be faster and more compact. Registration generates data which can be used for research (getting to know more about the
patients) and policy making (e.g. insurance companies, governmental).
Declaration of interest
None declared
O-10.03
TRAINING OF A NOVICE LYMPHOEDEMA CLINICIAN IN UPPER LIMB CIRCUMFERENTIAL
MEASUREMENT
M Matthews, James Cook University, Townsville, AUSTRALIA
S Gordon, James Cook Uni, Townsville, AUSTRALIA
Background: Skills of taking upper limb circumferential measurements as an outcome measure to diagnose and quantify limb
swelling and to monitor changes in limb size are usually acquired through post-graduate education. Novice lymphoedema
clinicians, newly graduated health professionals, or those who have no experience in the field of lymphoedema, require a
protocol for training in circumferential measurement that ensures high intra-measurer reliability. Anatomical and incremental
landmarks are used in clinical and research setting, however there is no literature regarding the training required to achieve
reliable upper limb circumferential measurements.
Objective: To determine the effect of training and standardization of upper limb circumferential measurements, on intrameasurer
reliability of a novice clinician.
Method: An Intra-measurer, test-retest reliability study for upper limb circumferential measurements investigated ten women,
with no history of a condition or injury likely to affect the size, movement and function of their upper limb. Circumferential
measurements of both upper limbs of each participant were performed at anatomical landmarks and at 10cm increments
from the ulna styloid by a novice clinican. After five minutes, the arm was remarked and remeasured. Intraclass correlation
coefficients (ICCs) were then calculated to determine measurement test-retest reliability.
Results: The provision of a 30 minute supervised training session, followed by four weeks of independent practice (16 hours),
and a skills revision session, is sufficient for a novice clinician to produce upper limb circumferential measures of good
reliability. Circumferences taken at 10cm increments from the ulna styloid were more reliable than those performed at
anatomical landmarks.
Conclusions: This training and standardised measurement protocol can be confidently used to train novice practitioners in
reliable circumferential measurements for clinical and research activities. Further research is required to determine if the
training time is optimal or could be decreased.
Declaration of interest
None declared
91

O-10.04
LIMB VOLUMETRY: COMPARISON OF MAGNETIC RESONANCE IMAGING WITH
OPTOELECTRONIC MEASUREMENT
G Szolnoky, University of Szeged, Szeged, HUNGARY
A Palkó, Department of Radiology, University of Szeged, Szeged, HUNGARY
M Varga, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY
E Varga, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY
L Kemény, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY
Background: Volume measurement is an essential outcome parameter in the assessment of decongestive therapy. The
optoelectronic device, Perometer has already been validated using tape measurement and water dispacement method and
was found to be a reliable and convenient tool. Limb volume determination with magnetic resonance imaging (MRI) is an
advanced method that can also precisely display tissue and fluid composition.
Objective: We aimed to compare MRI with Perometer in leg volume measurement and to determine correlation coefficient
between these two volumetric methods before and after decongestion.
Methods: 20 legs of 10 patients (mean age: 56.65 ys) with phlebolymphedema were measured with MRI and Perometer prior
and subsequent to complex decongestive physiotherapy (CDP) consisting of manual lymph drainage (MLD), intermittent
pneumatic compression (IPC) and multilayered compression bandaging. Limb volumes were compared to calculate
correlation coefficients.
Results: Pre-and posttreatment limb volumes strongly correlated in the two groups (r>0.9), therefore both methods appeared
to be adequate in the measurement of limb volumes and therapy-related changes.
Conclusion: Optoelectronic measurement and MRI nearly equally assess leg volumes in lymphoedema patients.
Declaration of interest
This lecture is going to be a part of Bauerfeind sponsored block.
O-10.05
LOWER LIMB LYMPHEDEMA FOLLOWING TREATMENT FOR GYNAECOLOGICAL CANCER
T Lahtinen, Kuopio University Hospital, Kuopio, FINLAND
J Pyykönen, Kuopio University Hospital, Kuopio, FINLAND
M Komulainen, Kuopio University Hospital, Kuopio, FINLAND
J Nuutinen, Delfin Technologies Ltd, Kuopio, FINLAND
M Anttila, Kuopio University Hospital, Kuopio, FINLAND
M Tuppurainen, Kuopio University Hospital, Kuopio, FINLAND
Background Lymph node dissection is an integral part of gynecological cancer treatment and surgical staging. This procedure
has been associated with the development of lower limb lymphedema (LLL). Mayrovitz et al (Lymphology 41;87,2008) have
demonstrated that the tissue dielectric constant (TDC) is a useful indicator for the assessment of lymphedema in patients
with unilateral postmastectomy lymphedema.
Objectives To compare the sensitivity of TDC (MoistureMeterD, Delfin Technologies Ltd) and limb circumference
measurement in the assessment of post-therapy LLL in lower limbs among gynaecological cancer patients in a gross-sectional
setting.
Methods Bilateral TDC measurements have been performed for 106 cancer patients from thigh and calf. Limb circumference
from the same sites was measured with a tape measure and visual evaluation of the limb was performed.
Results The mean age of the patients was 66.7 + 10.7 years (range 31.1 - 90.9 years). There were 52 endometrial, 40 ovarian/
tubal, 8 cervical and 6 vulvar cancers. The mean time from surgery to the measurements was 2.9 + 2.2 years. Right limb
pitting was seen in 11.7 % while left pitting in 17.5 % of the patients. The right leg teleangiectacy occurred in 43.7% vs. left
51.5% of the patients. With left leg pitting the calf TDC value was 35.9 + 10.4 and respective leg circumference 24.9 ± 2.9 cm.
The respective TDC values for non-pitting patients were 27.2 ± 7.5 and leg circumference 23.5 ± 2.7 cm. The difference was
32 % between pitting and non-pitting edema when evaluated by the TDC measurement and 6.0 % when evaluated by the
circumferential measurement.
Conclusions We conclude that the TDC measurement is 5.3 times more sensitive to indicate changes of LLL in a lower leg
than the circumferential measurement. This coincides well with the previous estimates of 4-5 (Nuutinen et al 2004, Mayrovitz
et al 2008).
Declaration of interest
J Nuutinen, represents manufacturer of the MoistureMeterD
92

O-10.06
A NON-INVASIVE, LOW COST, PORTABLE PHOTOGRAPHIC APPLICATION FOR LIMB VOLUME
CALCULATIONS IN LYMPHOEDEMA
L Mc Fetridge, Flinders University & Flinders Medical Centre, Adelaide, AUSTRALIA
O J Pallotta, Flinders University & Flinders Medical Centre, Adelaide, AUSTRALIA
N B Piller, Flinders University & Flinders Medical Centre, Adelaide, AUSTRALIA
Background: Measuring and monitoring limb volume is an effective method for assessing the efficacy of treatments for
lymphoedema. The ideal tool for limb volume measurement should be non-invasive, inexpensive and portable, while also
providing accurate and repeatable results. Current methods, including fluid displacement, limb circumference measurement,
perometry, computer tomography and laser scanning, do not meet all of these requirements.
The technique proposed utilises automated computer aided imaging techniques (Photogrammetry) to calculate limb volumes
and track the changes over time. Imaging through photography has the advantage of being non-invasive, low-cost, portable,
highly accurate and repeatable. In addition, photography provides both the clinician and patient with a visual record of their
treatment progression.
Objectives: To demonstrate the benefits of limb volume measurement and limb volume changes based on photographic
imaging techniques with the aim to produce an automated, low-cost, portable, accurate and repeatable measurement tool for
rural and remote areas.
Methods: The volume of a range of artificial limbs as well as lymphoedema limbs will be measured with imaging techniques
and compared to the results from the traditional measures, such as perometry, water displacement and circumference
measurement.
Results: The final results will be available at the meeting but the accuracy of photogrammetry seems dependent on several
interrelated factors, the resolution of the camera, the size of the object of interest, the number of photographic images taken,
and the geometric layout of the pictures relative to the limb. These issues are all manageable.
Given a camera resolution of at least three mega-pixels, photogrammetry is capable of a measurement resolution of less than
1 mm. This is suitable for the measurement of the expected volume changes in Lymphoedema limbs between clinic visits.
Conclusions: Photographic imaging can provide provide quantitative and qualitative indications which allow us to monitor
volume and shape changes in lymphoedema over time. The incorporation of this technique into a smart phone or a tablet
could be easily implemented, creating a platform for an inexpensive, portable measurement system usable in rural and remote
areas.
Declaration of interest
None declared
O-10.07
A NEW TOOL, THE INDUROMETER, FOR ASSESSING SUPERFICIAL CHANGES AS LYMPHOEDEMA
PROGRESSES
N Piller, Flinders University, Adelaide, Australia, M McEwen, Flinders Medical Centre, Adelaide, Australia, O Pallotta, Flinders
Medical Centre, Adelaide, Australia, S Tilley, Lymphodema and Laser Therapy, Adelaide, Australia, T Wonders, Flinders
University, Adelaide, Australia, M Waters, Flinders University, Adelaide, Australia
Background: Lymphoedema is a failure of the lymphatic system to remove fluids from the tissue. The initial stages are
characterised by a predominance of fluid. As it progresses, the epifascial tissue has increasing deposits of fat and concomitant
fibrotic induration. Over time, affected limbs vary in compliance and composition. Targeted treatment requires an accurate
diagnosis of these changes.
Tonometry is used to measure the tissue’s resistance to compression, providing an objective assessment of lymphoedema,
tissue changes and treatment efficacy. However the Tonometer has a hard to read display, the results are not stored and had
to be read while held upright, in place on the limb. A new tool, the Indurometer, has been designed to replicate the function
of the Tonometer, and overcome its shortcomings.
Objectives: This study investigates the use of an Indurometer on secondary arm lymphoedema and compares its performance
with the older Tonometers to determine if it is an appropriate replacement.
Methods: Both the Tonometer and Indurometer were used to assess tissue compliance in 22 subjects from the Lymphoedema
Assessment Clinic at Flinders Medical Centre and the Lymphoedema and Laser Therapy Clinic in Adelaide. Measurements
were taken on bilaterally at the anterior surface of: mid-lower arm, mid-upper arm, chest (between the second and third ribs).
Three operators participated in the study and their feedback on using both devices was recorded.
Results: The Indurometer and Tonometer had similar repeatability. The Tonometer had consistent repeatability at all
measurement sites, while the Indurometer’s deteriorated for measurements at the anterior chest. Both devices had variable
repeatability between operators. All operators rated the Indurometer easier to use than the Mechanical Tonometer.
Conclusion: While the Indurometer and Tonometer had similar repeatability, the Indurometer overcome many of the
Tonometers shortcomings. Both devices had repeatability performance dependent on the operator, which needs to be
addressed. A tracking Indurometer has been designed to monitor the user’s technique during the measurement. This will
allow the collection of a large data set of operator techniques, which may lead to a redesigned instrument with minimal interoperator
variability.
Declaration of interest
Two of the authors of this article have received renumeration from Flinders Biomedical Enterprises Pty Ltd. If an indurometer can be successfully developed and offered for sale, it will
be sold through Flinders Biomedical Enterprises Pty Ltd.
93

O-10.08
POST-OPERATIVE LYMPHOEDEMA: THE EFFECT OF LIMB DOMINANCE
L Ward, The University of Queensland, Brisbane, Australia
K Refshauge, University of Sydney, Sydney, Australia
J Beith, Sydney Cancer Centre, Sydney, Australia
L Koelmeyer, Westmead Breast Cancer Institute, Sydney, Australia
J Lee, University of Sydney, Sydney, Australia
J French, Westmead Breast Cancer Institute, Sydney, Australia
O Ung, Royal Brisbane and Women's Hospital , Brisbane, Australia
S Kilbreath, University of Sydney, Sydney, Australia
Background: Bioimpedance spectroscopy (BIS) is a highly specific and sensitive tool for detection of unilateral breast cancerrelated
arm lymphoedema. Detection with BIS is based on established reference ranges determined in a control healthy
population. We have compared post-operative with pre-operative BIS measurements to determine the proportion of women
with impedance ratios that exceed the normal ranges at each of these time points. The aim of the study was to investigate the
impact of limb dominance on these proportions.
Methods: As part of a longitudinal study, women diagnosed with early breast cancer (n = 328) were recruited preoperatively
and followed post-operatively. Bioimpedance measurements were obtained pre-operatively and 1 to 3 weeks
post-operatively to determine the inter-limb bioimpedance ratio. All women underwent breast and axilla surgery, with 41%
undergoing mastectomy, and 55% undergoing sentinel node biopsy. The inter-limb bioimpedance ratio was determined from
measurements of each arm with electrode placement using the equipotential principle.
Results: Pre-operatively, 1 out of 153 women, in whom the dominant limb was at risk, exceeded the BIS threshold compared
to 8 out of 179 in whom the non dominant limb was at risk. Post-operatively, 11 women in whom the dominant limb was at
risk and 25 women in whom the non-dominant limb was at risk exhibited ratios greater than the thresholds. Both of these
proportions were significantly greater than that expected based upon normal distribution in the control population (z-test).
Overall, the change in range post-operatively was 0.22 ± 0.066, with 59.9% exhibiting an increase in the ratio post-operatively.
For those that increased their BIS inter-limb ratio postoperatively, the mean increase was 0.066 ± 0.056.
Conclusion: Notably, 2.5 times as many women in whom surgery was on the non-dominant side compared to those in whom
surgery was on the dominant side presented with BIS ratios post-operatively indicative of lymphoedema. Evidence from
other studies suggests that, contrary to popular belief, limb usage is protective for lymphoedema. We speculate that effect of
limb dominance may reflect preferential limb use during the acute postoperative period.
Declaration of interest
Auithor Ward consults to ImpediMed Ltd.
O-11.01
CORRECT SEMANTICS IN LYMPHOLOGY AND CONSEQUENT CORRECT GUIDELINES
S Michelini, San Giovanni Battista Hospital, Roma, ITALY
A Failla, San Giovanni Battista Hospital, Roma, ITALY
G Moneta, San Giovanni Battista Hospital, Roma, ITALY
M Cardone, San Giovanni Battista Hospital, Roma, ITALY
F Cappelino, San Giovanni Battista Hospital, Roma, ITALY
A Fiorentino, San Giovanni Battista Hospital, Roma, ITALY
INTRODUCTION: The diagnostic and therapeutic protocols in lymphedema too often in the world today are assigned to
empirical criteria and are not supported from evidence-based medicine. The guidelines provide a valuable corporate help to
clarify in this area.
AIMS: It’s very important that International Society of Lymphology Consensus Document should be clear and containing
right and appropriate terms; that's why some statements that do not provide sufficient information to be followed by operators
should be better explained . METHODS It was rated the level of recommendations of the main statements contained in the
Consensus Document of the International Society of Lymphology on the following aspects: definition, lymphoscintigraphy,
physical therapy (manual lymph drainage, pressotherapy, bandaging, kinesiology), Drugs, Surgery, Liposuction, Prevention.
RESULTS: Starting from the definition of lymphedema (a clinical condition and not a disease) all the other aspects studied
showed a very low average level of recommendation (b, c). For some diagnostic principles (lymphoscintigraphy) and
therapeutic (drugs, lymphatic drainage, pressothearpy) there is little evidence of standardization of methods or assays.
CONCLUSIONS: The study shows the need to promote within the International Soiety multicenter studies that lead to
the standardization and validation of the statements reported by the Consensus Document, in the light of evidence based
medicine.
Declaration of interest
None declared
94

O-11.02
LYMPHEDEMA ASSOCIATED SKIN MANIFESTATIONS: A CLINICAL OVERVIEW
R Damstra, Nij Smellinghe hospital, drachten, NETHERLANDS
Introduction: Lymphedema is a disabling clinical condition caused by impairment of the lymphatic system, which leads to
swelling of subcutaneous soft tissue. As a result, accumulation of protein-rich interstitial fluid and lymph stasis additional
swelling, fibrosis and adipose tissue hypertrophy occurs. Because of the close relation between the lymphatics in the
subcutaneous tissue and the skin, dermatological manifestations are often present and cause additional lost of quality of life
for the patient who is already suffering from lymphedema.
Objectives: Understanding of lymphedema associated skin manifestations or its early recognition can often lead to prevention
of more severe complications, aggravation of initial lymphedema or can consequently initiate new anti cancer treatment.
Method and results: Three groups of skin diseases will be presented:
1. Skin manifestations resulting from lymphedema. They can be related to the lymphatic vessels, e.g. peau d’orange,
lymphectasia, micro- and macro lymph cysts and lymph fistulae or due to (epi)dermal changes as chronic inflammation ,
fibrosis and papillomatosis.
2. Skin manifestations resulting from immunodeficiency due to lymphatic impairment. These can be either infectious
(erysipelas) or secondary tumours as Kaposi's sarcoma, lymphoma, melanoma and non-melanoma skin cance
3. Manifestations of recurrence of the primary tumor in cancer related lymphedema. Early recognition is crucial in order to
re-evaluate oncological treatment. Examples are metastasis cutis and ‘malignant lymphedema’.
4. Concomitant skin diseases without a relation to lymphedema or lymphatic impairment. These patients need a proper
dermatological treatment in addition to to the lymphedema treatment.
Conclusion: Besides knowledge of diagnosis and treatment of lymphatic diseases, a general knowledge of dermatology can be
of big help when confronted with lymphedema.
Often a proper dermatological diagnosis will influence the treatment program of the patient. Especially in patients previously
treated for cancer, the physician should always consider if the origin of lymphoedema is malignancy recurrence, and therefore
close dermatological examination should be performed. It is highly recommendable to consult a dermatologist when discrete
skin changes are seen in patients with lymphedema in general and with a history of cancer in particular.
Declaration of interest
none declared
O-11.03
USING MULTISPIRAL COMPUTED TOMOGRAPHY IN DIAGNOSIS OF LYMPHEDEMA OF LOWER
EXTREMITIES.
T V Apkhanova, Federal State Institution «Russian Scientific Center of Rehabilitation Medicine and Health Resort Science of the
Ministry of Health and Social Development», Moscow, RUSSIAN FEDERATION
V A Badtieva, Federal State Institution «Russian Scientific Center of Rehabilitation Medicine and Health Resort Science of the
Ministry of Health and Social Development, Moscow, Russian Federation
V G Bardakov, Federal State Institution «National Medical and Surgery Center bay name NI Pirogov of the Ministry of Health and
Social Development of the Russian Federation, Moscow, Russian Federation
In the diagnosis of lymphedema of the lower extremities is dominated by non-invasive technology: lymphoscintigraphy and
computed tomography.
Objective: To study the CT scans of patients with lymphedema of the lower extremities with certain patterns of pathological
changes and their structure depending on the form and stage of disease.
Materials and Methods: We examined the CT scans of extremities of 15 patients with lower extremity lymphedema I-III
stages, including 12 women and 3 men, aged 18 to 73 years (mean age 43 years). The disease duration ranged from 2 to 48 years.
Primary lymphedema has suffered in 6 patients, secondary - 9 patients. CT was conducted in the modern 64-spiral CT "PHILIPS
BRILLIANS 64 ", slice thickness -5 mm.
Results: In all cases, patients with lymphedema (regardless of etiology) revealed thickening of the skin, more pronounced in the
III stages. Increasing the thickness of the subcutaneous space was also observed in all cases, more pronounced in stage III-IV.
In 13 out of 15 cases, typical changes of subcutaneous tissue in the form of "honeycomb" structure formed by the overgrowth
of fibrous filaments oriented sections in the form of parallel and transverse striation.The patient with stage III lymphedema
showed a sharp increase in density due to the expressed fibrosis of the subcutaneous fatty tissue, thickness fascia. CT in patients
with flebolymphedema showed increased subcutaneous space, subfascial space and thickening of the skin, the characteristic
changes in the subcutaneous space in the form of "honeycomb" structure was not detected in any of these patients. CT at
lipolymphedema revealed increased subcutaneous space through expansion of adipose tissue, but not observed thickening of
the skin and increase subfascial space.
Conclusion: In general, the distinguishing features of primary from secondary lymphedema, according to CT, have not been
identified. CT changes largely depended on the stage of disease, severity of asymmetry, growths of fibrous tissue and increase the
thickness of skin and subcutaneous tissue. Changes in the subcutaneous space in the form of "honeycomb" structure, observed
in the classical lymphedema, are not typical for flebolymphedema and lipolymphedema.
Declaration of interest
None declared
95

O-11.04
POST-MASTECTOMY SYNDROME AND ITS RELATIONSHIP TO LYMPHOEDEMA.
M Wald, Charles University Prague, Prague, CZECH REPUBLIC
J Adámek, Charles University , Prague, CZECH REPUBLIC
H Váchová, Charles University , Prague, CZECH REPUBLIC
Background and Objectives: Post-mastectomy pain syndrome (PMPS) is a condition affecting 22% to 72% of the women who
have had surgery for breast cancer. Its symptoms include: burning, achy feeling around the breasts and chest, “frozen” shoulder
that restricts range of motion at the shoulder and arms, tenderness around the area, and pain and tingling in scar tissue.
PMPS is believed to be primarily caused by a neuropathic disorder associated with phantom breast pain, intercostobrachial
neuralgia and neuroma pain.
Methods: Based on an 11-year follow-up involving 119 patients who underwent onco-surgical treatment of breast cancer,
the authors demonstrate a statistically significant association of PMPS with limb and non-limb lymphoedema, axillary WEB
syndrome and subsequent disorders affecting the ipsilateral shoulder girdle and arm. These may result in the development
of craniocervical and/or craniobrachial syndromes with both somatic and vegetative manifestations. The authors present
evidence that an early diagnosis and treatment of lymphoedema, followed by a physical therapy of the musculoskeletal system
when indicated, can eliminate PMPS almost completely.
Results and Conclusion: In the authors’ own group of patients who had advanced upper-limb asymmetry in both volume and
weight, vertebrogenic pain syndrome and restricted shoulder motion, the results show that liposuction is effective as a causal
therapy for pathological conditions associated with upper-extremity lymphoedema.
Acknowledgement: This research was partly supported by the Internal Grant Agency of the Ministry of Health, Czech
Republic, project no. NS9906-4/2008
Declaration of interest
None declared
O-11.05
DIAGNOSIS AND MANAGEMENT OF SECONDARY LYMPHEDEMA DUE TO METASTASIS
K F van Duinen, Nij Smellinghe hospital, Drachten, NETHERLANDS
C C W Theunissen, Nij Smellinghe hospital, Drachten, NETHERLANDS
R J Damstra, Nij Smellinghe hospital, Drachten, NETHERLANDS
Background: Lymphedema is a complication frequently encountered in patients treated for cancer, especially after
lymphadenoectomy and/ or radiotherapy. Although lymphatic impairment is sometimes caused by obstructive solid
metastasis, there are cases presenting secondary lymphedema with minor dermatological features without detectable solid
metastasis. Managing secondary lymphedema due to metastasis needs a special approach.
Objectives: To recognise and manage a patient with secondary lymphedema due to metastasis
Methods: Description of clinical presentations of malignant lymphedema (recognition of clinical symptoms, diagnostic
approach and treatment) and review of literature.
Results: Secondary lymphedema caused by infiltration of the superficial dermal lymphatics is rare and resembles dermatosis.
Various forms of metastatic skin lesions are described. Among cancer patient with skin infiltration, skin involvement
was most commonly seen with breast cancer. Secondary lymphedema du to malignant infiltration should be considered
particularly when lymphedema develops quickly, is constantly present, dilated veins are visible and patients are complaining
of intolerable, intense pain because of infiltration to the nervous system. Early recognition of disease etiology of local swelling
in combination of minor skin changes is important tot start a anti-cancer treatment combined with lymphological treatment
to improve survival and quality of life.
Conclusion: Lymphedema caused by malignant infiltration is a chronic progressive disease with poor prognosis.
Close dermatological examination of minor skin abnormalities in patients with a history of cancer and lymphedema is
recommendable.
Declaration of interest
none declared
96

O-11.06
DEFINING A THRESHOLD FOR INTERVENTION IN BREAST CANCER-RELATED LYMPHEDEMA
IS 3% VOLUME CHANGE TOO LOW?
A Taghian, Massachusetts General Hospital, Boston, UNITED STATES, M N Skolny, Massachusetts General Hospital, Boston,
UNITED STATES, C L MIller, Massachusetts General Hospital, Boston, UNITED STATES, T A Russell, Massachusetts General
Hospital, Boston, UNITED STATES, J O' Toole, Massachusetts General Hospital, Boston, UNITED STATES, M Ancukiewicz,
Massachusetts General Hospital, Boston, UNITED STATES, M Specht, Massachusetts General Hospital, Boston, UNITED
STATES, S J Isakoff, Massachusetts General Hospital, Boston, UNITED STATES, B L Smith, Massachusetts General Hospital,
Boston, UNITED STATES
BACKGROUND: There is no established threshold that indicates when intervention for breast cancer-related lymphedema
(BCRL) should be initiated. A previous study by Stout et al (Cancer 2008) suggested that a 3% change in limb volume is an
appropriate threshold warranting the need for therapy with little evidence to support that this volume change will progress
without treatment.
OBJECTIVES: The intention of this study is to determine the appropriate point of intervention in patients with BCRL through
analysis of the natural history of lymphedema progression.
METHODS: Patients diagnosed with unilateral breast cancer were prospectively screened pre-operatively and throughout
follow-up with perometry to assess bilateral changes in arm volume. At each time point (tx), relative volume change (RVC) of the
treated arm was calculated using volume ratios of treated (T) to non-treated (N) side compared to baseline (t1) (RVC=(Ttx/Ntx)/
(Tt1/Nt1)-1) (Ancukiewicz et al, 2010). The thresholds of ≥3%, ≥ 5% or ≥ 10% RVC were evaluated by review of measurement
data. Patients were classified according to the threshold initially crossed. Baseline and pre-clinical RVC were defined as 0-3% or
3-4 months, respectively.
RESULTS: Among 2240 patients with baseline measurements, 777 met the criteria for this analysis with a median of 5
measurements and 24.3 months follow-up. Respectively, 22.8% (n=177), 15.4% (120), and 1.8% (14) of patients reached the 3%,
5% and 10% thresholds. After reaching 3%, 5% and 10% RVC: 85.3%, 70.8% and 42.9% returned to baseline or pre-clinical RVC;
4.5%, 17.5% and 0% exhibited Mild edema, and 10.2%, 11.7% and 57.1% progressed to Moderate edema by the end of follow-up,
respectively.
CONCLUSIONS: Our analysis revealed that 85.3% of patients that crossed the 3% threshold never progressed to mild or
moderate lymphedema. This suggests that 3% may be too low of a threshold and intervention may be more burdensome than
beneficial. Our data demonstrates that a 5% threshold may be more appropriate for intervention given that 29.2% of patients
progressed, and a 10% threshold clearly demonstrates the need for intervention.
Declaration of interest
None Declared
O-11.07
ARM MORBIDITY AFTER BREAST CONSERVING THERAPY FOR BREAST CANCER. OBJECTIVE
FINDINGS AND SELF-ESTEEMED SYMTOMS
I Tengrup, Lund University, Skåne University Hospital, Malmö, SWEDEN
L Tennvall - Nittby, Lund University, Skåne University Hospital, Malmö, SWEDEN
I Christiansson, Lund University, Skåne University Hospital, Malmö, SWEDEN
Background: Swelling of the arm and impaired shoulder mobility are well-known consequences of treatment of breast cancer.
The incidence of these problems varies considerably in different studies.
Objectives: This prospective study report of incidence of lymphoedema, impaired shoulder mobility and the incidence of arm
symptoms registered in patients treated with breast-conserving surgery and axillary dissection level I and II with or without
postoperative radiotherapy.
Methods: 110 consecutive patients were examined yearly for 5 years for arm volumes and arm mobility. 75 patients had
postoperative radiotherapy to the remaining breast and 35 were randomised to the control group without postoperative
radiotherapy. The axilla was not included in the radiation field.
Results: 22% in the radiotherapy group developed lymphoedema and 57 % impaired shoulder mobility. Corresponding figures
in the control group were 12% and 30% respectively. The patients answered a questionnaire where they stated perception of
swelling and impaired mobility or not. 25% with registered lymphoedema did not state problems with arm swelling and 7
patients stated problems with arm swelling where no swelling was registered. Medical records showed that only 50% of the
patients with lymphoedema had a record of swelling and were referred to a physiotherapist. Impaired shoulder mobility was
in most cases registered during the first two years after surgery. Around 20 % of the patients with registered impaired mobility
stated impaired mobility and almost none of them had any medical records of the impaired mobility.
Conclusions: The incidence of lymphoedema after breast conserving surgery with postoperative radiotherapy to the remaining
breast tissue is twice as high as after breast conserving surgery without radiotherapy. The incidence of impaired shoulder
mobility is twice as high in the radiotherapy group compared with the control group. 25% of the patients with registered
lymphoedema do not state any problem with arm swelling. In 50% of the patients with lymphoedema no medical records
mentioned this and the patients had no referral to a physiotherapist. Around 50% of the patients with registered impaired
shoulder mobility perceived impaired mobility according to the questionnaire and in their medical records no mentioning
of the problems.
Declaration of interest
None declared
97

O-11.08
CHARACTERISTIC INDOCYANINE GREEN (ICG)-ENHANCED LYMPHOGRAPHY FINDINGS: A
NOVEL LOWER EXTREMITY LYMPHEDEMA SEVERITY STAGING SYSTEM
T Yamamoto, The University of Tokyo, Tokyo, JAPAN
M Narushima, The University of Tokyo, Tokyo, JAPAN
N Yamamoto, The University of Tokyo, Tokyo, JAPAN
K Doi, The University of Tokyo, Tokyo, JAPAN
A Oshima, The University of Tokyo, Tokyo, JAPAN
M Mihara, The University of Tokyo, Tokyo, JAPAN
M Gerhard, Johns Hopkins Hospital, Baltimore, United States
T Iida, The University of Tokyo, Tokyo, JAPAN
I Koshima, The University of Tokyo, Tokyo, JAPAN
Background: Indocyanine green (ICG) lymphography has been a useful modality in the clinical examination of patients with
lymphedema. However, no formal classification system of ICG lymphography findings according to the lymphedema severity
exists.
Objectives: The aim of this study was to describe, analyze, and classify characteristic ICG lymphography findings in order to
uniformly guide surgical treatment of lymphedema using this modality.
Methods: Seventy eight limbs of 45 patients with lower extremity lymphedema were assessed by ICG lymphography. All
lymphography images were recorded in photographs and movies. Images were reviewed and analyzed to classify characteristic
findings according to clinical severity as determined by Campisi clinical lymphedema staging.
Results: Lymphography findings were classifiable into two patterns. Mild cases of lymphedema were characterized by a linear
lymphatic channel pattern (linear pattern). In more severe cases, lymphatic channels demonstrated retrograde lymphatic flow
(dermal backflow pattern) and diminution or absence of linear channel patterning. Three dermal backflow patterns, splash,
stardust, and diffuse, were identified, and correlated with progression of lymphedema severity. These findings supported the
generation of a novel anatomical lymphedema severity staging system, the dermal backflow staging system.
Conclusions: ICG lymphography is a safe, minimally invasive, and useful method for evaluation of lower extremity
lymphedema. Characteristic ICG lymphography patterns are consistent and correlate with clinical severity. The dermal
backflow staging system can facilitate patient stratification, discussion between referring parties, and surgical planning.
Declaration of interest
None declared
O-11.09
THAILAND LYMPHEDEMA DAY CARE CENTER: PROPOSING A FORMAT FOR MANAGING
LYMPHEDEMA UNDER LIMITED RESOURCES
W Ekataksin, Mahidol University, Bangkok, THAILAND
W Ekataksin, Mahidol University, Bangkok, THAILAND
N Chanwimalueang, Mahidol University, Bangkok, THAILAND
P Suebtrakul, Mahidol University, Bangkok, THAILAND
P Piyaman, Mahidol University, Bangkok, THAILAND
P Wongwat, Mahidol University, Bangkok, THAILAND
W Khajornsaksumeth, Mahidol University, Bangkok, THAILAND
B K Hanboon, Mahidol University, Bangkok, THAILAND
Background In Asia, Thailand is the sixth after Japan, India, China, Taiwan, and Korea, where lymphedema care is available.
With a dedicated MD and a number of locally trained staff, we have successfully established a clinic that gathered more
than 2300 patients domestic and overseas from 31 countries in five years. Objectives To propose a praticeable yet sizeable
unit for lymphedema, and to identify essentials for clinical need. Methods and Results Under a day care protocol, one
physician covered 10-20 in-patients on a weekly basis with 6-12 attending therapists from 0900 to 1600 h. Everyday 3-5
OPD appointments were digested to feed the beds of coming weeks. After taking anamnestic history, physical examination,
and photographic record, an MRI was assigned, if required; hospital-routine laboratory was not done. The enrolled patients
received 1) compression therapy, 2) cryotherapy, and 3) nutritional therapy. Compression therapy comprised a series of
bandaging combined with twisting tourniquet technique (see a separate abstract in this meeting). Pneumatic intermittent
compression pump and vibration device were adjuvant; manual lymphatic drainage was not adopted. Only urea cream was
used, no other drug prescription, except for occasional diuretics. Lunch was provided as a vegan diet with sodium restricted
(equivalent to 6-8 g/d). While doing treatment in a non-partitioned single hall, patients socialized to form a patient circle.
The course included a social event involving relatives, taking a group picture of arm-and-leg contest, and an MRI-reading
class where everybody could learn how to read own films compared with others, and ask questions. Evaluation was done
daily before and after, by measuring limb circumferences at 7 segments. At discharge day 5, most patients were satisfied
with the average 50% swelling reduction. A home program was assigned individually, using a combination of tourniquet set,
bandaging, compression garment, etc., to match with first follow-up in 1-2 m; subsequent follow-ups set at 3-6 m interval
upon a good show-up. Conclusions Under a simple setting, using a self-manageable simple device, yielding a rapid result, we
simply propose with confidence the day care model for practice elsewhere from mega city to hilltop.
Declaration of interest
None declared
98

O-12.01
THE EFFECT OF LYMPH TAPING ON SEROMA FORMATION AFTER BREAST CANCER SURGERY
J Bosman, Medisch Centrum Zuid, Eelde, NETHERLANDS
N B Piller, Flinders Medical Centre, Adelaide, AUSTRALIA
Background: The most common complication of breast cancer treatment is seroma formation. Persistent seromas have
traditionally been treated with repeated aspirations, however, the use of aspiration can be problematic and may produce
additional inflammation and oedema. Lymph taping has the potential to prevent or reduce seroma formation, but currently
its potential benefits have not been fully investigated. Objectives: To investigate the potential of lymph taping to combat
seroma formation. Methods: Nine women treated for breast cancer were recruited to this randomised clinical trial; four
developed seromas requiring aspiration. Bio-impedance spectroscopy of the breast was used to assess intra- and extra cellular
fluid levels in each of the four quadrants of the breast. Participants also filled out a quality of life (QoL) questionnaire.
From day one postoperatively, lymph taping was applied over the watershed between skin territories on the posterior thorax
between the spine and axilla on those allocated to the treatment group. Measurements were repeated at five, nine and sixteen
days. Results: The extra cellular fluid value at t16 was 0.1037 ± 0.0324 (15.3% decrease) over t1 in the lymph taping group and
0.1066 ± 0.0227 (4.6% decrease) in the current best practice group (n=4 in each group). After 16 days of treatment, substantial
changes were found in burning sensations, tightness and heaviness in favour of the lymph taping group. In particular, pain
perception in the lymph taping group improved. Conclusions: This study has demonstrated that lymph taping has the ability
to reduce extra cellular fluid accumulation and improve a range of quality of life measures. Lymph Taping has the potential to
become a non invasive method to manage seroma.
Declaration of interest
The CureTape® for this study was funded by FysioTape B.V. the Netherlands.
O-12.02
EFFECT OF ORIENTAL DRUGS ON CALCITONIN GENE-RELATED PEPTIDE IN LYMPHEDEMA
TREATED BY PHYSIOTHERAPY
H Hasegawa, Kinki Univ. Hospital, Sakai, Sakai, Osaka, JAPAN
H. Hasegawa and M. Ohkuma*, Department of Nephrology and *Dermatology, Sakai Hospital, Kinki University, School of
Medicine, Osaka, Japan
Introduction:The authors have already shown CGRP and substance P are raised after physiotherapy by magnetic fields,
vibration and hyperthermia. This may explain why this physiotherapy is effective because these neuro-transmitting substances
intensify the contraction of lymphatic smooth muscle cells.
Objectives: This trials have been performed to show these Oriental drugs stimulate more elevation of CGRP after the
physiotherapy.
Materials and Methods:Serum CGRP is evaluated in the physiotherapy treated and oritental drugs given 5 cases of lymphedema
patients. The controls are done without giving drugs.The physiotherapy is performed by pulse magnetic
fields, vibration and hyperthermia.
Results:CGRP is not especially elevated even though the physiotherapy is perfomed with oral Oriental drugs.
Discussion:Tj. 100 contains sanshool and Tj. 25 contains shinamon. The both are known to stimulate vanilloid receptors.
This physiotherapy itself brings a perfect healing of lymphedema(Ohkuma, 22rd International Congress of Lymphology,
2009). The reason why these Oriental drugs have not helped to stimulate vanilloid receptors more is not known. It is still
worth while to give this combined treatment because it reduces the volume of the thigh more efficiently than the physiotherapy
alone. We should look for some substances to stimulate the receptors more efficiently.
Conclusion: Oral Oriental drugs, Tj. 100 & Tj. 25 which have been given during the physiotherapy have not increased CGRP
more than the control, the physiotherapy alone.
Declaration of interest
None declared if there is no conflict to declare.
99

O-12.03
A PRIMARY LYMPHODEMA OF UPER LIMB WAS CURED BY COMBINATION OF TCM WITH
WESTERN MEDICINE
L Zhiyu, Shandong University School of Medicine, Jinan, CHINA
D Zhaoxi, Shandong University School of Medicine, Jinan, CHINA
Backgrond: A boy suffering from primary lymphodema of uper limb after the birth. He see the doctors everywhere in china
but his edema is became Severity. Upto he was seven years old the edema part was some tissue necrosis and his mather ask to
cut of the limb. We treat it with combination of TCM with Western medicine.
Material and method: ointment of chinese herbs, bandage, massage, chinese medicine for oral use, oral negtive pressure and
transplantation of lymphatic endotheial stem cells were employied.
Results: After treatment for 3 years it became better and better. Now he has basicly recovered normal level include structure
and function of uper limb and hand.
Declaration of interest
None declared
O-12.04
LYMPHOTROPIC THERAPY OF ACUTE INFECTIOUS PULMONARY DISEASES
I Kurnikova, Izhevsk's Federal Medical Academy, Izhevsk, RUSSIAN FEDERATION
Y Levin, Russian Peoples' Friendship University, Moscow, RUSSIAN FEDERATION
F Kurieva, Russian Peoples' Friendship University, Moscow, RUSSIAN FEDERATION
Aim. To assess the methods of retrosternal lymphotropic administration of antibacterial preparations in the treatment of
infectious pulmonary destructions.
138 patients aged from 28 to 57 with acute infectious destructive pulmonary diseases were examined and treated, among
them 18 patients with gangrenous abscess and lung gangrene, 29 with double pulmonary lesion and multiple abscesses and 92
patients with a single purulent abscess. The basic group consisted of 46 patients, whose therapeutic complex in acute period
included the course of lymphotropic retrosternal dioxidine administration. The other group of 92 patients (comparison
one) received antibacterial agents parenterally. The technology according to Levin envisages slow ( 15 drops per minute)
injection of 10 ml 0,5% dioxidine solution diluted on 200 ml 0,9% of NaCL to retrosternal fat. 0,5% novocain was used as
a conductor. Apart from physical examination, laboratory findings characterizing acute phase of inflammation (CRP, α₂globulins,
fibrinogen, sialic acids), transaminases, protein metabolism, roentgenography, immunological tests of 1 and 2
levels were assessed.
Results. In the basic group the intoxication period was 20-30% shorter than that in the comparison one. T⁰ fall was registered
at 2-nd-3d day from the therapy onset. Dynamics of laboratory values of acute phase proteins showed their significant
reduction in the basic group at the 5th-7th day from the therapy onset. Considerable part of immunogram shifts in the
observation period did not occur, but when estimating remote results it was found out that in patients of the basic group the
signs of secondary immunodeficiency were observed in 17% of cases as compared to 80% of patients in the compared group,
5 of whom died of infections following chest operations for residual lung cavities. Full and clinical (residual dry cavity in the
lung)recovery were registered in 45 patients (95%). In the comparison group full recovery was observed in 17 patients (%),
clinical one in 35 patients (%). The others demonstrated chronicity of the process.
Conclusion. Using retrosternal lymphotropic administration of antibacterial preparations in infectious pulmonary diseases
allows to reduce acute period of the disease and improve prognosis.
Declaration of interest
None declared
100

O-12.05
FOOD AGGRAVATION: EFFECT OF DIETARY HABITS STUDIED IN 2300 PATIENTS WITH
LYMPHEDEMA AND THE LIKE
W Ekataksin, Mahidol University, Bangkok, THAILAND
N Chanwimalueang, Mahidol University, Bangkok, THAILAND
M Teerachaisakul, Chulalongkorn University, Bangkok, THAILAND
Background It is known to Thai that daylily consumed food can induce aggravation of symptomatology, called slaengh.
An individual is said to have a bad lymph, when unidentified eczema or insect bites repeatedly result in multiple papular
or macular rashes with prominent pigmentation with lasting scar in limbs. Objectives and Methods To determine if food
modifies clinical course, we at Thailand Lymphedema Day Care Center, examined 2300 patients from 31 countries. Emphasis
was placed on medical history to correlate food preferences, for poultry, pork, meat, seafood, egg, and milk, with onset of
cellulitis, skin lesions, leg complaints, weakness, tenderness, pain hypersensitivity, and fever. Many patients recalled their acute
attack in association with a fatty/proteinaceous meal. MRI was investigated to visualize pathologic dilatation and proliferation
of peripheral lymphatics. Results About 70% of patients had a positive history, of which four groups were recognized. In
group I with skin manifestations, lymphedema was rather minor, but lymphadenitis evident. Eruptions readily receded when
omitted slaengh food, and recurred when returned to such consumption as of pork, chicken, and shrimp. Group II with either
primary or secondary lymphedema, was typically characterized by cellulitic episodes. All patients admitted they remained
amazingly free of fever as long as they ingested no animal products. Patients of group III, constituting 60% population,
presented with lymphedema profunda (see a separate abstract in this meeting). Their leg complaints, chronic fatigue, and
general tenderness, including muscle ache, bodily discomfort, migraine, and dizziness, literally diminished or vanished after
treatment, but could be triggered to resume on exposure to slaengh diet as of chicken, or pork or diary products. Group
IV patients with recurrent leg ulceration, had more or less striking swelling; their venous profile abnormality was clearly
demonstrated on MRI. Ulcer spontaneously healed in 2-3 months of abstinence from slaengh. Lipodermatosclerosis also
improved significantly. Conclusions With little doubt, dietary habit modify clinical course of lymphedema. Although little
is known of its molecular mechanism, our observation with vegan diet strongly suggests that lymphangitis, lymphadenitis,
cellulitis, panniculitis, arthritis, synovitis, and folliculitis, which aggravate the symptoms and complications, can be avoided.
Declaration of interest
None declared
O-12.06
LYMPHEDEMA, PAIN AND THE USE OF TAPING
M Amore, Hospital Militar, Buenos Aires, ARGENTINA
P Yanes Chandia, Fundacion Favaloro, Buenos Aires, ARGENTINA
J L Ciucci, Hospital Militar, Buenos Aires, ARGENTINA
L Marcovecchio, Hospital Militar, Buenos Aires, ARGENTINA
A Mendoza, Hospital Militar, Buenos Aires, ARGENTINA
Background: For some years the neuromuscular taping is a technique used by doctors and physiotherapists in addition to all
kinds of muscle pains, ligament injuries, fibrous scars and edema.
Objectives: Demonstrate the usefulness of neuromuscular taping in the treatment of pain in patients with lymphedema.
Methods: For this study, we work with 20 patients with lymphedema, of which 12 were of upper limb and 8 lower limb . All
patients underwent myolymphokinetic exercises after the taping. Was used to quantify the pain visual analogue scale.
Results: The use of neuromuscular taping decreases pain in muscles and joints in patients with lymphoedema, allowing them
to make a complete routine of myolymphokinetic exercises.
Conclusion: Being a new technique in our country, they have to wait to assess the long-term results. The most important
objective is the reduction of muscle pain and shoulder joint in cases of upper limb lymphedema or back in lymphedema of
both members from 24 hours of application.
Declaration of interest
none declared
101

O-12.07
AN INNOVATIVE APPROACH TO TREATING LYMPHATIC ASSOCIATED PATHOLOGIES USING
OSTEOPATHIC SPINAL MANIPULATIONS
S Merrett, Flinders, Adelaide, AUSTRALIA
N Piller, Flinders, Adelaide, AUSTRALIA
The manual lymphatic pump technique is acknowledged to be effective in the treatment of lymphoedema. The question is
raised as to whether other manual techniques (such as 'spinal manipulations') can be used to achieve changes in lymphatic
dynamics.
Various manual therapists utilise techniques that are classified as 'manipulative'. Although the fine details vary between the
professions (for example Osteopaths use "High Velocity Low Amplitude" (HVLA) thrusts) the general premise is to use an
operator directed thrust technique to achieve a cavitation (audible popping noise) in the prescribed joint of the patient. These
manipulative techniques are associated with improved joint ranges of motion, altered biomechanics, neurological changes
and the release of chemical messengers. As the cysterna chyli is primarily innervated via the 11th thoracic ganglion, it is
hypothesised that a manipulation in this region of the thoracic spine may result in localised increases in sympathetic tone,
causing enhanced pumping of the lymphatic tissues and resulting in an increase in local and systemic lymphatic flow.
The current work therefore aims to establish whether an Osteopathic HVLA thrust technique to the thoracic region has
any influence on the lymphatic flow through the cysterna chyli. For the initial study a cohort of healthy volunteers are to be
recruited. Each person will be assessed pre and post intervention to establish if any changes in their physiological parameters
are demonstrated as a result of the Osteopathic intervention. The physiological parameters and body composition will be
measured using the INBody 3.0 and the Impedimed LU400 in the Department of Surgery, Lymphoedema Assessment Unit,
Flinders Medical Centre, Australia.
The paper will present the results from the study as well as exploring the potential mechanisms of action for the intervention.
Based on the results it will be possible to establish whether an Osteopathic HVLA thrust technique to the thoracic region
provides an innovative adjunct and/or alternative treatment modality for enhancing lymphatic flow through the cysterna
chyli. If the provisional study demonstrates suitable outcomes in the healthy volunteers then it will be repeated in those with
clinically manifest lymphoedema of the legs and lower body.
Declaration of interest
none declared
O-12.08
A YOGA INTERVENTION FOR BREAST CANCER-RELATED LYMPHOEDEMA
J Douglass, Flinders University, Adelaide, AUSTRALIA
M Immink, UniSA, Adelaide, Australia
N Piller, Flinders Universoty, Adelaide, Australia
BACKGROUND: Breast cancer related lymphoedema (BCRL) is a common sequelae of breast cancer treatment with reported
incidence from 6 - 83%. Established BCRL will persist for the remaining lifetime potentially impacting almost every aspect of
life. Historically best practice advice was to restrict using the arm, however recent research indicates that exercise may reduce
BCRL-related symptoms. Given the importance of exercise for breast cancer survivors generally it is important to identify
physical activities that are safe and beneficial for women who have, or are at risk of BCRL. Yoga practice has been shown to
benefit women recovering from breast cancer treatment; however no research has been conducted into the effects of a yoga
program in women with BCRL.
OBJECTIVE: A preliminary investigation into the effectiveness of a yoga-based program; which includes adapted exercise,
relaxation, and meditation. Primary outcomes were the reduction in objective measures of lymphoedema and secondary
outcomes to improve BCRL symptoms and quality of life.
METHODS: A randomised-control trial was conducted n=24 women with unilateral BCRL. All participants received
education in self-management and risk reduction. An intervention group attending a four-week yoga-based program
involving weekly classes and daily home practice. A wait-listed control group received self-management and risk reduction
education alone. Objective measurements were taken pre and post test using bioimpedance spectroscopy (BIS), perometry
and tissue tonometry. Questionnaires were used to record self-reported symptoms, quality of life, and hope. All participants
kept a journal of their daily activities and the intervention group also recorded frequency of their home practice.
RESULTS: Overall there were no statistically significant changes in lymphoedema between the intervention and control
groups. There were some clinically relevant changes for individual participants but this did not show a strong trend for either
an increase or decrease in objective measures. Similarly self reported symptoms and QOL scores did not show any significant
differences between the two groups.
CONCLUSION: BCRL status and symptoms were neither improved nor exacerbated as a result of participation in an adapted
yoga program. Further larger trials are warranted to examine the potential benefits of yoga for the management or prevention
of BCRL.
Declaration of interest
None declared
102

O-12.09
LYMPHEDEMA PROFUNDA: A NEW CLINICAL ENTITY, A NEW ROLE ADDED FOR
LYMPHOLOGISTS
W Ekataksin, Mahidol University, Bangkok, THAILAND
Background Some patients have desperately sought solution as to their sickness, “swelling from inside,” a subjective sense that
so far unverified objectively. As a result, the emerging treatment at Thailand Lymphedema Day Care Center has been consulted;
such sufferers has mounted to above one thousand during the last two years. Objectives To document clinical entity under the
discipline of lymphology and to define what lymphologists have to offer. Methods When primary or secondary lymphedema
could not be diagnosed, patients were subject to a “pinpoint pain, palmpress painless” (PPP/PPP) test. In positive cases, if
the quadriceps were finger-pressed laterally or medially along the femur, or the paratibial lines done likely, tenderness was
elicited; pain disappeared promptly if palm-pressed instead. Calves, popliteal fossa, and gluteal areas were likewise elicitable for
tenderness. These were lymphedema profunda (LEP). Still, a quarter of patients had tender areas extended into body, armpits,
neck, head, face, back, breast, and upper limbs; they were referred to as lymphedema profunda with body involvement (LEP/
BI). All were investigated with MRI half or whole body; reconstruction of T2W/fat suppression was essential for diagnosis.
Results LEP patients came from all classes of BMI, 30 kg/m2, more of the overweight and obese. With a
wide range of 12-90 years of age, LEP were 90% female, most abundant in middle decades, usually with lipoedema. On MRI,
lymphatic dilatation and saccular formation was found corresponding to the tender areas, i.e. paratibial, myofascial, and deep
subcutis. In LEP/BI lymphatic fluid characteristically spread in breast tissue, often associated with axillary lymphadenitis;
sometimes lymph pooled along flank lines down to hips. Chief complaints as leg fatigue, joint pain, night cramp, hip and low
back pain, disappeared after our prescribed compression therapy. Surprisingly breast pain vanished as immediately as the
arms regained maximum strength. Conclusions LEP/BI patients had been suspected/diagnosed variously, such as myositis,
fibromyalgia, neuritis, carpal tunnel syndrome, disk hernia, seronegative spondyloarthritis, rheumatoid arthritis, lupus,
gastroesophageal reflux disease, fibrocystic change of mammary gland, postmenopausal syndrome, migraine, true vertigo,
schizophrenia, etc. They came to accomplish a better quality of life via management by a lymphologist.
Declaration of interest
None declared
O-13.01
"NEW HOPE FOR LYMPHOEDEMA PATIENTS"
G Manokaran, Apollo Hospitals, Chennai, INDIA
As you all know patients with lymphoedema are so unfortunate that they never get cured irrespective of the etiology, only
lymphatic filarasis in Stage I and Stage II lymphoedema are curable and reverable. Lymphoedema progresses due to secondary
infection, cellulitis, lymphangitis due to injury, intertrigo (fungal infection) and focal sepsis like carries teeth in the patients.
Controlling or eliminating these problems with simple foot hygiene, washing with soap and water, using antifungal cream
or powder, eliminating the focal sepsis by dentist along with Manual Lymph Drainage (MLD) and bandaging with regular
physiotherapy helps in keeping this problem under control.
Only very few congenital, post-surgical lymphoedema patients needs micro-vascular surgery, lymphatico lymphatic
anastomosis, free lymph node or muscle transfers to address this problem, though not cured completely. Liposuction is found
to be very useful in post-mastectomy lymphoedema.
LF lymphadema which loses its shape needs multiple stage reduction surgery followed by physiological operations or MLD.
Our policy of treating these patients by multi-modality therapy will be discussed as an ideal recommendation for these
patients through a power-point presentation, for roughly twenty minutes.
Declaration of interest
None declared
103

O-13.02
"GENITAL MANIFESTATION OF LYMPHATIC FILARASIS"
G Manokaran, Apollo Hospitals, Chennai, INDIA
Lymphatic filarasis has affected more than seventy million people world over, out of which forty million has been affected
with genital manifestations. Male are more commonly affected than female. The most common manifestations among male
being hydrocile, filarial scrotum, rhamphorns penis and among female being genital warty lesions, vesicles, lymphorea, etc.
As this being most psychological disturbing, emotionally upsetting and embrassing situation for these unfortunate patients,
they seek medical help most of the time at the very last stage of the disease.
As this affects their sexual function and bring down their self-esteem, they all need some immediate long-term relief. For the
past thirty years, we have treated various types of genital manifestations of lymphatic filarasis with various techniques, both
in the male and female.
Declaration of interest
None declared
O-13.03
PRECLINICAL LYMPHOEDEMA - A LYMPHOSCINTIGRAPHIC CORRELATION
G Manokaran, Dept of Plastic Surgery, Apollo Hospitals, Chennai, INDIA
In an endemic country like India there are patients who has been referred to us for diagnosis of vague symptom like multiple
joint pain, which are fleeting in nature, but comes periodically in spite of seeing orthopaedician, rheumatologist. We
exemine the patients clinically, they may not have any clinical signs. Lymphoscintigraphy shows changes with dilatation of
lymphatics in the affected limb. After administratin of antifilarial DEC for 3 weeks the symptoms disappear. They are treated
prophylactically every month in a small dose for one year. Follow-up show no clinical symptoms and the lymphoscintigraphic
changes are reversed. We call this preclinical or atypical lympatic filariasis, which can only be diagnosed by LAS.
Declaration of interest
None declared
104

O-13.04
LYMPHATIC FILARIASIS: A METHOD TO IDENTIFY SUBCLINICAL LOWER LIMB CHANGE IN PNG
ADOLESCENTS
S Gordon, James Cook University, Douglas, AUSTRALIA
W Melrose, James Cook University, Douglas, AUSTRALIA
J Warner, James Cook University, Douglas, AUSTRALIA
P Buttner, James Cook University, Douglas, AUSTRALIA
L Ward, University of Queensland, St Lucia, AUSTRALIA
Background: The mosquito-borne parasitic disease lymphatic filariasis (LF) is endemic in around 81 tropical countries, has
a global burden of around 120 million cases, and is classified by the World Health Organization as the second most common
cause of long term disability after mental illness. The effects of LF on the lymphatic system often become apparent during
adolescence when the lower limb swells due to lymphedema and males develop hydrocele.
Objective: To establish a non-invasive, mobile field method to identify early, sub-clinical changes of lymphedema secondary
to LF in the lower limbs of adolescents in Papua New Guinea (PNG).
Methods: Ethical approval for this study was provided by the PNG Medical Research Council. The study was undertaken in
the village of Opau, Central Province, PNG. Fifty-three adolescents, 25 LF infected and 28 LF non-infected, in age and sexmatched
groups, using the Binax ICT rapid card test for filarial antigen were recruited to the study. None of the participants
had overt signs of lymphedema. Lymphedema assessment measures were used to assess lower limb tissue compressibility
(tonometry), limb circumference (tape measure), intra- and extra-cellular fluid distribution (bioimpedance) and joint range
of motion (goniometry).
Results: Thigh circumference and posterior thigh tissue compressibility (tonometry)were significantly greater in the LF
infected adolescents. ROC curve analysis to define optimal cut-off of the tonometry measurements indicated that at 3.5,
sensitivity of this potential screening test is 100% (95%-CI = 86.3%, 100%) and specificity is 21.4% (95%-CI = 8.3%, 41.0%).
It is proposed that this cut-off can be used to indicate early tissue change characteristic of LF in an at-risk population of PNG
adolescents.
Conclusions: Further longitudinal research is required to establish if all those with tissue change subsequently develop
lymphedema. However, thigh tonometry to identify early tissue change in LF positive adolescents may enable early
intervention to minimize progression of lymphedema and prioritization of limited resources to those at greatest risk of
developing lifetime morbidity.
Declaration of interest
None declared.
O-13.05
SURGERY OF ELEPHANTIASIS NOSTRAS VERRUCOSA OF THE FOOT IN CHRONIC LYMPHEDEMA
OF THE LEG
D A. A. Lamprou, Nij Smellinghe Hospital, Drachten, NETHERLANDS
P. Klinkert, Tjongerschans Hospital, Heerenveen, Netherlands
O. R M. Wikkeling, Nij Smellinghe Hospital, Drachten, Netherlands
R.J. Damstra, Nij Smellinghe Hospital, Drachten, Netherlands
H. G. J. Voesten, Nij Smellinghe Hospital, Drachten, Netherlands
Background: In chronic (untreated) lymphedema of the legs, Elephantiasis Nostras Verrucosa (ENV) is a well known but
rare complication . It appears as a severe deformity of the skin (mostly of the toes and forefoot) as an end result caused
by chronic stasis of lymphe fluid. This so called Papillomatosis (pseudotumour-like proliferation of the skin) may develop
when there is epidermal acanthosis, hyperkeratosis and proliferation of the connective tissue. Under the microscope these
papillomata contain a very small number of dilated lymphatics. Papillomatosis not only is a port d’entree for bacterial
infection and subsequent erysipelas but also causes impairment of locomotion and therefore negatively influences lymphe
transport capacity of the leg.
Objectives: To demonstrate that the ‘shaving’ technique combined with postoperative compression is a safe and effective
treatment for Elephantiasis Nostras Verrucosa.
Methods: This presentation will show the results of the treatment in 15 patients with Elephantiasis Nostras Verrucosa of the
feet. After initial conservative therapy , patients were treated by surgery: excessive lobular hyperkeratotic tissue was initially
removed with sharp excision followed by contour correction by means of shaving by a one-bladed razor until pinpoint
bleeding could be demonstrated. Compression was resumed directly after surgery with ointment and non adhesive dressing.
After completion of wound healing garments with toe-caps were prescribed. None of the patients had an infection.
Results: During follow-up there was no recurrence of the Elephantiasis Nostras Verrucosa.
Conclusion: ‘Shaving’ technique combined with a multi-disciplinary approach including pre- and postoperative compression
therapy and lifelong wearing of compression garments is effective in the treatment of Elephantiasis Nostras Verrucosa.
Declaration of interest
None declared
105

O-13.06
PODOCONIOSIS IN ETHIOPIA. A PILOT STUDY TO IMPROVE THE MANAGEMENT OF
LYMPHEDEMA.
M LOPEZ - AGUSTIN, Fontilles&fundacion Francisco Lorente, VALENCIA, SPAIN, M GUTIERREZ - DELGADO, University
Hospital La Fe, VALENCIA, SPAIN, I FORNER - CORDERO, University Hospital La Fe, VALENCIA, SPAIN
Background: Podoconiosis is a non-infectious cause of lymphedema, frequent in some African countries. It provokes not
only medical problems of elephantiasis and repetitive dermatolymphangitis, but also a severe disability and a social stigma.
Objectives: This pilot study aims to improve /to implement the management of lymphedema secondary to podoconiosis in
a rural hospital in Southern Ethiopia.
Methods: A call for donation of compression garments was done in Spain, to give any used and retired garment, even if
deteriorated, in different associations of lymphedema patients (i.e. ACVEL) and in the Forum of Lymphedema in the internet
(http://www.med-foren.de/ ). The collected garments, principally stockings were sent to the Rural Hospital in Gambo,
Southern Ethiopia.
A physiatrist M Lopez-Agustin worked there for 6 months, between November 2010 to April 2011, sponsored by Fontilles
and Fundacion Francisco Lorente.
The working plan was:
- To train the staff in the lymphatic system, the causes of lymphedema, prevention strategies, skin care, intensive treatment
and maintenance.
- Decongestive lymphatic treatment of the patients
- Adaptation of the donated garments for maintenance phase
Results: Fifteen patients with lower limb lymphedema secondary to podoconiosis have received DLT. The reduction of the
lymphedema volume was significant with 10 sessions of treatment. The maintenance phase was made possible to perform by
means of the donated garments.
This improvement in the management of this neglected disease has generated:
- The appointment of a physiotherapist trained in lymphedema in the Rural Hospital of Gambo.
- An increase in the number of the patients coming to the hospital looking for attendance.
- A start to reduction of the social isolation of patients.
Conclusions: This pilot study has had good results in helping lymphedema management in Southern Ethiopia. The donation
of used garments by chronic patients can be a feasible and effective step to improve the maintenance phase of the patients with
lymphedema in places with limited resources.
Declaration of interest
None declared.
O-14.01
MICROSURGERY IN PREVENTING AND TREATING LYMPHEDEMA AFTER SKIN MELANOMA
TREATMENT
F Boccardo, University of Genoa, Italy, Genoa, ITALY
C Campisi, University of Genoa, Genoa, ITALY
C Campisi, University of Genoa, Genoa, ITALY
R Lavagno, University of Genoa, Genoa, ITALY
S Accogli, University of Genoa, Genoa, ITALY
F De Cian, University of Genoa, Genoa, ITALY
P L Santi, University of Genoa, Genoa, ITALY
C Campisi, University of Genoa, Genoa, ITALY
Background: The appearance of lymphedema after inguinal and axillary lymph nodal dissection due to melanoma treatment
is a crucial problem that highly jeopardizes one’s quality of life.
Objectives: To evaluate the efficacy of microsurgical procedures in the prevention and management of lymphedema after skin
malignant melanoma treatment.
Methods: The study includes 37 patients who underwent complete iliac and groin dissection and axillary lymphnodal
dissection for the treatment of skin malignant melanoma. In 16 patients with melanoma at the trunk, microsurgical
lymphatic-venous anastomoses were performed at the groin (10) and at the axilla (6) simultaneously with lymphnodal
dissection. In other 21 patients with melanoma at the extremities (13 lower and 8 upper limbs), lymphedema was treated
by microsurgery at later stages after proper time from melanoma treatment and an accurate oncologic assessment. They all
underwent lymphoscintigraphy to assess superficial and deep lymphatic circulation of the limb and Duplex Scan to rule out
the presence of any venous disorder. All patients were assessed with volume measurements at short and long term follow-up
and, post-operatively, lymphoscintigraphy was performed in 11 patients.
Results: Microsurgical preventive approach allowed to avoid the occurrence of secondary lymphedema in all patients
treated with lymphatic-venous anastomoses performed simultaneously with lymphnodal dissection. Those patients operated
on afterwards, based on a proper oncological follow-up, had significant (about 80% averagely) reduction of edema. Postoperative
lymphoscintigraphy demonstrated the patency of anastomoses at over 5 years from operation.
Conclusions. Proper preventive and microsurgical therapeutic strategies of secondary peripheral lymphedema, that include
lymphoscintigraphy and reconstructive microsurgical procedures, proved to reduce the incidence of lymphedema after
melanoma treatment and to successfully manage already stabilized lymphedema.
Declaration of interest
None declared
106

O-14.02
SHOULDER-ARM MORBIDITY IN EARLY BREAST CANCER PATIENTS TREATED WITH TWO
DIFFERENT RADIATION TECHNIQUES
N Adriaenssens, VUB/UZB, Jette (Brussels), BELGIUM, H Van Parijs, UZB, Jette, BELGIUM, V Vinh - Hung, UZB, Jette,
BELGIUM, T Reynders, UZB, Jette, BELGIUM, M De Ridder, UZB, Jette, BELGIUM, J Lamote, UZB, Jette, BELGIUM, P
Lievens, VUB, Jette, BELGIUM
BACKGROUND: Adjuvant radiation therapy (RT) after breast cancer surgery, especially to the axilla, is a risk factor for the
development of shoulder-arm morbidity, but it reduces the risk of local recurrence by approximately 33% and increases survival
rates. With the introduction of modern radiation technologies, long term irradiation sequelae have decreased.
Hypofractionation shortens the treatment schedule and is an acceptable alternative to the conventional RT in terms of curation.
TomoTherapy ® lowers the delivered irradiation dose to vital organs.
Minor changes in fractionation and dose distribution are associated with a large variation in the risk of developing shoulderarm
morbidity. Since hypofractionation delivers a bigger size of dose per fraction, a higher incidence of shoulder-arm morbidity
could be expected.
OBJECTIVES: The main objective is to determine whether the incidence of shoulder-arm morbidity in early breast cancer
patients treated with hypofractionated RT with TomoTherapy® is higher than in patients treated with conventional post-surgery
RT.
METHODS. Breast Cancer Related Lymphedema of the arm (BCRL), shoulder mobility and scapula positioning have been
evaluated before the intervention and one to three months after finishing the intervention.
Circumferential tape measurements have been performed to diagnose BCRL, through the ≥ 2 cm and ≥ 10% diagnostic criteria,
together with self-reported subjective BCRL symptoms. Shoulder mobility has been assessed by a goniometer and scapula
positioning has been determined by inspection, palpation and the lateral scapular slide test.
RESULTS. The principal results of 93 pts show that there is no significant difference (p < .05) in BCRL incidence, shoulder
mobility impairment and altered scapula positioning between the control and the intervention group, before and after the
intervention.
CONCLUSIONS: Hypofractionated RT with TomoTherapy ® does not cause higher BCRL incidence, impaired shoulder mobility
and altered scapula positioning compared with conventional post-surgery RT, one to three months after finishing the RT.
Our research group is preparing the results of the follow-up of one, two and three years after finishing the RT, in the required
118 patients, including vital organ toxicity, quality of life and tonometry as main outcome measures, which will be presented at
the congress.
Declaration of interest
None declared
O-14.03
LYMPHEDEMA OF THE BREAST IN BREAST CANCER PATIENTS FOLLOWING BREAST
CONSERVING SURGERY WITH RADIATION THERAPY
N Adriaenssens, VUB/UZB, Jette (Brussels), BELGIUM
H Verbelen, VUB, Jette, BELGIUM
J Lamote, UZB, Jette, BELGIUM
P Lievens, VUB, Jette, BELGIUM
BACKGROUND: The National Institutes of Health Consensus Development Conference on Treatment of Early-Stage Breast
Cancer indicated, in 1990, that breast conserving surgery with radiation therapy (RT) is the primary therapy for the majority
of women with early stage breast cancer. It is preferable to total mastectomy, because it provides survival equivalence while
preserving the breast, but several patients develop lymphedema in the operated breast (BE).
OBJECTIVE: The main objective of the study is to determine the incidence and degree of BE in female breast cancer patients
following breast conserving surgery with RT, less than five years post surgery. Determination of risk factors, influence on
quality of life and pattern of bra use are secondary objectives.
METHODS: Subjective symptoms of the operated breast, like swelling, redness, peau d’orange and sensibility disorders
have been scored on a scale between 0 (symptom not present) and 10 (symptom is intolerable). The EORTC QLQ-BR23
questionnaire has been completed to assess the quality of life.
RESULTS: In the 131 included patients, the incidence of BE is 75.6 %, but the mean degree of BE is only 13.8%. There is a
significant negative correlation (p < 0.05) between the degree of BE and the time since surgery, and a significant positive
correlation (p < 0.05) between the degree of BE and BMI. No relation is found between the degree of BE and axillary dissection,
location of the tumor, preoperative bra cup size or hand dominance.
There is a significant negative correlation (p < 0.001) between the degree of BE and body image/future perspective. A
significant positive correlation (p < 0.001) is found between the degree of BE and side effects of systemic therapy/breast
symptoms/arm symptoms/upset with hair loss (p = 0.019).
CONCLUSION: Despite the benefits of breast conserving surgery, BE is a common complication, negatively influencing
quality of life.
Our research group is developing an objective diagnostic method for BE, because incidence and degree vary widely according
to the subjective criteria that are used today. This will be presented at the congress with the results of the influence of BE on
pattern of bra use.
Declaration of interest
None declared
107

O-14.04
ARM LYMPHOEDEMA AND IMPAIRED SHOULDER MOBILITY AFTER TREATMENT FOR PRIMARY
BREAST CANCER BY ELDERLY WOMEN
I Christiansson, SUS Malmö, Malmö, SWEDEN
Background: The aim was to study the incidence of arm lymph oedema and impairment of shoulder mobility after breast
cancer surgery in combination with or without postoperative radiotherapy.
Objectives: Women aged 70 -79 years.
Methods: Forty-six women aged 70-79 years with breast cancer who were treated with two different surgical methods were
studied prospectively regarding lymph oedema in the arm and reduction of the mobility in the shoulder. Follow up was done
after one and two years. All patients had axillary clearance. Thirty were treated with modified radical mastectomy, sixteen
with partial mastectomy. Nineteen patients had radiotherapy with two different methods. After modified radical mastectomy
the thoracic wall, glandulary fields in the axillary and fossa supraclavicaris were radiated. After partial mastectomy only the
operated breast was radiated.
Results: After modified radical mastectomy and radiotherapy 6/9 patients had arm lymph oedema and impaired shoulder
mobility. After partial mastectomy with radiotherapy 2/10 had lymph oedema. If radiation therapy was not given 2/27 had
lymph oedema. Impaired shoulder mobility showed the same pattern. More advanced tumour stage correlated positively with
increased frequency of lymph oedema. Five of the seven patients who developed lymph oedema during the first year also
had impaired mobility (p10%. Following inguinofemoral surgery, LVC of 5-10% and >10% was noted
in 21% and 25%, respectively. LVC was more common in those with body mass index >30kg/m2, LND, inguinal vs. axillary
LND, and radiation therapy. The median (range) change in symptom scores from baseline for axillary LND patients with
LVC >10% was 9 (1,11) compared to 1 (-1,7) for patients with 5% LVC was
1.97 (95% CI:1.08-3.60) for inguinal LND compared to axillary LND.
Conclusions: Using a prospective approach and objective criteria, LVC >5% is a common occurrence in melanoma patients.
Symptom scores were significantly increased for patients with LVC >10%, except for those undergoing inguinal LND as they
had a high number of symptoms regardless of LVC. Inguinal LND is associated with a 2-fold increase in LVC compared to
axillary LND. Informed consent for melanoma patients undergoing lymph node surgery should include a discussion of the
risks of postoperative lymphedema.
Declaration of interest
None declared
108

O-14.06
IS THERE A LINK BETWEEN LYMPHOEDEMA TREATMENT AND BREAST CANCER
REOCCURENCE?
R Dawson, Flinders University, Bedford Park, AUSTRALIA
D de Vries, Flinders University, Bedford Park, AUSTRALIA
N Piller, Flinders University, Bedford Park, AUSTRALIA
J Rice, Flinders Medical Centre, Bedford Park, AUSTRALIA
Background: The treatment of lymphoedema encompasses many modalities. Manual lymphatic drainage, compression devices
and low level laser are known to increase lymph flow from and through the affected extremity. However there are occasional
rumours that these lymph flow enhancing treatments can spread cancer cells and contribute to disease progression.
Objectives: To determine if there is any relationship between low level laser therapy and manual lymphatic drainage, and the
re-occurence of cancer.
Methods: Ethics permission from Southern Adelaide Health Service/Flinders University human research ethics committee
was obtained to conduct the audit. The primary data was collected as medical records for patients of the Flinders Breast Cancer
Unit and Lymphoedema Assessment Clinic between 1994 and 2010. This data consisted of 1536 patients and contained all
necessary bio-data. Records for breast cancer treatment were kept for all patients. A breast nurse kept a diary of cancer reoccurrence
from 2000-2010. From this data, records of treatment for breast cancer between 2000 and 2008 for 1298 individual
patients, of whom 52 had treatment for lymphoedema were extracted, as well as the records of cancer re-occurrence dated
between 2000 and 2010. All data were aggregated and summarised using MS Access 2007.
Results: To test whether there was a significant difference between the proportion of patients who underwent lymphoedema
treatment against those who did not, a two-tailed statistical test with a confidence level of 99% was made. The results show
there is no significant difference between the proportions of cancer re-occurrence between patients who received treatment
for lymphoedema and those who did not.
Conclusions: Treatment of lymphoedema consisting primarily of low level laser and manual lymphatic drainage does not
impact on cancer re-occurrence rates.
Declaration of interest
None declared
O-14.07
AXILLARY LYMPH NODES BEFORE AND AFTER COMPLETE AXILLARY CLEARANCE IN WOMEN
UNDERGOING BREAST CANCER SURGERY
A Szuba, Wroclaw Medical University, Wroclaw, POLAND, A Chachaj, Wroclaw Medical University, Wroclaw, POLAND,
M Koba - Wszędybył, Wroclaw Medical University, Wroclaw, POLAND, R Hawro, University School of Physical Education,
Wroclaw, POLAND, R Jasiński, University School of Physical Education, Wroclaw, POLAND, R Tarkowski, Wroclaw Medical
University, Wroclaw, POLAND, K Szewczyk, Wroclaw Medical University, Wroclaw, POLAND, A Jodkowska, Wroclaw Medical
University, Wroclaw, POLAND, U Pilch, University School of Physical Education, Wroclaw, POLAND, M Woźniewski, University
School of Physical Education, Wroclaw, POLAND
BACKGROUND: There are only few studies on effects of axillary lymph node dissection (ALND) on upper extremity
lymphatic drainage evaluated by lymphoscintigraphy. Preoperative evaluation of patients before ALND may provide further
clues to better understanding of pathogenesis of breast cancer related lymphedema. OBJECTIVES: The study was designed
to evaluate changes in upper extremity lymphatic drainage after ALND in comparison to the preoperative status using
lymphoscintigraphy.
METHODS: 30 women (mean age: 55,97; range: 29–80 years) with a new diagnosis of unilateral invasive breast carcinoma
who had surgery that included ALND were examined. Standard procedure that encompasses removal of levels I, II and
III nodal tissue in one bloc was performed in every case, regardless to the clinical axillary lymph nodes (ALNs) status. All
women underwent lymphoscintigraphy of upper extremities preoperatively and 1-6 weeks after surgery. In 22 women upper
extremity venous system was also evaluated pre- and postoperatively with photoplethysmography.
RESULTS: Analysis of lymphoscintigrams revealed that after surgery ALNs were observed in 26 of 30 examined women. In
comparison to the preoperative status they were visualized in the same location (12 women), in the same and additionally in
different location (9 women), or only in different location (4 women). No lymph nodes was noticed in 1 woman and presence
of lymphocoele in 4 women. Lymphatic transport from the upper extremities estimated by qualitative lymphoscintigraphy
was not affected by the surgery: differences between lymphoscytygraphic axillary ratio and tracer disappearance rate before
and after ALND were not statistically relevant. Also venous function examined by photoplethysmography was not affected by
surgery: venous pump index and venous refill time did not differ before and after surgery.
CONCLUSIONS: ALNs can be detected in majority of women who underwent ALND. Current surgical technique of level
I+II+III ALND does not allow to dissect all the ALNs in majority of operated women. Visualization of ALNs in different
locations in comparison to the preoperative status in almost half of the women indicates that collateral lymphatic pathways
were recruited and may represent a compensatory mechanism after impairment of axillary lymphatic circulation.
Declaration of interest
None declared
109

O-14.08
CORDING IN THE PRESENCE OF BREAST CANCER RELATED LYMPHEDEMA: A PROSPECTIVE
STUDY ON NATURAL HISTORY
J O' Toole, Massachusetts General Hospital, Boston, UNITED STATES, M N Skolny, Massachusetts General Hospital, Boston,
UNITED STATES, C L MIller, Massachusetts General Hospital, Boston, UNITED STATES, T A Russell, Massachusetts General
Hospital, Boston, UNITED STATES, M Specht, Massachusetts General Hospital, Boston, UNITED STATES, M Ancukiewicz,
Massachusetts General Hospital, Boston, UNITED STATES, R Schainfeld, Massachusetts General Hospital, Boston, UNITED
STATES, S J Isakoff, Massachusetts General Hospital, Boston, UNITED STATES, B L Smith, Massachusetts General Hospital,
Boston, UNITED STATES, A G Taghian, Massachusetts General Hospital, Boston, UNITED STATES
BACKGROUND: Cording following treatment for breast cancer(BC) is a painful condition that has been reported as self-limiting
and occurring only in the post operative period. To date, no large cohort has been monitored for this problem in a prospective and
ongoing manner, nor has the association of lymphedema with cording been studied.
OBJECTIVES: Our purpose was to assess the incidence and time course of cording following treatment for BC and determine if it
is associated with upper extremity lymphedema.
METHODS: From August 2009 to December 2010, 135 women with unilateral BC were evaluated as part of a prospective trial
screening for BC related lymphedema. Participants were assessed with bilateral volumetric arm measurements with perometery
and by completing a survey of upper quarter symptoms, cording, physical function, and quality of life. Edema was quantified as
the relative volume change (RVC) compared to baseline. Lymphedema was defined as an RVC≥5% above baseline. Per protocol,
measurements occurred pre- and post-operatively, following chemotherapy and/or radiation, and at 4-7 month intervals. Groups
were compared utilizing the Fisher exact test.
RESULTS: Post-operative cording was reported in 37.8% (51/135) of patients at the first visit following surgery, with mean
time to follow up of 3.6 weeks. 15.7% (8/51) of these patients also had lymphdema. 86 patients were measured at a second time
postoperatively, with a mean time to follow of 4.3 months. 34.9% (30/86) continued to report cording at that time. 26.7% (8/30) of
these cases reported cording for the first time. Of patients who reported cording at this point, 60.0% (18/30) had an axillary lymph
node dissection and 43.3% (13/30) had a mastectomy. Cording at this point was associated with axillary node dissection (P5%. The presence of cording at this time was strongly associated with
lymphedema (P=0.007).
CONCLUSION: The results demonstrate that cording following treatment does occur beyond the early post operative period. The
data indicates that cording that persisted for several months following surgery was strongly associated with lymphedema supporting
the need for continued study of the natural history of cording.
Declaration of interest
None declared
O-15.01
THE LIPO-LYMPHEDEMA: DEFINITION OF DISABILITY BY INTERNATIONAL CLASSIFICATION OF
FUNCTIONING.
M Cardone, San Giovanni Battista Hospital, Roma, ITALY
S Michelini, San Giovanni Battista Hospital, Roma, ITALY
A Failla, San Giovanni Battista Hospital, Roma, ITALY
G Moneta, San Giovanni Battista Hospital, Roma, ITALY
F Cappelino, San Giovanni Battista Hospital, Roma, ITALY
A Fiorentino, San Giovanni Battista Hospital, Roma, ITALY
INTRODUCTION: The lipedema affects about 10% of the female population and is characterized by the presence of pain,
swelling, mechanical and overall functional impairment and a tendency to easy bruising and hematomas. In advanced stages
is associated with lymphostasis. The disease, to date, is not included in the International Classification of Diseases
AIMS: The purpose of this study is defining the disability caused by the disease for treatment, prevention and definitive
international framework in a nosological pont of view.
METHODS: 64 patients with lipedema were studied in the three evolutionary stages (all females aged between 7 and 81
years). The clinical features were described with the International Classification of Functioning before and after physical
decongestive treatment. All patients underwent lymph drainage, non elastic multilayer bandage, vacuumtherapy.
RESULTS: It was found a direct proportionality between the clinical stage of the disease and the functional commitment
of the patients, evidenced particularly in the domains D (activities and performances) and E (influence of environmental
factors) of the Classification. In particular, in stage I the qualifiers found coincided with slight physical effort (1); in stage II
it was highlighted the presence of at least one qualifier expression of medium commitment in each domain (2). In stage III,
there was at least one qualifier between the two domains, which demonstrate a major commitment (3).
CONCLUSIONS: The study shows the severity of the disease developed in the late stages, which translates into a major
handicap for the patient. This should help the recognition of lipedema as a real 'disease'.
Declaration of interest
None declared
110

O-15.02
COMPLEX DECONGESTIVE THERAPY IN LIPEDEMA
G Szolnoky, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY
S Diana, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY
L Kemény, Department of Dermatology and Allergology istället för Department, Szeged, HUNGARY
According to general view, fat tissue cannot be compressed therefore its volume is barely reducible. The available two
studies seem to disagree with this concept. However both studies found significant volume decrease due to compression
supplemented with physiotherapy, these values are insufficient to have a considerable impact on limb shape, cosmetological
appearance and mobility.
Anecdotical reports agree that high compression pressure is useless in lipedema because patients tolerate only low pressure.
In the clinical practice we prescribe high compression pressure stockings to the majority of our lipedema patients therefore
own observations discouraged this opinion.
We were interested to elucidate this controversy therefore recently conducted a retrospective cohort study to compare the
wearability of pantyhoses with 23-32 mmHg (lower) and 34-46 mmHg (higher) original pressures.
17 patients constantly wearing lower and 22 patients with higher pressure pantyhoses were included. Interface pressure
measurement was performed at B1 in each limb and subjective perceptions were assessed with chronic venous insufficiency
questionnaire (CIVIQ).
There was a significant difference between mean interface pressure values. None of the questions of CIVIQ made a distinction
between lower and higher pressure stockings.
This clinical trial supports our experience that lipedema patients can tolerate lower and higher pressures nearly equally.
Declaration of interest
None declared
O-15.03
LONG-TERM OUTCOME AFTER SURGICAL TREATMENT OF LIPEDEMA
H Brorson, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
A Warren Peled, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
S Slavin, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
Background: Lipedema is a condition characterized by abnormal deposition of adipose tissue in the lower extremities leading
to circumferential bilateral lower extremity enlargement typically seen extending from the hips to the ankles.
Methods: Diagnosis of the condition is often challenging, and patients frequently undergo a variety of unsuccessful therapies
before receiving the proper diagnosis and appropriate management. Patients may experience pain and aching in the lower
extremity in addition to distress from the cosmetic appearance of their legs and the resistance of the fatty changes to diet and
exercise.
Results and Conclusion: We report a case of a patient with lipedema who was treated with suction-assisted lipectomy and use
of compression garments, with successful treatment of the lipodystrophy and maintenance of improved aesthetic results at 4
years’ postoperative follow-up.
Declaration of interest
None declared
111

O-15.04
PAIN IN LIPOEDEMA
I Meier - Vollrath, Hanse-Klinik, Lübeck, GERMANY
Introduction: In the scientific literature complaints in patients with lipoedema are mainly described as pain due to pressure
or as tenderness.
Objective: To better classify the quality of pain in lipoedema and to determine the extent of complaints.
Methods: 50 patients with lipoedema stage II received a questionnaire with 30 items containing adjectives of sensory and
affective pain qualities. For these items they could choose between ”fits exactly”, “fits fairly well”, “fits little”, or “does not fit”. In
addition, patients were asked to describe their complaints with their own words.
Results: In most cases the items “pressing” and “nagging” were chosen. Many patients used the characterizations “heavy”,
“tearing”, “distressing”, “enervating”, “fierce”, “unbearable”, exhausting”, and “pinching”. The median values of all patients´
sensory and affective scores showed – compared to people with chronic pain – “average” values. However, by using their own
words, the complaints were often described as extremely burdensome.
Conclusion: For describing their pain only few items were used by lipoedema patients. There were great interindividual
variations. Beside objective clinical aspects also subjective aspects of pain should be considered in the characterization and
the grading of lipoedema.
Declaration of interest
None declared
O-15.05
LIPOEDEMA AND ASSOCIATED COMPLAINTS (OBESITY, ORTHOPAEDIC PROBLEMS)
W Schmeller, Hanse-Klinik, Lübeck, GERMANY
In Western society the percentage of people with a body mass index (BMI) > 30 kg/m2 is said to be between 10 and 20%
(Kunz et al, 2010, Dt. Aerzteblatt). In a study of 112 women with lipoedema, who underwent liposuction in our clinic within
the last 7 years, this percentage was 46%. Even higher numbers (85%) are reported in a different study (Child et al. 2010, Am
J Med Genet).
It is unclear, whether obesity is a result of wrong eating habits or a symptom of the disease itself. Following liposuction, about
30% of the patients report an – often small, sometimes huge - weight increase. In these cases, the increase of volume is mainly
in the trunk area, but not in the operated extremities. One might speculate, that, though often seen, adiposity is not a specific
feature of the disease itself.
Orthopaedic problems are often found in patients with lipoedema. They mainly manifest in the knee and sometimes in the
ankle region. This is the result of an abduction in the leg axis due to the increased volume of the thighs or of circumscribed fat
bulges in the knee area, causing a wrong position during standing and an unnatural gait during walking. So there is a strain
on the leg joints, often resulting in a knock knee.
Following liposuction of the thighs, the leg axis improves and some patients report, that their joint pain improves or even
disappears after some time.
So liposuction in lipoedema can reduce knee and ankle pain; early treatment may even prevent these often associated
orthopaedic problems.
Declaration of interest
None declared
112

O-15.06
LIPEDEMA AND QUALITY OF LIFE
S Michelini, San Giovanni Battista Hospital, Rome, ITALY
M Cardone, San Giovanni Battista Hospital, Rome, ITALY
A Failla, San Giovanni Battista Hospital, Rome, ITALY
G Moneta, San Giovanni Battista Hospital, Rome, ITALY
F Cappellino, San Giovanni Battista Hospital, Rome, ITALY
A Fiorentino, San Giovanni Battista Hospital, Rome, ITALY
The list of illnesses recognized by the World Health Organization does not include the lipedema. In many medical reality
health care, public and private, and in medical-legal fees, this condition is considered a cosmetic problem and not a real
disease.
Following the three-stage trials in which the disease evolves with time seriated follow-up, 115 patients suffering from
lipoedema there has been a progressive deterioration of motor and the subject's autonomy in activities of daily living.
A questionnaire administered to patients to highlight what were the main concerns related to subjective health showed the
following results: first place economic concerns to address the problem (29%), followed by problems in the family (22%) and
in 'scope of work (including the fear of losing their jobs) (18%), followed by problems related to sexuality (13%), relationship
problems (9%), the expectation of care (5% ) and the expectation of healing (4%).
In all subjects a deep sense of frustration emerged related to the awareness of the substantial ineffectiveness of medical and
physical treatment and difficulties in being able to deal with the liposuction surgery, in many cases (especially in advanced
clinical stages) performed several times, often with unsustainable costs . The study demonstrates the considerable negative
impact determined by lipoedema on the quality of life of patients affected by it and testifies the need for the disease to be more
appropriately considered by health care systems, public and private.
Declaration of interest
None declared
O-16.01
ASSOCIATION BETWEEN MEASUREMENT DATA AND LYMPHEDEMA PATIENT INFORMATION
USING TEMPORAL MINING TECHNIQUE
S Xu, University of Missouri, Columbia, UNITED STATES
C Shyu, University of Missouri, Columbia, United States
J Armer, University of Missouri, Columbia, United States
Background: Though most lymphedema (LE) clinical settings and research organizations have measurement data for LE
patients, these measurement data are mainly used to track patients limb volume change (LVC) over time. Few practitioners
try to analyze trends of measurement data and connect these trends with patient information. There is no evidence-based
recommendation regarding LVC trends from published best practice guidelines.
Objectives: To develop data mining framework for temporal knowledge discovery from lymphedema patient data, which
aims to improve lymphedema management for the LE community.
Methods: We use perometry to collect LE patients’ measurement data by research nurses at every lab visit during the
30-months period starting from pre-surgery. We use ±5% as the boundary of LVC by comparing each patient’s limb volume
with pre-operative limb volume which is considered as a baseline measurement. After preprocessing data, we fed the data
into our temporal mining framework to discover temporal patterns of the measurement data. We used 10% LVC as the LE
diagnostic criteria.
Results and Conclusions: There are 69 patients meeting LE diagnostic criteria among the total number of patients (n=216) in
our dataset. We first found associations between LVC patterns and LE diagnosis – there are 43% patients having stable LVC
at from post-op to 6 months, who have a 20.4% chance to meet the LE diagnostic criteria, while there are 11% having stable
LVC at post-op, 3rd month, and increased LVC at the 6th month, who would have a 67% chance to meet the LE diagnostic
criteria. This could provide an evidence-based recommendation for surveillance during the six months after surgery, even
though patients might have stable LVC at post-op and the 3rd month post-op. We also correlated measurement data with
patient symptom data to examine association between trends of LVC and symptom data, where swelling was the early sign
of developing LE. We can also correlate measurement data with other patient demographic data and treatment data for
our future work. This temporal mining framework is expected to provide evidence-based and relevant clinical temporal
knowledge for the LE community to improve lymphedema management.
Declaration of interest
None declared.
113

O-16.02
DEVELOPMENT OF A MINIMUM DATA SET TO ASSIST IN INTERNATIONAL COLLABORATIVE
LYMPHEDEMA STUDIES
J Reneker, University of Missouri, Columbia, UNITED STATES
J Armer, University of Missouri, Columbia, United States
B Stewart, University of Missouri, Columbia, United States
C Shyu, University of Missouri, Columbia, United States
Background: The American Lymphedema Framework Project (ALFP) is teaming up with various sites in the United States
and abroad to collect lymphedema patient data. This collective information is used to define a Minimum Data Set (MDS),
which includes common and relevant attributes from the heterogeneous data sources.
Objectives Aggregated data in the MDS will be available for viewing and querying by eligible researchers according to
established protocols. Research findings from the MDS will be available for all levels of stakeholders and provide evidencebased
content for the Best Practice Document. Citings of findings will be reported in aggregate and will not have individual
affiliations attached.
Methods: Patient information incorporated into the MDS includes both objective and subjective measurements. This
information is collected at different sites throughout the world in different ways but will be presented to all MDS stakeholders in
a unified format. For instance, objective measurements in the MDS include, among other attributes, limb volume calculations
which can be perometer readings, circumference measurements, water displacement, etc. The MDS will accommodate and
normalize these differences for end users, which will greatly facilitate cross-site studies of limb volumes by the research
community worldwide. Also, quality-of-life data that pertains to a patient’s management of the disease will be a part of the
MDS. For instance, some sites may ask participants to rate various issues common to lymphedema patients such as their
ability to maintain daily activities and/or their feelings of depression or stress, etc. Different sites may ask slightly different
questions pertaining to the same issue and, therefore, receive slightly different answers. In these cases, stakeholders will be
able to aggregate similar information in the MDS to subsequently query. Individual stakeholders are encouraged to request
the development and incorporation of desired queries for all stakeholders to use.
Results and Conclusions: The MDS data is currently being pooled across multiple institutions and will be available for
informatics tools, such as data mining, text mining and decision support systems to provide up-to-date and dynamic findings
that are true evidence-based for all stakeholders.
Declaration of interest
None declared
O-16.03
ALFP THERAPISTS SURVEY: PATIENT CHARACTERISTICS AND TREATMENT OPTIONS FOR
THERAPISTS MANAGING LYMPHEDEMA IN UNITED STATES
J Armer, University of Missouri, Columbia, MO, UNITED STATES
J Feldman, NorthShore University Health System, Evanstonb, IL, United States
J Cormier, University of Texas M D Anderson Cancer Center, Houston, TX, United States
M Austin, University of Missouri, Columbia, MO, United States
B Stewart, University of Missouri, Columbia, MO, United States
Background: Persons with an impaired lymphatic system are at a lifetime risk for developing lymphedema (LE), a chronic
condition requiring careful management to maintain the health and quality of life of the patient. Symptom management
by a trained LE therapist is critical to improving quality of life during cancer survivorship. However, precise information
regarding these management techniques and related treatment patterns is not well understood.
Objectives: The goal of this survey was to collect information about the management of LE and treatment options in the US
as reported by therapists.
Methods: Under the guidance of the American Lymphedema Framework Project research and steering committees, an
online survey was developed between January and October 2009, with survey administration occurring over two weeks in
November 2009. Invitations to complete the survey were sent to an existing database of therapists, LE training organizations,
and members of industry for further dissemination.
Results and Conclusions: The analysis included responses from 419 therapists from 46 states. Respondents typically had
a background in physical (50%) or occupational therapy (34%). Nearly all (93%) reported having completed a 135-hour
training course on LE treatment and management, and the majority had advanced training beyond 135 hours (60%). The
practice settings included hospital-based outpatient clinic (65%), private practice (26%), and hospital-based inpatient
service (14%). The treatment options most often reported were Comprehensive Decongestive Therapy (CDT), exercise/
movement, risk-reduction education, and skin care. Patients of respondents with oncology-related LE received treatments
on the upper extremities (59%), followed by lower extremities (32%), trunk (20%), head and neck (7%), and genitals (6%).
These preliminary findings provide evidence that a trained group of therapists provide care for patients with LE in a variety
of practice settings. Treatment with CDT is available in almost all clinical settings, while other options such as exercise/
movement and risk reduction education are also used.
Declaration of interest
None declared.
114

O-16.04
DISCOVERING DISTRIBUTIONS OF TRAINED LYMPHEDEMA THERAPISTS, TREATMENT
CENTERS, AND LYMPHEDEMA PATIENTS USING GEOGRAPHIC INFORMATION SYSTEM
S Xu, University of Missouri, Columbia, UNITED STATES
C Shyu, University of Missouri, Columbia, United States
B Stewart, University of Missouri, Columbia, United States
J Armer, University of Missouri, Columbia, United States
Background: The Geographic Information System (GIS) has been widely used in different fields, such as business, education,
and health care. It could be especially beneficial for the lymphedema (LE) community by identifying LE therapists and
treatment centers, because many LE patients don’t know what LE is or where to get proper LE treatment. Due to this lack of
awareness, it is hard to detect LE at an early stage which is the key to successful control and management of LE.
Objectives: Our objective was to improve awareness and accessibility for LE patients by using GIS to identify available LE
resources not only in the US, but also internationally.
Methods: As a pilot study, we first collected geographical information on breast cancer survivors and LE therapists in Missouri
from different data bases related to our research. Later on, we fed the geographical data into the GIS system and examined
associations between distributions of LE therapists and breast cancer survivors. We also used geographical information from
a database of LANA-certified therapists to examine the distribution of LE therapists nationally. In order to compare different
population distributions, we cross-mapped the population at risk for breast cancer with location of LE therapists.
Results and Conclusions: Findings from our GIS tool could provide information on availability of different LE resources
and identify regions that need LE resources. Those findings could also help policy-makers in arranging and planning LE
resources. Even though we only examined the Missouri breast cancer population specifically, there are potential opportunities
for other national and international organizations and patients to examine geographical availability of LE resources and the
pool of potential LE patients, which could improve accessibility for the LE community and help policy-makers in balancing
LE resources based on needs.
Declaration of interest
None declared
O-16.05
DEVELOPMENT OF ICF CORE SETS FOR LYMPHEDEMA: LITERATURE REVIEW
P Viehoff, Erasmus Medical Centre, Rotterdam, NETHERLANDS
Y Heerkens, Dutch Institute of Allied Health Care, Amersfoort, NETHERLANDS
D van Ravensberg, Dutch Institute of Allied Health Care, Amersfoort, NETHERLANDS
J Hidding, Dutch Association of Physical Therapists in Lymphology, Zutphen, NETHERLANDS
M Martino, Erasmus Medical Centre, Rotterdam, NETHERLANDS
BACKGROUND The International Classification of Functioning, Disability and Health (ICF) offers a system to describe the
functioning of the patient. Since the ICF is too comprehensive for daily practice, Core Sets can be composed for easier use.
OBJECTIVES The review is part of the development of ICF Core Sets for lymphedema. The purpose of the review is to get
clear the researchers point of view concerning meaningful concepts which can be classified by the ICF.
METHODS Databases were searched and then two researchers selected the articles. These were read and meaningful concepts
were classified according the ICF. This was also done by two researchers who had to come to consensus.
RESULTS A total of 149 articles were selected according to the in- and exclusion criteria.
The research is not yet concluded. At the time of the congress provisional data can be delivered.
CONCLUSION With ICF Core Sets for lymphedema the health care professional can work faster (no need to describe the
patient in words) and gets a better overview of the patient with lymphedema. The Core Sets can give direction to treatment
goals. The codes of the ICF can also be used to formulate outcome measures. Once there are ICF Core Sets digital registration
in terms of the ICF of the patient with lymphedema can be faster and more compact. Registration generates data which can
be used for research (getting to know more about the patients) and policy making (e.g. insurance companies, governmental).
Declaration of interest
None declared
115

O-16.06
NEW MULTIDISCIPLINARY CENTRE FOR MANAGEMENT OF CHRONIC OEDEMA WITH EXPERT
FUNCTION OF DIAGNOSES AND TREATMENT
S Birkballe, Bispebjerg University Hospital, Copenhagen NV, DENMARK
T Karlsmark, Bispebjerg University Hospital, Copenhagen NV, DENMARK
S Nørregaard, Bispebjerg University Hospital, Copenhagen NV, DENMARK
F Gottrup, Bispebjerg University Hospital, Copenhagen NV, DENMARK
Background: Hypothesis: An independent, multidisciplinary centre for management of chronic lymphoedema with an
accepted national expert function focusing on all types of chronic oedemas (primary and secondary) is the optimal way
to improve diagnoses, treatment and prophylaxis of chronic oedema and sequelae. Design: A clinical perspective analysis.
Setting: An independent, multidisciplinary centre focusing on all types of chronic oedemas, organized as a university hospital
department, and integrated as a national expert function in the health care organization of Denmark.
Patients and Methods: Patients with all types of chronic oedema referred to and treated in the centre during the first years of
its existence provided a model for a new multidisciplinary structure for diagnoses and treatment of chronic oedema involving
specialist physicians with expert knowledge of lymphoedema, dermatologists, surgeons specialized in wound treatment,
medical educators, specialist nursing staff, podiatry staff, dieticians, physiotherapists, orthotists and clinical physiologists.
Results: During the first 4½ years of the fully functioning centre for management of chronic oedema, a total of 8000 patient
consultations were preformed in the outpatient clinic, and 150 patients with severe oedema was hospitalised in the inpatient
ward. The concept of the centre has resulted in improved diagnoses, treatment and prophylaxis of patients with chronic
oedema and has decreased rates of long-term sequelae. The structure has provided excellent opportunities for basic and
clinical research as well as establishing expert education for all types of health care personnel. The centres structure has
been the background for establishing an expert function in management of chronic oedema, allowing this area to be fully
integrated in the Danish National Health Care System. Overall, the concept of the centre has enhanced the awareness and
knowledge about patients with chronic oedema and increased the status of this group of patients and their care.
Conclusions: Establishing multidisciplinary centres for management of chronic oedema integrated as an accepted national
expert function is an optimal way to improve the diagnoses, treatment and prophylaxis of all types of chronic oedemas. This
model, with minor adjustments, may be applicable for both industrialized and developing countries.
Declaration of interest
None declared
O-16.07
CANCER-RELATED LYMPHEDEMA: AN EDUCATIONAL INTERVENTION FOR GENITOURINARY
AND GYNECOLOGIC ONCOLOGY OUTPATIENT NURSES
K Smalky, MD Anderson Cancer Center, Houston, UNITED STATES, H Saez, MD Anderson Cancer Center, Houston, UNITED
STATES, R Martin, MD Anderson Cancer Center, Houston, UNITED STATES, J Leflor, MD Anderson Cancer Center, Houston,
UNITED STATES, R Askew, MD Anderson Cancer Center, Houston, UNITED STATES, M Kallen, MD Anderson Cancer
Center, Houston, UNITED STATES, R Tintner, The Methodist Neurological Institute, Houston, UNITED STATES, J Cormier,
MD Anderson Cancer Center, Houston, UNITED STATES
Background: Cancer-related lymphedema (CRLE) is a chronic, progressive, incurable condition which negatively impacts
patient quality of life. Although CRLE is often associated with breast cancer treatment, it can occur following surgical
treatments for a number of malignancies. The published literature acknowledges a lack of understanding of CRLE among
healthcare professionals.
Objectives: The aim of this study was to assess knowledge of CRLE before and after an educational intervention designed for
nurses working in an oncology outpatient clinic.
Methods: Nurses staffing the genitourinary (GU) and gynecologic (GYN) oncology outpatient clinics were invited to an
educational program on CRLE highlighting risk factors, natural history, modalities assessment, and treatment. Knowledge
assessments and practice surveys were administered before and after the program.
Results: 32 attendees averaged 10.1 years of experience in clinical cancer care, 9.8 of which were spent at the host institution.
Attendees reported an average of 7 patients voicing concern or being observed with swollen legs within the previous 6 months;
more than half were thought to be attributable to CRLE. If patients expressed concern about swelling, more than half (56.7%) of
respondents would recommend additional evaluation. Dramatic improvements were noted in nurse understanding of CRLE
with averages of 61.2 % of assessment items correct before the presentation and 93.2% correct following the presentation.
The greatest areas of improvement were in understanding risk for developing lymphedema (from 37% to 85% correct) and in
treatment and management of lymphedema (from 45% to 95% correct).
Conclusions: Experienced oncology nurses have knowledge deficits related to CRLE, particularly with respect to risk for
developing CRLE and for treatment and management of CRLE. A 45 minute educational session was effective in improving
nurse understanding with respect to both of these issues, however, follow-up assessment will be needed to determine if this
increase is sustained over time.
Declaration of interest
None
116

O-17.01
THE INCIDENCE OF LYMPHOEDEMA IN PARTIAL VERSUS TOTAL MASTECTOMIES
H Saeed, Flinders University, Adelaide, AUSTRALIA
M Samarin, Flinders University, Adelaide, AUSTRALIA
N Piller, Flinders University, Adelaide, AUSTRALIA
Background: Lymphoedema rates secondary to surgery have been suggested to be as high as 40%. The 2 million women
per year in the USA who get breast cancer are a significant social group and the burden of lymphoedema can be quite
severe. Identifying the relationship between partial and total mastectomies and lymphoedema could alter the current surgical
protocols.
Objectives: To identify the factors that influence lymphoedema in partial versus total mastectomy axillary clearance surgery.
Methods: A retrospective investigation of ~980 patients of the Flinders Medical Centre Breast Clinic from 1994-2009 was
undertaken comparing the incidence of lymphoedema in partial and total mastectomy axillary clearance patients with and
without radiotherapy
Results: On the basis of previous reports in the literature we anticipate there will be a statistical difference between incidence
of lymphoedema in patients receiving partial versus total mastectomy surgery.
Conclusions: If there is a positive correlation between partial and total mastectomies and lymphoedema this demonstrates
that total mastectomies cause lymphodema. Active targeted post-surgical patient education and the managent of any early
(latent) stage lymphoedema , before the onset of clinically manifest lymphoedema must then be initiated to reduce incidence,
as it is clear from the literature that early detection and reaction can reduce lymphoedema incidence and severity.
Declaration of interest
None declared
O-17.02
A RISK FACTOR-BASED CLINICAL DECISION TOOL TO IDENTIFY LYMPHEDEMA IN WOMEN
WITH EARLY BREAST CANCER
N Stout, National Naval Medical Center, Bethesda, UNITED STATES, L Pfalzer, University of Michigan - Flint, Flint, United
States, E Levy, National Institute of Health, Bethesda, United States, C Mc Garvey, CLM Consulting, Rockville, United States,
B Springer, Office of the surgeon general, Falls Church, United States, L Gerber, George Mason University, Vienna, United States,
P Soballe, Naval Hospital , San Diego, United States
Background: Risk factor identification is important in detection of breast cancer related lymphedema (BCRL). A clinical
decision tool is needed to provide a patient-specific assessment of risk factors related to lymphedema development. This
could promote risk stratification and contribute to early identification and treatment of lymphedema.
Objective: To outline the interrelationship of objective and subjective clinical risk factors for lymphedema in the context of a
clinical decision making rule.
Methods: LE was identified in sixty-three of 166 women in an IRB approved prospective, breast cancer morbidity trial. A
clinical upper quarter screen including volume assessment was conducted pre-operatively, one month and 3 month intervals
for one year following surgery. Social, demographic, disease specific variables and subjective reports were documented.
Lymphedema was defined as > 3 % increase in limb volume from pre-op and controlled for weight change. Classification and
regression tree (CART) analysis was used to recognize relationship patterns among the clinical variables associated with the
development of BCRL. CART analysis enables a non-parametric analysis of numeric data using unique algorithms to search
all possible independent variable relationships associated with the development of BCRL.
Results: The first CART split suggests that number of positive lymph nodes is the variable most associated with lymphedema.
BCRL development was seen in 100% of women with > 2 positive lymph nodes who also had shoulder external rotation ROM
< 80 degrees at one month post operatively. In women with < 2 positive lymph nodes BCRL was seen in 100 % of those who
were < 65 inches in height who also reported chest wall pain and had post-operative seromas.
Conclusions: This novel analysis involves pattern recognition among clinical variables associated with the development of
BCRL. The analysis produces a hierarchical, aggregate combination of contributing risk factors and becomes the derivation
of a clinical prediction rule for BCRL. Clinical prediction rules aid in classifying patients into clinically-important risk
categories and have applicability in lymphedema early identification and treatment. The risk profile presented here should be
prospectively assessed to validate a prediction rule in a clinical setting.
Declaration of interest
None declared
117

O-17.03
BREAST CANCER RELATED LYMPHEDEMA: COST OF PROSPECTIVE SURVEILLANCE COMPARED
TO STANDARD CARE
N Stout, National Naval medical center, Bethesda, UNITED STATES, L Pfalzer, University of Michigan-Flint, Flint, united states
B Springer, Office of the Surgeon General, Falls Church, united states, E Levy, National Institutes of Health, Bethesda, united
states, C McGarvey, CLM consulting, Rockville, united states, J Danoff, The George Washington University, Washington, united
states, L Gerber, George mason university, Vienna, united states, P Soballe, naval hospital, San Diego, united states
Background: Breast cancer related lymphedema (BCRL) is a costly disease sequela. Secondary prevention through prospective
surveillance aids in early identification and treatment of BCRL potentially reducing intensive rehabilitation and may be cost
saving. Prospective surveillance entails pre-operative assessment and ongoing interval surveillance using repeated measures
to detect change in limb volume over time.
Methods: We constructed cost models examine direct treatment costs associated with 2 groups: 1. PSM) All women with BC
receiving interval prospective surveillance assuming that 1/3 will develop early BCRL and require early intervention. 2. TM)
women referred for BCRL treatment using a traditional model of referral and treatment of clinically apparent lymphedema.
A sensitivity analysis was conducted for varied incidence rates associated with each protocol to adjust for uncertainty in rates
of onset of BCRL. We then extrapolated, using Excel what-if analyses, to identify cost associated with BCRL progression. All
estimates are in US dollars.
Results: Direct cost to treat early stage BCRL per patient per year using a PSM is $ 636.19. A TM cost is $ 3124.92 per patient
per year to treat advanced BCRL. Based on incidence rate of 33.5%, the cost of a PSM for 100 women over one year is $
38,272.83. This includes the cost of surveillance. The TM cost is $ 104,684.82 held to the same assumptions and without the
cost of surveillance monitoring. Sensitivity analysis varying BCRL incidence rates (7% to 48%) yielded cost ranges from: PSM
$29,315.50 - $43,799.20 and TM $ 32,811.66 - $149,996.16. Model comparison demonstrates that 27 / 33.5 anticipated cases
(80.5%) diagnosed through the PSM would have to progress to advanced stage lymphedema in order for the cost to eclipse
the base case cost of the TM based on our assumptions.
Conclusions: Prospective surveillance in the absence of impairment is clinically effective for early detection and treatment of
BCRL. This approach has the potential to be a cost saving mechanism as well. Further analysis of indirect costs and utility are
necessary to assess cost effectiveness. A shift in the paradigm of physical therapy towards a PSM may be warranted.
Declaration of interest
none declared
O-17.04
LONG-TERM FOLLOW UP PROCEDURES FOR LYMPHEDEMA PATIENTS FOLLOWING
LIPOSUCTION OF ARM AND/OR LEG LYMPHEDEMA.
B Svensson, Malmö University Hospital, Malmö, SWEDEN
K Ohlin, Malmö University Hospital, Malmö, SWEDEN
C Freccero, Malmö University Hospital, Malmö, SWEDEN
H Brorson, Malmö University Hospital, Malmö, SWEDEN
Introduction: Relevant and repeated control measures are important to get stable and successful results in the long run for
patients with chronic non-pitting lymphedema who have been treated with liposuction due to adipose tissue hypertrophy.
Methods: Measuring of excess volume: the difference between the edematous and non-edematous extremity is measured
with water plethysmography. The shape of the extremity is measured at fixed anatomic landmarks using a tape measure.
The range of motion of relevant joints are assessed. Measurements are taken to order compression garments. The goal is
complete reduction to obtain equal size of the extremities. Quality of life parameters are measured with SF-36, and a VASscale
measures subjective pain, and difficulties with activities of daily living (ADL). Photos are taken at all follow-up visits at
0,5, 1, 3, 6, (9) and 12 months, and then once a year.
Results: On average, complete reduction of the excess volume is achieved within 6-12 months. At the 12-months follow-up
visit, compression garments for the following year are ordered and then only yearly follow-up visits are needed without
additional treatment like CDT.
Conclusion: A multi-disciplinary team approach towards lymphedema patients treated with liposuction surgery has shown to
be successful. The idea is to create a "mental contract" between the patient and the team. The patient is aware of and accepts
our postoperative compression recommendations, and is at the same time encouraged by direct visual feed back from volume
measurements and circumferences at check-up visits.
There are no conflicts of interest.
Declaration of interest
"None declared".
118

O-17.05
THE EFFECT OF SEASONAL VARIATION ON UPPER LIMB SIZE AND VOLUME: AN AUSTRALIAN
STUDY
M Matthews, James Cook University, Townsville, AUSTRALIA
S Gordon, James Cook Uni, Townsville, AUSTRALIA
Background: Currently, there is limited information regarding variation of upper limb size, volume and fluid distribution in
a normal population with respect to heat and humidity. Understanding normal variation can assist in the provision of best
management for those with lymphoedema, living in hot, humid areas.
Objectives: To determine if variations in upper limb arm size, volume or fluid distribution occur in response to seasonal
variation in a healthy population.
Methods: This longitudinal cohort study was undertaken in Australia. Data collection was based on seasonal variation
as determined by monthly, average maximum temperatures and relative humidity levels and undertaken October, 2009
(Spring); February, 2010 (Summer) and June, 2010 (Winter). Participant questionnaires established arm dominance and
lifestyle factors. Women over 40 years of age, with no history of breast cancer or lymphoedema were included.
Gross upper limb size was measured using circumferential measures and calculated using the Sum of the Anatomical
Circumferences (SOAC) and volume was calculated from circumferential measures using the frustum calculation and
assumption for arm shape. Fluid distribution was determined using Bioelectrical Impedance Analysis (BIA). An impedance
ratio was used to determine the amount of extra-cellular fluid within the upper limbs.
Results: Sixty-three women participated in the initial data collection, with seven lost to follow-up. A significant relationship
was identified between seasonal variation and limb size as calculated by SOAC, with significant decreases in summer and
winter when compared to spring. Further analysis showed that circumferential measures taken at anatomical landmarks
during Spring were significantly larger than those taken at other times. Climate data for the Spring measurement were of high
temperatures and moderate humidity levels. There was no relationship between seasonal variation and limb volume or fluid
distribution.
Conclusions: The significantly larger limb size identified in Spring may be linked to high average maximum temperature and
low levels of humidity, and may indicate that SOAC is more sensitive at detecting changes in the limb than the other methods.
Research is now required examining other age and gender groups.
Declaration of interest
None declared
O-17.06
DIET AND LYPHOEDEMA: FACTS AND FALLACIES IN THE GREY AND POPULAR INTERNET
LITERATURE
R Dawson, Flinders University, Bedford Park, AUSTRALIA
N Piller, Flinders University, Bedford Park, AUSTRALIA
Background: A range of medically related internet sites provide patients with numerous options for the management of
lymphoedema, much of which is not peer reviewed or evidence based. Patients, unless well educated about their lymphoedema
may not be critical consumers. The great concern is that many patients may lack the ability to critically appraise and separate
the facts from the fallacies.
Objectives: To provide practitioners and patients with a report of conservative lymphoedema therapies (particularly focusing
on diet and exercise) currently recommended on the internet.
Through being informed, encourage better communication between patient and practitioner through the provision of more
credible advice to patients who approach them with information they have gathered from the internet.
Methods: Search Strategies: Google was used to find websites and the first 20 valid results from each search were investigated
for claims about lymphoedema strategies targeting diet/exercise. E-books were purchased from some sites. Search Terms:
lymphoedema, lymphedema, lymphatic dysfunction, diet, exercise, cure, management. Search Results: Eight topics/themes
were identified: Diet to achieve and maintain a healthy weight, Low carbohydrate diet, Low protein diet, Alkalising diet,
Low salt diet, Drinking distilled water, Abstanance from alcohol and caffeine, Oil pulling. Each was then investigated in the
peer reviewed literature for evidence that supported or refuted the claims made. The topics/themes were categorised into the
following: Safe and effective, no harm but no evidence and no evidence and potentially dangerous.
Results: Although some sites contained inaccurate information, this often accompanied accurate information, making
elucidating right from wrong even more difficult for an uninformed patient.
Conclusion: This search of grey literature on the internet reveals some concerning recommendations that are made to
lymphoedema patients. Patients should not be discouraged from taking initiative in their own health. It is however, crucial
that they are aware of the importance of being critical of any information they may gain from the internet, and that they discuss
any potential treatment strategies with their aware health professional or doctor before commencing a new intervention.
Declaration of interest
The Cancer Council of South Australia provided a Summer Research Scholarship
119

RT-02.01
LIPOEDEMA – AN INHERITED CONDITION
P Mortimer, Division of Clinical Science, St George’s, University of London, London, UNITED KINGDOM
Lipoedema is an under recognised condition either mis-diagnosed as lymphoedema or dismissed as obesity. A positive
family history is not unusual and the publication of a series of pedigrees suggests that lipoedema is a genetic condition [Child
AH, Gordon KD, Sharpe P et al. Lipedema: an inherited condition. Am J Med Genet 2010;152:970-7]. The pure phenotype is
as originally described in 1940 by Allen & Hines namely a regional lipohypertrophy (lipomatosis, lipodystrophy) associated
with pain, tenderness and easy bruising. Pain can be a disabling feature and may locate to joints eg knees, as well as affected
subcutaneous tissues. The inheritance appears to be either x linked dominant or autosomal dominant with sex limitation
hence the almost exclusive involvement with females. Lipoedema is presumably oestrogen-requiring as it usually manifests
at puberty or at times of hormonal change (pregnancy). Male involvement only seems to occur with hormonal abnormalities
[Bano G, Mansour S, Brice G et al. Pit-1 mutation and lipoedema in a family. Exp Clin Endocrinol Diabetes 2010;118:377-80]
Declaration of interest
None declared
RT-02.02
LIPEDEMA: PATHOPHYSIOLOGICAL FEATURES
G Szolnoky, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY
A Nemes, 2nd Department of Medicine, University of Szeged, Szeged, HUNGARY
É Dósa - Rácz, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY
M Varga, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY
E Varga, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY
L Kemény, Department of Dermatology and Allergology, University of Szeged, Szeged,
L Kemény, Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY
Background and Objectives: Most prominent lipedema hallmarks (capillary fragility (CF) and pain) or general perception
(GP) and their response to complex decongestive physiotherapy (CDP) or compression were investigated. We also aimed to
measure large blood vessel characteristics of lipedema patients.
Methods: CDP comprised once daily manual lymph drainage (MLD), intermittent pneumatic compression (IPC) at 30 Hgmm
pressure and multilayered and multicomponent short-stretch bandaging for 5 days. Volumetry was performed in accordance
with Kuhnke’s disc model or optoelectronic measurement, CF was assessed using vacuum suction method (VSM) and pain
was measured with a 10-item questionnaire, Wong Baker Faces and visual analogue scale (VAS) prior and subsequent to
therapy cycles. GP was compared with chronic venous insufficiency questionnaire (CVIQ) between groups using made-tomeasure
compression class 2 or 3 stockings. Aortic stiffness (β) was calculated upon echocardiography.
Results: CDP resulted in a significant reduction of limb volumes in both CDP and CDP+IPC groups, of the number of
petechiae and pain severity (p

RT-02.03
LOWER LEGS IN PATIENTS WITH LIPOEDEMA – A CHALLENGE FOR LIPOSUCTION.
I Meier - Vollrath, Hanse-Klinik, Lübeck, GERMANY
W Schmeller, Hanse-Klinik, Lübeck, GERMANY
Lipoedema, a chronic and progressive disease in women, mainly affects thighs and lower legs. In many cases spontaneous
pain, pain due to pressure and feeling of tension are more pronounced in the calves due to stronger oedema in this area. And
in addition the cosmetic impairment is more obvious.
While complex decongestive therapy (CDT) is able to temporarily reduce oedema and pain,the removal of fat of the lower legs
leads to long lasting effects and is therefore crucial. Liposuction is demanding for the surgeon due to the small subcutaneous
layer of the calf and ankle area. Hence there is an increased risk of causing skin irregularities and the surgical procedure itself
can be more painful. The healing period is prolonged compared to the thighs due to a longer period of postoperative oedema
and scar formation and is therefore also a bigger strain for the patients.
Critical evaluation of 112 of our lipoedema patients treated with liposuction in pure tumescent local anesthesia and with
vibrating microcannulas showed good results. There was an improvement of the disproportion with a mean reduction of the
circumference of the calves of 4 (1-11)cm. Beside the amelioration of shape, complaints like swelling and pain were reduced
significantly (p

O-18.01
THE ROLE OF HIGH-RESOLUTION ULTRASOUND IN THE DIAGNOSICS, THERAPY-PLANNING
AND MONITORING OF LYMPHEDEMA.
K Martin, Foeldiclinic, Hinterzarten, GERMANY
E Föeldi, Foeldiclinic, ,
Background: Ultrasound has found increasing use in the apparative diagnostics of lymphedema due to the ever-increasing
improvements in ultrasound scanners, particularly at the high-end level. Ultrasound machines with 17 MHz probes allow
differentiated examination of the skin and deeper soft-tissue regions.
Patients and material: Therapy-relevant possibilities for differential diagnostics in primary and secondary lymphedema of the
arm are presented using examples from the lymphological patient population at the Földi clinic. Furthermore, a sonographic
examination of cutis and subcutis thickness and volumetric change due to intensive complex physical decongestive therapy in
a defined group of patients with unilateral lymphedema of the arm will be presented. We used a Phillips iU 22 with a 17-MHz
linear probe, sensitive colour-doppler and harmonic imaging and optional panorama imaging as well as sono-CT.
Results: High-resolution soft-tissue ultrasound diagnostics should be used as the screening examination for locally therapyresistant
primary lymphedema of the hand and arm. With this method lymphangiomas can be diagnosed and their extent
and relevance for the volumetric progression can be assessed (e.g. in the back of the hand). Based on publications on skin-
thickness in lymphedema, relevant sonographic examinations were performed at the outset and conclusion of therapy. A
considerable, significant reduction in skin- thickness at 5 different measuring points on the affected arms was found. A
significant reduction in the thickness of the subcutis at the measuring points was also found. The arm volume, calculated
using the truncated- cone- method (Prof. Kuhnke) was reduced by 63% of the original edema volume on average over the
course of the intensive 3-4 week complex physical decongestive therapy.
Conclusions: High-resonance Ultrasound has further improved the diagnostic possibilities in Lymphology. Due to the
absence of side-effects this examination can be used repeatedly and also in children. Lymphangiomas existing within the
context of primary lymphedema can also be detected. Monitoring of the therapeutic results is possible, from volumetric
determination through to the measuring of the thickness of the skin and subcutaneous tissue. Significant alterations of these
measurements can be detected already after 3 - 4 weeks of intensive CDT.
Declaration of interest
Disclosure:The authors declare to have no financial relations to the mentioned companies
O-18.02
NEAR-INFRARED FLUORESCENCE IMAGING OF TUMOR-INDUCED LYMPHANGIOGENESIS IN
MELANOMA PATIENTS
J Rasmussen, University of Texas Health Science Center at Houston, Houston, UNITED STATES, I Tan, University of Texas
Health Science Center at Houston, Houston, UNITED STATES, M Marshall, University of Texas Health Science Center at
Houston, Houston, UNITED STATES, B Zhu, University of Texas Health Science Center at Houston, Houston, UNITED STATES
J Cormier, University of Texas M.D. Anderson Cancer Center, Houston, UNITED STATES, E Sevick - Muraca, University of
Texas Health Science Center at Houston, Houston, UNITED STATES
Background: Metastasis to the regional nodal basin is a primary prognostic indicator of patient survival in many cancers
including melanoma. Preclinical studies indicate that tumor-induced lymphangiogenesis may occur before metastasis while
histological studies indicate that the density of the lymphatics in the peri-tumoral tissue may correlate with the metastatic
state of the sentinel node. Indeed several pharmaceutical companies are actively developing therapeutics aimed at inhibiting
lymphangiogenesis as a means to prevent metastasis. Until now, however, tumor-induced lymphangiogenesis has not been
imaged in vivo in humans. In the past several years, developments in near-infrared fluorescence imaging have enabled its use to
non-invasively assess lymphatic structure and to quantitate lymphatic contractile function.
Objectives: In this study we seek to non-invasively image melanoma-induced lymphangiogenesis in humans and ultimately to
correlate lymphatic structure and function with the metastatic state of the sentinel lymph node to determine if near-infrared
fluorescence imaging may provide prognostic information on nodal metastasis.
Methods: Under an ongoing FDA and IRB approved protocol, multiple injections of 25µg of indocyanine green (total dose
≤400µg) were administered intradermally around the primary tumor and in corresponding locations on the contralateral side.
To image the movement of the dye through the lymphatics from the injection sites to the regional nodal basin, the tumoral area
was illuminated with diffuse 785nm excitation light and the resulting fluorescent signal was captured using an intensified charge
coupled device (ICCD) camera. The structural and functional differences between the tumor-draining lymphatics and the
corresponding contralateral lymphatics were compared and correlated with the metastatic status of the sentinel lymph node as
determined by standard pathological assessment.
Results and Conclusions: While to date we are still enrolling subjects, we have successfully imaged, for the first time, melanomadraining
lymphatics in humans. The images present distinct structural differences in the tumor-draining lymphatics, including
increased numbers and tortuosity of the lymphatic vessels, as compared to the corresponding contralateral lymphatics. These
results indicate that near-infrared fluorescence imaging can visualize tumor-induced lymphangiogenesis and as we continue
enrolling subjects may prove to be associated with metastatic nodal tumor burden.
Declaration of interest
None declared
122

O-18.03
USE OF INDOCYANINE GREEN FLUORESCENT LYMPHOGRARPHY FOR DEMONSTRATING
DYNAMIC LYMPH FLOW
H Suami, The University of Texas M. D. Anderson Cancer Center, Houston, UNITED STATES
D Chang, The University of Texas M. D. Anderson Cancer Center, Houston, UNITED STATES
K Yamada, Okayama University, Okayama, JAPAN
Y Kimata, Okayama University, Okayama, JAPAN
Background: Visualization of the lymphatic system is a challenging problem. Recently, indocyanine green (ICG) fluorescent
lymphography system was developed for visualizing the lymphatic vessels. ICG is a water-soluble compound and it has
been widely used for assessing cardiac output, hepatic function, and ophthalmic angiography. ICG emits energy in the nearinfrared
region between 840 and 850 nm when it is bound to protein in the tissue and excited by 750 nm light emitted diode.
Objectives: The lymphatic anatomy in the upper extremity was investigated using ICG fluorescent lymphography in three
healthy volunteers and fifteen patients with breast cancer-related lymphedema prior to a lymphaticovenular shunt operation.
Methods: ICG (0.01 - 0.02 ml) was injected into each finger web and at 3 locations at the volar side of wrist intradermally.
Lymph flow was observed and recorded for 20 minutes after the injections using the system.
Results: In healthy volunteers, fluorescent images of lymphatic vessels emerged at the dorsal hand and ran longitudinally
towards the proximal arm. They ascended in the posterior forearm and then gradually changed direction towards the medial
side of the upper arm en route to the axilla.
In patients with lymphedema, the lymphatic vessels could be identified at the dorsal hand, but a patchy reticular starburst-like
finding could be seen in the forearm instead of the linear structure seen in the healthy volunteers. Skin incisions (~2-3 cm)
were made at these identified sites, and prominent and patent lymphatic vessels were found. Surgical findings and image data
were concurrent with high accuracy.
Using the ICG fluorescent lymphography, we were able to demonstrate the differences in the anatomy of the lymphatic system
between healthy upper limbs and lymphedema limbs. We observed the reticular structures only in the lymphedema limbs.
These findings are similar to the "dermal backflow" sign observed in standard lymphangiography and lymphoscintigraphy.
Conclusions: The ICG fluorescent lymphography, allows for the prompt and accurate identification of the functional lymphatic
vessels and may have the potential to significantly improve the outcomes of lymphovenous shunt operations.
Declaration of interest
None declared
O-18.04
FLUORESCENT LYMPHOGRAPHY IN VISUALIZATION OF LYMPHATIC SYSTEM
O. V. Danilevskaya, Moscow State University of Medicine and Dentistry, Moscow, RUSSIAN FEDERATION, V. I. Polsachev,
Moscow State University of Medicine and Dentistry, Moscow, RUSSIAN FEDERATION, B. M. Urtaev, Moscow State University of
Medicine and Dentistry, Moscow, RUSSIAN FEDERATION, A. I. Marchenko, Moscow State University of Medicine and Dentistry,
Moscow, RUSSIAN FEDERATION, N. Y u. Mushnikova, Moscow State University of Medicine and Dentistry, Moscow, RUSSIAN
FEDERATION, N.A. Khananyan, Moscow State University of Medicine and Dentistry, Moscow, RUSSIAN FEDERATION, A. R.
Tsarapkina, Moscow State University of Medicine and Dentistry, Moscow, RUSSIAN FEDERATION, V. V. Yakubson, Moscow State
University of Medicine and Dentistry, Moscow, RUSSIAN FEDERATION, I. V. Yarema, Moscow State University of Medicine and
Dentistry, Moscow, RUSSIAN FEDERATION
Background. Today lymphoscintigraphy is widely used in different cases for diagnostic and medical purposes. This method makes
it possible to visualize lymph flow in order to make a diagnosis in case of assumption of lymphatic system affect in malignant
tumours, to reveal venous and lymph flow disturbance and to control the treatment efficiency. However labour intensity of the
method, insufficient contrasting, potential teratogenicity as well as the duration and high cost considerably restrict its range of
application. We have used the new technique of lymph flow visualization offered by the Japanese scientists in 2008 for the first
time with the application of green indocyanine.
Methods. We have offered, substantiated and used the new method of the lymphatic system visualization with the help of
fluorescence using 10% sodium fluorenate solution as a contrast substance. These methods have been used on volunteers without
any specific pathology. Volunteer lying on his back has injected without anaesthetics 0.5 ml of 10% sodium fluorenate solution
into the first interdigital space of dorslim of foot.
Results. Fluorescence has observed visually with the help of illuminator with light source of wave length 480 nm. The obtained
images have been registered with the digital camera within 70, 80 and 90 minutes after the injection of contrast substance. The
results of the research confirm the possibility of applying fluorescent lymphography for the lymphatic system visualization which
can be used for both diagnostic and medical purposes. In comparison with other ray methods it is more preferable due to its
simplicity, availability, safety, minimal invasiveness and economic benefits.
As fluorescent lymphography is a new technique it is necessary to investigate it further, to determine indications and
contraindications to its application, to select a certain contingent of patients.
Conclusions. Thus we are planning to continue the developing this new technology and carrying out investigations of patients
with lymphatic system pathology, oncology patients and those with acute surgical pathology. Applying new methods will extend
the indications for the further investigations, make prerequisites for studies in future and introduction into daily practice.
Declaration of interest
None declared
123

O-18.05
MANUAL LYMPHATIC DRAINAGE VISUALIZED BY LYMPHO-FLUOROSCOPY
J P Belgrado, Université Libre de Bruxelles, Bruxelles, BELGIUM
Belgrado JP ; Giacalone G; Bourgeois P; Bracale P; N.Röh , JJ.Moraine
Corresponding author:
JP Belgrado, PT Dhrs - Université Libre de Bruxelles - Faculté des Sciences de la Motricité – Lymphology Research Unit - CP 640
Campus Erasme - 808, route de Lennik - 1070 Bruxelles – Belgium
e-mail belgrado@ulb.ac.be
Background: Lymphoscintigraphy supports scientists to study the efficiency of manual lymphatic drainage and persists being
the reference imaging for lymphatics, but we can’t ignore its minimal ionizing effects on patients and physicians.
Subcutaneous injection of Indocyanine green and the observation of its diffusion under the skin by a specific camera, seems
to be an interesting new way of imaging in the study of lymphoedema and their treatment.
Objectives: To verify the efficiency of the “A.Leduc technique of manual lymphatic drainage” on resorption of oedema and
acceleration of the lymphatic flow inside the collectors.
To verify the possibility of mapping the functional lymphatic superficial network of patients with lymphoedema in order to
indicate the best way to treat.
Method: Lympho-fluoroscopies applied on 22 volountary patients presenting an unilateral secondary lymphedema of the
upper limb after adenectomy for breast cancer.
- Injection of a diluted solution of Indocyanine green in the second interdigital space. - “passive” period of 10 minutes :
observation of the progression of the tracer in the subcutaneous area.
- 20 minutes protocol of manual lymphatic drainage and permanent observation of the tracer’s progression under the skin.
Results: During the passive stage, we have repeatedly observed contractions of lymphangions and a slow diffusion of the
tracer inside of lymphatic collectors.
During the manual lymphatic drainage, we visualized systematically an increase of the lymph flow mapping progressively the
functional lymphatic network of the edema, even areas of dermal backflow.
Conclusions: Dynamic lymphofluoroscopy completes the arsenal of imaging tools in lymphology. It might help to verify the
efficiency of manual lymphatic drainage. It allows a mapping of the functional superficial lymphatic network.
Declaration of interest
None declared
O-18.06
INVESTIGATION OF SUBFASCIAL FAT IN ARM LYMPHEDEMA USING MRI-BASED FAT
QUANTIFICATION
P Peterson, Lund University, Malmö, SWEDEN
H Brorson, Lund University, Malmö, SWEDEN
S Månsson, Lund University, Malmö, SWEDEN
Background: Lymphedema is a common complication after breast cancer treatment. The condition soon leads to excess
adipose tissue in the epifascial compartment. However, it is not known whether there is an excess of fat also in the subfascial
compartment. Multi-echo imaging is a magnetic resonance imaging (MRI) based fat quantification technique, which provides
both quantitative and spatial information on fat accumulation.
Objectives: To compare the volume of fat in the subfascial compartment in forearms of patients with arm lymphedema,
before, and at four days and one month after liposuction using multi-echo imaging.
Methods: Seven women with arm lymphedema (median excess volume 1230 ml, range 685-1820 ml, median duration 2 years,
range 0-27) were examined with MRI before, and at four days and one month after liposuction. Three slices centered 10 cm
distally of the humeral epicondyle of each arm were acquired using a multi gradient echo sequence with eight echo times. The
voxel size was 1.6x1.6x5 mm3. From the acquired images, volume fat fraction maps were reconstructed using a linear least
squares algorithm. Regions of interest were drawn covering the subfascial compartment, excluding bone. Within the ROIs,
the volume of fat in fatty voxels, defined as voxels containing more than 20 % fat, was calculated. The values for the edematous
arm were compared to the values in the healthy arm using the Wilcoxon signed-rank test.
Results: The edematous arm showed significantly (p < 0.05) larger subfascial fat volume than the healthy arm at all time
points. The median differences in fat volume between the arms at the three time points were: 0.61, 0.37 and 0.75 ml. In the
healthy arm, the corresponding median fat volumes/total ROI volumes were: 1.41/37.73, 1.43/38.68 and 1.34/36.69 ml.
Conclusions: Fat quantification with multi-echo imaging makes the detection and quantification of localized fat accumulation
in and between organs possible. The increased fat volume was localized in the septal fat that is normally found between the
separate muscles. This finding indicates that there is also an increase in the subfascial fat volume in arm lymphedema. To our
knowledge, this has not been reported before.
Declaration of interest
None declared
124

O-18.07
DIAGNOSING LYMPHEDEMA WITH MRI: A REDEFINITION FOR THERAPEUTIC PURPOSES
W Ekataksin, Mahidol University, Bangkok, THAILAND
N Chanwimalueang, Mahidol University, Bangkok, THAILAND
W Nitiwarangkul, Police General Hospital, Bangkok, THAILAND
Background: Lymphedema classically is defined with an obstruction of lymphatic pathway, primary and secondary, or in
congenital cases, is diagnosed with an aplasia or hypoplasia of lymphatics. Seemingly correct as it appears, but on the other
hand is misleading as a matter of fact. It is consequently deemed untreatable. Lymphologists simply disagree.
Objectives: To evaluate the lymphedema by state-of-the-art technology MRI in its simplest modality, and to redefine the
disease for therapeutic purposes.
Methods: Of 2300 patients at Thailand Lymphedema Day Care Center during last five years, 60% were subject to MRI
examination (Siemens Magnetom Avanto 1.5 T) without contrast media. Basic modes included T1W and T2W/STIR fat
suppression, coronal, sagittal, and axial, conducted two stations for upper limbs, three for lower, and four for body involvement.
Serial images were reconstructed to yield results that were anatomically intuitive.
Results: Regardless of etiology, lymphedema under MRI appears unmistakably similar. There were two elements, a dilatation
and a proliferation of peripheral lymphatics in subcutaneous adipose layer; the more chronic the disease, the more thickness
the layer increases. Obese patients tended to have more pronounced dilatation and proliferation. Likewise lymphedma
congenita were noticed with abundance of lymphatic spaces that corresponded to fine tributaries; the findings contradicted
against their early childhood diagnosis from biopsy as lymphatic aplasia/hypoplasia. Sagittal T2W images provided a clear
view for genital lymphedema even in early stage. Spreading to contralateral limb was found via gluteolumbar and transpubic
communications. Coronal T2W was used to judge the proximal limit of leg swelling which sometimes involved waist and
flank. For arm, lymphedema that spread over the external chest wall or complicated with pleural effusion was evidently
visualized.
Conclusions: There is little doubt that plain MRI is helpful in guiding the targets for therapists, without which could be
overlooked by physicians. The redefinition of lymphedema, a dilatation and proliferation of peripheral lymphatics adapts
very well to modern treatment regime; dilated then make it collapsed, proliferated then make it atrophic, the two principles
of compression therapy. The existence of numerous collaterals overturns any who argues for the obstruction of lymph
passageway.
Declaration of interest
None declared
O-18.08
LYMPH DRAINAGE STUDIED BY LYMPHOSCINTIGRAPHY IN THE BREAST AFTER REDUCTION
MAMMAPLASTY AFTER 5 YEARS FOLLOW-UP
L Perbeck, Karolinska Institutet, Dept of Molecula Medicine and Surgery, Karolinska University Hospital Solna, Stockholm,
SWEDEN
R Axelsson, Karolinska Institutet, Dept of Clinical Science, Intervention and Technology, Karolinska University Hopsital
Huddinge, Stockholm, SWEDEN
L Svensson, Medical Physics, Karolinska University Hospital Huddinge, Stockholm , SWEDEN
Background: Theoretically reduction mammaplasty might result in a change in lymph drainage, which e.g. implies that the
sentinel node biopsy technique in breast cancer can not be used routinely after reduction mammaplasty.
Objectives: The aim of the study was to measure the lymph drainage by lymphoscintigraphy in different areas in the breast
before the operation and one month postoperatively when the breast still were swollen and long-term after 5 years using two
types of isotopes.
Methods: Nine patients (median age 41.6 year, range 26.7-52.7) who were operated by reduction mammplasty by the evelation
of the nipple-areola complex by a medial horizontal pedicle, were measured by lymphoscintigraphy with two types of isotopes,
99m Tc-nanocolloid and 99m Tc-dextran. Measurement were performed in four areas during 3 hours and expressed in
percent of the amount isotope injected. One month postoperative the measurements were repeated and also after 5 years.
Results: A median of the four areas were calculated. After 2 hours 93 percent of the injected of 99m Tc-nanocolloid remained
in the tissue measured preoperatively, 92 percent postoperatively and 90 percent after 5 years. Corresponding results using
99m Tc-dextran showed 91 percent, 87 percent and 95 percent, respectively. No major differences were found between the
different areas.
Conclusions: The results implies that one month postoperatively and after 5 years after a reduction mammaplasty there
was no difference in lymph drainage studied by lymphoscintigraphy using either 99m Tc-nanocolloid or 99m Tc-dextran
compared with the preoperative values.
Declaration of interest
None declared.
125

O-19.01
LYMPHATICOVENOUS SIDE TO END ANASTOMOSIS FOR TREATMENT OF PERIPHERAL
LYMPHEDEMA
J Maegawa, Yokohama City University Hospital, Yokohama, JAPAN
H Tomoeda, Yokohama City University Hospital, Yokohama, JAPAN
M Hosono, Yokohama City University Hospital, Yokohama, JAPAN
Efficacy of lympaticovenous anastomosis (LVA) has been controversial because of lack of evidence in late patency after
clinical applications. We have been applied lymphaticovenous side-to-end anastomosis (LVSEA) to patients with peripheral
lymphedema since 1998 because this type of anastomosis should be ideal compared with a fashion of end to end anastomosis.
From the view point of lymph flow in the lymphatics anastomosed, original lymph flow in LVSEA is theoretically preserved.
We present an evidence of late patency in LVSEA by using ICG fluorescence lymphography in patients with peripheral
lymphedema. 169 anastomoses were performed in the 32 patients. Out of the 169 anastomoses 60 anastomoses in the ankle
and dorsum of the foot could be evaluated and the remaining 70 anastomoses could not be evaluated in the other areas
because subcutaneous layer is too thick to be able to detect lymph vessels by ICG fluorescence lymphography in all the
patients. Late patency of the anastomoses could be observed in 25 anastomoses in the dorsum of the foot and the ankle areas
in 18 patients out of the 32 patients. Late patency could not be detected in the remaining 14 patients. There were several
patterns in ICG fluorescence lymphography could be observed at the patent anastomosed sites according to the anastomosed
vein; a dendritic, straight, and L shaped pattern. We present those patterns by video.
Declaration of interest
None declared
O-19.02
SURGICAL TREATMENT OF SECONDARY LYMPHOEDEMAS BY MICROSURGICAL LYMPH VESSEL
TRANSPLANTATION
D Tobbia, University Medicine Göttingen, Göttingen, GERMANY
G Felmerer, University Medicine Göttingen, Göttingen, GERMANY
Background: Chronic lymphoedema is a debilitating complication of cancer diagnosis and therapy and poses many challenges
for health care professionals. It remains a poorly understood condition that has the potential to occur after any intervention
affecting lymph node drainage mechanism. Microsurgical lymph vessel transplantation is increasingly recognized as a
promising method for bypassing the obstructed lymph pathways and promoting long-term reduction of oedema in the
affected limb.
Objectives: The purpose of the present study is to report our experience in alleviating secondary lymphoedema including
upper limb, lower limb, genital and facial oedemas.
Methods: A review of 14 patients with post-operative lymphoedema treated with autologous lymph vessel transplantation
between October 2005 and November 2009. 2 to 4 lymphatic vessel grafts were harvested from the inner aspect of the thigh
and used for bypassing areas of obstructed lymph flow. The grafts are anastomosed to the ascending lymphatics in the affected
limb and proximally to lymphatics in the neck. Patients underwent pre- and post-operative limb circumference measurements
and bioelectrical impedance analysis. In some cases magnetic resonance lymphangiography was also used to visualize the
lymphatic pathways.
Results: 7 of the patients had unilateral upper limb oedema, all showed clinical reduction of limb oedema as early as 2-3
days after surgery, this ranged from 20% to 60% (average 39.8%) decrease in oedema. This improvement continued steadily
over a follow up period of 3 years. The benefit of lymph vessel transplantation in the 5 patients that had unilateral lower limb
lymphoedema was less pronounced than the upper limb, this ranged from 10% to 33% (average 20%). One patient received
lymph vessel transplantation for isolated penis shaft oedema; he had striking resolution of lymphoedema. The patient with
unilateral facial edema, showed diminished swelling and more symmetry of facial appearance.
Conclusion: Lymph vessel transplantation enhanced lymphatic drainage in patients with secondary lymphoedema. Immediate
improvement of lymph flow was demonstrated with postoperative bioelectrical impedance measurements as compared
with baseline values. We were able to establish long-term patency of the lymph vessel anastomosis by magnetic resonance
lymphangiography.
Declaration of interest
None declared
126

O-19.03
SURGICAL TREATMENT FOR LYMPHOEDEMA AFTER BREAST CANCER: 4 YEARS OF EXPERIENCE
J MASIA, SANT PAU UNIVERSITY HOSPITAL (UNIVERSITAT AUTONOMA DE BARCELONA), BARCELONA, SPAIN
G PONS, SANT PAU UNIVERSITY HOSPITAL, BARCELONA, SPAIN
Introduction: Lymphedema is one of the most feared complications of breast cancer therapy and its treatment is a challenging
problem for plastic surgeons. Although more conservative surgery has been introduced, it continues to be a prevalent
iatrogenic problem that affects quality of life. In an attempt to provide breast cancer patients with an integral treatment we
initiate lymphedema treatment using two surgical techniques: lymph node transplant and lymho-venous anastomosis.
Method: Sixty-two patients with lymphoedema for more than two years underwent lymphatic venous anastomosis, in
eighteen of them we also did a lymph node transplantation as a complementary treatment.
Results: We clinically assessed the quality of skin tissue and the reduction of the circumference of the affected limb. After a
follow up of 6-46 months, we observed the circumference of the arm decreased from 0,9 to 6,1 cm (average 3,25 cm). The rate
of preoperative versus postoperative excess circumference decreased in range from 12 to 66,7% (average 38,45%).
Conclusion: Results were most satisfactory with the combination of the two techniques. In a first step, lymph node transplant
restores axillary lymph tissue and lympho-venous anastomosis then permits localized intervention in regions with resistant
and invasive lymphedema. Nevertheless, use of either technique alone also improved lymphedema. Treatment must thus be
individualized for each patient in order to achieve optimal results
Declaration of interest
None declared
O-19.04
5 YEAR EXPERIENCE OF LIPOSUCTION FOR CHRONIC LYMPHOEDEMA OF THE UPPER LIMB IN
DUNDEE, SCOTLAND
N Kandamany, Ninewells Hospital, Dundee, UNITED KINGDOM
K Munro, Ninewells Hospital, Dundee, United Kingdom
D Munnoch, Ninewells Hospital, Dundee, United Kingdom
Introduction: Chronic lymphoedema of the upper limb is a common complication of axillary surgery for breast cancer.
Effective treatment by liposuction has previously been demonstrated and we present our experience of treatment over the
last 5 years.
Methods: A prospective analysis of 12 patients who underwent liposuction followed by compressive therapy as described by
Dr. Brorson was carried out. 11 patients developed chronic unilateral upper limb lymphoedema following axillary surgery for
breast cancer and 1 patient following thyroidectomy.
Results: The mean preoperative arm volume difference was 1391mls (637-2428) and the mean ratio of the swollen arm to the
unaffected arm was 1.48 (1.3-1.7). A mean of 1712mls (925-2600) of fat was removed.
Mean percentage reductions following liposuction were 101% a 1 year (n=10), 123% at 3 years (n=9) and 136% at 5 years (n=2)
with a mean ratio of operated to non-operated arm of 0.89. All patients have been delighted with the results of treatment.
Conclusion: This prospective study has shown that liposuction for chronic upper limb lymphoedema is effective, safe and
long-lasting, comparable with results previously demonstrated by Dr. Brorson. A dedicated team, careful patient selection and
compliance with lifelong pressure therapy are essential to maintain the results and we will continue to develop an integrated
lymphoedema service in Scotland.
Declaration of interest
None declared
127

O-19.05
DOES LIPOSUCTION FOR UPER-EXTREMITY LYMPHOEDEMA HAVE A LONG-LASTING EFFECT?
M Wald, Charles University Prague, Prague , CZECH REPUBLIC
D Tomášek, Charles University , Prague , CZECH REPUBLIC
H Houdová, Centre for lymphoedema treatment, Pardubice, CZECH REPUBLIC
J Adámek, Charles University , Prague, CZECH REPUBLIC
J Hoch, Charles University , Prague, CZECH REPUBLIC
Background and Objectives: The main reason for liposuction is limb asymmetry due to non-pitting lipohypertrophy in the
epifascial region. Volume and weight asymmetry may result in vertebrogenic pain syndrome and restrict shoulder and upper
extremity motion.
Material and Methods: In the last six years the authors performed liposuction in 50 patients. The average time of bloodless
operation was 90 minutes. Immediately after surgery a compressive garment was applied. To improve microcirculation in the
operated limb, proteolytic enzymes were given orally. The patients were followed up at 3 and 12 months after surgery, and
then once every year.
Results: Before surgery, the biggest asymmetry, as assessed by the lymphoedema volume of the affected limb related to the
contralateral unaffected limb, was 3,279 ml and the smallest asymmetry was 598 ml, with the average value being 1,400 ml.
The average amount of aspirated adipose tissue was 1,460 ml, with the range of 3,200 ml to 800 ml. During follow-up of the
patients the average post-operative volume difference, as related to the contralateral arm, was 84 ml.
No immediate post-operative complications were observed. One patient developed erysipelas of the operated extremity
two weeks after surgery but she had had it many times before surgery. Generally, however, the occurrence of erysipelas
in the patients suffering from it before surgery dramatically decreased after liposuction. One patient developed deep vein
thrombosis of the lower extremity one week after surgery; this soon resolved with adequate treatment.
Conclusion: The major positive effects of liposuction in lymphoedema include improvement in upper-extremity motor
function, lower risk of recurrent vertebrogenic complaints caused by asymmetrical weight distribution. In addition,
liposuction reduces adipose tissue volume and thus prevents excessive fluid absorption.
All patients were fully satisfied with the results of treatment and considered their post-operative condition very good. The
most frequent co-morbidities caused by limb asymmetry in chronic lymphoedema associated with lipohypertrophy were
significantly reduced.
Acknowledgement: This research was partly supported by the Internal Grant Agency of the Ministry of Health, Czech
Republic, project No. NS9906-4/2008
Declaration of interest
None declared
O-19.06
END-STAGE BREAST CANCER RELATED ARM LYMPHEDEMA SURGICAL TREATMENT: A
PROSPECTIVE STUDY OF 100 PATIENTS
P. Klinkert, Hospital de Tjongerschans, Heerenveen, Netherlands
O. R. M. Wikkeling, Nij Smellinghe Hospital, Drachten, Netherlands
D A. A. Lamprou, Nij Smellinghe Hospital, Drachten, Netherlands
R. J. Damstra, Nij Smellinghe Hospital, Drachten, Netherlands
H. G. J. Voesten, Nij Smellinghe Hospital, Drachten, Netherlands
Background: The incidence of breast cancer related lymphedema varies between 7 to 40 % depending on the combination of
treatment modalities. Although most patients in earlier stages can and will be treated conservatively, end-stage non-pitting
lymphedema is non-responsive to compression as chronic stasis of high protein lymph fluid causes the start of a chain
reaction ending in hypertrophy of connective and adipose tissue.
Objectives: To demonstrate the long term results of Circumferential Suction-Assisted Lipectomy (CSAL) in end-stage
irreversible breast cancer related arm lymphedema (BCRL) in combination with flat –knit garments worn 24 hrs a day.
Methods: This was a prospective study of 100 patients in end-stage irreversible breast cancer related arm lymphedema.
After initial conservative treatment CSAL was used to reduce excess volume. Compression was resumed directly at the
end of the surgical procedure with short-stretch bandages, followed by flat-knit compression garments as soon as suction
cannula entrance wounds were healed. Arm volumes were measured pre- and postoperatively, after 1, 3, 6 and 12 months (
Lymphometer.)
Results: The mean preoperative volume difference was 1413 ml (IQR: 2956; 734 ml). The mean aspirate volume using CSAL
was 2340 ml (IQR 4350; 945 ml) . After 1 month the mean reduction in lymphedema volume difference was 106 per cent;
after twelve months 117 per cent.
Conclusion: Circumferential suction-assisted lipectomy combined with a multi-disciplinary approach including pre- and
postoperative compression therapy and lifelong wearing of compression garments is an effective technique in the treatment
of irreversible lymphedema of arm.
Declaration of interest
None declared
128

O-19.07
LIPOSUCTION IN THE MANAGEMENT OF LEG LYMPHOEDEMA – THE DUNDEE EXPERIENCE.
P Baker, Ninewells Hospital, Dundee, UNITED KINGDOM
A Munnoch, Ninewells Hospital, Dundee, UNITED KINGDOM
Background: Chronic lymphoedema of the upper limb is a common complication of axillary surgery for breast cancer.
Effective treatment by liposuction has previously been demonstrated and we present our experience of treatment over the
last 5 years.
Methods: A prospective analysis of 12 patients who underwent liposuction followed by compressive therapy as described by
Dr. Brorson was carried out. 11 patients developed chronic unilateral upper limb lymphoedema following axillary surgery for
breast cancer and 1 patient following thyroidectomy.
Results: The mean preoperative arm volume difference was 1391mls (637-2428) and the mean ratio of the swollen arm to the
unaffected arm was 1.48 (1.3-1.7). A mean of 1712mls (925-2600) of fat was removed.
Mean percentage reductions following liposuction were 101% a 1 year (n=10), 123% at 3 years (n=9) and 136% at 5 years (n=2)
with a mean ratio of operated to non-operated arm of 0.89. All patients have been delighted with the results of treatment.
Conclusion: This prospective study has shown that liposuction for chronic upper limb lymphoedema is effective, safe and
long-lasting, comparable with results previously demonstrated by Dr. Brorson. A dedicated team, careful patient selection and
compliance with lifelong pressure therapy are essential to maintain the results and we will continue to develop an integrated
lymphoedema service in Scotland.
Declaration of interest
None declared
O-19.08
SEVENTEEN YEARS’ EXPERIENCE OF COMPLETE REDUCTION OF ARM LYMPHEDEMA
FOLLOWING BREAST CANCER
H Brorson, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
C Freccero, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
K Ohlin, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
B Svensson, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
M Åberg, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
H Svensson, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
Background: Breast cancer is the most common disease in women, and up to 38% develop lymphedema of the arm following
mastectomy, standard axillary node dissection and postoperative irradiation. Limb reductions have been reported utilizing
various conservative therapies such as manual lymph and compression therapies. Patients with longstanding, pronounced,
non-pitting lymphedema do not respond to conservative treatment because diminished lymph flow and inflammation result
in the formation of excess subcutaneous adipose tissue. Total excision with skin grafting or reduction surgery seldom achieved
acceptable cosmetic and functional results. Microsurgical reconstruction involving lymphovenous shunts or transplantation
of lymph vessels/lymph nodes, although attractive as a physiological concept, cannot provide complete reduction in chronic
non-pitting lymphedema because it does not eliminate newly formed, subcutaneous adipose tissue collections.
Methods: 120 women with non-pitting edema, a mean age of 64 years and a mean duration of arm swelling of 9 years
underwent liposuction. Mean age at breast cancer operation, mean interval between breast cancer operation and duration of
lymphedema start were 52 years and 3 years respectively. Aspirate and arm volumes were recorded.
Results: Aspirate mean volume was 1865 ml with an adipose tissue concentration of 94%. Preoperative mean excess volume
was 1636 ml. Postoperative mean reduction was 102% at 3 months and more than 100% during 17 years’ follow-up, i.e. the
lymphedematous arm was somewhat smaller than the healthy arm. The preoperative mean ratio between the volumes of the
edematous and healthy arms was 1.5, rapidly declining to 1.0 at 3 months, and less than 1 after one year.
Conclusion: These long-term results demonstrate that liposuction is an effective method for treatment of chronic, nonpitting
arm lymphedema in patients who have failed conservative treatment. Because of adipose tissue hypertrophy, it is
the only known method that completely reduces excess volume. The removal of hypertrophied adipose tissue, induced by
inflammation and slow or absent lymph flow is a prerequisite to complete reduction. The newly reduced volume is maintained
through constant (24-hour) use of compression garments postoperatively.
Declaration of interest
None declared
129

O-19.09
THE SIMULTANEOUS TWO-PHASE DEBULKING PROCEDURE IN PATIENTS WITH LATE STAGE OF
BREAST CANCER RELATED LYMPHEDEMA
V Nimaev, Institute of Clinical and Experimental Lympholgy SB RAMS, Novosibirsk, RUSSIAN FEDERATION
M Shumkov, Institute of Clinical and Experimental Lympholgy SB RAMS, Novosibirsk, RUSSIAN FEDERATION
M Soluyanov, Institute of Clinical and Experimental Lympholgy SB RAMS, Novosibirsk, RUSSIAN FEDERATION
E Kombantsev, Institute of Clinical and Experimental Lympholgy SB RAMS, Novosibirsk, RUSSIAN FEDERATION
D Habarov, Institute of Clinical and Experimental Lympholgy SB RAMS, Novosibirsk, RUSSIAN FEDERATION
M Lubarsky, Institute of Clinical and Experimental Lympholgy SB RAMS, Novosibirsk, RUSSIAN FEDERATION
BACKGROUND. The debulking surgery of patients with the late stage of breast cancer related lymphedema (BCRL) has
complications both during and after the operation. It is connected with huge mass of changed tissue and troubles with
bleeding.
OBJECTIVES. To modify debulking surgery procedure for diminishing the complication rate.
METHODS. We have observed 170 patients with BCRL. Patients with late degree averaged 9,4% (16). Fifteen patients
underwent debulking procedures (8 – usual resection procedure and 7 - simultaneous two-stages procedures (STSP). STSP
consists of liposuction (first stage) before resection of skin-fat flap (second stage).
RESULTS. The average duration of usual procedures has made 150 + 43 minutes. The
intraoperative haemorrhage averaged 658,3+453 ml and demanded hemotransfusions in 4 patients (57,1 %). Average duration
of STSP has made 102,5+15 minutes. In one patient out of 7 (14,3 %) the haemorrhage was observed at the stage following
after removal of the arterial tourniquet which without need of haemotransfusion. Bleeding was not marked in other patients
due the accurate differentiation of bleeding vessels and their ligation or electrocoagulations at a stage of realization of a
haemostasis. Thus, the average volume of the changed tissue being removed during operation was about 2075+1100 ml.
CONCLUSIONS. Liposuction as the preliminary phase before resection of lymphedematous tissues allows to carry out more
precision hemostasis due to accurate control of vascular structures. As a result, the decrease of quantity of post-surgical
complications amounted 4,4 times, whereas the duration of surgical intervention 1,5 times.
Declaration of interest
None declared
O-20.01
PROSPECTIVE RANDOMIZED TRIAL ON THE EFFECTS OF PERIPHERAL LYMPHEDEMA
PHYSICAL-MICROSURGICAL TREATMENT VS. COMBINED PHYSICAL THERAPY.
C C Campisi, University of Genoa, Genoa, Italy, F Boccardo, University of Genoa, Genoa, Italy, M Adami, University of Genoa,
Genoa, Italy, C S Campisi, University of Genoa, Genoa, Italy, R Lavagno, University of Genoa, Genoa, Italy, C Campisi,
University of Genoa, Genoa, Italy, P Santi, University of Genoa, Genoa, Italy
Background: Primary and secondary lymphedema of both upper and lower limbs may be successfully managed by a correctly
timed synergistic physical-microsurgical approach.
Objectives: To report the wide clinical experience and the translational research studies in the microsurgical treatment of
peripheral lymphedema, underlying the role of a combined physical-microsurgical early treatment to obtain the best longterm
results.
Methods: From January 2009 to January 2010, 100 consecutive patients affected by peripheral lymphedema of both upper and
lower extremities were randomly divided in two groups. Fifty patients underwent a three steps approach (LVA group - LG)
defined by two weeks of pre-operative combined physical therapy (CPT), microsurgical derivative multiple lymphatic-venous
anastomoses (LVA) with the end-to-end telescopic technique and two weeks of post-operative rehabilitative treatment. The
other 50 patients (control group - CG) were treated with CPT alone during the same period of the LG. Patients were followed
up clinically at 1, 3, 6, 12 months by volumetry.
Results: Statistically significant (p-value < 0.01) difference between the two groups was evident in the volume changes with
respect to baseline. In the LG volume changes showed an excellent improvement in 84%, with an average reduction of 76%
of the excess volume. Of those patients, 36% were able to discontinue the use of conservative measures after one-year followup,
according to the early lymphedema stage. In the LG there was also reported an 89% reduction in the incidence of acute
lymphangitis. In the CG volume changes showed improvement in 52%, with an average reduction of 32% of the excess
volume and a 23% reduction in the incidence of acute lymphangitis.
Conclusions: Microsurgical multiple lymphatic-venous anastomoses have a key role in the treatment of peripheral lymphedema.
Microsurgical derivative techniques need an adequate learning curve but are easily reproducible as demonstrated also by
experimental researches. A combined physical-microsurgical approach should be the treatment of choice in patients not
sufficiently and successfully responsive to CPT alone. “Restitutio ad integrum” can be expected with CPT-microsurgery
performed earlier at the very first stages of the disease.
Declaration of interest
None declared
130

O-20.02
LONG TERM RESULTS AFTER RECONSTRUCTIVE MICROSURGERY USING LYMPHATIC
AUTOGRAFTS, PROVED BY RADIOLOGY AND NUCLEAR MEDICINE
R Baumeister, University of Munich, Dept. of Surgery, Munich, GERMANY
M Notohamiprodjo, University of Munich, Inst. of Radiology, Munich, Germany
M Weiss, University of Munich, Clinic of Nuclearmedicine, Munich, Germany
J Wallmichrath, University of Munich, Dept. of Surgery, Munich, Germany
S Springer, University of Munich, Dept. of Surgery, Munich, Germany
A Frick, University of Munich, Dept. of Surgery, Munich, Germany
The results for lymphedema treatment protocols are mostly based on circumferential and volume measurements.
Additionally, after microsurgical reconstruction of interrupted lymphatic channels using lymphatic autografts, there exists
the possibility to get the patency and function proved by independent investigators from the department of radiology and
nuclear medicine.
There is another important aspect , the estimation of the quality of life after or during the course of the treatment.
We report on our experiences on 352 patients. 199 suffered from lymphedemas of upper limbs, 143 of lower limbs and 10 of
penis and scrotum.
Significant reductions in volume where seen in our series in arm edemas also after 10 years follow up The mean values of
volume were reduced from 2911±146 cm³ to 2209±134 cm³ . In comparison, the unaffected side showed a volume of 1943±
cm³.
Also in leg edemas there was a significant reduction after a follow up period of more than 4 years. The mean values of volume
were reduced from 12153±522 cm³ to 10158±382 cm³. In comparison, the unaffected side showed a volume of 8868±367 cm³.
Additionally a marked reduction after 8 years was seen.
The patients have been investigated by lymphoscintiscans prior to and after surgery. These showed a significant improvement
indicating restoration of lymphatic outflow up to normalization.
With the help of Indirect Lymphography and MRI Lymphography, the patency of lymphatic autografts could be demonstrated
also after follow up period of more than 10 years.
Finally the Quality of life was significantly improved .
Declaration of interest
None declared
O-20.03
MICROVASCULAR BREAST RECONSTRUCTION AND LYMPH NODE TRANSFER FOR
POSTMASTECTOMY LYMPHEDEMA PATIENTS
E Suominen, Turku University Hospital, Turku, Finland
A Saarikko, Turku University Hospital, Turku, Finland
T Niemi, Turku University Hospital, Turku, Finland
T Viitanen, Turku University Hospital, Turku, Finland
T Tervala, Turku University Hospital, Turku, Finland
K Alitalo, Biomedicum MCBL, Helsinki, Finland
Background and Objective: Postoperative lymphedema after breast cancer surgery is a challenging problem. Recently, a novel
microvascular lymph node transfer technique, provided new hope for lymphedema patients. We wanted to combine this new
method with the standard breast reconstruction.
Methods: During 2008-2010 we performed free lower abdominal flap breast reconstruction on 87 patients. For all patients
with lymphedema symptoms (n=10) we used a modified lower abdominal reconstruction flap containing lymph nodes
and lymphatic vessels surrounding the superficial circumflex vessel pedicle. Operation time, donor site morbidity and
postoperative recovery between the two groups (lymphedema breast reconstruction - breast reconstruction) were compared.
The effect on the postoperative lymphatic vessel function was examined.
Results: The average operation time was 426 minutes in the lymphedema breast reconstruction group and 391 minutes in
the breast reconstruction group. The postoperative abdominal seroma formation was increased in lymphedema patients.
Postoperative lymphoscintigraphy demonstrated at least some improvement in lymphatic vessel function in five (5/6)
lymphedema patients. The upper limb perimeter decreased in seven (8/10) patients. Physiotherapy and compression was no
longer needed in three (4/9) patients. Importantly, we found that human lymph nodes express high levels of endogenous
lymphatic vessel growth factors. Transfer of the lymph nodes and the resulting endogeneous growth factor expression may
thereby induce the re-growth of lymphatic network in the axilla. No edema problems were detected in the lymph node donor
area.
Conclusion: Simultaneous breast and lymphatic reconstruction is an ideal option for patients that suffer from lymphedema
after mastectomy and axillary dissection.
Declaration of interest
ES,TN, TV, PH, TT none declared
AS is a member of the board of LXtherapies
131

O-20.04
EARLY AUSTRALIAN EXPERIENCE OF LIPOSUCTION TREATMENT FOR NON-PITTING CHRONIC
LYMPHOEDEMA.
J Tiong, Medica Centre,The Surgery Centre, Sydney, AUSTRALIA
H Mackie, Mt Walga Hospital, Sydney, Australia
K Shanley, 187, Macquarie St, Sydney, Australia
K Poon, Medica Centre,31 Dora St, Hurstville, Australia
Introduction: Since 2008,eight patients with chronic lymphoedema (3 legs and 5 arms) have been treated with liposuction to
reduce excess volume. All patients had previously been treated with complete decongective therapy and showed no pitting
but further reduction of the excess volume could not be achieved.All patients were compliant with wearing of compression
garments.
Method: All the patients underwent liposuction according to the selection criteria ,operative approach and postoperative
management as described by Brorson's et al at Skane University Hospital, Malmo,Sweden.
Result: The post operative follow-up will be presented and discussed.
Conclusion: The longitudinal follow-up of 8 patients demonstrate that liposuction for none pitting lymphoedema in reducing
the excess limb volume is successful.
Declaration of interest
None declared.
O-20.05
LIPOSUCTION NORMALIZES ELEPHANTIASIS OF THE LEG – A PROSPECTIVE STUDY WITH AN
EIGHT-YEAR FOLLOW-UP
H Brorson, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
C Freccero, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
K Ohlin, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
B Svensson, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
M Åberg, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
H Svensson, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
Background: Patients with long-standing pronounced non-pitting lymphedema do not respond to conservative treatment
or microsurgical procedures (such as lympho-venous shunts or transplantation) because slow or absent lymph flow, as well
as chronic inflammation, cause the formation of excess subcutaneous adipose tissue which cannot be removed by these
methods. Previous surgical techniques utilizing either total excision with skin grafting or reduction seldom achieved
acceptable, cosmetic and functional results. The swelling of chronic non-pitting arm lymphedema following breast cancer,
can be completely reduced by liposuction and has not recurred during more than ten years’ follow-up. Encouraged by this
experience, we decided to test the effectiveness of liposuction on leg lymphedema.
Methods: 41 patients with an age of 52 years and a duration of leg swelling of 15 years underwent liposuction due to nonpitting,
chronic lymphedema. There were 19 primary (PL), and 22 secondary lymphedemas (SL) following cancer therapy.
Age at cancer treatment and interval between cancer treatment and lymphedema start were 42 years, and 3 years respectively.
Age at onset of PL was 29 years. All patients had received conservative treatment before surgery without further reduction.
All were wearing compression garments before surgery. Aspirate and leg volumes were recorded.
Results: Aspirate volume was 4116 ml with an adipose tissue concentration of 94%. Preoperative excess volume was 4195 ml.
Postoperative mean reduction was 84% at 3 months and 105% at 1 year, and more than 100% during 8 years’ follow-up, i.e.
the lymphedematous leg was somewhat smaller than the healthy one. The preoperative mean ratio between the volumes of
the edematous and healthy legs was 1.4, rapidly declining to 1.0 at 6 months, and less than 1 after one year.
Conclusion: Liposuction is an effective method for treatment of chronic, non-pitting leg lymphedema in patients who
have failed conservative treatment. It is the only known method that completely reduces excess volume. The removal of
hypertrophied adipose tissue is a prerequisite to complete reduction. The reduced volume is maintained through constant use
of compression garments postoperatively.
Declaration of interest
None declared
132

O-20.06
LIPOSUCTION WITH COMPRESSIVE THERAPY FOR TREATMENT OF LOWER EXTREMITY
LYMPHEDEMA AND LIPOLYMPHEDEMA
M Topalan, Istanbul, Istanbul, TURKEY
Y Demirtas, Ondokuz Mayis, Samsun, TURKEY
Introduction: Excisional procedures are generally the only surgical option for patients with advanced lower extremity
lymphedema. These procedures are associated with several complications including recurrence, infection and extensive
cutaneous scarring. Reported here is the preliminary experience with application of liposuction to lower extremity
lymphedema and lipolymphedema cases.
Material and Methods: During the last three years, 28 lower extremities of 14 lipolymphedema patients and 35 lower
extremities of 25 lymphedema patients were treated with liposuction. The procedures were performed under tourniquet and
with the “dry technique.” Made-to-measure stockings in high compression classes were immediately dressed at the operation
table. The patients were informed to use the garments continuously and renewal was needed after 4 to 6 months.
Results: Twenty-six of the patients were female and 13 were male. Mean age of the patients was 32.9 years and mean follow
up was 22 months. Mean volume of the aspirate was 5.2 (range, 2.8-16) liters. Wound infection was observed in one patient,
seroma formation in another patient and a local skin necrosis occurred in another one. Among 28 patients who told that they
used the garments according to instructions, the postoperative volume of the limbs was preserved during follow up in 21
(13 lipolymphedema and 8 lymphedema), but the limbs began to enlarge in seven patients. The edema recurred in all of 11
patients who failed to use the garments properly.
Conclusion: Liposuction, when used in conjunction with compression garments, has proved to be a safe and effective way of
reducing upper extremity lymphedema. Though, its use for lower extremity is under debate. According to results of this study,
liposuction seems to be more efficient for treatment of lipolymphedema. Concerning the lymphedema, it should be reserved
for selected patients who prove their compliance with rigorous use of the garments preoperatively.
Declaration of interest
None declared
O-20.07
CIRCUMFERENTIAL SUCTION-ASSISTED LIPECTOMY IN END STAGE LEG LYMPHEDEMA: A
PROSPECTIVE STUDY IN 60 PATIENTS
H. G. J. Voesten, Nij Smellinghe Hospital, Drachten, Netherlands
D A. A. Lamprou, Nij Smellinghe Hospital, Drachten, Netherlands
O. R. M. Wikkeling, Nij Smellinghe Hospital, Drachten, Netherlands
R. J. Damstra, Nij Smellinghe Hospital, Drachten, Netherlands
P. Klinkert, Tjongerschans Hospital, Heerenveen, Netherlands
Background: The incidence of secondary lower limb lymphedema ranges from 40 to 60% in patients who underwent radical
inguinal or para-iliac lymphe node dissection with or without radiation therapy. In addition to this , primary lymphedema
of the leg has a prevalence ranging from 1/100.000 to 8/100. 000. Although conventional compression therapy is used in all
early cases , end-stage irreversible lymphedema is non-responsive to compression therapy.
Objectives: To demonstrate the long term results of Circumferential Suction-Assisted Lipectomy (CSAL) in end-stage (
primary or secondary) irreversible lymphedema of the leg.
Methods: This was a prospective study of 60 patients with chronic irreversible lymphedema of the leg. After initial conservative
treatment CSAL was used to reduce excess volume. Compression was resumed directly after surgery with short-stretch
bandages, followed by flat-knit compression garments. Leg volumes were measured pre- and postoperatively, after 1, 3, 6 and
12 months ( perometer)
Results: The mean preoperative volume difference was 4166 ml (IQR: 2863; 6820 ml). The mean aspirate volume using CSAL
was 6760 ml containing 74 per cent adipose tissue. After 12 months, the mean reduction in lymphedema volume difference
was 93 per cent.
Conclusion: Circumferential suction-assisted lipectomy combined with a multi-disciplinary approach including pre- and
postoperative compression therapy and lifelong wearing of compression garments is an effective technique in the treatment
of irreversible lymphedema of the leg.
Declaration of interest
None declared
133

O-20.08
TREATMENT OF LOWER LIMB ELEPHANTIASIS WITH COMBINATION OF CONSERVATIVE
TREATMENT, SURGICAL EXCISION AND LIPOSUCTION
K Dalen, Levanger Hospital, Levanger, Norway
M Veske, Levanger Hospital, Levanger, Norway
M Johansen, Levanger Hospital, Levanger, Norway
W van de Veen, St Olavs Hospital, Trondheim, Norway
H Brorson, Skåne University Hospital, Malmø, Sweden
Background: Deposition of inflammation-induced adipose tissue has been recognized as an important factor in some patients
with lymphedema. Recently, there have been described surgical techniques for liposuction of this excessive adipose tissue in
combination with compression therapy.
Objectives: We present a case of a 39 year old woman with primary lymphedema of the left lower limb. Due to obesity
(maximal weight 165 kg) she was treated with dietary weight reduction and then gastric bypass surgery in 2007. We highlight
a treatment of a combination of decongestive lymphatic therapy (DLT) including compression (bandaging) and lymphatic
drainage and surgical interventions. Due to excessive fibrous tissue, probably induced by obesity and concomitant venous
hypertension, a two stage surgical procedure was performed.
Methods: Limbs circumferences were measured every 4 cm from the malleoli to the groin to calculate the excess volume (EV).
Before liposuction and lateral surgical excision of fibrous tissue (November 2009) the patient underwent one year of DLT
to reduce the EV. Before liposuction and medial excision (March 2010) an additional four months of DLT was performed.
Prior to the both surgical procedures intensive DLT was performed daily during two weeks. After surgery the patient was
instructed to wear compression garments continuously.
Results: Prior to treatment in hospital DLT reduced maximal circumference of left leg from 102 to 71 cm, accompanied by
dietary weight loss from 107 to 88 kg. She was then treated by DLT at our outpatient clinic with reduction of the EV of the
left lower limb from 9376 to 5539 ml before the first surgical procedure. Before the second procedure the preoperative EV
was 2601 ml. Follow-up after one year showed maintained result, but the patient claimed to sometimes forgets to use her
compression garments due to the successful outcome.
Conclusion: We present a case of successful treatment of leg elephantiasis with a combination of conservative treatment,
surgical excision of fibrous tissue and circumferential liposuction.
Declaration of interest
None declared
O-20.09
DIFERENT RESULTS OF LIPOSUCTION FOR PRIMARY AND SECONDARY LOWER-EXTREMITY
LYMPHOEDEMA.
M Wald, Charles University Prague, Prague, CZECH REPUBLIC
J Adámek, Charles University , Prague, CZECH REPUBLIC
Background and Objectives: After using liposuction successfully as a method for upper- extremity lymphoedema treatment
in 2005, we started in 2007 with the same method in the treatment of lower-extremity lymphoedema. Here we present our
results with an emphasis on different long-term outcomes in primary and secondary lymphoedema.
Material and Methods: Liposuction was carried out in 21 lower extremities. Thirteen extremities were affected with primary
lymphoedema (PL group) and eight extremities had secondary lymphoedema (SL group). The average time of bloodless
operation was 120 minutes. Immediately after surgery a compressive stocking was applied. Proteolytic enzymes were given
orally to improve microcirculation of the operated limb. The patients were followed up at 3 and 12 months after surgery, and
then once every year.
Results: In the PL group the biggest volume asymmetryolume between the affected and unaffected lower extremities, was
9,673 ml and the smallest asymmetry was 939 ml. In the SL group, these values were 7,106 ml and 2,344 ml. The average
difference in lymphoedema volume between the PL and SL groups before surgery was only 400 ml (4,000 ml vs. 4,400). The
average amounts of aspirated adipose tissue were 2,300ml and 3,250ml in PL and SL groups, respectively. The largest aspirated
amounts were 9,673ml in the PL group and 7,106 ml in the SL group. The lowest aspirated amounts were 500 ml (in two
patients) in the PL group and 2,000 ml in the SL group. During follow-up of the patients the average post-operative volume
difference between the affected and unaffected extremities reached 2,750 ml in the PL group and 1,140 ml in the SL group.
Neither early nor late post-operative complications were observed.
Conclusion: All SL group patients were fully satisfied with the results of surgery and rated their post-operative condition
(symmetry of volume and weight) as very positive. In the PL group only 60% of patients showed objective or subjective
improvement.
Acknowledgement: This research was partly supported by the Internal Grant Agency of the Ministry of Health, Czech
Republic, project no. NS9906-4/
Declaration of interest
None declared
134

O-21.01
PREVENTION AND TREATMENT OF LYMPHATIC COMPLICATIONS DURING VENOUS SURGERY
F Boccardo, University of Genoa, Italy, Genoa, ITALY
C Campisi, University of Genoa, Genoa, ITALY
S Accogli, University of Genoa, Genoa, ITALY
C Campisi, University of Genoa, Genoa, ITALY
R Lavagno, University of Genoa, Genoa, ITALY
P L Santi, University of Genoa, Genoa, ITALY
C Campisi, University of Genoa, Genoa, ITALY
Background: Lymphatic complications not rarely occur in great and small saphenous vein surgery and their treatment is
sometimes difficult due to the significant lymphatic impairment caused by venous surgery.
Objectives: To evaluate the possibility to prevent and treat lymphatic complications in venous surgery by accurate diagnostics,
proper surgical technique and repairing microsurgical procedures.
Methods: 135 patients, affected from venous insufficiency and varices with history and clinical signs of associated lymphatic
impairment at lower limbs, addressed to great saphenous vein surgery, were studied retrospectively and divided in two
groups. In one group (65 patients, PG – preventive group) a protocol for prevention of lymphatic injuries was followed, in
the other group no lymphatic prevention was considered (67 patients, SG – standard group). Three patients did not conclude
the follow-up and therefore were excluded from the study. Patients were followed-up for 3 years. The preventive protocol
included pre-operative lymphoscintigraphy (LS) and the use of the blue dye injected during venous surgery to visualize
and prevent injuries to lymphatics and lymphnodes nearby venous structures. Microsurgical lymphatic-venous shunts were
performed after repairing saphenous valvular function (by an external valvuloplasty) in 21 patients of the PG group. Venous
Duplex Scan (VDS) was used in all patients. Follow-up consisted in limb volumetry compared to pre-operative conditions
and number of episodes of dermatolymphagioadenitis (DLA).
Results: Four patients of the SG had lymphedema (excess volume >or= 100 ml compared to pre-op conditions) and 5 patients
had one or more episodes of DLA. No patient in the PG had any lymphatic complication. VDS demonstrated great saphenous
vein valvular insufficiency in all patients. LS showed different patterns of lymphatic impairment and allowed to address PG
patients either to blue dye injection alone (44) or associated with microsurgical lymphatic reconstruction (21).
Conclusions: Accurate diagnostic investigation and proper surgical technique associated, when necessary, with microsurgical
procedures demonstrated to be of paramount importance in avoiding lymphatic complications during venous surgery.
Declaration of interest
None declared
O-21.02
MANAGEMENT OF HIGH EXUDATION OF THE ULCERS IN PATIENTS WITH LYMPHEDEMA (FINAL
RESULTS)
E. Dimakakos, Vascular Unit of Oncology Deparment of 3rd Internal Clinic of the University of Athens “Sotiria” Hospital, Greece
, Maroussi, GREECE
J. Kalemikerakis, TEI of Athens, Greece, , Greece
Z. Vardaki, TEI of Athens, Greece, , Greece
G. Fouka, TEI of Athens, Greece, , Greece
K. Syrigos, Vascular Unit of Oncology Deparment of 3rd Internal Clinic of the University of Athens “Sotiria” Hospital, Greece ,
, Greece
Background: Exudation of ulcers and consequently the leaking and the wet of the lower extremities is a very common and big
problem in patients with lymphedema which change dramatically the quality of their life and delay the healing of the ulcers.
Objectives: The aim of this work is to study the safe and the effectiveness of the dressing wound foam in the management of
the exudation and the wet of the bandage in patients with lymphedema
Methods: We studied 36 patients with ulcers who were randomized into two groups. Group (A) included 18 patients (13
women and 5 man) who were treated with a simple foam dressing (Baitain) for four weeks. Group (B) included 18 patients
(14 women and 4 men) who were treated with Silver foam dressing (Baitain Ag) for four weeks. The inclusion criteria were
patient with lymphedema, ulcers without signs of inflammation, ulcers > 10 cm diameter and superficial

O-21.03
INSUFFICIENT LYMPH DRAINAGE CAUSES ABNORMAL LIPID ACCUMULATION AND
DEGENERATES VEIN WALL.
H Tanaka, Hamamatsu University School of Medicine, Hamamatsu, JAPAN, N Yamamoto, Hamamatsu University School
of Medicine, Hamamatsu, JAPAN, M Suzuki, Hamamatsu University School of Medicine, Hamamatsu, JAPAN, Y Mano,
Hamamatsu University School of Medicine, Hamamatsu, JAPAN, M Sano, Hamamatsu University School of Medicine,
Hamamatsu, JAPAN, T Saito, Hamamatsu University School of Medicine, Hamamatsu, JAPAN, N Zaima, Hamamatsu
University School of Medicine, Hamamatsu, JAPAN, H Konno, Hamamatsu University School of Medicine, Hamamatsu, JAPAN
M Setou, Hamamatsu University School of Medicine, Hamamatsu, JAPAN, N Unno, Hamamatsu University School of Medicine,
Hamamatsu, JAPAN
Background: In patients with varicose vein, we have previously reported that the number of lymphatic vessels located around
incompetent great saphenous vein (GSV) was significantly decreased compare to that of competent GSV, which suggested the
pathological interaction between venous and lymphatic insufficiency.
Objectives: In this study, we recreated an animal model of lymphatic drainage insufficiency in perivenous tissue to investigate
the influence on the vein wall degeneration.
Methods: Rats’ lymphatic collecting vessels surrounding the femoral vein were ligated, which caused local retention of
lymphatic fluid in the perivascular tissue (model group). Histological study was performed in both the femoral vein and the
perivascular tissue. Imaging mass spectrometry (IMS) was performed to assess the distribution of lipid molecules in those
tissue. IMS can identify the accumulated lipid molecules as well as its distribution.
Results: The diameter of lymphatic vessels at 7 days after the treatment was significantly larger than that of lymphatic vessels
without the treatment (control group), and the number of the lymphatic vessels in the model group was significantly decreased
compare to that in the control group. IMS revealed that abnormal lipid molecules such as lysophosphatidylcholine (LPC)
(1-acyl 16:0), phosphatidylcholine (PC) (16:0/20:4), and triglyceride (52:3) were markedly accumulated in the perivascular
tissue in the model group. Adipocytes markedly increased in that region with positively stained with tumor necrosis factor
alpha. Furthermore, the femoral vein wall in the model group was thicker than that in the control group. Immunohistological
study identified that cleaved caspase 3, which is an apoptotic marker, was positively stained in the dilated lymphatic vessels
specifically in the model group.
Conclusion: These results indicated that the accumulation of lymphatic fluid due to the insufficient lymph drainage could be
associated with inflammation and degenerate the adjacent vein wall structure.
Declaration of interest
None declared
O-21.04
TREATMENT OF PHLEBEDEMA OF THE FACE : 14 CASES
A Hamadé, Emile Muller Hospital, mulhouse, FRANCE
C Krieger, Emile Muller Hospital, mulhouse, FRANCE
T Samkharadzé, Emile Muller Hospital, mulhouse, FRANCE
P Michel, Cabinet de Phlebology, Wingen-sur-Moder, FRANCE
G Obringer, Emile Muller Hospital, mulhouse, FRANCE
J C Stoessel, Emile Muller Hospital, mulhouse, FRANCE
M Lehn - Hogg, Emile Muller Hospital, mulhouse, FRANCE
Background.Compression or thrombosis of vena cava superior (VCS) provoke important edema of the face.Superior vena
cava syndrome (SVCS) requires an urgent management.
Methods.We report the case of 15 patients , 9 women and 6 men, aged from 32 to 75 years who presented malignant SVCS
with important dyspnea and facial edema. 9 patients presented compression of VCS by mediastinal tumor and in 5 patients
CT showed thrombosis of this vein. The first group (compression of VCS ) had been treated by percutaneaous stenting of
VSC and the second group ( thrombosis of VSC ) : 5 patients had been treated by thrombolysis and one patient by heparin
and corticosteoids.
Result. No major complication was reported in short and long-term follow up in the 2 groups.There was non recurrence of
the syptoms and the median survival after the stentig was 15 months.
Conclusion. Vascular stenting for malignant SVCS allows a rapid improvement of the symptoms ( dyspnea and edema ) .
Some cases require thrombolysis.
Declaration of interest
I disclose any conflict of interest including affiliations with
sponsoring companies
136

O-21.05
ESTIMATION OF BIOMECHANICAL ABNORMALITIES OF PATIENTS WITH CHRONIC
LYMPHOVENOUS INSUFFICIENCY OF LOWER EXTREMITIES.
S Katorkin, Samara State Medical University, Samara, RUSSIAN FEDERATION
G Yarovenko, Samara State Medical University, Samara, Russian Federation
Pathology of venous blood circulation leads to second functional and morphological changes of lymph outflow. Evident
vascular pathology of low extremities with edema, pain syndrome, dystrophic changes of muscles and trophic disorders leads
to functional and stadodinamical insufficiency of lower extremities.
Purpose: To improve results of treatment of chronic lymphovenous insufficiency of lower extremities by use of biomechanical
methods of functional diagnostic.
Methods: With the aim of complex functional diagnostic of venous, lymphatic and musculoskeletal system conditions were
used:lymphoscintigraphy, podometry, goniometry, plantography and optical projecting competer investigation of bearing,
functional electromyography.
It was examined 284 pathients with chronic lymphovenous insufficiency C4b-C6. 105 of them (37%) are men and 179(63,%)
are women. The reason of chronic lymphovenous insufficiency of 116 patients (40,8%) was varicosity, 168 patients (59,2%)
– posttrombophlebitis of lower extremities. For stimulation musclovenous pomp of crus, improvement of locomotion
and reduction of edema in treatment were used intermittent pneumocompression and biomechanical pneumovibration
stimulation of lower extremities.
Results: The results of examination of patients (C4b-C6) showed that 56% have scoliosis, 28% - osteohondrosis, 89% -
dysfunction of foot configuration, 45% - osteoarthritis. From our point of view, concomitant pathology of musculoskeletal
system and absence of adequate treatment is the main reason of life quality decline. Most evident biomechanical disorders
have patients with considerable edema and active trophic changes of soft tissues of lower extremities. Were noted pathological
changes of internal temporary structure of step cycle and lowering locomotion, especially in ankle joint. In C4b-C6 – there
is an overwork of affected extremity.
First developing an evident insufficiency of muscular system of crus and then of the hip. There is an increase of amplitude
of repulsion reaction foothold and speed of walk. Functional insufficiency of all lower extremity is developing.The use of
biomechanical pneumovibration stimulation leaded to improvement of statodinamical function of lower extremities,
locomotion in joints and developing of walk pattern.
Conclusion: Rehabilitation programs should be directed on edema liquidation, muscle system stimulation, amplitude
locomotion reconstruction, pathological walk liquidation and work on feedback principle.
Declaration of interest
None declare
O-21.06
REVISITING "VENOUS OBSTRUCTION IN THE ETIOLOGY OF LYMPHEDEMA PRAECOX"
W Hsu, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan
T Chang, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan
T Tsai, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan
Objectives: In 1964 Calnan et al reported that 66 % of lymphedem praecox is due to venous obstruction, which were treated
with open surgery for venous decompression in some patients. A retrospective study of primary lymphedema of lower
extremity that occurred before the age of 35 was conducted in our institute intending to identify the possible existence
of venous pathology in the pelvis. Since the beginning of 2007 we developed an algorithm for study of lower extremity
lymphedema focusing in the lymphedema praecox.
Materials and Methods: Between Oct. 2001 and Dec. 2010, 54 cases of primary lymphedema with onset age before 35 were
collected for study. Their median age of onset is 18 years old ranging from 12 to 35. Female to male ratio is 5 to 1. All patients
followed the study protocol and underwent noninvasive vascular test and catheter-directed iliac venogram with MDCT
(multi-detector computerized tomography) synchronously. The advantage of performing this imaging study is able to depict
both the arterial and venous morphology in the pelvis, anatomical variation and the inter-vascular relationship.
Results of study and management:
Among the 54 study cases, 48 patients (88.8 %) revealed pronounced left iliac vein compression with numerous collaterals and
other anatomical variation. Only 6 patients revealed no significant iliac vein compression at left iliocaval junction, however
stenosis at different level of external iliac vein was demonstrated. In stead of open surgery for venous decompression, we
performed intravenous angioplastic balloon dilatation with placement of metallic stents in patients with pronounced iliac
vein compression. The technical success rate is 100%. No surgical mortality was reported. The morbidity was minimal and
acceptable. The post-stenting follow-up showed that the patency rate at 3 months, 6 months and 12 months are 97.9%, 95.83%
and 89.58 % respectively. All patients with in-stent thrombosis were identified to have thrombophilia and were treated with
in-stent thrombolysis.
Conclusion: The underlying venous pathology of lymphedema praecox is further verified by the more advanced imaging
study and the treatment has been innovated to the endovascular technique.
Declaration of interest
None declared
137

O-22.01
MR LYMPHAMGIOGRAPHY: WHAT IS THE VALUE IN DIAGNOSIS OF PERIPHERAL LYMPHATIC
SYSTEM DISORDERS
N Liu, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai , CHINA
Peripheral lymphostatic diseases may be primary or secondary origin and caused by lymphatic system dysplasia, dysfunction,
or obliteration. It is essential to have sensitive and accurate diagnostic modality which can provide comprehensive information
of individual patient for both the treatment and etiological research purpose. The image results of more than 500 cases in
author’s clinic showed that MR lymphangiography is superior to the previously used image modality for providing high
quality imaging to outline the detailed structural and anatomical abnormalities of both lymphatic vessels and draining
lymph nodes. In the meant time MR lymphagiography can make real-time monitoring of lymph flow in the lymphatics and
nodes and make quantitative judgment of the functional state of the lymph system. So far MR lymphangiography is the only
image modality that is able to localize the edema fluid in the tissue and visualize the lymphatic system anomalies and assess
its functional state in a single acquisition. It is also helpful in differential diagnosis of lymphedema and venous edema or
lipedema. The comprehensive information provided by contrast MR lymphangiography is useful in staging and classification
of primary lymphostatic diseases and promote the development of rational therapeutics.
Declaration of interest
None declared
O-22.02
THE LYMPHATIC DRAINAGES OF MAMMARY EDEMAS AND/OR AFTER MAMMARY
RECONSTRUCTION DEMONSTRATED BY LYMPHOSCINTIGRAPHY
P BOURGEOIS, Université Libre de Bruxelles, Institut Jules Bordet, Brussels, BELGIUM, J P BELGRADO, Université Libre de
Bruxelles, Faculté des Sciences de la Motricité, Brussels, BELGIUM, J DEWILDE, Université Libre de Bruxelles, Institut Jules
Bordet, Brussels, BELGIUM, N KINDT, Université Libre de Bruxelles, Institut Jules Bordet, Brussels, BELGIUM, P BRACALE,
Université Libre de Bruxelles, Faculté des Sciences de la Motricité, Brussels, BELGIUM, M HARDY, Université Libre de Bruxelles,
Institut Jules Bordet, Brussels, BELGIUM, F URBAIN, Université Libre de Bruxelles, Institut Jules Bordet, Brussels, BELGIUM
Background: Edema of (one or more quadrant of) the breast (BE) after complete axillary (Ax) lymph node (LN) dissection for
breast cancer is sometimes seen associated to upper limb edemas (ULE) but also after mammary reconstruction procedures
(MRP) such as Deep Inferior Epigastric Perforator flap (DIEP). Few data also exist about the lymphatic drainages of the skins
of such flaps.
Objectives: To analyze and report the lymphatic drainage(s) of such situations.
Methods: The lymphoscintigraphic investigations of 14 patients with ULE who also presented BE (Group 1) were
(retrospectively) reviewed as well as the exams of 16 patients referred (prospectively in 15) after MRP (Group 2: 8 with DIEP,
5 with Latissimus Dorsi flap and prothesis (in 4) and 3 with “only prothesis”) among whose 6 had ULE and 7 presented BE
(6 after DIEP, with BE in normal “original” skin in 1). Drainages of the normal and/or edematous part(s) of the breasts and/
or of the cutaneous flaps were studied after intradermal injection(s) of 99mTc-labeled HSA nanosized colloids in these areas.
Results: BE could be related to lymphatic leakage from the axilla in one patient with ULE and with Latissimus Dorsi flap and
drained towards homolateral (H) internal mammary (IM) LN.
In Group 1, lymphatic superficial collateralisation towards the mid line was observed in 2 patients but without LN. Among
other 12 patients, lymphatic drainages were observed, either “isolated” (in 6), or “combined”, towards HAxLN in 7, HIMLN
in 3, contralateral (C) IMLN in 2 and CAxLN in 7.
Among the 16 patients of Group 2, lymphatic drainages were observed, either “isolated” (in 6 but in a single patient with BE
after DIEP), or “combined”, towards HAxLN in 11 (4 with BE after DIEP), HIMLN in 5 (3 with BE after DIEP), CIMLN in 3
(1 with BE after DIEP) and CAxLN in 10 (3 with BE after DIEP).
Conclusions: In “simple” BE or after MRP, lymphatic drainages of the normal and/or edematous mammary skins appear to be
highly variable from patient to patient. Lymphoscintigraphy represents thus the best way to optimize the Manual Lymphatic
Drainage treatments in such patients.
Declaration of interest
None declared.
138

O-22.03
ROLE OF LYMPHOSCINTIGRAPHY OF LOWER EXTREMITIES IN PATIENTS WITH INCREASED
BODY MASS
E Iker, Lymphedema Center, Santa Monica, CA, UNITED STATES
E lGlass, Medical Imaging of Southern , Santa Monica, CA, UNITED STATES
Background: Patients with enlarged legs and increased body mass index (BMI) are at risk for complications caused by, or
resulting in, swelling of the legs. Improper diagnoses in these individuals are associated recurrent infections, progressive
disease, increased surgical risk, and the risk of inappropriate treatments.
Objectives: We investigated the use of whole body lymphoscintigraphy (WBLS) to evaluate leg enlargement in these
individuals.
Methods: WBLS consists of sterile skin prep, local dorsal pedal anesthesia, intradermal-subcutaneous Tc99m colloid (~15
MBq), mild limb exercise, and imaging, at ~15-20 min., at ~2-3 hr., with ambulation. Normals demonstrate prompt flow to
inguinal nodes by 15–20 min. in discrete, nontortuous lymphatics. Normal images at 2-3 hr. demonstrate no dermal retention
and good inguinal nodal uptake.
Results: We evaluated 69 consecutive individuals with increased BMI ( > 25 kg/sq.m.) (55 female, 14 male, ages 13- 84)
with WBLS. Intact lymphatic systems and findings consistent with lipedema were demonstrated in 22. The remaining 47
demonstrated: primary lymphedema (LE) in 31, secondary LE in 12, phleboedema in 3, and obesity alone in 1. 47 of 69
demonstrated lymphatic dysfunction including deficient or accelerated lymph flow, deficient or no nodes, abnormal dermal
retention (in 31), or other abnormalities, often mixed. Dermal backflow was demonstrated in 75% with secondary LE
compared to 45% in primary LE and 36% in lipedema.
WBLS was useful in all cases for assessing etiology of leg enlargement, recurrent infections, and determining relative
contributions of adiposity, lipedema, and primary versus secondary LE. WBLS identifies patients at risk for progressive LE
and other complications after lymphadenectomy or other surgery, including sentinel node.
Conclusions: Patients with increased BMI commonly suffer with lymphatic disorders, in whom diagnosis can be difficult.
WBLS is a valuable tool for evaluation and classification of these individuals.
Declaration of interest
None for either author
O-22.04
CLINICAL ASPECTS OF LYMPHEDEMA AND LYMPHOSCINTIGRAPHY
M Cardone, San Giovanni Battista Hospital, Roma, ITALY
S Michelini, San Giovanni Battista Hospital, Roma, ITALY
A Failla, San Giovanni Battista Hospital, Roma, ITALY
F Cappelino, San Giovanni Battista Hospital, Roma, ITALY
F Romaldini, San Giovanni Battista Hospital, Roma, ITALY
D Puglisi, San Giovanni Battista Hospital, Roma, ITALY
A Semprebene, San Camillo Forlanini, Roma, ITALY
INTRODUCTION: Lymphoscintigraphy is the 'glod-standard' of diagnostic imaging in both primary and secondary
lymphedema. In all the current guidelines, however, the method is not yet standardized in carrying out, reducing in part the
specificity of the examination.
AIMS: The purpose of this study was to evaluate the clinical utility of lymphoscintigraphy in lymphedema, both for the
confirmation and better diagnostic definition and of indications for treatment and for prognosis.
METHODS: We studied 278 patients with lymphedema of the limbs (101 primary, 177 secondary). All the subjects
performed lymphoscintigraphy with subcutaneous injection of nano colloids in the plantar and palmar interdigital spaces.
The measurements were performed with gamma camera at 5 ', 30', 60 ' after the inoculation. The following parameters were
considered: dermal back flow, time of appearance of the stations of the limb-root, presence of lymph node sub-stations,
lymphatics alternative pathways. The examination was always performed bilaterally.
RESULTS: We found: distal dermal back flow in primary forms (96% of cases) and proximal in secondary ones secondary
(89%), variable time appearance at the root of the limb, presence of lymph nodes along the limb normally not displayed
(64% ), variable lower visualization of the stations at the root of the limb in primary forms, absent in the secondary ones,
presence of alternative lymphatic pathways (supra-pubic and supra-thoracic) in 59% of cases. In some cases it was observed
discrepancy between the lymphoscintigraphy (apparently the most affected) and clinical picture (less important).
CONCLUSIONS: Lymphoscintigraphy proves to be a very useful definition examination of lymphedema, in directing
therapeutical and surgical treaments and in prognosis.
Declaration of interest
None declared
139

O-22.05
LYMPHEDEMA OF THE PROSTHESIS-RECONSTRUCTED BREAST AFTER TRAUMA OR EXERCISE.
L Vandermeeren, Bordet Cancer Institute, Brussels, BELGIUM
P Bourgeois, Bordet Cancer Institute, Brussels, BELGIUM
G Andry, Bordet Cancer Institute, Brussels, BELGIUM
F C Urbain, Bordet Cancer Institute, Brussels, BELGIUM
Lymphedema of the prosthesis-reconstructed breast after trauma or exercise.
L. Vandermeeren° MD, P. Bourgeois* MD PhD, G. Andry’ MD, FC. Urbain° MD, Bordet Cancer Institute, Brussels, Belgium.
° Department of Plastic Surgery
* Department of Nuclear Medicine
‘ Head of the Department of Surgical Oncology.
Background: Breast reconstruction using implants after mastectomy and axillary lymph node dissection remains a very
popular technique despite the morbidity involved, such as infection. Late postoperative infections can be confused with
another, often overlooked, clinical entity : the late postoperative periprosthetic seroma.
Methods: 6 patients with late postoperative seroma after implant breast reconstruction were described and a dynamic lymphoscintigraphy,
using 99mTc-HSA-Nanocolloids, of the arms and breasts was performed.
The images were analysed by a dedicated nuclearist.
Results: Massive stagnation of lymph in the operative field is observed with poor axillary uptake and unusual lymph flow.
Conclusion: A periprosthetic seroma of the prosthesis reconstructed breast has its origin in a reverse lymphatic flow from the
arm caused by a reduced axillary uptake capacity.
Declaration of interest
None declared
O-22.06
LYMPHATIC DRAINAGE IN DIEP FLAPS AFTER BREAST RECONSTRUCTION
L Vandermeeren, Bordet Cancer Institute, Brussels, BELGIUM
P Bourgeois, Bordet Cancer Institute, Brussels, BELGIUM
G Andry, Bordet Cancer Institute, Brussels, BELGIUM
F C Urbain, Bordet Cancer Institute, Brussels, BELGIUM
LYMPHATIC DRAINAGE IN DIEP FLAPS AFTER BREAST RECONSTRUCTION
L. Vandermeeren° MD, P. Bourgeois* MD PhD, G. Andry’ MD, F.C.° Urbain MD, Bordet Cancer Institute, Brussels, Belgium.
° Department of Plastic Surgery
* Department of Nuclear Medicine
‘ Head of the Department of Surgical Oncology.
Introduction: Little is known about the development of new lymphatics in the transplanted tissue after free flap transfer.
Material and Methods: In a series of 20 breast cancer patients, lymphatic drainage of DIEP flaps was studied with dynamic
lymphoscintigraphy, using 99mTc-HSA-Nanocolloids injected intradermally in the reconstructed breast, at different times
postoperatively. The obtained images were analysed by a dedicated nuclearist.
The patient group was heterogenous in function of the administration of postmastectomy radiotherapy and extent of axillary
lymph node dissection.
Results: Our findings show a predictive pattern of lymphatic neoformation and drainage, that already develops in the early
postoperative phase. Comparison of data at different postoperative stages, demonstrates an increase of drainage capacity
in function of time. Postmastectomy radiotherapy has proven to be a major factor of influence. Volume changes of the
reconstructed breast in the early postoperative period can be interpreted as adaptation in the drainage capacity of the
mastecomy site following an increased local lymph formation.
Declaration of interest
None declared
140

O-22.07
A COMPARISON OF PHYSICAL AND FUNCTIONAL ASSESSMENT USING LYMPHOSCINTIGRAPHY
IN PRIMARY AND SECONDARY LYMPHEDEMA
M Hosono, Yokohama City University Hospital, Yokohama, JAPAN
J Maegawa, Yokohama City University Hospital , Yokohama, JAPAN
H Tomoeda, Yokohama City University Hospital, Yokohama, JAPAN
Background: Lower limbs lymphedema is classified as primary lymphedema or secondary lymphedema. Secondary
lymphedema causes infection, trauma and malignancy, but etiology of primary lymphedema is still unclear.
Objectives: Objectives of this report is to assess differentiations between primary and secondary lower limbs lymphedema in
types of lymphoscintigraphy we proposed and the staging of the Internatinal Society of Lymphology.
Methods: Subjects were 35 patients of primary lympedema and 156 patients of secondary lymphedema who were seen by this
department from May 1992-May 2010. All patients underwent lymphoscintigraphy. The images obtained were classified into
5 types according to the classification of Maegawa. At the same time, physical severity was assessed using the ISL stage. In
patients who underwent lymphoscintigraphy 2 or more times, we assess changes in images.
The incidence of edema in the right and left limbs was studied using a χ2 test. The association with the ISL stage and the type
of lymphoscintigraphic images was examined using a Yates corrected m×n χ2 test.
Results: The χ2 test revealed a significant difference in the incidence of secondary lymphedema in the right and left limbs but
no significant difference in primary lymphedema.
In lymphoscintigraphy, Type 1 and Type 4 images were often obtained in primary and secondary lymphedema patients,
respectively. Type 1 images were mostly obtained in patients of primary and secondary lymphedema with healthy limbs.
About relationships between the types of lymphoscintigraphy and the ISL stage, there was a significant difference in primary
and secondary lymphedema.
Changes in lymphoscintigraphy images obtained 47% in secondary lymphedema and 33% in primary lymphedema.
Conclusions: Primary lymphedema and secondary lymphedema are different in the incidence of edema in the right and left
limbs and changes in images. The type of lymphoscintigraphy we proposed may be applicable to both secondary and primary
lymphedema.
Declaration of interest
None declared
O-22.08
LYMPHOSCINTIGRAPHY IN VIZUALIZING PATHWAYS OF LYMPH AND TISSUE FLUID FLOW
DURING PNEUMATIC COMPRESSION THERAPY
W L Olszewski, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Zaleska, Medical Research Center, Warsaw, POLAND
A Domaszewska - Szostek, Medical Research Center, Warsaw, POLAND
J Cwikla, Central Clinical Hospital, Ministry of Internal Affairs, Warsaw, POLAND
Introduction. Lymphedema of limbs is treated by massage squeezing the mobile edema fluid toward the root of the extremity.
In the calf and thigh the natural fluid channels form along large blood vessels, as the saphenous, popliteal and femoral veins
and also around small unnamed vessels, leading to the groin region. There they end up at the inguinal crease where skin is
connected with the inguinal ligament and external oblique muscle by natural elastic fibers. Aim.The question arises whether
the accumulated tissue fluid can form natural subcutaneous channels crossing the inguinal crease to the hypogastrium. This
would facilitate absorption of fluid in normal hypogastrium tissues where connections with normal lymphatics could be
formed. Such newly created flow pathways would justify the common practice of treating the core (truncal) lymphatics as a
major therapy component before limb massage.
Methods. We investigated with use of lymphoscintigraphy the pathways of lymph and mobile tissue fluid flow: a) across the
inguinal and gluteal regions to the healthy non-swollen tissues of hypogastrium and b) in the hypogastrium to the lateral
and upper abdominal quadrants, during pneumatic massage of the limb. To prove that there was effective fluid flow during
pneumatic massage, the plethysmographic flow measurements were carried out.
Results. We showed that: (i) pneumatic compression pushed isotope in lymph in the still remaining functioning lymphatics
and tissue fluid in the interstitial space toward the inguinal region and femoral channel, (ii) there was no isotope crossing
the inguinal crease or flowing to the gluteal area, and (iii) isotope injected intradermally in the hypogastrium did not spread
during manual massage to the upper and contralateral abdominal quadrants.
Conclusions. Intermittent pneumatic compression is effective in pushing mobile tissue fluid and relocating large fluid volumes
toward the groin. However, it does not cross the inguinal crease. This challenges the commonly accepted notion of preparing
the hypogastrium prior to massage for receiving thigh lymph.
Declaration of interest
None declared
141

O-23.01
AGING AND LYMPH FLOW: STATUS, RESERVES, MECHANISMS
A Gashev, Texas A&M Health Science Center College of Medicine, Temple, TX, UNITED STATES
S Thangaswamy, Texas A&M Health Science Center College of Medicine, Temple, TX, UNITED STATES
T Nagai, Texas A&M Health Science Center College of Medicine, Temple, TX, UNITED STATES
T Akl, Texas A&M University, College Station, TX, UNITED STATES
V Chatterjee, Texas A&M Health Science Center College of Medicine, Temple, TX, UNITED STATES
G Cote, Texas A&M University, College Station, TX, UNITED STATES
Background. Effective lymph flow is crucial for fluid and macromolecules homeostasis, fat absorption, and immunity. Aging
alters all of these functions, however even status of contractility and flow in aged lymph vessels is not well characterized. The
role of the oxidative stress and chronic inflammation as risk factors for aging of lymph vessels is unknown.
Objectives. We investigated the aging-related changes in rat mesenteric lymph vessels (MLV) in reference to their NOdependent
modulation, level of the oxidative stress and status of the anti-oxidant defense mechanisms.
Methods. 9-mo and 24-mo old Fischer-344 rats were used. Diameters/pump indices of isolated/pressurized segments of MLV
were determined. High-speed cell microscopic video monitoring was used to calculate lymphatic diameters, contraction
frequency, flow velocity, and wall shear stress in vivo. Application of the non-selective nitric oxide synthase inhibitor -
L-NAME was implemented. Immunohistochemical labeling of iNOS in aged MLV and surrounding mesenteric tissues was
performed. Protein expression of three isoforms of superoxide dismutase (SOD) and 3–nitrotyrosine has been determined,
their immunohistochemical labeling has performed. The SOD activity and levels of lipid peroxidation were evaluated. Live
vessel fluorescent imaging with dihydroethedine (DHE) for whole MLV, and with Mitotracker Red – for mitochondria,
allowed to compare the levels of superoxide anions in adult and aged MLV.
Results. We found weakening of the lymphatic pump in isolated aged MLV including diminished tone, contraction amplitude,
frequency with corresponding decrease in their minute productivity. Application of L-NAME is able to enhance contractility
of aged MLV. Observations in situ revealed a greater degree of the contractile inhibition of aged MLV related to excessive NO
in natural tissue environment. Data demonstrate diminished ability of the aged MLV to resist to oxidative stress: decreased
SOD activity referred to diminished expression of its Cu/Zn isoform. High levels of superoxide anions and increased levels of
lipid peroxidation confirmed in aged MLV.
Conclusions. Cumulatively, these findings demonstrate links between age-related oxidative stress, inflammation and
functional disturbances in aged MLV. Results of in vivo studies demonstrate the potential to maintain normal lymphatic
transport function in elderly by correction of aged-induced environmental changes in tissues.
Declaration of interest
None declared
O-23.02
EXTRACELLULAR FLUID MOVEMENT IN ELEVATED LYMPHOEDEMATOUS AND HEALTHY UPPER
LIMBS: A STUDY USING BIOIMPEDANCE SPECTROSCOPY.
O Meddings - Blaskett, Flinders University, Adelaide, AUSTRALIA
C Galbraith, Flinders University, Adelaide, AUSTRALIA
N Piller, Flinders University, Adelaide, AUSTRALIA
Background: Elevation and use of compression garments are common methods for reducing extracellular fluid volume,
however our understanding of resulting fluid movement is limited. Normal anatomical variation between right and left
complicates the fluid movement picture. Differences in microvasculature, lymphatic distribution and muscle mass all appear
to result in asymmetrical fluid flux. Furthermore, arm dominance alters the left/right fluid balance, resulting in an overall
fluid movement picture that is difficult to interpret. We anticipate that enhancing understanding of fluid fluxes in healthy and
lymphoedematous limbs will help guide management of lymphoedema.
Objectives: The present study aimed to establish the differences in extracellular fluid movement between left and right arms;
between lymphoedematous and healthy arms, and between arms with a compression garment, versus those without.
Methods: Upper limb electrical resistance was measured via BioImpedance using an ImpediMed SFB7 machine. Three
measurements were taken every minute during the initial rest phase, and every thirty seconds during the elevation and final
rest phases. Alternate participants had compression garments fitted. Parameters such as handedness, surgical procedures,
medical treatments, and other relevant medical conditions were recorded. Participants were grouped into ‘garments’ or ‘no
garments’, lymphoedema ‘affected’ or ‘unaffected’ and ‘left’ or ‘right’.
Results: The present study showed that in phases of elevation and rest, right arm resistance increases more than left arm
resistance, in all groups. ‘Garments’ increase resistance in the final rest phase more than ‘no garments’. There was no difference
between ‘affected’ and ‘unaffected’ groups.
Conclusions: Fluid volume is inversely proportional to bioimpedance, so increases in resistance are attributed to fluid efflux
from the limb, and vice versa. We observed that right limbs drain fluid more effectively than left, likely due to a combination
of handedness and anatomical variation. Studies with more left-dominant subjects may clarify this. We also observed that
compression garments increased fluid drainage in all limbs, supporting the therapeutic use of compression. Interestingly, we
found no difference between affected and unaffected limbs, and suggest that segmental bioimpedance may better reflect fluid
fluxes within more localised areas.
Declaration of interest
None declared.
142

O-23.03
MITOGENIC EFFECT OF HUMAN TISSUE FLUID/ LYMPH ON KERATINOCYTE PROLIFERATION
A Domaszewska - Szostek, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Zaleska, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
W L Olszewski, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
Background. Cultured keratinocytes (KC) are needed for covering large burn wounds and ulcers. They can be cultured in
artificial media, however, the yield is always low and viability is limited. In our previous studies we found that human skin
tissue fluid and lymph (TF/L) contain high levels of growth factors and cytokines. The aim was to study the effect of human
TF/L containing IL-1β, IL-6, TNF-α, KGF, TGF-β on cultured human KC of human lower extremity skin and to show which
cytokines and growth factors of human skin TF/L have influence on KC: proliferation, differentiation and expression of
markers characteristic for epidermal stem cells
Material and methods. KC were isolated from lower limb skin and were cultured for 1 to 14 days in TF/L and culture in
standard medium served as a control. Neutralization of IL-1β, IL-6, TNF-α, KGF, TGF-β in TF/L and blocking their receptors
on KC helped to estimate which cytokine could stimulated KC proliferation and differentiation.
Results: KC cultured in TF/L showed higher percentage of dividing and cells from basal layer as well as lower percentage
of differentiated cells from upper layers vs control. Higher percentage of p63(48 vs 8), CD29(52.4 vs 41,4), Ki67(57 vs 23,8),
PCNA(63 vs 38), CK6(15,5 vs 4,4), CK17(10,6 vs 5,5), CK16(26,4 vs 15,3) and decrease in percentage of CK 10(52 vs 77,5),
filaggrin(19,6 vs 48,5) and involucrin(18,8 vs 45,3) positive KC was observed vs control. Neutralization of IL-1β, IL-6, TNF-α,
KGF and blocking their receptors on KC caused decrease in percentage of mitotic cells. Quantitative growth of KC revealed
higher proliferative ratio after KC culture in TF/L vs control. Neutralization of selected cytokines and growth factors except
TGF-β revealed lower total number of KC.
Conclusion. The investigated cytokines have a stimulating effect on proliferation of basal KC but not on their differentiation.
Declaration of interest
None declared
O-23.04
PHYSIOLOGICAL PARAMETERS FOR EFFECTIVE COMPRESSION THERAPY OF SWOLLEN LOWER
LIMBS
W Olszewski, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Zaleska, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Cakala, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Durlik, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
Introduction. Removal of excess of tissue fluid (TF) from injured tissue is indispensable for slowing down the progress of
lymphedema with hyperkeratosis, fibrosis and recurrent infections. Aim. Mechanical compression is at present the most
effective conservative method enabling tissue fluid to overcome tissue resistance and flow to the non-swollen regions.
Methods. Intermittent compression.We studied hydraulics of tissue fluid in swollen lower limbs (lymphedema, venous
ulcers, posttraumatic hematoma) using intermittent pneumatic compression. Twenty five patients with lymphedema stage
II/III of lower limbs were investigated. An 8-chamber sequential pneumatic device was used for compression therapy. The
parameters of compression were: inflation pressure 120-100mHg, sequentially from chamber 1 to 8, inflation time of each
chamber 50’’, daily for 1 h and for a period of 12 months. Skin tonometry was done in each patient before and after each
compression cycle. TF pressure was measured in the calf and thigh with use of subcutaneously placed pressure sensor.
Changes in circumference of compressed limb were measured continuosly using a plethysmograph. Flow was calculated
from changes in circumference. Results. TF pressure generated by massage was dependent on skin rigidity. In advanced cases
of lymphedema, pressures in the sleeve had to be raised as high as 150mmHg to obtain the transmural (TF) pressure of 40
mmHg. This was the minimum pressure necessary for TF flow. Tonometry. Tonometer piston was pressed against swollen
tissue to a depth of 10mm and applied force was read off on the scale. Simultaneously, TF pressure was measured under
tonometer. Applied force plotted against pressure gave hints how high massage pressure would be required to move TF.
Tonometer force of 1000g/sq.cm generated average TF pressures of 30mmHg, of 2000g/sq.cm 50mmHg, above 2000g/sq.cm
70mmHg. Massage pressures had to be set accordingly. Strain gauge applied around calf showed increase in circumferences
depending on the applied sleeve pressures. TF flow calculated from circumference increase ranged from 1 to 20 ml per
inflation cycle. Conclusions. Pneumatic compression in order to be effective should be based on prior skin tonometry and TF
pressure/flow measurements.
Declaration of interest
None declared
143

O-23.05
QUANTIFYING THE MOLECULAR MECHANISMS IN VITRO OF LYMPHATIC UPTAKE OF
LIPOPROTEINS FROM THE INTESTINE
J Dixon, Georgia Institute of Technology, Atlanta, UNITED STATES
M Faulkner, Georgia Institute of Technology, Atlanta, UNITED STATES
Background: It has long been appreciated that lymphatics play an essential role in transporting chylomicrons from the intestine
to the circulation (1). However recent work by numerous labs suggests that they play a more active role than previously
anticipated, and that lymphatic dysfunction in lipid transport in particular is detrimental to disease progression. For example
lipid often accumulates in the effected limb of lymphedema patients, making lipectomy an effective method of treatment;
and various mouse models with leaky lymphatic develop obesity or other lipid-related problems (refer to recent review (2)).
Objectives: Thus we have sought to develop a tissue engineered model of the lacteal to probe the molecular mechanisms
involved in lymphatic uptake of lipid and have used this model to demonstrate transcytosis of lipid through the lymphatic
endothelial cell (LEC) in vesicular compartments (3).
Methods: By culturing LECs with Caco-2 cells (a model enterocyte line) on opposing sides of a permeable transwell, we can
add various lipids to the apical side of the intestinal cells, along with a fluorescently-labeled long-chain fatty acid, and induce
these cells to secrete lipoproteins with the fluorescent probe now incorporated into the particle. This allows for quantitative
measurements of lipid uptake, flux and effective permeability into the LEC and across the LEC monolayer.
Results: We have found that this transport requires ATP, involves the molecular motors dynein and kinesin, and is transported
through the cell on microtubule tracks. Blocking any of these pathways with various inhibitors results in a decrease in LEC
effective permeability to lipid, but not to dextran, and an accumulation of lipid within the LEC.
Conclusions: Through these approaches it is becoming apparent that the lymphatics rely on active processes to take up lipid,
making this an important consideration when treating lymphatic disease.
1. J. B. Dixon, Ann N Y Acad Sci 1207 Suppl 1, E52-57 (2010).
2. J. B. Dixon, Trends Endocrin Met 21, 480-487 (2010).
3. J. B. Dixon, S. Raghunathan, M. A. Swartz, Biotechnol Bioeng 103, 1224-1235 (2009).
Declaration of interest
None declared
O-23.06
THOMAS BARTHOLIN AND THE DISCOVERY OF THE LYMPHATIC SYSTEM
C KRAG, University of Copenhagen, Herlev Hospital, Copenhagen, DENMARK
Thomas Bartholin (1616-1680) was a danish physician, naturalist and anatomist and as such credited with the first
description of the thoracic duct in man (1652) (few years earlier described in animals by Jean Pecquet) although contested
by Oluf Rudbeck (1630-1702). Bartholin´s greatest contribution to physiology was his discovery that the lymphatic vessels
constituted an entirely separate vascular system. At first he did explain the mesenteric lymphatic vessels as providing the liver
with chyle for the production of blood. Later, working with prosector Michael Lyser (1626-1659), Bartholin, in 1652, reached
the conclusion that the lymph vessels formed a hitherto unrecognised physiological system first published and described
in animals (Vasa lymphatica, nuper Hafniae in animantibus inventa, et hepatis exsequiae, 1653) and later in humans (Vasa
lymphatica, in homine nuper inventa, 1654).
Declaration of interest
None declared
144

O-23.07
EFFECT OF AGING ON LYMPHATIC PUMPING IN HUMAN LOWER EXTREMITIES
N Unno, Hamamatsu University School of Medicine, Hamamatsu, JAPAN
M Suzuki, Hamamatsu University School of Medicine, Hamamatsu, JAPAN
H Tanaka, Hamamatsu University School of Medicine, Hamamatsu, JAPAN
N Yamamoto, Hamamatsu University School of Medicine, Hamamatsu, JAPAN
M Nishiyama, Hamamatsu University School of Medicine, Hamamatsu, JAPAN
Y Mano, Hamamatsu University School of Medicine, Hamamatsu, JAPAN
M Sano, Hamamatsu University School of Medicine, Hamamatsu, JAPAN
T Saito, Hamamatsu University School of Medicine, Hamamatsu, JAPAN
H Konno, Hamamatsu University School of Medicine, Hamamatsu, JAPAN
Background: The lymphatic system possesses numerous active pumps to propel lymph to the central lymphatic systems.
Decreased pumping activity may be associated with lymphedema, and aging may affect the pumping activity. However, there
is no data regarding the difference in human lymphatic pumping by generations. Recently, we have reported a novel method
of measuring human lymphatic pumping using indocyanine green (ICG) fluorescence lymphography.
Objectives: In this study, we measured the lymphatic pumping of the lower extremities in various generations to assess the
effect of aging on the lymphatic pumping.
Methods: Lymphatic pumping was measured as follows. ICG fluorescence lymphography was performed by subcutaneously
injecting 0.3 ml of ICG (0.5%) into the dorsum of the foot. Real-time fluorescence images of lymph propulsion were obtained
with an infrared-light camera system (PDE: Hamamatsu Photonics K.K., Hamamatsu, Japan) in a sitting position. A custommade
transparent sphygmomanometer cuff was wrapped around the lower leg and connected to a standard mercury
sphygmomanometer. The cuff was inflated to 70 mm Hg, then gradually deflated at 5-min intervals to lower the pressure by 5
mm Hg steps until the fluorescence dye exceeded the upper border of the cuff (indicating that the lymphatic contraction had
overcome the cuff pressure). Lymph pumping pressure (Ppump) was defined as the value of the cuff pressure when the dye
exceeded the upper border of the cuff.
Results: A total of 159 healthy volunteers (318 legs, 93 males, 66 females) participated in this study. Ppump in each generation
was 42±16, 32.5±11, 27±16, 27±13, 27±14, 23±13, 21±12 mmHg (mean ± SD) in groups of 20-29, 30-39, 40-49, 50-59, 60-69,
70-79, >80 yrs old, respectively.
Conclusion: We have applied our novel technique of measuring lymphatic pumping in human lower extremities. The results
identified that aging affected the lymphatic pumping force, possibly by decreased contraction of the lymphatic vessels.
Declaration of interest
None declared
O-24.01
A NEW CLASSIFICATION OF GENITAL LYMPHOEDEMA AND ITS SURGICAL TREATMENT
G Felmerer, University Medicine, Göttingen, Göttingen, GERMANY, D Tobbia, University Medicine, Göttingen, Göttingen,
GERMANY, M Zvonik, niversity Medicine, Göttingen, Göttingen, GERMANY
Background: Genital lymphoedema is a debilitating condition which leads to functional and aestetic impairment. Patients
experience repeated bouts of cellulitis often requiring antibiotics. The oedemastous genitals can be so enlarged that dailly
mobility is significantly impeded. Quality of life is negatively affected and conservative treatment options are very limited.
Objectives: We present a new classification of genital oedema to optimise patient selection for plastic surgical reconstruction
of genital lymphoedema
Methods: From 2003 to 2011 we operated on 65 patients with genital lymphoedema according to the mentioned classification.
Male
Type I: Edema of foreskin with redundant foreskin tissue
Type IIA Redundant penile skin
Type IIB Redundant scrotal skin
Type IIC Redundant penile and scrotal skin
Type III Buried penis
Female
Type I Lymph cysts without redundant skin
Type IIA Redundant skin of internal labia
Type IIB Redundant skin of internal and external labia
Type IIC Features of both A and B
Type III Redundant skin in labia and mons pubis
Treatment-male
Type I Circumcision with or without removal of lymphcysts
Type IIA Wedge excision of penile skin and reconstruciotion
with dorsal based skin flap
Type IIB Subtotal excision of redundant scrotal skin and
reconstruction by mobilisation of non-oedematous skin flaps
laterally.
Type IIC Combination of type IIA and IIB
Type III Combination of IIB and lower apronectomy with
subtotal resection of mons pubis, and penille shaft coverage
with the internal layer of the prepuce.
Treatment-female
Type I Excision of lymph cysts
Type IIA Wedge-resection of redundant skin
Type IIB Sicle shaped excision of redundant skin
Type IIC Combination procedure of A and B
Type III Combined reduction plasty of mons pubis and of
the external labia with or without resection of minor labiae.
Results
Complications: 5 haematomas requiring sugical revision, 4 cases of minor skin necrosis, 10 cases of wound dehiscence with
porolonged healing course. All other patients healed uneventfully.
Conclusions This new classification of genital lymphoedema helps in the optimal selection of patients for different resection
procedures. Overall hight patient satisfaction and improved quality of life. Less frequent bouts of cellulitis.
Declaration of interest
None declared
145

O-24.02
LYMPHEDEMA WITH GENITAL COMPLICATIONS, SO FAR DESPERATE AND EMBARRASSING, BUT
NOW PREVENTABLE: FOUR CASE REPORTS
W Ekataksin, Mahidol University, Bangkok, THAILAND
N Chanwimalueang, Mahidol University, Bangkok, THAILAND
P Suebtrakul, Mahidol University, Bangkok, THAILAND
P Piyaman, Mahidol University, Bangkok, THAILAND
Background About 5% of patients at Thailand Lymphedema Day Care Center are presented with genital swelling, some of which
are manageable, if lymphologist is knowledgeable with slaengh, aggravating factors. Objectives To correct genitocutaneous
problems in a self-disciplined, no-medicine, no-surgery fashion, and to testify the concept of slaengh. Methods and Results
With Informed Consent signed, we report here two compliants and two non-compliants. Case I: 15 y/o female, lymphedema
congenita of lower extremities. Vaginal chylous lymphorrhea had been observed since age 3; more profuse when fried chicken
was ingested. The whitish vaginorrhea ceased immediately after twisting tourniquet technique, as the swollen legs reduced
progressively and came close to normal at fourth visit in less than a year. At year 3 follow-up, she surreptitiously but modestly
consumed such slaengh as chicken, pork, beef, and seafood, and gradually developed nucleation-laden papillomatosis in
labia majora/minora with milky discharge. When she switched to vegan food, the genital complications vanished. Case II: 19
y/o male, lymphedema congenita of left lower limb. By first treatment, the leg almost equaled. So far studded with pearl-like
lymph cysts, his scrotal skin also normalized. These lesions reappeared and disappeared every time he ate and quitted fish,
respectively. Case III: 28 y/o female, tuberculous lymphadenitis. Lymphedema of lower limbs responded well to treatment
scheme. She confessed pork as favorite, but from time to time when our diet regime was violated, her limbs flared up and
genital swelling worsened. Within two years, the labia majora prominently protruded, the mottled pigmentation darkened,
spreading widely over the perineum with papillomatosis and condyloma acuminatum. Case IV: 18 y/o male, primary
lymphedema praecox of lower extremities. Limbs were under control by our therapy, but his 20 cm-diameter scrotum wax
and wane. We managed to reduce it down to 10 cm, despite the numerous mushroom-like outgrowths on scrotal skin that
steadily enlarged, some ulcerated. With most slaengh to pork, chicken, and crabs, his scrotal sack lately grew to the knee
level. The patient was convinced of his slaengh, but confessed could hardly change dietary habit. Conclusions Vegan diet is
indispensable to avoid exacerbation of genital lymphedma.
Declaration of interest
None declared
O-24.03
CASEREPORT:TREATMENT WITH URIDOME FOR PENILE LYMPHOEDEMA
M Dahl, Skånes Universitetssjukhus Lund, LUND, SWEDEN
K Johansson, Skånes Universitet, LUND, SWEDEN
Two cases regarding genital lymphoedema in two male patients will be presented.
Male born 1944
Oedema with unknown genesis. In the summer of 2007 the patient noticed oedema in the penis that soon after spread to
the scrotum and in the fall of 2007 to the lungs. The oedema has since 2007 also after spread to the hips, back and to the
legs. The patient has undergone extensive medical exams and x-rays and no malignancy has been found. The patient has also
undergone lymphscintigrafy which shows a normal uptake in the inguinal lymphnodes but a somewhat slow uptake in the
abdominal nodes as well as a late and weak dermal backflow in the legs which according to the doctors could be perceived as
a secondary lymphoedema.
Male born 1949
Oedema with unknown genesis. In 2002 the patient underwent surgery for abdominal aorta aneurysm. At a trip abroad
during spring of 2009 he noticed penile oedema after intercourse. No sign of infection due to tropical causes was found.
MR- and CT-scans showed no apparent causes. After 2009 the patient has undergone surgery for an iliac aneurysm which
according to his medical journal did not affect the oedema.
Uridome as compression for penile oedema was mentioned and suggested at the Lymphology Congress in Shanghai 2007.
Both patients have been treated with uridome as compression with varied results and success.
Declaration of interest
None declared
146

O-24.04
THREE CASES OF PENO-SCROTAL LYMPHEDEMA OPERATED BY PLASTIC PROCEDURE
A PISSAS, FACULTY MEDICINE GENERAL HOSPITAL, BAGNOLS SUR CEZE , FRANCE
L SOUSTELLE, FACULTY MEDICINE GENERAL HOSPITAL, BAGNOLS SUR CEZE , FRANCE
A GEVORGYAN, FACULTY OF MEDICINE GENERAL HOSPITAL, BAGNOLS SUR CEZE , FRANCE
The authors report three cases of adult caucasian patients operated for peno-scrotal lymphedema with simple post -operative
course.They insist upon the precious collaboration between urologists , plastic surgeons and lymphologists.Penoscrotal
lymphedema is relatively rare in north hemisphere without filariosis.Those three cases represent probably a real secondary
lymphedema due to lymphatic reflux interesting the lower limbs and the scrotal region.Of course the evolution and the
aggravation were linked to attacks of dermato-lymhangio-adenitis.The origin was inflammatory and not malignant.The authors
insist upon the preoperative management with treatment of lymphedema; peroperatve disposition with antibioprophylaxy
and the postoperative involvement in physical treatment.For , in addition , the most important complication of this surgery is
the aggravation of the lymphedema of the lower limbs some weeks or months after plastic surgery of scrotal region.
Declaration of interest
none declared
O-24.05
SURGERY FOR EXTERNAL GENITALIA LYMPHOEDEMA
M Wald, Charles University Prague, Prague, CZECH REPUBLIC
L Jarolím, Charles University, Prague, CZECH REPUBLIC
J Adánek, Charles University, Prague, CZECH REPUBLIC
The incidence of secondary lymphoedema of external male and female genital organs is much lower than is the incidence
of lymphoedema of extremities. In Europe it has been reported as a result of lymphadenectomy and /or radiotherapy of the
inguinal or pelvic lymphatics in association with therapy of several malignancies or as an iatrogenic disorder. It develops
through the same stages and shows similar complications as lymphoedema of the extremities. In many cases lymphoedema
may progress into lipohypertrophy and elephantiasis. External genitalia lymphoedema interferes with the quality of patient’s
life because of problems with motion, personal hygiene, verrusocis lymphostatica and lymphorrhea. The authors present the
results of surgical treatment in 11 patients with this disorder, with emphasis given to indications for surgery, particular steps
of the surgical procedure, post-operative care and complications.
Declaration of interest
None declared
147

O-24.06
SURGERY OF MALE GENITAL LYMPHEDEMA
W Olszewski, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
S Gogia, Society for Administration of Telemedicine and Health Care Informatics and Indian Association for Medical Informatics,
New Delhi, INDIA
P Jain, Department of Plastic Surgery, Benares Hindu University, Varanasi, INDIA
M Zaleska, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Durlik, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
Introduction. Scrotal and penis lymphedema is not a frequent but extremely embarassing pathological condition. It eliminates
patients from sexual life, it is burdened by recurrent infections with septic symptoms and in advanced stages urination using
penis becomes impossible. The etiology is in 99% of cases of infective origin. On lymphoscintigraphy there is no flow from
the swollen organs to the inguinal lymph nodes. Moreover, in most cases lymphedema of hypogastrium subcutaneous tissue
develops. Fortunately enough genital lymphedema doesn’t affect testes and only the superficial lymph drainage is impaired.
Aim. To work out a fast surgical method of debulking scrotum and penis. Material. 48 male patients with obstructive
lymphedema of scrotum and penis were operated upon. In 32 patients penis was hidden in the swollen scrotum. In 5 cases
there was a saxophone penis with minor scrotal edema. Method. Patients were receiving amoxicillin or ciprofloxacin fro at
least 1 month before operation. Scrotum. Testes were temporarily exteriorized. A small anterior flap was made, bulk of scrotal
tissue was removed, large posterior flap was constructed. Testes were placed between skin flaps and their margins were
stitched together. Penis was freed from the swollen scrotum and circumcision was made. In cases with lax skin penis was
wrapped with a pedunculated flap. The saxophone penis had excess of skin removed from a longitudinal incision. Results.
Healing of surgical wounds was uneventful in all cases within 3-4 weeks. There was no dehiscence of wounds. The followup
in cases under observation for 3 years revealed slow increase in scrotal volume by approximately 20%. There was scar
formation in some penises with slight disfigurement. In all cases the sexual activities became possible.
Declaration of interest
None declared
O-25.01
COMPRESSION THERAPY IN MIXED ULCERS: SEARCH FOR AN EFFECTIVE PRESSURE RANGE NOT
AFFECTING ARTERIAL PERFUSION.
G Mosti, Medical University of Vienna, Vienna, AUSTRIA
H Partsch, Medical University of Vienna, Vienna, AUSTRIA
Objectives: To define bandage pressures which are safe and effective in treating leg ulcers of mixed, arterial-venous, aetiology.
Methods: In 25 patients with mixed aetiology leg ulcers receiving inelastic bandages applied with pressures between 20-30,
31-40 and 41-50 mmHg, the following measurements were performed before and after bandage application to ensure patient
safety throughout the investigation: Laser Doppler Fluxmetry (LDF) close to the ulcer under the bandage and at the great toe,
Transcutaneous Oxygen Pressure (TcPO2) on the dorsum of the foot and toe pressure as safety parameters. Ejection Fraction
(EF) of the venous pump was performed to assess efficacy on venous haemodynamics.
Results: LDF values under the bandages increased by 33% (95% CI 17-48, p < .01), 28% (95% CI 12-45, p

O-25.02
CUTANEOUS WOUNDS, EDEMA AND COMPRESSION: “CONDITIONING OF THE SKIN”
R J Damstra, Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital, Drachten, NL
Background: In general, cutaneous wound healing is a complex system with three phases: a physiological exudative phase
with edema formation, a proliferative phase with granulation formation and a reparative phase with scar formation and
tissue remodelling. Disturbance in the fine balance of wound healing by edema formation switches physiological acute
wound healing in chronic wound healing. The phenomena of impairment of wound healing by edema formation is well
known in venous ulcers, because edema is more pronounced as a result of advanced chronic venous insufficiency and venous
hypertension. Compression bandaging remains the cornerstone in the management of venous and lymphatic disease.
Aim: To describe the effect of edema formation on the wound healing of non-venous cutaneous wounds by short stretch
bandage and compression garments. The method is called conditioning of the skin.
Material and methods: The results are presented of patients with delayed wound healing treated in an out patient clinic.
Results: All wounds were initially treated with wound dressings without adequate compression during 3-6 weeks. When multi
layer inelastic bandaging was started, all wounds healed within 1-4 weeks. Because the reparative phase in wound healing last
for about 3 months, compression garments were wore during this time after wound closure
Conclusion: In all cutaneous wound-healing processes, edema formation is present and leads to impairment of healing.
Similar as in the treatment of chronic venous insufficiency with ulcer formation, compression therapy is very effective to
minimize edema formation and to initiate wound healing. In conclusion, compression therapy during the various stages of
wound repair stimulated wound closure and improves the quality of the skin. Therefore we call this “conditioning of the skin”.
Declaration of interest
None Declared
O-25.03
SCREENING FOR PERIPHERAL VASCULAR DISEASE IN CHRONIC OEDEMA. ARE ARTERIAL
DOPPLER WAVE FORMS USEFUL?
V Keeley, Royal Derby Hospital, Derby, UNITED KINGDOM
K Riches, Royal Derby Hospital, Derby, UNITED KINGDOM
Introduction: Peripheral arterial disease is considered a contra-indication to full compression treatment for chronic oedema.
In the UK, in leg ulcer clinics, the ankle brachial pressure index (ABPI) is a commonly used screening tool for peripheral
vascular disease. However, this can be difficult to measure in patients with chronic oedema and indeed the results obtained
may be inaccurate. Recording Doppler wave forms (DWF) in peripheral arteries may be a more practical and reliable tool in
this group of patients.
Objectives: To review the prevalence of abnormal DWF in patients attending a chronic oedema clinic with leg oedema and
to determine the causes of these.
Methods; Doppler wave forms are recorded routinely in new patients using a “vascular Assist” (Huntleigh, UK). Biphasic or
triphasic wave forms in the dorsalis pedis and the posterior tibial arteries are considered to be normal, whereas monophasic
wave forms suggest arterial disease and merit further investigation before compression can be considered.
Results: In 2010 DWF were recorded in 320 new patients with chronic leg oedema in our clinic. Of these, 28 patients (9%)
had at least one monophasic wave form on 44 limbs. 17 (Y%) had two or more monophasic wave forms.
Further investigation, initially with arterial duplex scans revealed significant peripheral vascular disease in the vast majority
of these patients. A number of patients were referred to vascular surgeons and further studies such as MR angiography was
performed.
Conclusions:In this preliminary study, patients with monophasic DWF do seem to have arterial pathology, which may be
asymptomatic. These results have affected our management of patients: in some, where the cause has been reversible e.g. with
angioplasty or stenting, full compression has been possible subsequently. In others, modified (reduced pressure) compression
has been possible. In others with significant irreversible vascular disease, compression has been contra-indicated. Further
studies are required to validate this technique formally in patients with chronic oedema.
Declaration of interest
None Declared
149

O-25.04
EVALUATION OF A 2-LAYER COMPRESSION SYSTEM IN TREATMENT OF A LYMPHOEDEMA
PATIENT WITH ARTERIAL STENOSIS
T Zee, De Behandelbank, Arnhem, NETHERLANDS
Background: Evidence of the effect of compression therapy for patients with lower leg lymphedema is well established in 2011.
Compression therapy is considered as contra-indicated in patients with arterial stenosis. Patients with both lymphedema and
arterial disorders in the same extremity place the therapist for a challenging dilemma. Arterial stenosis as a contraindication
for compression therapy has limited evidence. In this N=1 design study a new cohesive 2 layer compression is used in the
treatment of a patient diagnosed with arterial stenosis and lymphedema.
Objective: In this study we reconfirm the effect of compression therapy in lymphedema. Complications due to ischemia
caused by lack of arterial inflow are monitored and evaluated.
Method: A 66 y.o woman was diagnosed with mild primary lymphoedema of the left leg in her youth. In 2009 an arterial
reconstruction was preformed after several years of complaints due to arterial sclerosis. The small saphenous vein was
harvested in the right leg and used to make an arterial bypass in the femoral artery in the groin. Severe swelling occurred
after this operation.
Treatment consisted of CDT with the use of a new cohesieve 2 layer compression system applied to the whole leg. Pressure
of the bandage was monitored by using a Picopress device. Volume of the leg was estimated by circumference measurement
every 4 cm and calculated using the formula of the truncated cone.
Results and conclusions: The bandage showed high pressures immediate after application (53-78mmHg). After three day
there was a pressure reduction of 50%. After 10 days a significant reduction in volume was measured. A compression garment
was ordered. Therapy (manual lymphatic drainage en IPC) was continued without bandaging the leg, waiting for the ordered
garment. There was an immediate recurrence of swelling of the leg, suggesting that the bandage was an essential component
of treatment. There were no complications due to ischemia despite the arterial inflow restrictions.
Declaration of interest
none declared
O-25.05
USE OF 2-LAYER COMPRESSION SYSTEM IN TREATMENT OF A PATIENT WITH FONTAINE STAGE
IV
M Lauret - Roemers, Fysiotherapie Van Diepen, UTRECHT, NETHERLANDS
Background Evidence of the effect of compression therapy for patients with lower leg lymphedema was well established in 2011.
Compression therapy is considered as contra-indicated in patients with arterial problems. Patients with both lymphedema
and arterial disorders in the same extremity place the therapist with a challenging dilemma. Arterial disorder, as a contraindication
for compression therapy, has limited evidence. This old lady walking with the help of a rollator, was advised to
walk because of the Fontaine IV and must therefore fit in her shoes. She also suffers from arterial ischaematic ulcera and
lymph-leakage. In this N=1 design study a 2 layer compression is used in treatment of a patient with diagnosed Fontaine IV
and lymphedema in the left leg. Objective: In this study, we re-confirm the effect of compression therapy in lymphedema,
by using only a 2 layer system without any further padding. Complications due to ischemia caused by lack of arterial inflow
are monitored and evaluated. Method A 86 y.o woman was diagnosed with arterial sclerosis obliterans (Fontaine IV) of the
left leg, co-morbity of heart failure and severe gonartrosis in the left knee. In December 2010 an arterial reconstruction was
performed: arterial bypass PTFE left leg , the AFS was partially closed. Severe swelling occurred after this operation in the
left leg and foot. Treatment consisted of CDT with the use of the 2 layer compression-system on the left foot and leg. Volume
of the leg was measured by a circumference measurement every 4 cm and calculated using the formula of the truncated cone.
Results and conclusions The bandage was very convenient because she was still able to fit in her shoe with this bandage. After
21 days a significant reduction of 1861,16 ml volume was measured in the left leg. This means a 41,5 % reduction in 2 weeks.
(See the graphics and pictures in the poster) A compression garment was then ordered whilst the lymph-leakage stopped and
manual lymphatic drainage and exercises) was continued. There were no complications due to arterial problems.
Declaration of interest
none declared
150

O-25.06
COMPRESSION MAY CAUSE PROBLEMS IN PATIENTS WITH CARDIAC OEDEMA
K Riches, Derby Hospitals NHS Trust, Royal Derby Hospital, Derby, UNITED KINGDOM
Introduction: In practice patients may present to lymphoedema clinics with chronic leg oedema where heart failure may
be the major cause or a significant contributory factor. The treatment of lymphoedema utilises compression therapy. In
patients with uncontrolled heart failure compression therapy is contraindicated. Therefore, a simple blood test is useful in
determining the appropriate management of this group of patients.
Brain natriuretic peptide (BNP) is a biologically active peptide released from the cardiac ventricles in response to stretching
of the chamber. BNP has vasodilator, natriuretic, diuretic and renin inhibition properties. This peptide has been shown to
be elevated in patients with congestive heart failure. Elevation of plasma BNP is increasingly being used in the diagnosis and
treatment of congestive heart failure.
United Kingdom guidance on the management of heart failure recommends measuring plasma BNP alongside
electrocardiograms as screening tools in the diagnosis of heart failure. Plasma levels of BNP fall after effective pharmacological
treatments of heart failure. Therefore, measuring BNP concentrations can be used to monitor the efficacy of the treatment of
heart failure in addition to being a diagnostic tool.
Aims of audit: The audit was developed to confirm that measurement of BNP aids clinical diagnosis and the appropriate
management of patients with chronic oedema of the lower limbs.
Results: Since January 2006 approximately 850 patients with leg oedema have been referred to the service. BNP has been
reviewed in 69 (8%) patients attending the clinic. 32/45 BNP measurements undertaken in the clinic and 8/24 undertaken
previously were abnormal.
Of all of the patients with an abnormal BNP, 25 patients received compression therapy but this was modified for the majority
of this group, i.e. at reduced pressure. One patient was treated for heart failure and did not require lymphoedema treatment.
Discussion: Undertaking BNP measurement in selected patients can aid diagnosis and management planning. This audit has
demonstrated that some patients require modification of compression in light of the BNP resultst.
Conclusion: This audit suggests that BNP measurement may play a useful part in the assessment and management of patients
with chronic oedema.
Declaration of interest
None declared
O-26.01
PROSPECTIVE TRIAL COMPARING A NEW 2 LAYER COMPRESSION VERSUS INELASTIC
MULTICOMPONENT BANDAGING IN LEG LYMPHEDEMA
R J Damstra, Nij Smellinghe hospital, Drachten, NETHERLANDS
D A A Lamprou, Nij Smellinghe hospital, Drachten, NETHERLANDS
H Partsch, Private pratice, Vienna, Austria
Background: Inelastic multicomponent bandages are the standard of care in managing lymphoedema.
Aim: to compare the efficacy of such bandages with that of a new, less bulky two-component system.
Material and methods: Thirty hospitalized patients suffering from moderate to severe unilateral lymphedema (stage 2-3) of
the leg were randomized in 2 groups of 15 patients each. One group received the new 2 Layer Compression System (2LC), the
other was treated by conventional Inelastic Multilayer Compression bandages (IMC). Bandages were removed and reapplied
after 2 and after 24 hours.
Bilateral lower leg volume was measured by means of classic water displacement volumetry before bandage application, after
2 hours and after 24 hours. Sub-bandage pressures (interface pressure) were measured after bandage application, before
removal, after reapplication two hours later and before removal after 24 hours.
The main outcome parameters were volume reduction of the affected leg and interface pressure loss after two and 24 hours.
Results: Overall volume reduction after 24 hours was 8·4% in the 2LC group compared to 4·4% in the IMC bandages group
(P

O-26.02
A MODEL APPROACH FOR ASSESSING OPTIMUM COMPRESSION FOR AN IRREVERSIBLE LOWER
LIMB LYMPHOEDEMA
S THEYS, Clin Univ Godinne, YVOIR, BELGIUM
J C Schoevaerdts, Clin Univ Godinne, YVOIR, BELGIUM
J F r Thirot, HE Europe-Charleroi, Montignies/Sambre, BELGIUM
T h Deltombe, Clin Univ Godinne, YVOIR, BELGIUM
The main problem optimizing the conservative treatment of an irreversible lower limb lymphoedema (ILLL)is the choice of
the effective compression (P). The purpose was to investigate whether interstitial compliance influences both the rate of leg
swelling reduction and the optimum value of compression. To this end, variation in volume (Vol) of 12 ILLL was measured
plethysmographicaly during different compression. Results showed a strong interaction between Vol and P. The data allow
drawing a hyperbola with a left convexity, turned to the axis of the Vol. The initial part of the curve is steep: for a little
variation of P, there is a great variation of Vol. But with growing ILLL, the curve slope slowly down. The interstitial distension,
the residual capacitance is reduced. Beyond this swivel, it becomes necessary to raise, more and more, the compression to
mobilize fewer oedema. Finally, the curve becomes a horizontal: the expansion of oedema is stopped. In other words, in
highly compliant tissue, as in old ILLL, the elastic tissue is overstretched by chronic oedema and the elastic recoil is poor. So,
with low compression or hydrostatic pressure it is extreme difficult reducing ILLL but there is a high potential in recurrence.
The results could give further support to the concept that the oedema decongestion yield varies according with the Vol-P
ratio that is to say to the consistence. So, the optimum value of compression may be low (30 mm Hg) with low compliance but
becomes high (150 mm Hg in our study)as oedema has a high compliance. In conclusion, the determination of the specific
Vol-P ratio of any given case of ILLL, at a given time, would lead to more optimize its decongestive treatment.
Declaration of interest
None declared
O-26.03
INTERNATIONAL COMPRESSION CLUB- PRACTICAL IMPLICATIONS
H Partsch, Medical University of Vienna, Vienna, AUSTRIA
Background: The mission of the ICC is to increase the scientific level concerning compression therapy by creating a platform
for exchanging ideas and initiatives between interested medical experts and producers of compression products.
Previous activities
Since 2005 several consensus meetings have been organized followed by publications which can be found under www.icccompressionclub.com.
Practical implications
Several proposals to achieve higher scientific standards in planning future trials have been worked out:
1. Valid clinical methods to measure compression pressure which corresponds to the dosage in drug trials (Dermatol
Surg 2006;32:224)
2. Guidelines how to test compression materials (Eur J Vasc Endovasc Surg 2008;35: 494)
3. Practical aspects how to classify compression bandages (Dermatol Surg 2008;34:600)
4. Indications for compression therapy: Areas of lacking evidence ( Int Angiol 2008;27:193)
5. Methods for measuring the effects of compression therapy (several articles in Int Angiol. 2010; October-issue)
6. Optimizing compression therapy in breast cancer related lymphoedema of the upper extremity (Int Angiol
2010;29:442)
7. Compression therapy in chronic oedema of the lower extremity (Int Angiol submitted).
8. A discussion on several dogmas in compression therapy should also help to stimulate research ( ICC-Meeting in
Brussels, May 2011)
Conclusion: Up to now compression therapy which is the cornerstone in the conservative management of chronic oedema
including lymphoedema is mainly based on experience. Some proposals from the ICC could help to stimulate research and
to achieve stronger scientific insights into this underestimated area.
No conflict of interests
Declaration of interest
None declared
152

O-26.04
SEARCH FOR AN OPTIMAL COMPRESSION PRESSURE TO REDUCE EXTREMITY OEDEMA
H Partsch, Medical University, Vienna, AUSTRIA
R Damstra, Nij Smellinghe, Drachten, NETHERLANDS
H Mosti, Casa Barbantini, Lucca, ITALY
Background: Standard care in the initial treatment phase of patients with chronic oedema and lymphoedema starts usually
with the application of inelastic bandages.
Objectives: to measure volume reduction of a swollen extremity depending on the amount of pressure exerted by inelastic
material during the first week of treatment.
Methods: 36 patients with moderate to severe unilateral breast cancer related arm lymphoedema were investigated in a lymph
clinic in the Netherlands, 42 legs of 30 patients with chronic oedema of the lower extremities (excluding severe lymphoedema)
were examined in a phlebological centre in Italy. The arm- patients were randomized to receive inelastic arm bandages with a
pressure between 20-30 mm Hg or 44-68 mm Hg. The leg patients were either treated with compression stockings (23-32 mm
Hg) or with inelastic bandages (pressure 53-88 mm Hg). Water-displacement volumetry was used to measure the volume
changes of the treated extremities, after 2 and 24 hours in the arm-patients and after 2 and 7 days in the leg-patients.
Results: In the arm patients low pressure achieved a higher degree of volume reduction than high pressure , which was -2,5%
vs -1,4% after 2 hours and -5,2% vs. -4,2% after 24 hours ( n.s.).
In patients with leg oedema compression stockings after 7 days attained a volume reduction (-10, 1%) which was in the same
range of what could be achieved by bandages after 2 days (-11, 2%). While stockings in the range between 20 and 40 mm Hg
showed a good correlation between exerted pressure and volume reduction, bandages applied with a resting pressure of more
than 60 mm Hg resulted in a decreasing volume reduction.
Conclusions: There is obviously an upper pressure limit beyond which further increase of pressure seems contra-productive.
For inelastic bandages this upper limit is around 30-40 mm Hg on the upper and around 50-60 mm Hg on the lower extremity.
A possible explanation is the different action of compression on Starling’s equilibrium on one hand and on the lymphatic
drainage on the other.
No conflict of interests
Declaration of interest
None declared
O-26.05
CONTROLLED COMPRESSION THERAPY AFTER LIPOSUCTION OF LEG LYMPHEDEMA – HOW TO
KEEP CONTROL OVER TIME
K Ohlin, Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
B Svensson, Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
C Freccero, Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Department of Medical Sciences
Malmö, Lund University, Malmö, SWEDEN
H Brorson, Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Department of Medical Sciences
Malmö, Lund University, Malmö, SWEDEN
Background: Lymphedema can successfully be treated with liposuction and Controlled Compression Therapy (CCT). The
aim of CCT is to increase compression until the volume of the lymphedematous leg is smaller or equal to the healthy one and
to maintain the outcome.
Objectives: This study presents how CCT works in practice, leading to complete reduction, and how this works over time.
The need of compression garments is discussed in relation to the patients’ activity levels and the severity of the lymphedema.
Methods: Four patients, one male and three female, aged between 18 and 69 years were investigated. Two patients had
primary and two secondary lymphedema. The excess volumes were measured preoperatively, and at 0,5, 1, 3, 6, 9,12 and
18 months postoperatively, then annually. Extra check-ups were planned when needed. At the check-up, the outcome was
evaluated and complementary measures were added, if necessary. At each occasion the treatment strategy was identified.
Results: The treatment strategies used in CCT are: decrease circumferential measurements of compression garments, increase
compressions class, use of several compression garments (multilayer), increase the amount of garments prescribed at the
same time, and taking in existing garments. The choice of strategy depends on where increased compression is needed on
the whole leg or part of it. It also depends on the patients’ abilities to put on the compression garment and the patients’
preferences and motivation.
Conclusions: Varying strategies can be used and combined to increase compression until complete reduction is achieved. This
compression then needs to be maintained and evaluated at regular check-ups to keep a good result over time.
References:
Brorson H et al. J Lymphoedema 2008; 1: 38-47. Lymphology 2008; 41: 52-63.
Declaration of interest
None declared
153

O-26.06
STANDARIZATION OF A PRESSURE-MEASURING DEVICE FOR OPTIMIZING LYMPHEDEMA
TREATMENT WITH COMPRESSION GARMENTS
C Freccero, Skane University Hospital, Malmö, SWEDEN
E Jense, Skane University Hospital, Malmö, Sverige
K Ohlin, Skane University Hospital, Malmö, Sverige
B Svensson, Skane University Hospital, Malmö, Sverige
H Brorson, Skane University Hospital, Malmö, Sverige
Background: The use of compression garments in treating lymphedema following breast cancer is a well-established method. Though
compression garments are classified in theoretically calculated compression classes, little is known about the actual subgarment
pressure provided.
Objectives
1. To establish a mehod of measuring subgarment pressure using the I-scan® (Tekscan Inc.) pressure measuring equipment along
the extremity.
2. To analyze initial subgarment pressure along the extremity of 5 similar compression garments from three various manufacturers.
3. To analyze subgarment pressure of three manufacturers’ garments over time after standardized wear and tear.
Method and material: Five compression garments from 3 different manufacturers were custom-ordered to fit plastic legs. Initial
readings were made using the I-scan® pressure-measuring tool from Tekscan. The garments were then washed and put on the plastic
legs every day to simulate for wear and tear. Pressure measurements were obtained once a week during 4 weeks to assess changes in
subgarment pressure.
Results: Successful measurements of subgarment pressure were obtained using the Tekscan system. The results show a satisfying
homogeneity within garments from the same manufacturer. There were significant initial differences between some of the
manufacturers. Garments were then subjected to 4 weeks of washing. No significant decrease of subgarment pressure was observed
during the observation period for any of the manufacturers. On the other hand, there were inconsistent significant differences
between the manufacturers during the observation period.
Conclusion: This in vitro study showed that Tekscan pressure-measuring equipment could measure subgarment pressure in vitro.
There were variable differences between the different manufacturers as regards to exerted pressure, but no change for each separate
manufacturer. To assess the life span of compression garments and decrease in subgarment pressure, using simulated wear and tear,
garments must be observed for much longer time, probably 3-6 months. To simplify measurements in vivo, a sensor for subgarment
pressure measurement needs to be developed.
Declaration of interest
None declared.
O-26.07
PROSPECTIVE TRIAL COMPARING THE EFFECT OF JUXTA-FIT VERSUS TRICO BANDAGES IN
TREATING LEG LYMPHOEDEMA
R Damstra, Nij Smellinghe hospital, Drachten, NETHERLANDS
D- A A Lamprou, Nij Smellinghe hospital, Drachten, NETHERLANDS
H Partsch, Private pratice, Vienna, Austria
Background: Inelastic multicomponent bandages are the standard of compression in the initial treatment phase of
lymphoedema. The inelastic Juxta fit device (JFD), which can be easily adjusted by the patient to the circumference of the
limb and was originally developed to maintain the effect of a lymphedema treatment but not for initial treatment.
Aim: To compare the efficacy of JFD with classic short stretch bandages concerning volume reduction and interface pressure
loss in the initial treatment phase
Material and methods: Thirty hospitalized patients suffering from moderate to severe lymphedema (stage 2-3) of the leg
were randomized in 2 groups of 15 patients each. One group received the new Juxta fit device. These patients were trained
by an experienced nurse on how to adjust the compression by themself as soon as the patients sensed the therapeutical
pressure became ineffective. The control group was treated with conventional Inelastic Multilayer Compression bandages
(IMC) applied by an experienced nurse. Bandages were removed and reapplied after 2 and after 24 hours.
Bilateral lower leg volume was measured by means of classic water displacement volumetry before bandage application,
after 2 hours and after 24 hours. Sub-bandage pressures (interface pressures) were measured at the B1 location after bandage
application, before removal, after reapplication, after 2 hours and before removal 24 hours later.
Primary outcome parameters were volume reduction of the affected leg and interface pressure loss after 2 and 24 hours.
Results: A preliminary evaluation of 13 patients in each group showed a mean volume reduction after 24 hours of 11.3% in
the JFD group compared to 7.3% in the IMC bandages group (n.s.). The interface pressure dropped significantly after two and
24 hours in the IMC group, but much less in the JFD group due to self-adjustment.
Conclusion: The JFD is very effective in the initial treatment phase compared to IMC bandages in the conventional treatment
of moderate to severe lymphedema. The possibility of self-adjustment of JFD enhances the efficacy of the clinical outcome.
Declaration of interest
none declared
154

RT-03.01
INTERCONNECTED TREATMENT OPTIONS – A BENEFIT FOR THE PATIENT
R Baumeister, University of Munich, Munich, GERMANY
There is a bunch of suggestions for successful treatment of lymphedema with a wide range starting from simple elevation ,
pharmacological treatment , physical manual drainage , specific exercises, mechanical compression, compression stockings
towards different types of surgical interventions.
Each of these methods may have its specific value. Often however there is a tendency to claim the exclusive usefulness for one
or the other method.
In the view of the patient there is a definite order of desires: cure as the most important one, less invasive treatment , freedom
of continuing treatment, invasive treatment as secondary option with the sequence: reconstruction if possible and resection
if necessary.
With respect to the wishes of the patients each method proposed should be discussed in this order.
To elucidate this, open discussion between the therapist and the patient is necessary and helpful.
This will lead to transitions from one treatment option to the other and possibly to a combination of treatment protocols
supervised jointly by the different specialists.
As an example the procedure is shown using the experiences with conservative treatment, reconstructive microsurgical
options and resection treatment in Germany.
A round table discussion following the presentation of the different methods at the final stage of the congress is the right
occasion to initiate this procedure as a routine in daily praxis.
Declaration of interest
None declared
RT-03.02
LONG-TERM OUTCOME AFTER LYMPHATIC MICROSURGERY FOR PERIPHERAL LYMPHEDEMA.
C Campisi, University of Genoa - University Hospital , Genoa, Italy
P Santi, University of Genoa, Genoa, Italy
C C Campisi, University of Genoa, Genoa, Italy
R Lavagno, University of Genoa, Genoa, Italy
C S Campisi, University of Genoa, Genoa, Italy
F Boccardo, University of Genoa, Genoa, Italy
Background: Authors’ wide surgical play in the therapy of both primary and secondary peripheral lymphedema by
microsurgical procedures is mentioned as performed at the Centre of Lymphatic Surgery and Microsurgery of the University
of Genoa, Italy.
Objectives: To report the over 30 years vast clinical experience and the consistent long-lasting outcome concerning the
treatment of peripheral lymphedema by advanced derivative and reconstructive microsurgical techniques.
Methods: Between 1973 and 2011 over 1900 patients underwent microsurgery including derivative lymphatic-venous
anastomoses (LVA technique) and lymphatic reconstruction by interpositioned vein grafted shunts (LVLA technique) with
an average follow-up of more than 10 years. Objective assessment was undertaken by volumetry, venous duplex scan and
lymphoscintigraphy. The outcome obtained in treating lymphedemas at different stages was analyzed in terms of volume
reduction, stability of results with time, reduction of dermatolymphangioadenitis (DLA) attacks, necessity of wearing elastic
supports and use conservative measures post-operatively.
Results: Results were objectively assessed by volumetry and lymphoscintigraphy. Volume changes showed a significant
improvement, till over 84% volume reduction comparing pre-operative conditions. Among patients with lymphedema at
earlier stages (stage I and stage II A), over 86% could progressively give up the use of conservative measures and elastic
supports, and 42% of patients with late stage lymphedema (stage II B and stage III) could decrease the use of physical
therapies. Most considerably, considering lymphedema tertiary prevention in later stage disease, the significant volume
reduction diminished DLA attacks of about 91%. Histological findings showed minor lymphatic and lymph nodal tissue
changes in early stage lymphedemas, whilst significant fibrotic lesions have been demonstrated in late stage lymphedemas.
Conclusion: Microsurgical lymphatic derivative and reconstructive techniques allow to bring about positive results in the
treatment of both primary and secondary peripheral lymphedema, above all in early stages when tissue changes are slight and
allow almost a complete restore of lymphatic drainage.
Declaration of interest
None declared
155

RT-03.03
WHY PERFORM LIPOSUCTION IN PATIENTS WITH CHRONIC NON-PITTING LYMPHEDEMA?
H Brorson, Lund University, Dept of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, SWEDEN
The occurrence of adipose tissue hypertrophy in patients with chronic non-pitting lymphedema has been shown in several
papers. We recommend liposuction in patients with chronic non-pitting lymphedema in order to remove the excess volume.
New ideas and concepts of treatment, however, require evaluation and confirmation before they are accepted and become the
standard of care.
Liposuction can thus be performed in patients who fail to respond to conservative management or microsurgical reconstructive
procedures because the hypertrophy of the subcutaneous adipose tissue cannot be removed or reduced by these methods.
A combination of liposuction and reconstructive microsurgery, in order to avoid the wearing of garments, may be an
interesting option but seems not feasible in chronic late stage lymphedema since the delicate anatomy and intrinsic transport
capacity of the lymph vessels is destroyed.
Declaration of interest
None declared
RT-03.04
NEXT STEP – HOW TO ENHANCE THE BEST TREATMENT OPTION OF THE CLIENT?
A Kärki, Satakunta University of Applied Sciences, Pori, FINLAND
Systematic reviews of the clinical trials concerning conservative lymphedema treatments systematically support the use of
compression in different forms. The therapist should be able to critically read existing studies, but the basic education has not
enough supported this scientific reading skills. The lack of awareness of the existing evidence of best practice raises some
concerns. If the therapists are not aware of the evidence base for the treatments they use, they will not be able to explain
and discuss the treatment options with their patients. The lymph therapists should seriously think about increasing their
awareness and also take their own steps to build the evidence base through rigorous and well-designed research settings.
If the evidence do not support the methods used – the methods should be developed. The professional practice of therapist
should be evolving by the study results. It is not enough anymore to rely on old regimes if the study results do not support
their use. The next step in therapeutic practices should be user-centered studies of enhancing best practices among altered
user groups.
Declaration of interest
None declared
156

O-27.01
NEW FRONTIERS IN LYMPHATIC RESEARCH
S Rockson, Stanford Center for Lymphatic and Venous Disorders, Stanford University School of Medicine, Stanford, UNITED
STATES
The last decade has witnessed an unprecedented explosion of new information that has been accrued about lymphatic vascular
development and genetics, its contractile biology, and the processes of normal, abnormal and therapeutic lymphangionesis.
An overview of these developments will be undertaken, with an eye toward the implications for the diagnosis and treatment
of lymphatic diseases.
Declaration of interest
None declaed
O-27.02
PDGF (PLATELET DERICVED GROWTH FACTOR) IN THE PRIMARY LYMPHEDEMA.
M Ohkuma, Kinki Univ. Hospital, Sakai, Kazo, Saitama, JAPAN
PDGF(platelet derived growth factor) in the Primary lymphedema
Hasegawa F and Ohkuma M*
Department of Nephrology and * of Dermatology, Sakai Hospital, Kinki University, School of Medicine, Osaka, Japan
Introduction and Objectives:One of the differences between the primary and secondary lymphedema is disorder in VEGFR3
in the former. How about the PDGF? In European Congress of Lymphology, Warsaw, Poland, 2011 The authors have
demonstrated PDGF-BB is low in the secondary lymphedema*.
Material and Method:sera were tqken from 6 cases of primary lymphedema and compared with those of 5 normal volunteers.
The data were evalauated for PDGF-BB by ELISA.
Result: PDGF-BB in the serum of 6 cases of primary lymphedema is high if compared with those of normal volunteers.
Discussion: From the result of scintigraphic findings of primary and secondary lymphedema lymphatic proliferation and
distribution is insufficient in the former.This accerelated PDGF value in the primary lymphedema may be due to a positive
feed back due to poor prolifration ability.On the
contrary potential ablity for proliferation is restored in the secondary lymphedema. It is said that lymphatics of the old patients
in secondary lymphedema are difficult to grow or proliferate. In the effective treatment for the two kinds of lymphedema
should be different. To stimulate the lymphatic proleferation and foming a new anastomosis may be a good treatment for the
primary lymphedema
Conclusion:PDGF is high in primary lymphedema as compared with the normal volunteers.
* The authos have demonstrated to the contrary in 21st international congress of lymphology, Shanghai, 2007.
Declaration of interest
None declared if there is no conflict to declare.
157

O-27.03
CLINICAL AND GENETIC STUDY OF ITALIAN FAMILIES WITH PRIMARY LYMPHEDEMA
S Michelini, San Giovanni Battista Hospital, Roma, ITALY
M Bertelli, MAGI non profit Human Medical Genetics Insitute, Rovereto, ITALY
M Cardone, San Giovanni Battista Hospital, Roma, ITALY
S Cecchin, MAGI non profit Human Medical Genetics Insitute, Rovereto, ITALY
L Pinelli, MAGI non profit Human Medical Genetics Insitute, Rovereto, ITALY
F Cappelino, San Giovanni Battista Hospital, Roma, ITALY
A Guerrini, MAGI non profit Human Medical Genetics Insitute, Rovereto, ITALY
F Agostini, MAGI non profit Human Medical Genetics Insitute, Rovereto, ITALY
A Fiorentino, San Giovanni Battista Hospital, Roma, ITALY
INTRODUCTION Primary Lymphedema usually arises at puberty (but in some cases at birth or later) and may be associated
with dystichiasis (double row of eyelashes). This syndrome may be transmitted as autosomal dominant with variable penetrance.
The genes involved are mainly the one coding for the transcription factor FOXC2 and the one coding for receptor 3 of vascular
endothelial growth factor.
AIMS To conduct a clinical study in patients from 11 italian selected families in order to analyse the genotype-phenotype
correlation and shed light on prevalence of hereditary lymphoedema associated with FOXC2 and VEGFR3 mutations.
METHODS Patients were selected by a network of medical specialists in Lymphology located in 11 Italians regions. The
diagnostic criteria considered in this study include assessment of Lymphedema by Lymphoscintigraphy, exclusion of secondary
causes, enrolment of patients whose family had at least 2 cases of Lymphoedema and disease onset earlier than 25 years. Genetic
analysis was carried out after obtaining informed consent. Test involved the extraction of DNA by Salting-out from 100 blood
samples (1ml for each) which was followed by PCR amplification of the entire coding region and thus sequencing.
RESULTS Genetic screening is still ongoing but a novel mutation (p.Ile926Thr), a mutation already described in literature
(Gly854Ser)and several changes in intron sequence (c. 3686+83 ins G, c.3001+80 _ +81ins TAGGGTAACC) not yet published
were detected.
CONCLUSIONS To our knowledge, this is the first italian study in which FOXC2 and VEGFR3 mutations were sought among
a wide range of clinically selected patients with Primary Lymphedema. The results achieved so far show evidence of novel
mutations and sequence variations in intronic regions. Compared to the American series, our show a significantly lower rate
of mutation, suggesting the existence of a new gene playing a major role in the etiology of primary Lymphoedema in Italian
Patients.
Declaration of interest
None declared
O-27.04
SOME CASES OF FAMILIAL LOW-LIMB LYMPHEDEMA IN SIBERIAN REGION (PRELIMINARY
REPORT)
V Nimaev, Institute of Clinical and Experimental Lympholgy SB RAMS, Novosibirsk, RUSSIAN FEDERATION
M Gubina, Institute of Cytology and Genetics, Novosibirsk, RUSSIAN FEDERATION
M Lubarsky, Institute of Clinical and Experimental Lympholgy SB RAMS, Novosibirsk, RUSSIAN FEDERATION
I Kulikov, Institute of Cytology and Genetics Research Institute of Therapy, Novosibirsk, RUSSIAN FEDERATION
A Povestchenko, Institute of Clinical and Experimental Lympholgy SB RAMS, Novosibirsk, RUSSIAN FEDERATION
V Maksimov, Research Institute of Therapy, Novosibirsk, RUSSIAN FEDERATION
V Konenkov, Institute of Clinical and Experimental Lympholgy SB RAMS, Novosibirsk, RUSSIAN FEDERATION
BACKGROUND. Milroy disease is caused by mutation in the FLT4 gene which encodes the vascular endothelial growth
factor receptor-3 (VEGF-R3). Approximately 85%-90% of individuals who have a mutation in FLT4 develop lower-limb
lymphedema by the of age of three years; conversely, 10%-15% of individuals with an FLT4 mutation are clinically unaffected.
Opinions about mutation in any genes in patients with Meige disease are controversial yet. We know nothing about
investigations of these rare diseases in Russian population.
OBJECTIVE: Identification of genes responsible for predisposition to certain forms of lymphedema. Fil the questionnaire
form to compile genealogies for family analysis. For all examinees DNA samples for molecular genetic studies will be provided
METHODS: Analysis of the questionnaire and pedigree analysis of clinical manifestations. Separation of DNA. The
conditions for PCR and sequencing of exons 22-23 and 22 intron FLT4 located at 5q35.3 have been matched.
RESULTS: We have been determined that the only family have clinical features of Milroy disease. Two another families have
presence of low-limbs swelling in puberty and characterized as Meige disease. All of three families have no any syndrome
associated with lymphedema. Preliminary analysis revealed a mutation of the gene FLT4 22 intron (37896G / T) (GenBank
accession No NG011536) and 23 of exon C / T (at position 3198). The mutation that we identified in exon 23 previously had
been described in the patients with lymphedema from Japan.
CONCLUSION: Thus, we have identified mutations in the gene FLT4 for both Milroy and Meige desease. The survey of all
families with family lymphedema, including those without clinical manifestations, mutations in the genes FLT4 and FOXS2
may bring new information about the cause of hereditary lymphedema in the Siberian region, which differs from those in
other populations.
Declaration of interest
None declared
158

O-27.05
A RAT MODEL FOR EXPERIMENTAL SUPERMICROSURGICAL LYMPHATICOVENULER
ANASTOMOSIS
Y Demirtas, Ondokuz Mayis, Samsun, TURKEY
M Topalan, Istanbul, Istanbul, TURKEY
Introduction: Although supermicrosurgical lymphaticovenuler anastomosis has been used for the treatment of lymphedema
with encouraging results in the last decade, it lacks a thorough experimental basis. Because, a relevant model to assess the
longterm patency has not been revealed yet. This study aimed to develop a reliable small animal model for objective evaluation
of the technique.
Material and Methods: Subcutaneous tissue of the ears and the lower extremities of five rabbits were dissected to visualize the
lymphatic trunks following “Patent Blue Violet” dye injection. None of the explored trunks were suitable for lymphaticovenuler
anastomosis for being smaller than 0.2 mm. Then, lumbosacral trunks of the same rabbits were exposed at the retroperitoneal
region. Relatively larger diameters of these lymphatic trunks inspired the idea of developing the experimental model in rats.
The anatomy of the lumbosacral lymphatic trunks and the neighboring veins was investigated via midline laparotomy in five
rats, as well as the possibility of supermicrosurgical lymphaticovenuler anastomosis.
Results: In opposition to the former acquiescence that the lumbosacral lymphatic trunks were located posterior to the renal
veins, we elicited that these lymphatics traversed the renal veins anteriorly constituting the easiest anatomic location to
identify them as staining was inconsistent. The diameters of the trunks ranged between 0.2-0.4 mm and it was possible to
anastomose them to neighboring internal genital veins with supermicrosurgical technique: six to eight stitches using 12-0
sutures with 40-50 micron needles.
Conclusion: The lumbosacral lymphatic trunks of the rat have consistent anatomy, are easily explored at the retroperitoneum
and are critically large enough to allow supermicrosurgical lymphaticovenular anastomosis. This model could be used to
validate the experimental basis of the technique. Though, routine microsurgical instruments and laboratory microscopes are
inadequate to perform this operation; specialized instruments, thinner microsutures and a superior microscope are needed.
Declaration of interest
None declared
O-28.01
TREATMENT OF SECONDARY LYMPHOEDEMA WITH MICROSURGICAL LYMPH NODE
AUTOTRANSPLANTATON
D Tobbia, University Medicine Göttingen, Göttingen, GERMANY
M Johnston, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
J Semple, Women’s College Hospital, University of Toronto, , Toronto, Canada
Background: Breast cancer related lymphoedema continues to represent a distressing consequence of axillary lymph node
dissection. We propose the novel concept that the lymph node is the crucial element in maintaining fluid balance and its
removal rather than damage to the lymphatic vessels could be the key to triggering lymphoedema.
Objectives: The purpose of this study was to develop an experimental approach to quantify lymph transport rate after lymph
node excision in sheep. We examined whether the re-implantation of a vascularized lymph node would prevent oedema and
restore lymphatic function.
Methods: Lymph transport was quantitated in the popliteal lymphatic system of sheep by injecting radioactive Human Serum
Albumin (HSA) into one of the prenodal lymph vessels. The recovery of the tracer in plasma was measured at 8, 12 and 16
weeks after nodal excision. These values were compared with similar time points in intact limbs (control) and limbs that
received a vascularized lymph node transplant.
Results: The control limbs became progressively more oedematous in the first few days following lymphnodectomy (33.8%
increase relative to pre-surgical measurements). This oedema improved over time but did not resolve completely in the
majority of animals even at 16 weeks after surgery. Assessment of the mass transport of the HSA showed recoveries at 8, 12
and 16 weeks (% injected/hr) of 10.6 ± 1.5 (n=7), 14.4 ± 1.0 (n=7) and 13.9 ± 1.0 (n=6) respectively compared with 19.3 ±
2.2 in node-intact limbs (n=8). Following autologous lymph node transplantation, the preliminary results were variable with
recoveries of 18.2, 15.3 and 16.1 at 8 weeks and 20.7 and 12.6 at 12 weeks. Oedema in two of the animals at 8 and one of the
animals at 12 weeks post microvascular node transplant resolved completely, incidentally these were also the animals that
showed mass transport rates similar to the control group.
Conclusion: This is a new method to assess the impact of lymph node excision in a sheep lymphoedema model.
Microsurgical transfer of an autologous lymph node following nodectomy may have the potential to prevent the formation of
chronic oedema and help restore lymphatic transport function.
Declaration of interest
None declared
159

O-28.02
MICROSURGICAL TECHNIQUE AND FUNCTION OF LYMPHO-LYMPHONODULAR ANASTOMOSES
IN THE RAT MODEL.
J Wallmichrath, University Hospital of the Ludwig-Maximilians University , Munich, GERMANY
A Frick, UniversSurgical Clinic and Policlinic, University Hospital of the Ludwig-Maximilians University, Munich, GERMANY
R G H Baumeister, Surgical Clinic and Policlinic, University Hospital of the Ludwig-Maximilians University , Munich, GERMANY
BACKGROUND: The continuity of lymphatic vessels in secondary lymphedemas can be restored by microsurgical lymphatic
vessel transplantation. Sometimes, the connection of the transplant is difficult because of a lack of appropriate lymphatic
recipient vessels.
OBJECTIVE: Our study focuses on the microsurgical completion and functional testing of lympho-lymphonodular
anastomoses.
METHODS: In 36 Sprague-Dawley-rats the retroperitoneal lymphatic structures were prepared after staining with patent
blue V dye. In group A (n=12), the left lumbar trunk was cut cranially and its distal part was turned over to the right lumbar
lymph node where a microsurgical lympho-lymphonodular anastomosis was performed in a single stitch technque. In group
B (n=12), treatment was similar but without anastomosing. Group C (n=12) consisted of animals with a sole transection of
the left lumbar trunk. The lymphatic drainage was examined using patent blue after 8 to 16 weeks.
RESULTS: All animals of group A showed patent transposed lymph vessels and anastomoses with blue staining of the right
lumbar lymph node. Only one animal of group B and two animals of group C showed a blue staining of the right lumbar
lymph node.
CONCLUSIONS: The microsurgical fabrication of lympho-lymphonodular anastomoses leads to a safe and durable lymphatic
connection. The known plasticity of lymphatic vessels with the potential of spontaneous anastomosing seems to be higher
between lymphatic vessels than between lymphatic vessels and a lymph node.
Declaration of interest
None declared.
O-28.03
MONOCYTIC RESOURCE OF LYMPHATIC ENDOTHELIAL LIKE CELLS
Z Zou, Shandong University, Jinan, CHINA
Z Zou, Shandong University, Jinan, CHINA
T Tian, Shandong University, Jinan, CHINA
Background: Monocytes have been highlighted due to their potency as endothelial progenitor cells. However, whether
monocytes can transdifferentiate into lymphatic endothelial cells is scarcely studied. Objectives: To induce monocytes to
transdifferentiate into lymphatic endothelial cells. Methods: Monocytes were isolated by density gradient centrifugation and
purified by an adhesion process. Cultured in EGM-2 in fibronectin coated flasks for 7 d, they were detected of the expression
of both antigens specific for lymphatic endothelial cells (Prox-1, LYVE-1, Podoplanin and VEGFR-3), and antigens shared by
vascular endothelium and lymphatic endothelium (vWF and VEGFR-2) by flow cytometry, PCR and immunocytochemistry.
Results: After 7 d of induction, the monocytes transformed into spindle or polygon in shape. By immunoflurorescence,
the cells turned out to express Prox-1, LYVE-1, Podoplanin, VEGFR-3 and vWF, but the expression of VEGFR-2 was weak
and unstable. The PCR and flow cytometry results conformed to the immunoflurorescent outcome. Conclusion: In spite
of the absence of VEGFR-2 expression, the result suggests a potentiality of monocytes to transdifferentiate into lymphatic
endothelial like cells in vitro under appropriate conditions.
Declaration of interest
Supported by Shandong Provincial Scientific Funds (ZR2009CZ014).
160

O-28.04
ANTIGEN-PRESENTING CELL FUNCTION WITHIN RAT MUSCULAR LYMPHATICS
D Zawieja, Texas A&M Health Science Center, Temple, UNITED STATES
W Wang, Texas A&M Health Science Center, Temple, UNITED STATES
E Childs, Texas A&M Health Science Center, Temple, UNITED STATES
E Bridenbaugh, Texas A&M Health Science Center, Temple, UNITED STATES
Many immune cells are classically thought to traffic through the lymphatics on their route to the nodes as part of the
normal innate and learned immune response. The architecture of the mesenteric lymphatic network provides a unique site
for entrance of macromolecules and cells absorbed from the intestine to the lymph stream. These can be transported, via
mesenteric pre-nodal lymphatics (PreNL), to the nodes in which innate and learned immune response are initiated. Agents
that leave the node in lymph are then carried by post-nodal collecting lymphatics (PstNL), and thoracic duct (TD) to the
blood. Antigen-presenting cells (APCs) are specialized cells that probe, recognize, phagocytose & display antigen complex
with major histocompatibility complex II (MHCII) on its surface, to start the immune response. They are classically thought
to sense antigens in the tissues, home to and enter initial lymphatics en route to the node via lymph flow. We provide evidence
of a resident population of APC in the PreNL that are uniquely positioned to sense and present antigens directly from
lymph. We measured the distribution and morphology of the APCs in rat mesenteric PreNL, PstNL and TD by fluorescence
immunohistochemistry. We demonstrate that: 1. MHCII-positive APCs reside within the muscularized lymphatic wall that
have pseudopods that extend to the endothelium subendothelium. 2. These APCs rapidly (

O-28.06
THE REGULATION OF TISSUE HUMORAL TRANSPORT, LYMPHATICDRAINAGE AND LYMPHATIC
SYSTEM FUNCTIONS IN GENERAL PATHOLOGY
Y Levin, O Rodionova, E Artamonova, F Kurieva, I Panova, V Milov,, I Kurnikova, G Kukushkin, Y Sharikov, K Syzdykova.
Russian Peoples' Friendship University, Moscow, RUSSIAN FEDERATION
1. Literature data analysis and experiments made (1965–1982) evidenced that interstitial, tissue and lymphatic humoral
transport (T&LHT) are involved in all pathological processes regardless of their etiology. Emerging disturbances affect a
diseases pathogenesis and outcome. Said above allowed to formulate the task of developing clinical methods of regulating
T&LHT, interstitium and lymphatic system functions in general pathology.
In experimental researches (Y.Levin and coauthors 1965-1972) it was found out that some pharmacological and homeopathic
preparations, some herbs and their combination, some mineral and potable waters exert the necessary effect. A nontraumatic
method of saturating lymphatic system with medical preparations was developed.
2. Clinical medicine has acquired the possibility of:
-regulating tissue fluid formation, tissue lymphatic drainage, lymph transport;
-optimizing lymphatic system functions by affecting lymph (its composition, rheology,
metabolism);
-sanitating cells environment and cells themselves;
-creating detoxicative system at cellular-organismal level (ERL);
-developing lymphotropic therapy that allows to reduce toxic effect of medical preparation (MP), to create high MP
concentration in the sites of pathological foci.
3. Long term clinical observations (1972–2002) showed that such methods facilitate the treatment of many diseases (myocardial
infarction, atherosclerosis, hypertension, bronchial asthma, disturbancies of immunity, hormonal and other systems of the
organism). Evident positive effect was obtained in inflammatory pathology (pneumonia, bronchitis, pancreatitis and so on).
Special significance they acquired in sanitary medicine. Into practical medicine the methods created have been introduced
under the terms: “All-clinical lymphology” and “Endoecological medicine”.
4. The methods developed have been recommended for wide application by Russian and International Congresses (Russia,
1982, Argentina, 1992, Greece, 2002, Cyprus, 2007). The legal basis is represented by a Patent, authorship certificates, Orders,
Instructive and Methodical Letters of USSR and RF Health Ministries (1987–2005), Resolution of Russian academy of medical
sciences (2005). Social and economic effect was confirmed by RF Counting Chamber, 2005.
Conclusion: the developed methods make considerable contribution to therapeutic and
sanitary medicine and require wide application.
Declaration of interest
None declared
O-29.01
COMPARISON OF THREE DRAINAGE OPTIONS IN IRREVERSIBLE LOWER LIMB LYMPHOEDEMA
S Theys, Cliniques Universitaires Godinne, Yvoir, BELGIUM
J F r Thirot, HE Europe-Charleroi, Montignies/Sambre, BELGIUM
A Genette, HE Europe-Charleroi, Montignies/Sambre, BELGIUM
J C Schoevaerdts, Cliniques Universitaires Godinne, Yvoir, BELGIUM
T h Deltombe, Cliniques Universitaires Godinne, Yvoir, BELGIUM
Our aim was to compare the effect of three drainage options on irreversible lower limb lymphoedema (ILLL). Therefore,
12 consecutive patients (45.5 years old) with massive (147%) and old (18 years) ILLL (7 primary, 5 secondary) received
by random assignement three sessions of retrograde drainage: a manual drainage (MD), two 7-cells pneumatic drainage
(PD) (QIM914.2)(30 or 90 mm Hg). Each 16 min session was spaced in time by 15 min of rest.The order of execution
was randomly permuted after each case. Relative volume changes of the calf were continuously (120 min) recorded with a
Hg-plethysmograph (SeriMedPL12)gauge fitted 10 cm below the knee. The results show that volumetric calf decrease was
progressive and reaches 5 ml/100ml oedema manually, 6.5 ml/100ml oed by means of a 30 mm Hg PD and 12 ml/100ml oed
by means of a 90 mm Hg PD. It has been noted no significant difference between the low (30 mm Hg) M or PD. But, there was
a clear difference (p

O-29.02
PREDICTIVE FACTORS OF RESPONSE TO COMPLETE DECONGESTIVE THERAPY IN UPPER
EXTREMITY LYMPHEDEMA FOLLOWING BREAST CARCINOMA
S Haghighat, ICBC/SBMU, Tehran, IRAN (ISLAMIC REPUBLIC OF)
M Lotfi - Tokaldany, Tehran Heart Center , Tehran, IRAN (ISLAMIC REPUBLIC OF)
A A Khadem Maboudi, SBMU, Tehran, IRAN (ISLAMIC REPUBLIC OF)
M Karami, SBMU, Tehran, IRAN (ISLAMIC REPUBLIC OF)
A Bahadori, SBMU, Tehran, IRAN (ISLAMIC REPUBLIC OF)
J Weiss, 5., Cox Health, Mo, USA
Background: Post mastectomy chronic lymphedema as a complication of breast cancer treatment is now managed with
Complete Decongestive Therapy (CDT).
Objectives: Research was performed to study the factors correlating with the result of CDT in controlling the upper extremity
lymphedema following breast cancer.
Methods: The study population consisted of patients with lymphedema referred to the Lymphedema Clinic of the Iranian
Center for Breast Cancer for control of arm edema. After recording the demographic and clinical data, patients were treated
with CDT for 2 – 3 weeks.
Results: One hundred and thirty seven patients (mean age ±SD; 53.5 ± 10 years) were studied. In 48.7% of patients, the
affected arm was the dominant limb. Fifty percent of patients experienced lymphedema during the first year after surgery.
The mean duration of lymphedema was 35 ± 43 months. Mean volume reduction was 43% ± 14.87% (p = 0.03). There was
significant relationship between the percent of volume reduction and start lymphedema volume (p=0.003) and duration of
lymphedema (p=0.002).
Conclusion: This study concluded that CDT is a very effective treatment for post mastectomy lymphedema, especially if it is
provided in earlier stages of disease. It has also an important role in reducing clinical symptoms and improving limb function.
It seems that it is essential to use and develop CDT as an effective method of controlling post mastectomy lymphedema.
Declaration of interest
None declared.
O-29.03
INTEGRATED TREATMENT APPROACHES IN LYMPHEDEMA.
G Moneta, San Giovanni Battista Hospital, Roma, ITALY
S Michelini, San Giovanni Battista Hospital, Roma, ITALY
A Failla, San Giovanni Battista Hospital, Roma, ITALY
M Cardone, San Giovanni Battista Hospital, Roma, ITALY
F Cappelino, San Giovanni Battista Hospital, Roma, ITALY
V Zinicola, San Giovanni Battista Hospital, Roma, ITALY
INTRODUCTION: Lymphedema as main treatment recognizes the decongestive complex physical treatment, and customized
in each case. The therapeutic approach depends on the needs of individual patients and clinical stage. The best and most
durable results are heavily dependent on a precise evaluation of the 'compliance' of the patient towards the treatment. AIMS
The purpose of this study was to identify the most effective treatment pathways in patients with primary or secondary
lymphedema, possibly pointing out the opportunities provided by each mechanical and manual methods.
METHODS: We studied 362 patients with lymphedema (129 primary and 243 secondary aged between 0 and 78 years). All
subjects performed multi-layer bandaging and manual lymph drainage combined with isotonic exercises. The sequential
pressotherapy was performed only in patients who were susceptible to prevailing passive physical therapy. Shock waves were
excluded in children under 5 years and to all those who experienced non-acceptance of the method (for these ultrasounds
were performed on the fibrotic areas). Occupational therapy was given to secondary forms of lymphedema. To all subjects it
was prescribed the final elastic garment at the end of the acute phase. RESULTS
After treatment lasting 3 weeks (average 15 sessions) 321 showed a marked clinical improvement, 23 patients showed mild
clinical improvement or stationary (pitting -test weakly positive at baseline). 18 patients abandoned the protocol for various
reasons (generally poor compliance to the bandage).
CONCLUSIONS: A careful study of compliance for each treatment by the subject can provide in patients with primary
or secondary lymphedema the best and most stable clinical results. The elastic garment contributes significantly to the
maintenance of the results. For these reasons, the AA. before taking charge of patients, require the same acceptance of the
wearing of the garment at the end of intensive phase therapy.
Declaration of interest
None declared
163

O-29.04
PREVENTING POSTOPERATIVE LIMB OEDEMA WITH FARROWWRAP® COMPRESSION.
A Munnoch, Ninewells, Dundee, Dundee, UNITED KINGDOM
J Wigg, Leduc UK, Staffordshire
Background: Isolated limb hypertrophy and lipodystrophy can pose unique problems for both patient and surgeon. The excess
fat can be removed by liposuction, but requires postoperative compression to prevent haematoma and oedema formation. The
size and shape of the limb can make compression garment fitting difficult. FarrowWrap® provides an effective and functional
alternative form of compression which is easy to apply. We present 2 cases recently treated with liposuction.
Case 1
A 42 year old woman with Proteus-type syndrome underwent staged right upper limb reduction to correct a 10 litre volume
excess. An excisional procedure was undertaken to reduced upper arm circumference at 1st stage. For the 2nd stage, 2.5 litres
of fat was removed from the forearm and compression garments applied. This proved problematic, with the garment constantly
slipping, with daily bandaging required as an alternative, a timely and painful procedure. At the 3rd stage operation to remove
4 litres of fat from the upper arm, a FarrowWrap® garment was applied to the upper arm immediately postoperatively – this
was comfortable, easy to apply, replace and reposition. The product was easily washed and was well received by patient and
staff.
Case 2
A 40 year old man with congenital analbuminaemia had significant lypodystrophy and fatty excess on both thighs, with
mild lymphoedema of the lower legs. Liposuction of the left thigh to remove 4 litres of fat was undertaken and a full length
FarrowWrap® garment applied. This was easy to apply and ensured that adequate compression was appropriately applied to
the leg. The fit and compression was maintained and easily adjusted on reduction due to the flexibility of the FarrowWrap®
using Velcro fastening.
Discussion: Following limb liposuction, appropriate compression is required to minimise haematoma and oedema formation,
and to help with soft-tissue redraping. With unknown muscle bulk and bilateral disease, measuring for compression garments
pre operatively can be a lottery, with a risk that they are too loose/tight. This may adversely affect outcome. These problems
have been solved with the FarrowWrap® system, especially the ‘trim to fit’ making it an appropriate, effective postoperative
dressing.
Declaration of interest
Jane Wigg is employed by Haddenham Healthcare Ltd, who supply Farrow products in the UK
O-29.05
INFECTION RECURRENCE IN POSTMASTECTOMY LYMPHEDEMA PATIENTS TREATED BY
COMPLETE DECONGESTIVE TREATMENT
S Haghighat, Iranian Center for Breast Cancer, Tehran, IRAN (ISLAMIC REPUBLIC OF)
F Haji Mollahoseini, Iranian Center for Breast Cancer, Tehran, IRAN (ISLAMIC REPUBLIC OF)
F Zayeri, Shahid Beheshti University, Tehran, RAN (ISLAMIC REPUBLIC OF)
M Habibi, Iranian Canter for Breast Cancer, Tehran, RAN (ISLAMIC REPUBLIC OF)
Background: Infection is one of the side effects of lymphedema due to impairment of macrophages and lymphocytes
circulation in lymphedematous organ. Reduction of lymphedema volume can reduce the amount of stagnant fluid in the
tissues, thereby potentially preventing or eliminating infections.
Objectives: The aim of this study was determining reduction rate of infection episodes in treated lymphedema by CDT and
ascertaining its predicting factors.
Methods: In this study, 58 patients of postmastectomy lymphedema who had the history of arm infection and been treated by
CDT were interviewed by telephone. The history of recurrent cellulitis were asked and the impact of demographic and clinical
factors, maintenance phase advices such as self massage, bandaging at night, doing exercise, using arm sleeves during day and
doing protective behaviors on recurrence of infection were assessed.
Results: The frequencies of infection were 1-17 and 0-4 episodes, respectively before and after the CDT. The mean percent
reduction of infection attacks was 85.54% ±36.74 during 2-3 years after treatment. In spite of the protective effect of most
maintenance phase activities, in Poisson regression analysis, using arm sleeve in day (p=0.035) and end volume of edema after
CDT treatment (p

O-29.06
EFFECTIVENESS OF TWISTING TOURNIQUET TECHNIQUE® FOR LYMPHEDEMA TREATMENT
N Chanwimalueang, Mahidol University, Bangkok, THAILAND
W Ekataksin, Mahidol University, Bangkok, THAILAND
P Piyaman, Mahidol University, Bangkok, THAILAND
Background Twisting Tourniquet Technique® (TTT) is a series of simple maneuver for reducing the swelling of extremities.
TTT is designed as a hand-operated progressive tightening device based on the mechanism that changes a spirally rotating
twist into a circumferentially constricting force to compress around an edematous limb. Duration of use is a few days for
a swift reduction phase and as long as a few months for a maintenance and a consolidation phase, depending on severity
and grading. Each patient is required to get trained to properly use this technique by enrolling to a 5-day treatment course
at Thailand Lymphedema Day Care Center, and further practicing at home. Objective To evaluate the effectiveness of TTT
in patients with a unilateral lymphedema. Methods From 2,310 patients that came to our Lymphedema Day Care Center
during 2006-2011, 530 subjects, mean age 55 years, range 6-85 years, were included to the present study. The volume of the
affected extremity was compared before and after the 5-day treatment course. Results For 242 patients with upper extremity
involvement, 2.5% primary, and 97.5% secondary lymphedema, the average reduction in limb volume was 434 mL, range 66-
1,845 mL, and calculated rate of swelling reduction was 48.9%, range 16.5-106.8%. For 288 patients with a lower extremity
involved, 28.1% primary and 71.9% secondary lymphedema, the average reduction of limb volume was 1,805 mL, range, 195-
9,191 mL, and the calculated rate of swelling reduction was 54.1%, range 17.8-113.5%. Conclusions With the striking effective
reduction in the swollen limbs, in literally 5 days, we confidently yet humbly attempt to expand its use as a new clinical tool
for treating lymphedema as well as swelling of other etiologies (see separate abstracts in this meeting).
Declaration of interest
None declared
O-29.07
COMPRESSION THERAPY OF SWOLLEN LOWER LIMBS- TISSUE FLUID HYDRAULICS, CLINICAL
EFFECTS
M Zaleska, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
W Olszewski, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Cakala, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
P Jain, Department of Plastic Surgery, Benares Hindu University, Varanasi, INDIAIntroduction. Removal of edema tissue
fluid (TF) from swollen tissues is indispensable for prevention of limb volume increase, development of fibrosis and dermatolymphangioadenitis.
Aim. To apply mechanical compression enabling TF flow to overcome tissue resistance and create flow
to non-swollen regions. Methods. Hydraulics of tissue fluid in swollen lower limb (lymphedema, venous insufficiency with
ulcers, posttraumatic hematoma) were studied using sequential pump at various pressures with no deflation of distal segments
and measuring subcutaneous tissue fluid pressure with wick-in-needle method, tissue fluid movement with plethysmography
and tissue compliance with tonometry. Results. Minimum TF pressures enabling fluid flow ranged between 25 and 30 mmHg.
Depending on the stage of lymphedema, to reach this pressure level, sleeve pressures had to be raised from 80 to above 120
mmHg. Much the same was necessary in edema in the postthrombotic syndrome with fibrotic skin. Tonometry measuring
skin and subcutis rigidity was found indispensable for choosing proper inflation pressures. Tonometer force of 120mmH. Continuous recording of circumference changes at
6 levels allowed to calculate centripetal tissue fluid movement. It ranged 13-120 ml at each sleeve inflation. Conclusions. In
10 advanced lymphedema cases stage III/IV treated with inflation pressure of 120mmHg, no distal chambers deflation, for
12months 1 hour a day, a decrease in calf girth by 5-7 cm was obtained and no debulking surgery was needed.
Declaration of interest
None declared
165

O-30.01
PRACTICAL LYMPHEDEMA SELF-MANAGEMENT: AN ASSESSMENT OF PATIENT SATISFACTION
AND PERCEIVED EFFECTIVENESS OF TREATMENT MODALITIES
K Ashforth, Dominican Hospital, Santa Cruz, UNITED STATES
J Cosentino, Dominican Hospital, Santa Cruz, UNITED STATES
Background: Home management of lymphedema is an important consideration for the clinician. Many patients have
limited access to traditional CDT which includes manual drainage of the lymphatics (MLD) and bandaging. Home or
clinic treatment by a professional therapist or trained family member may be limited by lack of availability, lack of financial
resources, insurance limitations and inability to reach treatment centers. Self-performance can be ineffective as a result of
patient limitations including: range of motion, strength, endurance or motivation. Therefore, consistency, compliance and
effectiveness of home treatment can vary.
Objectives: The purpose of this study was to examine home treatment modalities for patients with lymphedema and determine
which were utilized most frequently and successfully.
Methods: We conducted a survey of 30 patients treated at our clinic for lymphedema of upper and lower extremities, ranging
in ages from 45 to 79. All patients studied had a history of cancer and developed lymphedema as a result of surgery with
lymph node excision. Patients were interviewed for satisfaction and compliance in their home program modalities. All
patients were treated initially with conservative therapy consisting of compression, skin care, elevation, exercise, and MLD.
Patients who did not show significant response to this therapy received in-clinic treatment with pneumatic compression
pumps. Patients were discharged after individualized training in self MLD, use of bandaging and/or elastic, quilted and rigid
compression garments and use of the pneumatic compression pump if provided by insurance.
Results: Patient responses were analyzed as a whole and also subgrouped based on diagnostic category and by access to
modalities. Patients who had access to all modalities (based on insurance coverage) rated pneumatic compression most
effective (100%) followed by quilted compression (72.7%) and MLD and elastic compression (each 63.6). (Of the total group,
the treatment modalities judged by patients to work most effectively were quilted garments (70%), pneumatic compression
(63.3%), and MLD (50%.)
Conclusions: This survey indicated that pneumatic compression and quilted compression garments were ranked highest in
effectiveness for home treatment by this group of patients. Additional studies are warranted to assess comparative efficacy.
Declaration of interest
K Ashforth: BioHorizon Medical,Consultant; Lympha Press USA, Consultant; Prairie Medical, Consultant
O-30.02
COMPARING TWO TREATMENT METHODS FOR POST MASTECTOMY LYMPHEDEMA: CDT ALONE
AND IN COMBINATION WITH IPC
S Haghighat, ACECR/ICBC, Tehran, IRAN (ISLAMIC REPUBLIC OF)
M Lotfi - Tokaldany, Tehran Heart Center, Tehran, IRAN (ISLAMIC REPUBLIC OF)
M Yunesian, TUMS, Tehran, IRAN (ISLAMIC REPUBLIC OF)
M E Akbari, SBMU/CRC, Tehran, IRAN (ISLAMIC REPUBLIC OF)
F Nazemi, ACECR/ICBC, Tehran, IRAN (ISLAMIC REPUBLIC OF)
J Weiss, 5., Cox Health, Mo, USA
Background: Varying methods for controlling breast cancer related lymphedema have been prescribed but there is no cure
for it.
Objective: This study was conducted to compare two treatment methods for postmastectomy lymphedema: Complex
Decongestive Therapy (CDT) and Modified CDT (MCDT) combined with Intermittent Pneumatic Compression (IPC).
Materials & Methods: One hundred and twelve patients referred to the Lymphedema Clinic of the Iranian Center for Breast
Cancer in 2008, were included in a randomized clinical trial. They were randomly allocated into two equal groups receiving
daily CDT alone or in combination with IPC. The volume reduction of the upper limb was measured by water displacement
volumetry.
Results: No statistically significant differences in demographic and clinical variables between the two groups were observed.
During the intensive phase (phase I) of treatment, CDT alone yielded a significantly higher mean volume reduction than the
combination modality (43.1% vs. 37.5%; p = 0.036). Limb volume measured three months following treatment, showed 16.9%
volume reduction by CDT alone, and 7.5% reduction by MCDT plus IPC.
Conclusion: This study demonstrated that the use of CDT alone, or in combination with IPC significantly reduced limb
volume in patients with post mastectomy lymphedema. CDT alone provided better results in both treatment phases. Further
studies will help to define the role of multidisciplinary approaches in the management of postmastectomy lymphedema.
Declaration of interest
This research has been undertaken with a grant support from Academic Center for Education, Culture and Research (ACECR).
166

O-30.03
A NEW TREATMENT OF LYMPHEDEMA BY SEQUENTIAL COMPRESSION COMBINED WITH THE
OTHER PHYSIOTHERAPY
M Ohkuma, Kinki Univ. Hospital, Sakai, Sakai, Osaka, JAPAN
A New Treatment of Lymphedema by Sequential Compression Combined with Physiotherarpy by Magnetic Fields,Vibration
and Hyperthermia
M. Ohkuma and H. Hasegawa*
Department of Dermatology, *Nephrology, Sakai Hospital, Kinki University, School of Medicine, Osaka, Japan
Introduction:W. Ekataksin has reported squeezing tourniquet method for lymphedema treatment (2009) and W. Olszewski,
sequential compression method (2010). They are good method to decrease the edema in a short time. But edema regurgitates
easily.
Material and Method: I. five patients are treated by sequential compression* for 2 weeks, II. Eight patients, by sequential
compression for 2 weeks added by physiotherapy**for 2 weeks, III. 14 cases are treated in the same way as II. but for 4 weeks
respectively, IV. Only physiotherapy** are given for 4 weeks. All patients are secondary lymphedema of the lower extremity.
* Sequential compression:The extremity is divided into 4 segments with compression by means of 4 sphygmomanometers
starting from the periphery by the initial pressure of 100 mmHg with a gradual decrease by10mmHg each after progressing
to the proximal parts. They are compressed for 5 minutes each being repeated after 5 minutes intermission. ** physiotherapy
is performed by pulse magnetic fields(10mT), vibration(100-160/s) and hyperthermia.
Results:III method is the most effective followed by IV. IV is better than II.
Discussion: If the tissue has edema, it contains less oxygen, inflammation becomes more intensive inducing more
collagenesis & acanthosis, immunity is impaired and lymphangiogenesis is more disturbed. Sequential compression helps
lymphedematous tissue to get rid of edema. However to decrease edema alone(ex. by manual massage) is not enough to treat
lymphedema. Physiotherapy undertaken here does something good from the above point of view(Ohkuma, 2009). That is
why this combination treatment is the best.
Conclusion: To treat secondary lymphedema of the lower extremity by sequential compression and physiotherapy by magnetic
fields, vibration & hyperthermia for 4 weeks respectively is very effective.
Declaration of interest
None declared if there is no conflict to declare.
O-30.04
PHYSICAL THERAPIES IN THE DECONGESTIVE TREATMENT OF LYMPHEDEMA: A PHASE III,
MULTICENTER, RANDOMIZED, CONTROLLED STUDY.
I FORNER - CORDERO, University Hospital La Fe, VALENCIA, SPAIN, J MUNOZ - LANGA, University Hospital Dr. Peset,
VALENCIA, SPAIN, J M DEMIGUEL - JIMENO, Hospital San Pedro , LOGRONO, SPAIN, P REL - MONZO, University
Hospital La Fe, VALENCIA, SPAIN
OBJECTIVES: to assess the efficacy of MLD, pneumatic massage (PM) and Intermittent Pneumatic Compression therapy (IPC)
followed by multilayered bandages (MB) in the treatment of lymphedema.
METHODS: we conducted a multicenter, randomized, controlled study in patients with primary or secondary lymphedema, stage
II-IV, affecting upper (UL) or lower limb (LL), when Excess volume (EV)>10%.
Patients were stratified within UL and LL and then randomized to receive 20 sessions of the following regimens:
- A (control group): MLD, IPC (multi-compartmental pump) +MB;
- B: PM +IPC +MB;
- C: IPC +MB.
The end-point “Percentage reduction in EV (PREV)” was assessed at the end of treatment and at 1st month. A blinding was
performed for both, the evaluator and the statistician.
The “Percentage reduction in volume (PRV)”, adverse events and predictive factors of response were analysed.
A sample size (n=59 per group) was calculated for an equivalence analysis, to detect a +/-10% variability in PREV with a power
of 90% and an assumed drop-out rate of 10%. Between 2003-2009, 194 patients were randomised (129 UL, 65 LL) and 182 were
treated. Lymphedema was secondary in 71.6%, stage III-IV 84.5% and 7.7 years of chronicity. Baseline EV was 899 ml (95%CI:810-
989) in UL and 2192 ml (95%CI:1556-2829) in LL. Demographic and clinical characteristics were well balanced between the 3 groups.
RESULTS: Global mean PREV was 71.9% (95%CI:64.6-79.1), without significant differences between groups: 76.1% (95%CI:58.9-
93.3) in group A, 67.8% (95%CI:56.7-78.9) in B and 71.0% (95%CI:63.0-79.0) in C (p=0.784). Global mean PRV was 15.4%
(95%CI:14.5-16.3) without differences between groups: 15.1% (95%CI:13.5-16.7) in group A, 15.3% (95%CI:13.5-17.0) in B and
15.8% (95%CI:14.6-16.9) in C (p=0.800). LL patients showed a better PREV (103.5%; 95%CI:74.1-132.9) than UL (66.1; 95%CI:59.7-
72.6) (p

O-30.05
PRINCIPLES OF PNEUMATIC COMPRESSION THERAPY
W Olszewski, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
P Jain, Department of Plastic Surgery, Benares Hindu University, Varanasi, INDIA
M Zaleska, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Cakala, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
Two questions connected with pneumatic massage are: how high should sleeve pressures be in order to generate tissue
fluid (TF) propelling pressures and flow and how to secure unidirectional flow of TF toward non-swollen groin and hip
or arm and prevent back-flow. Methods. Twenty patients with lymphedema of lower limbs stage I-IV were studied. Soft
tissue tonometry (TN) was performed before massage. TF pressures (TFP) were measured at 6 levels of lower limb during
sequential pneumatic 8 chamber massage, using wick-in-needle technique. Strain gauge plethysmography (SGP) recording
girth changes was performed at the same levels. Parameters of compression: inflation pressure 50-120mHg sequentially from
chamber 1 to 8, inflation time of each chamber 55’’, for 1 h. Results. Tonometry. Compression force 0.2kg in stage I to 2.5kg
in stage IV was needed to create a tissue depression of 10mm. Pump pressures. Depending on TN results different pump
pressures were set up. In stage I with TN 0.2, sleeve pressure of 50mmHg created TF pressures of 25-40mmHg, in stage IV
with TN 1.5kg, pressure 120mmHg generated TF pressures of 70-100mmHg. TF flow. SGP calculated from girth changes
was high in stage I and low in IV. It ranged from 12-120ml to 0 ml for each chamber, respectively. There was no correlation
between TF pressure and TF flow. Conclusions. Knowledge of physiological parameters of tissue and TF (tissue compliance,
pressure/flow) allows to set pneumatic massage device at proper levels. There is usually a high pressure gradient across skin
due to its rigidity (fibrosis).
Declaration of interest
None declared
O-30.06
FORMATION OF TISSUE FLUID CHANNELS IN LYMPHEDEMATOUS SUBCUTANEOUS TISSUE
DURING INTERMITTENT PNEUMATIC COMPRESSION THERAPY
W Olszewski, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Zaleska, Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Cakala, Research Center, Polish Academy of Sciences, Warsaw, POLAND
P Jain, Department of Plastic Surgery, Benares Hindu University, Varansi, INDIA
Introduction. In advanced lymphedema of lower limbs of postinflammatory, posttraumatic or postsurgical etiology the
collecting lymphatics are obstructed. Lymph flow is practically nil. Tissue fluid accumulates in soft tissues spaces. Pressures
generated by muscular contractions and massage move fluid through spontaneously formed tissue channels. These irregular
shape channels are seen along small vein tributaries, in the loose connective tissue and along collagen bundles. We tried to
enhance formation of these channels by high pressure long-term pneumatic massaging. Aim. To observe formation of tissue
channels during high pressure pneumatic therapy using lymphoscintigraphic and biopsy histochemical methods. Material.
Ten patients with lymphedema stage II/III of lower limbs were investigated. An 8-chamber sequential pneumatic device
was used for compression therapy. The parameters of compression were: inflation pressure 120-100mHg, sequentially from
chamber 1 to 8, inflation time of each chamber 50’’, daily for 1 h and for a period of 12 months. Lymphoscintigraphy with
Nanocoll was performed before, after 6 and 12 months of treatment. Skin and subcutaneous tissue biopsies were taken before
and after treatment. Specimens were injected with Paris Blue in chloroform and made translucent to visualize spaces filled
with mobile tissue fluid and subepidermal lymphatics. Results. Lymphoscintigraphic imaging. After one year of massaging
multiple wide channels filled with tracer could be seen in the subcutis on the internal aspect of thigh and along large blood
vessels running to the groin. There were no channels around the hip, in the hypogastrium and buttocks. Immunohistochemistry
of biopsies revealed presence in subcutis and around veins of open spaces not lined by cells, negative on staining with LYVE1
specific for lymphatic endothelial cells. These spaces were stained with Paris Blue and were of irregular shape with many
interconnections. Conclusions. Long term high pressure pneumatic compression brings about formation of multiple fluid
channels running to the groin and femoral channel but not to the lateral parts of the limb. These channels are not lined with
endothelial cells.
Declaration of interest
None declared
168

O-30.07
MANUAL AND PNEUMATIC MASSAGE - TISSUE FLUID AND LYMPH TRANSFER TO THE NON-
LYMPHEDEMATOUS TISSUES
W Olszewski, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
P Jain, Department of Plastic Surgery, Benares Hindu University, Varanasi, INDIA
M Zaleska, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Cakala, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
E Stelmach, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
Background. As lymphatics became obstructed and are not anymore a fluid conduit, the accumulating tissue fluid (TF)
should be mechanically transferred to the non-swollen tissue through the tissue spaces. Two main problems connected
with manual massage are: how high should the external pressures generated by the massaging hand be and how to secure
unidirectional flow of TF to the proximal parts of the limb and prevent back-flow. Methods. We measured TF pressures, using
the wick-in-needle technique, in limbs with different stages of lymphedema during manual and pneumatic massage. Results.
In order to manually move TF (pressing of skin deep to fascia level) external pressures of 60 to 100 mmHg had to be applied
for 30-60 seconds. After discontinuation of external pressure, the indentation filled up within 60-90 seconds. Unidirectional
(centripetal) translocation of TF flow by hand massage was difficult to obtain because of lateral- and back-flow. Sequential
pumping had advantage of pushing fluid proximally with no back-flow because of high pressure in inflated distal sleeve
chambers. Moreover, pressures applied circumferentially by inflated sleeve prevented lateral and back-flow of TF. Effective
pressures moving forward fluid depended on skin compliance. In cases with fibrotic skin effective sleeve pressures had to be
raised above 100 mmHg to reach only 40mmHg in subcutis. Conclusions. Both manual and pneumatic massaging may be
effective depending on evaluation of skin and subcutis rigidity and subsequently establishing proper massage pressures. The
disfigured parts of limb (above ankle) can successfully be treated by manual but less by pneumatic massage.
Declaration of interest
None declared
O-30.08
THE GIANTS. TREATMENT OF BIG LYMPHEDEMAS WITH CDT.
A GERSMAN, HOSPITAL EVA PERON. GRANADERO BAIGORRIA- Prov. of SANTA FE, ROSARIO, ARGENTINA
A GERSMAN, HOSPITAL EVA PERON, ROSARIO, ARGENTINA
The author presents in this paper a brief explanation of fat phisiology, and his experience treating big elephantiasic lymphedema
patients, applying complex decongestive treatment (CDT).
Declaration of interest
None declare
169

POSTER PRESENTATION
ABSTRACTS

P-01.08
MUSCLE ACTIVITY AND MECHANICAL LOAD IN THE SHOULDERS OF WOMEN WITH BREAST
CANCER RELATED LYMPHEDEMA.
K Johansson, Skåne University Hospital, Lund, SWEDEN
J Linnell, Lund University, Lund, SWEDEN
A Sandsborg, Lund University, Lund, SWEDEN
E Horneij, Lund University, Lund, SWEDEN
Background: Breast cancer related arm lymphedema may affect the function of the upper limb. Studies are lacking regarding
whether the muscle activity and the mechanical load in the shoulder are affected. The neuromuscular activity occurring
during a muscle contraction can be recorded with electromyography (EMG). EMG is a valid method to evaluate muscle
activity.
Aim: The aim of the study was to describe and analyze the difference in muscle activity and mechanical load between the
healthy and the affected shoulder among patients with breast cancer related arm lymphedema Method: Explorative study.
Nine patients with a mean lymphedema relative volume of 33,0±6,7 (mean ± SD) were included. Muscle activity was registered
in m. trapezius pars descendens and the anterior part of the deltoid muscle. The arm was elevated in the scapular plane and
three tests of voluntary maximal contraction and a 30 second isometric work was performed. EMG data was recorded and
analyzed in the program MegaWin 3.1. The arm was weighed in a relaxed position and photographed during elevation in the
scapular plane to receive information for biomechanical calculations.
Result: Work as a percentage of maximum voluntary contraction was in m. trapezius pars descendens in the affected shoulder
47.0±19.4percent and in the healthy shoulder 33.2±18.77percent (p=0.021). The corresponding values in the anterior part of
the deltoid muscle were 60.2±10.8 percent and 53.4±11.1percent. Significant difference of torque in relation to arm extesion
measured in Newton meters was found between the affected and the healthy shoulder (p = 0.008).
Conclusion: The study indicates that lymphedema following breast cancer treatment may cause an increased mechanical load
and increased muscle activity in m. trapezius pars descendens of the affected shoulder in relation to the healthy shoulder.
Declaration of interest
None declared
P-02.07
MICROARCHITECTURE OF PRELYMPHATIC SYSTEM IN RAT LIVER AND INTERFACE TO
LYMPHATICS REVEALED BY THREE-DIMENSIONAL RECONSTRUCTION
P Piyaman, Mahidol University, Bangkok , THAILAND
W Ekataksin, Mahidol University, Bangkok , THAILAND
K Kaneda, Osaka City University Medical School, Osaka, JAPAN
Background: Liver contributes 25 – 50 % of the lymph flow in thoracic duct. Nevertheless, microanatomy of the path that
leads the lymph from perisinusoidal space to initial lymphatics in portal tract is still unclear.
Objectives: To show the microanatomy of prelymphatic pathway in rat liver.
Methods: Livers of male Wistar rats were investigated under portal tract edema in endothelin-1 infusion portal hypertension
(Kaneda et al, 1998). The specimens were subjected for 1) light microscope of toluidine blue semithin serial sections followed
by three-dimensional reconstruction, and 2) transmission electron microscopy.
Results: In control liver, it was difficult to identify structures in portal tract interstitium. While in endothelin-1 treated,
the components could be delineated separately upon edematous background. Fibroblasts were most numerous forming a
network subdividing portal tract interstitium into polygonal interstices, resembling honeycomb architecture (Ekataksin et
al, 2000). These interstices were measured 10-15 microns averagely, 20-40 microns near larger portal veins, 5 – 10 micron
surround bile ducts and arterioles. Each interstice had interruption in wall allowing for transportation. Periphery, the
fibroblastic network casted anchors on (1) basal laminae of cholangiocyte, (2) basal laminae of portal/arterial smooth muscle
cells, (3) hepatocytes, (4) lymphatic endothelial cells. Three-dimensional reconstruction showed that the network almost
completely surrounded distal branches of initial lymphatics. Some segments of lymphatics sent cytoplasmic projection to
join the fibroblastic network. Such segment were defined as “incipient lymphatics” lined by cells with hybrid morphology;
endotheliofibroblast. The latter featured endothelial portion lining lumen and fibroblastic portion adjoining with fibroblast
counterpart.
Conclusion: Path from perisinusoidal space to lymphatics is a journey through series of interstices constructed by
fibroblasts, not endothelium, regarded as “prelymphatic channel” (Foeldi, 1968; Casley-Smith, 1976; Ohtani et al, 2003).
Endotheliofibroblast is nominated for a hybrid cell located at the interface of prelymphatic-lymphatic system indicating
transitional stage of fibroblast becoming lymphatic endothelium.
Declaration of interest
None declared
172

P-03.09
THE LYMPHATIC HYPO-REACTIVITY AND CALCIUM DESENSITIZATION FOLLOWING
HEMORRHAGIC SHOCK
C Niu, Hebei North University, Zhangjiakou, CHINA
Z Zhao, Hebei North University, Zhangjiakou, CHINA
Y Zhang, Hebei North University, Zhangjiakou, CHINA
Z Liu, Hebei North University, Zhangjiakou, CHINA
J Zhang, Hebei North University, Zhangjiakou, CHINA
Background: Lymph circulation is an important component of circulation system and is strongly associated with the
development of severe shock, lymphatic contraction disturbance also presented in the development of severe shock and
further promoted the progress of the critical condition.
Objectives: To observe the changes of the lymphatic reactivity on norepinephrine (NE) in hemorrhagic shock rats, and
explore the calcium sensitivity mechanism.
Methods: Thirty-two Wistar rats were randomly divided into sham group and shock group, the changes of lymphatic pressure
(LP) and contractility of mesenteric lymphatic (ML) to NE at different times in shock were observed, and the indices such as
∆LP, ∆F, ∆Index I, ∆Index II, ∆LD-Index were used. The other 49 rats were divided into sham group, shock group (shock 1h
and shock 2h subgroups) for mading thoracic duct ring, and 48 activated isolated lymphatics in each groups were used for
assaying the lymphatic reactivity to NE and calcium sensitivity with isolated vessels perfusion system.
Results: The response of LP to NE was decreased from shock 0.5h and the hypo-reactivity was maintained until shock 3h.
The reactivity of ML contractility indices to NE in shock group were significantly lower than that of sham group and preshock
at shock 1h, 1.5h and 2h. The NE concentration-response curves of lymphatic ring in shock 1h and 2h groups and
calcium concentration-response curves in shock 2h group were obviously right shifted, the reactivity to NE and contraction
to calcium, Emax, pD2 were markedly reduced. In shock 2h group, the lymphatic reactivity to NE and calcium sensitivity
were signficantly increased but reduced with sham group after incubating with calcium sensitizer Ang II, and it was decreased
after incubating with calcium sensitivity inhibitor Ins.
CONCLUSION: Lymphatic reactivity is progressive decline during the process of hemorrhagic shock, its mechanism is
related to calcium desensitization. The results suggested the lymphatic hypo-reactivity is the one of mechanisms of lymphatic
hypo-contraction in shock rats.
Declaration of interest
None declared
P-03.10
ROLE OF NITRIC OXIDE ON ISOLATED LYMPHATIC REACTIVITY DURING HEMORRHAGIC
SHOCK
Z Zhao, Hebei North University, Zhangjiakou , CHINA
C Niu, Hebei North University, Zhangjiakou , CHINA
L Qin, Hebei North University, Zhangjiakou , CHINA
Y Zhang, Hebei North University, Zhangjiakou , CHINA
Y Si, Hebei North University, Zhangjiakou , CHINA
L Zhang, Hebei North University, Zhangjiakou , CHINA
J Zhang, Hebei North University, Zhangjiakou , CHINA
Background: The spontaneous contractions of lymphatics are the major propel power of lymph circulation, the lymphatic
contractile activity playing an important role in the pathogenesis of severe shock and its mechanisms is related to lymphatic
reactivity. The nitric oxide (NO) plays an important role in the development of shock and involves in the vascular hyporeactivity
and organ damage. Therefore, whether NO involves in the regulation of lymphatic reactivity after shock? Objective:
In order to research the changes of lymphatic reactivity to substance P (SP) and investigate the probable role of NO during
the process of hemorrhagic shock. Methods: We determined contraction frequency (CF), end systolic diameter, end diastolic
diameter and passive diameter of isolated lymphatics during hemorrhagic shock (0h, 0.5h, 1h, 2h, 3h) at transmural pressure
of 3 cmH2O, and then stimulated with gradient SP using pressure myograph system, and calculated the tonic index (TI)
and fractional pump flow (FPF). The different values of CF, TI and FPF between pre- and post- administration of SP were
calculated and expressed as ∆CF, ∆TI and ∆FPF to further assess the lymphatic reactivity. Moreover, to observe the effects of
NO, the 0.5h-shocked lymphatics were incubated by L-Arg (NO donor), L-Arg+ODQ (soluble guanylate cyclase inhibitor),
the 2h-shocked lymphatics were incubated by L-NAME (nitric oxide synthase inhibitor), L-NAME+aminophylline
(phosphodiesterase inhibitor), with 5 min, respectively. Results: After SP incubation, the ∆CF, ∆TI and ∆FPF of 0h- and
0.5h-shocked lymphatics were increased, that of 2h- and 3h-shocked lymphatics were lowered significantly compared with
control on one or several concentrations. After shocked lymphatics incubated by tool agents, at various concentration
conditions of SP, L-Arg reduced this indices of 0.5h-shocked lymphatics, and this effect was suppressed by ODQ obviously;
L-NAME elevated this indices of 2h-shocked lymphatics and the manifestation of lymphatics exceeded the values of control
levels, the effect was supressed by aminophylline significantly. Conclusion: The lymphatic reactivity presents a biphasic
change during hemorrhatic shock, which is manifested by an increase at early shock and decrease at late shock. NO involves
in the biphasic modulation of shocked lymphatics and its effect might be achieved by cGMP.
Declaration of interest
None declared
173

P-03.11
MESENTERIC LYMPH DUCT LIGATION IMPROVES HYPO-VISCOSAEMIA AND ABNORMAL
ERYTHROCYTE RHEOLOGY IN ACUTE BLOOD LOSSING RATS
C Niu, Hebei North University, Zhangjiakou, CHINA
Z Zhang, Hebei North University, Zhangjiakou, CHINA
Background: The hemorrheologic events in the pathogenesis of hemorrhagic shock subjected to acute blood lossing (ABL)
becomes a key target of shock theropy. Objective: To observe the effects of mesenteric lymph duct ligation (MLDL) on
blood viscosity and erythrocyte rheology in ABL rats, and investigate the role of intestinal lymphatic pathway during ABL.
Methods: Twenty Male Wistar rats were radomly divided into ABL and ABL+MLDL group. Blood (one fourth of whole
blood volume) was withdrawn by automatic withdrawal-infusion machine through right common carotid artery (CCA)
after rats were anesthetized. In ABL+MLDL group, the mesenteric lymph duct (MLD) was ligated after ABL, and in ABL
group, only threading under the MLD. The survival situation of 24h was recorded. After 24h, survival rats were anesthetized
again, 6ml blood was withdrawn through lift CCA rapidly. The indices of blood viscosity and erythrocyte rheology were
determined before and after experiment. Results: There were 6 rats alive in ABL group, and 9 rats alive in ABL+MLDL
group, the ABL+MLDL group was slightly better than ABL group. The whole blood viscosity, whole blood relative viscosity,
hematocrit, erythrocyte deformability, electrophoresis lengh and erythrocyte migration were lower, the whole blood relative
viscosity, plasma viscosity, erythrocyte sedimentation rate (ESR), K value of edquation, K value of emendation, electrophoresis
time, erythrocytes aggregation index were raised or longer than that of before hemorrhage significantly in ABL group,
respectively. In the ABL+MLDL group, the changes of those indices such as the whole blood viscosity, whole blood relative
viscosity, hematocrit, erythrocyte deformability, etc. were increased accordance with ABL group; But compared with ABL
group after 24h, the plasma viscosity, ESR, K value of edquation, K value of emendation, erythrocytes aggregation index
and electrophoresis time in ABL+MLDL group were lower, the whole blood viscosity, whole blood relative viscosity and
hematocrit, electrophoresis lengh, erythrocyte migration and deformability were rasing, significantly. Conclusion: The whole
blood viscosity, electrophoresis function and erythrocyte deformability were reduced and plasma viscosity and erythrocyte
aggregation ability were rising in ABL rats; and the MLDL could markedly improve the hypo-viscosaemia and abnormal
erythrocyte rheology in ABL rats.
Declaration of interest
None declared
P-03.12
HUMAN SKIN TISSUE FLUID/LYMPH CYTOKINES AND GROWTH FACTORS - THEIR ROLE IN
LYMPHEDEMA SKIN CHANGES
M Zaleska, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
A Domaszewska - Szostek, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Cakala, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
W Olszewski, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Durlik, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Zaleska, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
A Domaszewska - Szostek, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Cakala, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
W Olszewski, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
M Durlik, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
Objective. Tissue fluid/lymph (TF) contains cytokines, chemokines, growth factors originating from blood, parenchymatous
and infiltrating cells. These proteins regulate immune processes but also influence cellular events in skin and lymph nodes
draining lymphedematous inflammatory tissues. Stimulation of keratinocytes and fibroblasts results in hyperkeratosis and
fibrosis of tissues. Cytokines regulate this process. Aim. To measure concentration of pro- and anti-inflammatory cytokines
and chemokines in human lower limb skin tissue fluid/lymph in normal subjects, patients with obstructive lymphedema
without and with bacterial dermatitis and their effect on keratinocytes.
Methods. TF was collected from lymphatics in lower leg from cannulated lymphatics or puncture of the superficial dilated
plezus. Cytokines measured with ELISA. Results. 1) pro- and anti-inflammatory (IL1β, TNFα, IL1Rα, MIP1α, MCP1, IL6,
IL12, TGF β), 2) regulating epidermal and dermal cellular ( KGF, MMP9, TIMP 1 and 2, PDGF BB) and 3) lymphatic structure
(VEGF, VEGF C, CCL21 and 27) were measured in patients : A) without any dermal conditions( N), B) lymphedema without
dermatitis (LD), C) lymphedema complicated by dermatitis (L). 1) In all patients groups it was higher than in N. IL10 and
12 levels were low. 2) KGF, MMP9 and TIMPS concentration was significantly higher than in N in all groups, 3) VEGFs and
CCL21 and 27 were much elevated in lymphedema. Conclusions. Concentration of cytokines in tissue fluid/lymph varies
depending on the type of processes in the skin. Most of cyto- and chemokines are produced locally and their level exceeds
that of serum. Measuring humoral factors in TF gives insight into tissue events that is not possible with measuring serum
concentrations.
Declaration of interest
None declared
174

P-06.09
WHETHER OR NOT PUNCTURING THE IPSILATERAL ARM AFTER AXILLARY NODE DISSECTION.
A REVIEW.
P van Gulick - Gielink, NVFL, Amersfoort, NETHERLANDS
J Hidding, NVFL, Amersfoort, NETHERLANDS
Background. After axillary node dissection (AD), breast cancer patients are often advised to be careful with the corresponding
arm to lower the risk of developing lymphedema. Therefore these patients try to avoid intravenous punctures (IVP), blood
pressure measurements and other skin puncturing in the ipsilateral arm. However, medical personnel tend to question the
necessity of this advice. This leads to discussion and confusion with the patients.
Objective. To aggregate existing evidence, on the risk of developing lymphedema following IVP or other skin punctures in
breast cancer patients after AD.
Methods. Pubmed was searched on “lymphedema and (intravenous procedure or skin puncture)”.
Results. Four relevant articles were found with different study designs. A prospective study (n=188) found that IVP/ skin
puncture, versus none, had a relative risk of 2.44 (95%CI 1.33–4.47) on development of lymphedema in a group of 18
ipsilateral punctured patients. Other studies (n= 14 and n=311) were retrospective and found, respectively, no or very small
risk (2%). One of these studies described a hospital (Royal Marsden) protocol on puncturing procedures after lymph node
removal. A case-control study (n=101) did not find IVP as a risk factor for lymphedema.
Conclusions. The four studies were of moderate quality and could not be compared. The results of the prospective study
and the other studies are contradictory. Therefore it remains difficult to advise whether it is safe to puncture or not in the
ipsilateral arm after AD. More research is urgently needed. The described Royal Marsden protocol might be recommended
until further evidence is found.
The authors indicate no potential conflicts of interest.
Declaration of interest
None declared
P-07.07
FLUORESCENCE-BASED MEASUREMENTS OF NITRIC OXIDE IN ISOLATED LYMPHATICS
O Gasheva, Texas A&M Health Science Center College of Medicine, Temple, TX, UNITED STATES
J Wilson, Texas A&M University, College Station, TX, UNITED STATES
E Rahbar, Texas A&M University, College Station, TX, UNITED STATES
J Moore, Texas A&M University, College Station, TX, UNITED STATES
H G Bohlen, Indiana University , Indianapolis, IN, UNITED STATES
D Zawieja, Texas A&M Health Science Center College of Medicine, Temple, TX, UNITED STATES
Background. Nitric oxide (NO) plays a principal role in the endothelium/shear-dependent regulation of contractility in rat
thoracic duct (TD) and mesenteric lymphatics (ML). Studying the role of NO in lymphatic function requires the development
of novel tools to determine its concentrations in lymphatics with reference to their contractile status.
Objectives. To develop and implement a fluorescent assay that regionally maps [NO] in isolated lymphatics to dynamically
monitor [NO] under changes in shear stress – an important modulator of lymphatic contractility.
Methods. Isolated, cannulated & pressurized ML were used in this study. Vessels were loaded with the NO-sensitive dye –
DAF-FM and exposed to flow from axial pressure gradients of 0 to 1, 3, 5 and 7 cm H2O. At the end of each experiment, ML
were treated with the NO donor – SNAP. DAF fluorescence from the ML was imaged using confocal microscopy. In separate
experiments, direct measurements by NO-sensitive electrodes were performed in situ.
Results. Using DAF-FM fluorescence, we found that increases in the rate of change of fluorescence intensity (ROCFI) were
dependent on the imposed flow/shear stress applied to the ML. Treatment by the NO donor demonstrated the validity of
the approach and ability of DAF-FM to respond effectively. Increases in DAF-FM ROCFI during elevations of imposed flow
in ML correlates with data obtained with direct measurements of ML wall [NO] in situ with electrodes during the increased
lymph flow that accompanies hypotonic volume expansion.
Conclusions. Our findings suggest that DAF-FM may be effectively used to detect and spatially map the production of NO
in the lymphatic wall, and to measure and map NO production in normal and pathological states. Thus, the use of a specific
fluorescent NO indicator - DAF-FM could provide a potentially powerful tool to evaluate the status of lymphatic function.
Declaration of interest
None declared
175

P-08.07
THE USE OF PATIENT INFORMATION TO PREVENT LATE AND LONG-TERM IMPAIRMENTS AFTER
BREAST CANCER TREATMENT
A Skördåker, Red Cross Hospital, Solna, SWEDEN
U Steen - Zupanc, Red Cross Hospital, Solna, SWEDEN
L Pettersson, Red Cross Hospital, Solna , SWEDEN
A Jonsson, Karolinska University Hospital, Solna, SWEDEN
K Johansson, Lund University Hospital, Lund, SWEDEN
Up to 74% of women treated for breast cancer suffer from later impairments occuring in the operated area or arm/shoulder.
These impairments include lymphoedema, pain, sensory problems, restricted movements, muscle weakness and phantom
sensations. Preventive patient information is often insufficient. The project aimed to improve knowledge among breast cancer
patients to prevent later impairments.
At present, the study includes 62 patients treated for breast cancer at Sophiahemmet Hospital in Sweden. Forty study
group patients have received the preventive measures and twenty-two control group patients have been given the usual
care information. The study group patients provided measurements of arm volume (Kuhnke 1976), shoulder movement
(goniometer), pain index (VAS 1976), BMI and estimation of quality of life using questionnaires (LiSat-11 and EORTC
QLQ-C30). These measurements were taken pre-operative and then annually over a four-year period. Study group patients
also received preventive information 10 weeks after the operation. Physiotherapy was provided as required. A questionnaire
was completed by study group patients at the end of the project. Fifty-six % of the questionnaires were answered and eightyfour
% totally agreed that they had benefit from participating in the project.
Results: the incidence of lymphoedema (defined as an increase in volume of 5 % compared to the non-operated arm) was
15% in the study group and 45% in the control group. Result of arm volume and end-point 3-4 years after completed cancer
treatment: volume difference in ml and % in study group was approximately 0 compared with the control group where the
volume difference was 66 ml or 3, 4 %, with a significant difference between the groups.
Result from quality of-life instrument LiSat-11 in study group, statistically significant improvements for the variables: life as a
whole, financial situation and leisure situation were seen between inclusion and end-point. Conclusion: preventive measures
are of significant importance for the prevention of lymphoedema among breast cancer treated patents.
Reamining data from quality of-life instruments will be analyzed and presented att 23´rd International Congress of
Lymphology in Malmö in September 2011.
Declaration of interest
None declared.
P-09.04
MEASUREMENT OF RESISTANCE TO COMPRESSION USING ULTRASONOGRAPHY WITH REAL-
TIME PRESSURE MONITORING
J Park, Seoul National University College of Medicine, Seoul, KOREA, REPUBLIC OF
K S Seo, Seoul National University College of Medicine, Seoul, KOREA, REPUBLIC OF
Background: Lymphedema is one of the most common complications in breast cancer patient. The physical properties of
lymphedema tissue such as hardness and tightness of the arm affect the quality of life. Previously, the evaluation of resistance
to compression (RC) using ultrasonography was introduced as a useful tool for the measurement of hardness. However, the
pressure cannot be controlled precisely in this method.
Objectives : In this study, we aimed to evaluate the pattern of tissue thickness with control of precise pressure and to estimate
the reliability of the RC parameters using ultrasonography with real-time pressure monitoring.
Methods: Sixteen healthy volunteers participated in this study. The ultrasonographic images with compression were obtained
with real-time pressure monitoring device. Two examiners conducted these procedures and analyzed the RC independently.
Results: The intra-rater reliabilities of measuring skin and subcutis thickness were excellent (>0.80), and the inter-rater
reliabilities were good (0.60-0.80) at skin and excellent (>0.90) at subcutis. The intra-rater reliabilities of measuring skin and
subcutis RC were good (0.70-0.80) at skin and excellent (>0.80) at subcutis, and the inter-rater reliabilites were fair (0.50-0.60)
at skin and excellent (>0.80) at subcutis.
Conclusions: These results suggest that measuring the thickness and RC using the ultrasonography with real-time pressure
monitoring might be more reliable tool for evaluating the hardness of soft tissue in the upper extremities.
Declaration of interest
None declared
176

P-09.05
PREDICTION OF TREATMENT OUTCOME WITH BIOIMPEDANCE MEASURE IN BREAST CANCER
RELATED LYMPHEDEMA(BCRL) PATIENTS
G J Yun, University of Ulsan College of Medicine, Seoul, KOREA, REPUBLIC OF
S J Lee, University of Ulsan College of Medicine, Seoul, KOREA, REPUBLIC OF
Y J Sim, University of Kosin College of Medicine, Seoul, KOREA, REPUBLIC OF
J Y Jeon, University of Ulsan College of Medicine, Seoul, KOREA, REPUBLIC OF
Objective: Lymphedema is a common problem in breast cancer patients. Bioimpedance measure is known to be useful in
early detection of lymphedma and assessing treatment outcome. The lower bioimpedance value reflects that there is more
volume of fluid in the tissue. When there is more fluid than fibrotic or fatty component in the tissue, the treatment outcome
will be better. In this study, we investigated if bioimpedance measure can predict the treatment outcome in BCRL patients.
Method: Unilateral upper extremity BCRL patients after surgery were included. These patients received complex decongestive
therapy for two weeks (five days per week), and we measured bioimpedance at a 5kHz using Inbody 7200®, arm circumferences
at 10cm above and below from the elbow in both upper extremties. We evaluated the correlation of the bioimpedance ratio of
uninvolved arm to involved arm and the difference of arm circumferences before and after the treatment.
Results: Seventy five patients were enrolled in this study. The higher bioimpedance ratio was significantly correlated with
the higher reduction of arm circumference at 10cm below the elbow after treatment, but the bioimpedance ratio was not
significantly correlated with the difference of arm circumference at 10cm above the elbow.
Conclusion: The composition of the tissue influence the treatment outcome of lymphedema patients. So, it is important to
know the local tissue composition with measuring bioimpedance. These results show bioimpedance measure before treatment
is a useful method in predicting the outcome of patients with lymphedema, especially in below elbow level. We concluded
that bioimpedance measure can be used as routine screening tool in lymphedema patients to predict the outcome.
Declaration of interest
“None declared”
No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with
which the authors are associated.
P-09.06
THE ULTRASOUND INTERNAL VOLUMETRY IN THE ASSESSMENT OF LYMPHEDEMA
F Passariello, Centro Diagnostico Aquarius, NAPOLI, ITALY
Introduction: The Indirect Tape Volumetry (ITV) is an easy procedure, which however isn't able to evaluate the involvement
of the tissue layers in lymphedema.
The Ultrasound Internal Volumetry (UIV) is an indirect measurement method, which computes the volumes of limb
compartments.
Materials and Methods: A tape meter, a dermographic pen and an echo device are needed. A high resolution >= 10 MHz
linear probe is used, with a “small parts” configuration and a near focalization.
The Ultrasound Internal Volumetry (UIV) measures the volumes of the coutaneous, subcoutaneous and musculo-skeletal
compartments. Standard limb reference points are used to get more stable measures. The computation follows the cone trunk
formula (frustum metod), modified and extended to the computation of the internal volumes. In addition, lengths can be
related to the height and standardised according to the weight and to the body mass index (BMI) or to the standard length
of limb segments. Measured data are managed by the UIV Lymph (Aquarius srl 2011) software, which provides computation
and data store facilities.
Results:Our UIV experience dates to 1 year, mainly with upper limbs examinations of patients who underwent breast surgery
owing to mammalian onchological pathology, with/without associated chemiotherapy and radiant therapy.
Lower limb pathology, less frequent, was too an important occasion of clinical application.
UIV, though still in a qualitative observational phase, allows us to detect localised and still subclinic disfunctions often with
initial synthoms.
Discussion:Thw UIV allows a low-cost lymphedema monitoring, the detection of the involvement of tissue layers, the
localization of very initial and subclinic changes. Finally, the reconstruction of an useful pathway for the flow in zones where
the EM is unchanged.
Declaration of interest
None declared
177

P-09.07
MEASUREMENTS OF LOWER EXTREMITY LOCAL TISSUE WATER IN HEALTHY WOMEN
VOLUNTEERS – VALIDATION AND REPRODUCIBILITY.
M Radmer Jensen, University of Copenhagen / Bispebjerg Hospital, Copenhagen NV, DENMARK
S Birkballe, University of Copenhagen / Bispebjerg Hospital, Copenhagen NV, DENMARK
S Nørregaard, University of Copenhagen / Bispebjerg Hospital, Copenhagen NV, DENMARK
T Karlsmark, University of Copenhagen / Bispebjerg Hospital, Copenhagen NV, DENMARK
Background: MoistureMeter D measures Tissue Dielectric Constant (TDC), which is a unitless physical quantity proportional
to tissue water content. MoistureMeter D has successfully been applied in several studies on upper extremity lymphoedema
and may become an important tool in the diagnosis and treatment of lower extremity swelling; however, it has been shown
that multiple factors affect the measured value. To validate its application on the lower extremity this methodological study
has been performed.
Objectives: 1) To assess the influence of anatomical location, hair growth, moisturizer use, subject age and BMI on lower leg
TDC. 2) To investigate the interobserver variability of TDC-measurements. 3) To obtain a normal reference value for the
lower leg.
Methods: 34 healthy women volunteered for the study. Age, BMI, moisturizer use and hair removal was recorded.
Measurements were performed by 3 blinded investigators in a randomized sequence on clearly marked locations on the foot,
ankle and lower leg. Each investigator measured all locations once. The applied probe (M25) measured TDC to an effective
depth of 2.5 mm.
Results: Age was 42.7±10.5 years (mean±SD) and BMI was 24.6±4.1 kilograms/m2. TDC was 37.5±6.4 on the foot, 29.0±3.1
on the ankle and 30.5±3.9 on the lower leg. The foot TDC was significantly higher than both ankle and crus TDC (p < 0.000,
one-way ANOVA). There was no significant difference between ankle and crus TDC (p=0.349). Neither age, BMI, hair removal
or moisturizer use had any significant effect on measured lower leg TDC (p > 0.05, UNIANOVA). Intraclass Correlation
Coefficients for the 3 investigators was 0,765 for the foot, 0,935 for the ankle and 0,938 for the lower leg respectively.
Conclusion: Feet measurements are significantly higher compared to ankle and crus values and are similar to published
lymphoedema values. The interobserver agreement was excellent on crus and ankle measurements but poorer in the foot
measurements. Thus foot TDC values should be interpreted with great care. Neither age, BMI, hair removal or moisturizer
use had a significant effect on TDC in this setup. An upper normal limit of 38 (mean+2SD) for lower leg TDC is suggested.
Declaration of interest
None declared
P-09.08
PREDICTION OF TREATMENT OUTCOME WITH BIOIMPEDANCE MEASUREMENT IN LOWER-
EXTREMITY LYMPHEDEMA PATIENTS
G J Yun, University of Ulsan College of Medicine, Seoul, KOREA, REPUBLIC OF
S J Lee, University of Ulsan College of Medicine, seoul, KOREA, REPUBLIC OF
J Y Jeong, University of Ulsan College of Medicine, seoul, KOREA, REPUBLIC OF
Y J Sim, University of Ulsan College of Medicine, seoul, KOREA, REPUBLIC OF
In a previous study, bioimpedance measure before treatment was a useful method in predicting the outcome of patients with
upper limb lymphedema. So, we investigated if bioimpedance measure can predict the treatment outcome in patients with
lower leg lymphedema
Method: Unilateral lower extremity lymphedema patients after gynecologic cancer surgery were included. These patients
received complex decongestive therapy for two weeks (five days per week), and we measured bioimpedance at a 5kHz using
Inbody 7200®, and leg circumferences at knee, ankle, foot dorsum, 10 cm above and below from the knee in both lower
extremities. We evaluated the correlation of the bioimpedance ratio of uninvolved leg to involved leg and the difference of leg
circumferences before and after the treatment.
Results: Twenty seven patients were enrolled in this study. The bioimpedance ratio was not significantly correlated with the
reduction of leg circumference in all sites, but the bioimpedance ratio was significantly correlated with the duration of disease.
Conclusion: In contrast to upper limb lymphedema, bioimpedance measure did not show the treatment outcome of lower leg
lymphedema patients. It may be contributed to many factors influence leg edema. But as the disease duration was longer, the
edema was severe. So it may be necessary to treat lower leg lymphedema early.
Declaration of interest
None declared
178

P-10.09
AN INNOVATIVE APPROACH TO EXAMINING LYMPHEDEMA OCCURRENCE: TRAJECTORIES AND
AREA UNDER THE CURVE
J Armer, University of Missouri, Columbia, MO, UNITED STATES
B Stewart, University of Missouri, Columbia, MO, United States
Baackground: The experience of lymphedema (LE) is variable as related to the pattern of LE emergence, with characteristics
related to time since diagnosis, duration of the LE episode, frequency of limb volume change (LVC) events, and overall time
spent in the state defined as LE. Recognition of these characteristics, examination of trajectories, and application of the ability
to quantify LE state through calculation of Area Under the Curve provide an opportunity to further examine the association
of LVC with psychosocial and functional outcomes of interest.
Objectives: Our objective was to explore new ways to quantify LE occurrence to better examine impact of LE on survivorship
outcomes. Further, participants will understand the potential variations in lymphedema experience, including those in
patterns of emergence, duration of each episode, frequency of events, and time spent in the lymphedema state.
Methods: Participants were enrolled following BC diagnosis and followed every 6 months through 60 months. The criterion
of 10% LVC (LePCT) by perometry was chosen to demonstrate use of trajectories and utility of calculating Area Under
the Curve (AUC). We examined times when a subject met the criterion as a means of following the trajectory of LE and
quantified the proportion of (calendar) time that a subject appeared to have LE by looking at the AUC determined by the
individual’s graph. As study time differed, rather than look at AUC alone, we looked at the percent of time that a subject met
the LE criterion by dividing AUC by total study time.
Results and Conclusions: Over the 60-month time-stamps of data collection points, we examined trajectories or patterns of
events where participants met the LE criterion of interest. An individual may have a single LVC “spike” or may have multiple
“spikes.” These cases may be acute, transient, or chronic. Further, individuals may experience the LVC early or late in the
survivorship trajectory. These variations contribute to varying AUC and percent of the (calendar) time that a subject meets
the LE criterion. These approaches provide an opportunity to further examine the association of LVC with psychosocial and
functional outcomes of interest in cancer survivorship
Declaration of interest
None declared
P-11.10
CHRONIC PERIPHERAL LYMPHEDEMA: CLINICAL, ETIOPATHOGENETIC, AND DIAGNOSTIC
ANALYSES A SINGLE-CENTER EXPERIENCE
Y Akcali, Erciyes University, Kayseri, TURKEY
M Kula, Erciyes University, Kayseri, TURKEY
E Mavili, Erciyes University, Kayseri, TURKEY
Background. Lymphedema (LE) is excessive accumulation of interstitiel fluid as a consequence of impaired lymphatic
drainage due to congenital or acquired causes.
Objectives. We aimed to analyze our cases with lymphedema using more new diagnostic, descriptive classifications.
Patients and methods. In the last five years, we reviewed 267 patients with chronic limb LE, who were managed in our
department. More than half of the patients (54.6%) were excluded because of data absence in study parameters, scintigraphic
standardization etc. Median age was 35 years (range, 1 month to 84 years). Most of the patients were women (85%). The ratio
of involvement of upper/lower extremity LE was 1/35 for primary LE. They had usually unilateral LE (85,7%); bilateral lower
limb were involved in 17 patients. Diagnostic methods were patient’s history, physical exam, and ultrasonography (Level
I), lymphoscintigraphy (Level II), and CT-san, MRI, magnetic resonance lymphangiography (MRLA) (level III). Modified
CEAP-L classification, and Lee’s four-staged lymphoscintigraphic classification was used.
Results. Swolling was presenting symptom in all patients. ‘Buffalo hump’ was more frequent finding in the patients with
congenital LE (62.5%). Fixed edema (C2) was frequent (89,0%). ‘Peau d’orange’ was exist in 14% of the patients. Onychmycosis
was frequent concomitant finding (31,8%). Positive Stemmer’s sign was frequent (69%). Exudation (S1, 13,9%, and S2, 7,8%),
lymphangitis (L1, 8,4%, and L2, 10,3%), lymphostatic ulcer (C3, 1,9%, and C4, 3,8%), and elephantiasis (6,6%) were less
frequent clinical presentations. The majority of the patients in our study had primary LE (I-III) (64%), and lymphedema
praecox (II) was predominant (51,8%). Klippel-Trénaunay syndrome (4,8%), yellow-nail syndrome, congenital telangiectasia,
and neurofibromatosis associated with LE. Lipolymphedema (17,2%) and obesity (26,6%) was important. Lymphatic
obstruction (Po) was frequent pathophysiologic finding (76%). Stage II (55.8%) was frequent in lymphoscintigraphic staging.
Conclusion. Lymphedema is a challenging problem with protean manifestations. Universal clinical, etiopathogenetic, and
diagnostic approaches will help to solve this enigmatic disorder.
Declaration of interest
None declared
179

P-11.11
DEVELOPMENT OF LIPODERMATOSCLEROSIS OBSERVED IN LYMPHEDEMA PATIENTS IS
ACTUALLY A SLAENGH TO PORK
W Ekataksin, Mahidol University, Bangkok, THAILAND
Background Taking advantage of a large population of patients enrolled for treatment at Thailand Lymphedema Day Care
Center, it was possible to classify lymphedema based characteristically on categories of slaengh, food-related aggravating
fators. Pork and its derivatives are among the most common food found to be associated with cellulitic attack, acute leg
pain, habitual induration, chronic inflammation, and ulceration, an end stage of which can result in a lipodermatosclerosis.
Objectives To analyze the slaengh effect of pork on clinical pictures of lymphedematous legs, and to provide a new option
for management. Methods and Results Among 2,300 patients diagnosed as lymphedema, more than 250 were found as
slaengh to pork and pork-originated food/products. Manifestations were as various as 20 subtypes. Among them there were
folliculitis, keratosis pilaris, arthritis, tendinitis, ankle lipomatosis, papular dermatitis, panniculitis, vasculitis, cellulitis, and
erysipelas. Many patients remembered a sharply localized leg pain; some episodes were short hours after ingesting pork. Some
unintentionally, yet knowingly, consumed pork and reproduced an aching calf. Some were accompanied with a stubborn
itching sensation, the scratch thereafter caused a wound likely to ulcerate; the latter healed but sometimes took weeks or
months or even years to get healed. Many developed increased pigmentation of lower legs; some also found pronouncedly in
perineum. Unpleasant coloration of shins and calves often was a major concern for seeking medical care. Swelling could be
mild or moderate in some cases, but severe in others; the lymphedema usually involved leg segment plus ankle and dorsum
of foot and toes, leaving the thigh normally unaffected. Complications with varicosis and inguinal lymphadenopathy were
obvious in some individuals. Following treatment protocol at our Day Care Center, clinical pictures improved significantly;
swelling reduced, pain vanished, pigmentation diminished, ulcer healed, varicosed veins receded, hardened skin gradually
softened, walking difficulties and night cramps disappeared. They testified similarly that leg complaints were no longer a
problem. Conclusions Observations were clear that pathologic conditions in legs of lymphedema who are slaengh to pork can
be managed. Although histopathological process was not identified, the effects the patients benefited guarantee a therapeutic
result lymphologists can expect.
Declaration of interest
None declared
P-11.12
SHOULD BREAST CANCER-RELATED LYMPHEDEMA BE DIAGNOSED BASED ON ABSOLUTE OR
RELATIVE (PERCENT) ARM VOLUME CHANGE?
A G Taghian, Massachusetts General Hospital, Boston, UNITED STATES
C L Miller, Massachusetts General Hospital, Boston, UNITED STATES
M N Skolny, Massachusetts General Hospital, Boston, UNITED STATES
L E Warren, Massachusetts General Hospital, Boston, UNITED STATES
T A Russell, Massachusetts General Hospital, Boston, UNITED STATES
J O' Toole, Massachusetts General Hospital, Boston, UNITED STATES
M Ancukiewicz, Massachusetts General Hospital, Boston, UNITED STATES
BACKGROUND: Objective evaluation of breast cancer-related lymphedema is commonly performed by taking circumference
or volumetric measurements and by comparing the affected arm vs opposite arm and/or earlier measurements. In published
clinical studies, the diagnosis of lymphedema has been based on a variety of criteria. Some of popular criteria involve absolute
changes such as the difference of arms circumferences by 2cm or of arm volumes by 200mL. Other set of criteria involve
relative (percent) changes, such as change of arm volume by 10%.
OBJECTIVES: To evaluate absolute vs relative criterion of arm volume change for diagnosis of lymphedema following
treatment of unilateral breast cancer.
METHODS: We used bilateral perometer measurements of arm volumes of 677 patients screened for lymphedema before and
following treatment of breast cancer between 2005 and 2008. We evaluated statistical distribution of arm volume, calculated
the effect of 2cm circumference change or 200ml arm volume change for various patients, finally evaluated temporal variation
of absolute vs relative sequential arm volume changes in a subset of 124 patients with 6 to 13 sequential measurements.
RESULTS: Baseline arm volumes exhibited an approximately log-normal distribution with median 2596 and range from 1270
to 7405mL. The change by 200mL corresponds to 15.4%, and 3.3%, respectively, for volumes of 1300 and 6000mL; a local 2cm
circumference increase corresponds to volume change of 6.0% for 1799mL and 9.8%, for 4376mL. The temporal variation of
absolute changes in the volume of opposite arm correlated with initial arm volume, patient weight, and BMI (P

P-11.13
THE INCIDENCE OF LYMPHEDEMA RELATED TO BREAST CANCER THAT RESOLVES WITHOUT
INTERVENTION
J O' Toole, Massachusetts General Hospital, Boston, UNITED STATES, T A Russell, Massachusetts General Hospital, Boston,
UNITED STATES, M N Skolny, Massachusetts General Hospital, Boston, UNITED STATES, C L MIller, Massachusetts General
Hospital, Boston, UNITED STATES, M Specht, Massachusetts General Hospital, Boston, UNITED STATES M Ancukiewicz,
Massachusetts General Hospital, Boston, UNITED STATES, R A Raad, Massachusetts General Hospital, Boston, UNITED
STATES, S J Isakoff, Massachusetts General Hospital, Boston, UNITED STATES B L Smith, Massachusetts General Hospital,
Boston, UNITED STATES, A G Taghian, Massachusetts General Hospital, Boston, UNITED STATES
BACKGROUND. Timely and accurate identification of breast cancer related lymphedema is considered to be the cornerstone
of successful management. Despite some suggestion in the literature that not all lymphedema is persistent, to date this
phenomenon has not been supported with data.
OBJECTIVES: Our primary aim was to assess the incidence of breast cancer related lymphedema that resolves (transient),
versus the lymphedema that persists and requires intervention. The secondary objective of this study was to evaluate the
treatment factors associated with transient and persistent lymphedema.
METHODS: Women treated for unilateral breast cancer were prospectively measured with perometry prior to surgery, and
followed for serial measurements after surgery. For this study patients with at least 3 measurements and 6 months follow up
were evaluated. Lymphedema was defined as a relative volume change (RVC) of ≥ 5% above the baseline measurement. If
edema persisted > 4months it was classified as persistent. If edema returned to

P-14.09
THE EFFECT OF A THORAX BANDAGE ON SEROMA FORMATION POSTOPERATIVE IN A BREAST
CANCER PATIENT
A T M Nieuwenhuijsen, St. Antonius Ziekenhuis, Nieuwegein, NETHERLANDS
Background: Seroma formation is a common complication after breast cancer surgery and delays the recovery. Excessive
seroma formation puts pressure on the wound which is painful for the patient, gives limitations on daily activities and delays
further treatments.
Objective: To investigate if the use of a thorax bandage postoperative reduces seroma formation in a breast cancer patient.
The practical aspects of wearing the thorax bandage will be described.
Methods: In this report the case of a 62 year old woman will be presented after surgery for breast cancer both sides: modified
radical mastectomy (MRM) on the right and an axillary lymph node dissection (ALND) on the left. The selection criteria
were: status after MRM and at least one seroma aspiration . After the surgery the axilla on the left got infected and the patient
had to be hospitalized five days for treatment with antibiotics. The research design is a n=1 single subject design, where
a baseline situation is followed by an intervention phase (four weeks physical therapy treatments and the use of a thorax
bandage on the surgical site on the right) Measurements were taken at baseline and follow-up: score on the visual analog
scale (VAS) and the Disability of the Arm, Shoulder and Hand Questionnaire Dutch language version (DASH-DLV).
Results: After the start of the physical therapy interventions there were no more seroma aspirations needed on the right.
The patient found the thorax bandage comfortable. “It makes me feel safe”. Three times the pain score is measured and a
DASH-DLV is completed. Over a period of four weeks the VAS score decreased with 26 mm and de DASH-DLV score with
16 points. Both scores are clinical relevant for the patient.
Conclusion: In this case report the application of a thorax bandage seemed clinical successful for the patient. Further studies
are necessary to investigate the effect of a thorax bandage on seroma formation. At least the experience of the patient was
positive.
Declaration of interest
none declared
P-14.10
EFFECT OF MAGNETIC STIMULATION IN SPINAL CORD ON LIMB ANGIOGENESIS AND
IMPLICATION FOR LYMPHEDEMA
J Beom, Seoul National University College of Medicine, Seoul, KOREA, REPUBLIC OF
B M Oh, Seoul National University College of Medicine, Seoul, KOREA, REPUBLIC OF
K S Seo, Seoul National University College of Medicine, Seoul, KOREA, REPUBLIC OF
Background: Lymphedema caused by breast, cervical or endometrial cancer operation has high prevalence, but is nearly
intractable to treat. It needs an innovative method such as induction of lymphangiogenesis. Recently, a few animal studies
suggested the beneficial effect of repetitive transcranial magnetic stimulation (rTMS) in angiogenesis of the brain tissue.
However, compared with the growing number of researches about rTMS of the brain, there is no study on the effect of
repetitive magnetic stimulation (rMS) of the spinal cord on the limb angiogenesis closely linked to lymphangiogenesis.
Objectives: To investigate the effect of repetitive magnetic stimulation of the spinal cord on limb angiogenesis in healthy rats
and explore its implication for the treatment of lymphedema.
Methods: Twelve adult male Sprague-Dawley rats were divided into four groups as follows: sham rMS followed by tissue
harvest 5 minutes later (group 1, n=2), 1Hz rMS and tissue harvest 5 minutes later (group 2, n=3), 20Hz rMS and tissue
harvest 5 minutes later (group 3, n=3), 20Hz rMS and tissue harvest 30 minutes later (group 4, n=4). Animals were treated
with 20-minute rMS with 120% of the motor threshold on their left side of upper lumbar spinal cord. Expression of angiogenic
factors, that is, Akt, phospho-Akt, endothelial nitric oxide synthase (eNOS), phospho-eNOS were measured by western blot.
Bilateral hindlimb muscles (quadriceps and gastrocnemius) were harvested.
Results: Expression of Akt in left quadriceps increased in group 4 compared with group 2 and 3 (3.4 and 5.3-fold each,
p=0.026). Expression of eNOS in left plus right quadriceps markedly increased in group 3 and 4 compared with group 1 and
2 (p=0.007). Expressions of eNOS and Akt in gastrocnemius were not comparable between four groups (p>0.05).
Conclusion: Repetitive magnetic stimulation of the spinal cord may exert an angiogenic effect closely linked to
lymphangiogenesis. It has clinical implication for the possible therapy of lymphedema caused by cancer operation. Future
studies with the specific lymphatic endothelial cell markers are required to confirm the effect of repetitive magnetic stimulation
on lymphangiogenesis.
Declaration of interest
None declared
182

P-14.11
THE EFFECT OF COMPLEX DECONGESTIVE PHYSIOTHERAPY FOR MALIGNANT LYMPHEDEMA :
PILOT STUDY
Y J Sim, Kosin University College of Medicine, Busan, KOREA, REPUBLIC OF
B H Kim, Kosin University College of Medicine, Busan, KOREA, REPUBLIC OF
E H Kong, Kosin University College of Medicine, Busan, KOREA, REPUBLIC OF
Background: Complex decongestive physiotherapy (CDPT) is the most commonly used and standard treatment for
lymphedema. However, there were no literatures that showed the effect of CDPT for malignant lymphedema.
Objective : To investigate the effects of CDPT for the treatment of malignant lymphedema in upper or lower limb.
Methods : The patietns (N=22) who diagnosed as having malignant lymphedema in breast cancer and gynecological cancer
were assigned to this study. CDPT except manual lymphatic drainage (MLD) was done in all patietns for 2 weeks. The
main outcome measurements were the circumference of the limb (proximal, distal and total) for the volume changes, visual
analogue scale (VAS)for pain and the short form-36 version 2 questionnaire (SF-36) for the quality of life (QOL) and posttreatment
for each patient.
Results : There was a stastistically significant difference of volume between pre and post-treatment as 8.02% (distal : 7.00%,
proximal: 8.62%). There were improvements of the VAS as 1.5 points after CDPT. And physical and mental component
summary of SF-36 (PCS and MCS) showed statistical improvements.
Conclusion : Our results suggenst the CDPT program except MLD is helpful for patients with malignant lymphedema in
upper or lower limb and that have significantly positive effects of QOL.
Declaration of interest
none declared
P-14.12
MALIGNANT PLEURAL EFFUSION AND ASCITES OCCURRING IN CONJUNCTION WITH CANCER
METASTASIS TO THE LYMPHATIC STOMATA
H Oshiro, Tokyo Medical University, Tokyo, Japan, M Miura, Oita University, Oita, Japan, O Ohtani, University of Toyama,
Toyama, Japan, A Kudo, Nippon Dental University, Tokyo, Japan, Y Shimazu, Nippon Dental University, Tokyo, Japan, T Aoba,
Nippon Dental University, Tokyo, Japan, K Okudela, Yokohama City University Hospital, Yokohama, Japan, K Nagahama,
Yokohama City University Hospital, Yokohama, Japan, Y Inayama, Yokohama City University Hospital, Yokohama, Japan, T
Nagao, Tokyo Medical University, Tokyo , Japan
Background: Little is known about pathophysiology of human lymphatic stomata.
Objectives: The aim of this study was to elucidate anatomicopathological significance of human lymphatic stomata in the
pathogenesis of malignant pleural effusion and ascites.
Methods: 58 autopsy cases were investigated. These cases consisted of 37 men and 21 women; mean age of 67.5 years old; 9
gastric, 8 colorectal, 7 biliary tract, 7 pancreatic, 4 hepatic, 7 genitourinary, 8 pulmonary, 3 esophageal, and 5 other organ
cancers; 44 adenocarcinomas, 7 squamous cell carcinomas, and 7 other histological subtypes; and 36 well or moderately
differentiated types and 22 poorly or undifferentiated types.
Results: (1) The best anatomical regions to observe lymphatic stomata were the pulmonary ligament in the pleural cavity and
the diaphragmatic peritoneum in the peritoneal cavity. (2) 25 percent of left malignant pleural effusion cases, 30 percent of
right malignant pleural effusion cases, and 12 percent of malignant ascites cases demonstrated neither serosal direct invasion
nor serosal dissemination of cancer. (3) Univariate analysis demonstrated that pleural dissemination, pulmonary hilar lymph
node metastasis, venous angle lymph node metastasis, and metastasis to the lymphatic stomata on the pulmonary ligament
were significantly high risk factors of malignant pleural effusion; however, multiple logistic regression analysis demonstrated
that only the metastasis to the lymphatic stomata on the pulmonary ligament was a significantly independent risk factor
of malignant pleural effusion in each pleural cavity. (4) Univariate analysis demonstrated that peritoneal direct invasion,
peritoneal dissemination, upper para-aortic lymph node metastasis, primary biliary tract cancer, adenocarcinoma histology,
and metastasis to the lymphatic stomata on the diaphragmatic peritoneum were significantly high risk factors of malignant
ascites; however, multiple logistic regression analysis demonstrated that only the metastasis to the lymphatic stomata on the
diaphragmatic peritoneum was a significantly independent risk factor of malignant ascites.
Conclusions: These results suggest that cancer metastasis to the lymphatic stomata on a certain region is a significant predictor
rather than serosal direct invasion or serosal dissemination of cancer, and that cancer metastasis to the lymphatic stomata
plays a role in the pathogenesis of malignant pleural effusion and ascites.
Declaration of interest
None declared.
183

P-14.13
DIFFERENTIAL DIAGNOSIS OF LYMPHEDEMA IN A PATIENT WITH A LUNG CANCER AND A
HUMERAL FRACTURE.
I FORNER - CORDERO, C RUBIO - MAICAS, E DUARTE - ALFONSO, R GARCIA - SAEZ, University Hospital La Fe,
VALENCIA, SPAIN
A 65 years-old woman, with a history of hypertension and lung carcinoma treated with concomitant chemo-radiotherapy,
was referred to the Rehabilitation clinic from the orthopedic surgeon after a right humeral fracture. The fracture occurred
three months before and was treated surgically with an internal fixation.
The clinical examination showed:
- An important limitation of active and passive shoulder
mobility.
- Severe swelling of the upper limb, from hand to arm with
pitting sign suggestive of lymphedema.
- The upper limb is extremely painful, erythematous
with stiffness in the elbow, wrist and hand, allodynia and
diaphoresis.
At the Lymphedema Unit, the following diagnoses were
considered:
- Complex regional pain syndrome type I (CRPS)
- Venous thrombosis secondary to fracture and lung cancer
- Lymphedema secondary to: radiation therapy, trauma or
tumour lymphatic invasion.
- Infection of the fixation implant
- Superior vena cava syndrome due to tumour compression.
Some additional test and consultation to various specialties
were performed to reach a diagnosis:
P-14.14
FOXC2 DEFICIENCY AND MELANOMA SPREAD IN A MOUSE MODEL
S Daley, University of Arizona, Tucson, UNITED STATES
E Bastidas, University of Arizona, Tucson, United States
J Washington, University of Arizona, Tucson, United States
M Bernas, University of Arizona, Tucson, United States
M Witte, University of Arizona, Tucson, United States
Background: The lymphatic system has been implicated in the growth, development, and dissemination of many cancers and
lymphatic involvement often guides clinical evaluation, prognosis, and therapeutic approaches for most solid organ cancers.
The availability of mouse models with lymphatic dysfunction offers an opportunity to delineate the role the lymphatic system
plays in cancer development and spread.
Objectives: This preliminary study examines melanoma growth and adjacent and distant tumor spread in a haploinsufficient
mouse model (Foxc2 +/-) that exhibits generalized lymphatic hyperplasia, occasional hindlimb lymphedema, and bilateral
distichiasis. We evaluated the presence and size differences in primary, secondary, and tertiary tumors in both Foxc2 +/- and
wildtype (Foxc2 +/+) mice.
Methods: Groups of adult C57/B16 mice with a targeted disruption of Foxc2 expression (Foxc2 +/-) were compared to
wildtype mice. Mice were injected in the left dorsal ear with 200,000 B16-F10 murine melanoma cells and observed for
approximately 23 days at which time they were sacrificed, primary, secondary, and tertiary tumors evaluated for incidence
and volume, metastasis and reflux assessed and graded, and tissues harvested for histological analysis. Data analysis was
conducted using t-test and Mann-Whitney rank sum tests.
Results: Tumor take was 100% in Foxc2 +/+ mice (n=20) compared to 92% in Foxc2 +/- mice (n=24) (n.s.). Primary tumor
incidence was significantly decreased in the Foxc2+/- model (71%) compared to +/+ mice (95%) (p

P-19.10
MICROSURGICAL LYMPHOVENOUS ANASTOMOSES AFTER 45 YEARS- INDICATIONS,
TECHNIQUES AND FOLLOW-UP EVALUATION METHODS
W L Olszewski, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
Over the last 42 above 1000 microsurgical lympho-venous shunts (lymphnode-vein, lymphatics-vein) were performed in our
center in patients with lymphedema of lower limbs. The follow-up has been from 5 to 40 years. The indications for shunts were:
postsurgical (after hysterectomy), postinflammatory, hyperplastic and idiopathic lymphedema. The 5-year follow-up results
were dependent on the type of lymphedema. In postsurgical group 80% (in the survivals), 40-50% in postinflammatory, above
80% in hyperplastic, and 5-10% in idiopathic group showed decrease of swelling and DLA (dermato-lymphangio-adenitis)
rate. Basing on the accumulated experience the main problems have been formulated: (i) establishing proper indications,
(ii) postoperative evaluation of shunt patency, (iii) reasons for shunt obliteration, (iv) discrimination of effectiveness of
shunts fromthat of elastic support, massage and antibiotic therapy. 0ur present remmendations are as follows: (i) indications:
lymphoscintigraphy of superficial and deep systems delineating at least one lymphatic and fragment of inguinal lymph node
within 3h in all patients with obstructive edema, fast growing edema after hysterectomy or groin dissection not controlled
by elastic support, hyperplastic lymphedema in children and teenagers, decompression of thigh lymph stasis before lower
leg debulking.(ii)contraindications: lack of even rudimentary lymphatics on lymphoscintigraphy, inflammatory changes in
skin and lymphatics, idiopathic lymphedema (previously hypoplastic, precox and tarda), (iii) immediate postoperative low
molecular heparin for 6 weeks, long-lasting penicillin for one year or longer, elastic stockings, intensive walking and muscular
exercises, foot hygiene (iv) postoperative evaluation: lymphoscintigraphy with liver scanning (time of appearance of tracer
in blood circulation), subsidence of DLA attacks, lack of increase of circumference or volume. Conclusions. The 5-year
follow-up of patients operated in the 1960- and 70-ties without additional therapeutic modalities showed evident efficacy of
microsurgical shunting. Today combined microsurgery, long-lasting penicillin and elastic support with intensive muscular
exercise do not allow to evaluate the independent effect of lympho-venous shunting.
Declaration of interest
None declared
P-20.10
SURGICAL DEBULKING PROCEDURES IN VERY ADVANCED LYMPHEDEMA OF LOWER LIMBS
W Olszewski, Medical Research Center, Polish Academy of Sciences, Warsaw, POLAND
P Jain, Indian Lymphology Centers in Varanasi and Thanjavur, Varanasi, INDIA
J Victor, Indian Lymphology Centers in Varanasi and Thanjavur, Thanjavur, INDIA
Very advanced stage IV lymphedema of lower limbs cases are not common in the Western hemisphere. They account for less
than 1 percent of all lymphedema patients. However, they are frequent in the Asian and African countries. The number of
advanced cases is estimated at a level of 10-15 million. The historical surgical procedures comprised total denuding of limb
down to fascia and covering with epidermal grafts. The results were unsatisfactory because of non-healing, acute infections
in the non-removed skin, epidermal ulcerations and plasma leakage from the uncovered surfaces and increasing edema of
the dorsum of foot. Our studies revealed presence of microorganism in the calf and foot skin biopsies. The question arouse
whether these microbes may not be responsible for non-healing and increasing foot edema. Basing on the contemporary
knowledge of type and localization of infection as well as visualization of lymphatic pathways allowed to redesign the surgical
procedures. The by us designed new approach with preoperative preparation and surgical protocol include: 1. Antibiotic
preparation (ciprofloxacin 1.0 g daily for 3 months, 2. Daily disinfection of skin with antimicrobial soap containing phenol
or similar chemical for 14 days before operation, 3. Two-week limb elevation in bed, 4. Limb surgery divided into 2 stages: a.
removal of fibrotic inguinal lymph nodes and vessels, b. 3-4 weeks later formation of long anterior and posterior flaps below
the knee and above the ankle, without denuding the entire calf down to the fascia as in the classic Kondoleon’s operation.5.
bed -confined limb and continuation of 0.5 g cipro for another month. Upper and lower flap underwent marginal necrosis
healed later on by granulation. Occasionally epidermal grafts were laid on 5. elastic support (pressure grade III). This modified
approach allowed patients to become ambulant, prevented further destruction of joints and frequent life-endangering
septicemias. It also allowed males normal sexual contacts.
Declaration of interest
None declared
185

P-24.07
EFFECTS OF REDUCTION OPERATION WITH GENITAL LYMPHOEDEMA ON THE FREQUENCY OF
ERYSIPELAS AND LIFE QUALITY
G Felmerer, University Hospital Goettingen, Göttingen, GERMANY
E Földi, Földiklinik, Hinterzarten, GERMANY
Background: Genital lymphoedema represents a severe strain for the patients affected. The erysipelatous infection is the most
frequent complication of the lymphoedema, also in the genital region.
Objectives: The objectives of this study were: to investigate the frequency of erysipelas in patients with genital lymphoedema
and genital lymphatic cysts, to observe the influence the resection operation on the frequency of erysipelas, and to indicate
changes in the quality of life due to the resection operation.
Methods: The data for 93 patients undergoing treatment within the scope of integrated care as a result of a genital lymphoedema
in the Földiklinik, Hinterzarten and the Department of Plastic and Hand Surgery of the University Hospital Freiburg during
the period 1997-2007 were investigated.
Results and Conclusions: The results of the study indicated that lymphatic cysts were the most important risk-aggravating
factor for recurrent erysipelas with lymphorrhea in the genital region (P

P-27.06
POSSIBLE ROLES OF PODOPLANIN POSITIVE CELLS IN LYMPHATIC VESSEL REGENERATION
DURING THE WOUND HEALING
K Shimizu, Tokyo Women's Medical University, Tokyo, JAPAN
T Ezaki, Tokyo Women's Medical University, Tokyo, JAPAN
[Aim] Regeneration of the microcirculation including lymphatic vessels (LVs) is very important for the remodeling of the
tissue organizations. However, the understanding of LV regeneration has been hampered by the lack of the specific markers
for LVs. In this study, we investigated the LV regeneration in a wound-healing model of the mouse tongue using with specific
markers.
[Materials and Methods] We made a 1mm deep-laceration on the tongue in C57BL/6 mice under anesthesia. The mice
were perfusion-fixed with 4% paraformaldehyde after the injury and cryosections of the tongues were made. Some samples
were stained for either podoplanin or LYVE-1 as specific lymphatic markers and examined by a confocal laser-scanning
microscope. The total RNA was extracted by the lacerated tongues. These RNA were examined for podoplanin and CCL21
by RT-PCR amplification.
[Results and Discussion] By day5 after injury, the epithelium completely healed and the granulation was formed in the
subcutis where many active fibroblast-like cells were populated and formed fine meshworks without any signs of LV. However,
these fibroblast-like cells expressed podoplanin, but not LYVE-1. The RT-PCR revealed that CCL21 and podoplanin mRNAs
increased as early as on day1 after injury. These results may suggest that the podoplanin positive fibroblast-like cells form an
extravascular pathway in the wound tissue like the podoplanin positive meshworks in the spleen as a prelymphatic routes as
previously reported (Shimizu et al., 2009).
Declaration of interest
None declared
P-29.08
LONGER TERM CHANGES IN BIOIMPEDENCE FOLLOWING LIPOSUCTION FOR CHRONIC ARM
LYMPHOEDEMA RELATED ADIPOSITY
H Mackie, Mt Wilga Private Hospital, Sydney, AUSTRALIA
J Tiong, Sydney, Australia
K Shanley, Sydney, Australia
Introduction: Sustained reductions in limb volume have been reported following Liposuction and continued compression
garmenting.
Objective: This study looked at changes in extra cellular fluid measurement following this procedure.
Method: Liposuction was performed on four patients with chronic arm lymphoedema adiposity according to selection
criteria and protocols developed by Dr Brorson.
Bioimpedence spectroscopy (BIS) recordings used an Impedimed Lymphometer were performed in months prior to and
immediately before surgery and in the days, months and years after surgery at the same time as circumferential and water
displacement measurements were undertaken.
Results: Prior to surgery circumferential measurements and BIS had stabilised. There was a greater than 1000ml measured
volume difference between affected and unaffected arms. Pre-surgical BIS varied from L-Dex less than 10 to over 40.
Immediately after Liposuction with removal of about 1000ml of fat there was a dramatic reduction in circumferential and
water displacement measurements to near or below the unaffected arm measurement.
There was an increase of extra cellular fluid as measured by BIS which remained above immediate pre-operative levels up to
3 months post operative. At six months post-liposuction BIS recording was below pre-operative level and with longer term
follow up BIS continued to fall significantly lower than the levels achieved by pre-liposuction compression management.
Conclusion: Following liposuction for lymphoedema adiposity compression garments on the affected arm are measured
using the unaffected arm measurement. This compression maintains the excellent surgical volume reduction and manages
operative swelling. The effectiveness of the compression on the liposuction volume reduced arm results in “improvement” in
lymphoedema as assessed by BIS.
Declaration of interest
None declared
187

P-29.09
COMPARATIVE STUDY OF THE EFFICIENCY OF METHODS CRYOTHERAPY OF LYMPHEDEMA OF
LOWER EXTREMITIES
T Apkhanova, Federal State Institution «Russian Scientific Center of Rehabilitation Medicine and Health Resort Science of the
Ministry of Health and Social Development», Moscow, RUSSIAN FEDERATION
In Clinic Center developed methods of cryotherapy of lymphedema of the lower extremities: cryomassage,
cryoelectrostimulation feet with using a cold temperatures to-20º C.
We have treated 142 patients with lymphedema of the lower limbs I-III stage. All patients randomized were divided into
the following groups: group 1 received a course of manual massage feet on a reflex-segmental method, group 2 -course of
cryomassage feet, for which we used cryopack with an operating temperature ̶ 18 º C, group 3 - a course of electrostimulation
lumbar region and the region of the calf muscle, group 4 - cryoelectrostimulation with using the cold applicators temperature
-4 º C in the shin area.
Regression of edema of lower extremities after a course of manual massage on a reflex-segmental method was 11,4%, after
a course of cryomassage 44, 06%, after a course of electrostimulation -40, 4%, after a course of cryoelectrostimulation -62,
8%. In all patients, according to the Laser Doppler Flowmetry were observed: the stagnant type of microcirculation, decrease
in basal blood flow, indicating that spasm of the arterioles, increase in the vascular tone. After the course of a manual
massage decreased the amplitude of the respiratory oscillations, indicating a decrease in venous stasis in the venules, while
maintaining high tone arterioles. After the course of cryomassage legs decreased stasis in venules, the increased tone of
arterioles decreased. After a course of electrostimulation increased of basal blood flow. This resulted in insufficient venous
drainage to the preservation of venous stasis in the microcirculatory bed and the increased vascular tone of arterioles. This
resulted in insufficient venous drainage to the preservation of venous stasis in the microcirculatory bed and the increased
vascular tone of arterioles. In contrast to electrostimulation, cryoelectrostimulation has a positive impact on all links of
microcirculation: decreased tone of arterioles, decreased venous stasis at the level of the venules, improves basal blood flow,
and consequently tissue perfusion.
Thus, we have found that the use of cryotherapy, significantly increases the effectiveness of physiotherapy treatment of
lymphedema of the lower extremities.
Declaration of interest
None declared
P-29.10
STATISTICAL EXAMINATION OF LYMPHATICOVENOUS ANASTOMOSIS AND PREOPERATIVE
COMPLEX DECONGESTIVE PHYSIOTHERAPY FOR TREATMENT OF PERIPHERAL LYMPHEDEMA
J Maegawa, Yokohama City University Hospital, Yokohama, JAPAN
H Tomoeda, Yokohama City University Hospital, Yokohama, JAPAN
M Hosono, Yokohama City University Hospital, Yokohama, JAPAN
A Tosaki, HIgashikanagawa Tosaki puncture clinic, Yokohama, JAPAN
Although there are reports on complex decongestive physiotherapy (CDP) and surgical treatment for peripheral lympedema,
only a few detailed descriptions on treatment protocols that combine CDP and surgery. Several facilities have been recently
established for lymphaticovenous anastomosis. However, the statistical analysis of the direct effects of surgery on edema
has not been thorough. We performed CDP before and after surgery at the same facility, and then implemented a statistical
examination of changes in the circumference of affected limbs on which lymphaticovenous anastomosis had been performed
using the same patients. Further, we examined the differences in edema improvements using classifications based on the
preoperative lymphoscintigraphy. The subjects were 55 patients with chronic lower limb lymphedema; 39 had secondary
lymphedema and 16 primary lymphedema. We calculated the mean circumference of the lower limb during the initial
examination as well as 100 days before and after surgery. We performed a statistical comparison of the mean lower limb
circumference using the Types I, II, and III that we proposed on the basis of preoperative lymphoscintigraphy as the SA cohort
(N = 15), Types IV and V as the SB cohort (N = 24), and the primary lymphedema cases as the P cohort (N = 16). The results
identified a significant difference between in the mean values during the initial examination and 100 days before surgery in
both secondary cohorts. A significant difference was observed in the mean values 100 days before and after surgery in the
SA, but no significant difference in the SB. In the P, a significant difference was observed in the mean values 100 days before
and after surgery, and in the mean values during the initial examinations and 100 days before surgery in nearly all measured
parts. These results show that CDP before surgery has significant effects on primary and secondary lymphedema and that
surgery is effective in primary lymphedema and the SA. Reduced edema in lymphaticovenous anastomosis was identified in
the SA, in lymphatic functions were presumably preserved in comparison to others. Thus we believe that anastomosis needs
to be performed before lymphatic functions worsen.
Declaration of interest
None declared
188

P-29.11
ENDOLYMPHATIC PHARMACOKINETICS OF MEROPENEM AT LOCAL PYOINFLAMMATORY
PROCESS OF ABDOMINAL CAVITY – EXPERIMENTAL RESEARCHES RESULTS
I. V. Yarema, B. M. Urtaev, A. I. Marchenko, A. A. Akopyan, R. A. Simanin, O. V. Danilevskaya, R. I. Yarema, P. S. Neklyudova,
Moscow State University of Medicine and Dentistry, Moscow, RUSSIAN FEDERATION
Background. The over-all mortality at pyoinflammatory process of abdominal cavity is equal to 20.7–58.2%. Despite its high
efficiency antibacterial therapy frequently does not give the desirable results.
Objectives. The comparative analysis of pharmacokinetics of Meropenem after its intravenous and endolymphatic intradaction
has been carried out in experiment.
Methods. The concentration of Meropenem in blood and abscess cavity within 24 hours has been compared among 17
patients with appendiceal abscesses. Endolymphatic injection has performed by catheterization of peripheral lymphatic
vessels on foot.
Results: It has been find out, that minimal inhibitory concentration of the antibiotic in blood (18,7±1,94 mcg/ml) after
endolymphatic injection has occurred in an hour after the injection and remained stable up to 24 hours. By the end of the 24th
hour after injection the concentration of Meropenem in blood has been 5.5±0.33 mcg/ml. Mean maximum concentration
(Cmax) has made 35.9±2.93 mcg/ml, Tmax has been equal to 6 hours, T½ has been equal to 9 hours.
Abscesses content analysis has shown that average concentration of Meropenem in abscess cavity in 6 hours after a single
endolymphatic injection has made 8.2±0.76 mcg/ml. The MIC90 of antibiotic has been stable up to 18th hour (4.3±0.29 mcg/
ml).
At analysis of the results of intravenous administration of Meropenem its average concentration in blood in 1 hour after the
intravenous injection has been equal to 47.3±3.24 mcg/ml, but MIC90 has been not detected in blood already in 6 hours. The
average Cmax has been 47.3±3.24 mcg/ml, Tmax has been equal 1 hour, T½ has been the same.
The concentration of Meropenem in abscess cavity in 1 hour after the injection has been 5.7±0.47 mcg/ml. In 6 hours after
the injection Meropenem hasn’t been detected in abscess content.
The average AUC24 in the group with endolymphatic injections has been 4,61 mcg*ml/h, and the AUC24 in the group with
intravenous injections has made 6.48 mcg*ml/h. The ratio AUC24 endolymph./AUC24 intraven. has made 71.14%.
Conclusions. The investigation has proved that the concentration of the antibiotic in tissues of patients’ organism, particularly
in abscess cavity, persists longer at endolymphatic injection.
Declaration of interest
None declared
P-29.12
SUBSTANTIATION OF ENDOLYMPHATIC ANTIBIOTIC THERAPY OF POLYNEURITIS
A. I. Marchenko, I. D. Stulin, E. Y u. Demidova, R. I. Yarema, E. Y u. Ponomareva, O. V. Danilevskaya, N. D. Postriganova,
A. R. Tsarapkina, Moscow State University of Medicine and Dentistry, Moscow, RUSSIAN FEDERATION
Background. Treatment of neuritis is a great problem of practical medicine because of difficulty to reach high and continuously
retainable antibiotic concentration in nerve fibers. At traditional antibiotic therapy there is no accumulation of antibiotics in
nerve fibers.
Objectives: to prove the existence of the link between cerebrospinal fluid and lymph at the level of perineural spaces
(endoneurium), where elementary links of lymphatic system are located. The lymphatic system provides a drainage function
and proves the necessity of endolymphatic antibiotic therapy of acute inflammation of nerve fibers.
Methods. In experiment on 21 animals antibiotic Kefzol has been injected in the dose of 15 mg/ml into peripheral lymphatic
vessel. In order to determine the concentration of antibiotics samples of serum, lymph and cerebrospinal fluid have been
taken, consequently every: 1st, 3rd, 6th, 12th, 18th, 24th, 36th, 48th, 60th, 72nd hour after the injection of Kefzol.
Results. After the 1st, 12th, 24th and 48th hours the concentration of Kefzol has been 689, 607, 321 mcg/ml in lymph, and
31.4, 149.6, 31.7, 11.8, 5.4 mcg/ml in blood respectively. Inguinal, pelvic lymphatic nodes, sciatic and tibial nerves have been
removed from each dog sequentially every 6th, 12th, 18th, 24th and 48th hours after Kefzol injecting in order to determine
its concentration. The concentration in pelvic lymphatic nodes after 6th, 12th, 24th hours has been 46.1, 45.3, 35.5 mcg/ml,
and in sciatic nerves it has been 21.3, 17.4, 7.3 mcg/ml respectively. Thus there has been established smooth and prolonged
reduction of Kefzol concentration during 24 hours in lymph and serum at endolymphatic injection. Lymphatic nodes and
nerve trunks held the concentration at the high levels longer, in cerebrospinial fluid it has stayed at therapeutic level up to
36–48 hours.
Conclusions. Endolymphic therapy allows reaching high and continuously retainable therapeutic antibiotic concentration in
nerve fibers at single drug injection. Such concentration is much higher than the minimal inhibitory concentration which
suppresses the growth of pathogenic flora. This experimental research allows quite objectively presume that the links between
lymph – interstitium – perineural spaces and liquor exists. This fact opens wide perspectives in clinical practice.
Declaration of interest
None declared
189

P-29.13
LYMPHOEDEMA AND HEALTH RELATED QUALITY OF LIFE BY EARLY TREATMENT IN
LONGTERM SURVIVORS OF BREASTCANCER.
K Karlsson, Division of physiotherapy, Karolinska University Hospital, Stockholm, SWEDEN
I Wallenius, Department of Oncology, Academical Hospital, Uppsala, Sweden
L Nilsson Wikmar, Department of neurobiology, Care sciences and society,Karolinska Institutet, Stockholm, Sweden
H Lindman, Department of oncology, Academical Hospital, Uppsala, Sweden
B Johansson, Department of oncology, Academical Hospital, Uppsala, Sweden
Background: According to the literature lymphoedema is regarded as a chronic disease which will progress without treatment.
Earlier studies show that women with lymphoedema will experience lower quality of life.
Objectives: This is a comparative retrospective study and the purpose was to compare medical background data,the
progression/regression of arm lymphoedema and health related quality of life for women who no longer stay in contact with
the lymphoedema clinic (project group), to women who did have treatment and regular visits at the clinic (treatment group).
Material: The project group (n=72) have significantly less visits at the clinic (p

P-29.15
SUCCESSFUL EVIDENCE FROM TWISTING TOURNIQUET TECHNIQUE® FOR LYMPHEDEMA
TREATMENT
N Chanwimalueang, Mahidol University, Bangkok, THAILAND
W Ekataksin, Mahidol University, Bangkok, THAILAND
P Piyaman, Mahidol University, Bangkok, THAILAND
Background We have developed a series of simple tools for decreasing the sizes of swelling limbs, patented and referred to
as a Twisting Tourniquet Technique® (TTT). These progressive tightening devices are based on the principle of transforming
the act of twisting, screw-like rotation, into a compression force, constricting circumferentially around an axis. With an ease
of use and a self-manageable design, patients are required to enroll to a 5-day therapeutic program at Thailand Lymphedema
Day Care Center, a reduction phase, get trained, and continue using it at home, a maintenance phase. Regular follow-ups
with a lymphologist will ensure a consolidation phase and a complete cure. Objective To compare the differences, the visually
perceptible results of lymphedematous extremities before and after treatment by TTT. Methods During 2006-2011, more
than 2,300 patients, appointment, walk-in, and referral, consulted our Day Care Center for medical treatment. Successive
photography was recorded while their swollen limbs improved. Underlying conditions consisted of a wide spectrum,
malignancies, congenital abnormalities, Klippel Trenaunay syndrome, infections, injury, trauma, tumor, tuberculosis,
neurofibromatosis, varicosis, venous insufficiency, deep vein thrombosis, cardiopulmonary disorders, renal failure, liver
disease, lymphoma, lipomatosis, lipoedema, obesity, fibromyalgia, myofascial pain, chronic fatigue syndrome, rheumatoid
arthritis, SLE, HIV, and lymphatic filariasis. Results With most of the patients complying with the treatment protocol,
compression therapy, cryotherapy, and nutritional therapy (vegan diet with sodium restriction), we were able to maximize
the effectiveness of the regime, rendering a striking outcome rapidly. To some individuals 10 to 50 years of suffering was
abolished right away in months, changing their attitude of once being a disable, and amazingly increased quality of life.
Conclusions Visual evidence was self-explanatory. Social recognition is being accumulated so that we have changed the
manner physicians and oncologists used to handle their patients, and the rest of patients’ life. With successfully treated
patients, a living testimony, we propose to establish a TTT unit for a routine adoption to a hospital.
Declaration of interest
None declared
191

AUTHOR INDEX

AUTHOR INDEX
NAME NUMBER
194
A
Accogli,S..........................................................O-14.01, O-21.01
Adámek, J .........................................O-11.04, O-19.05, O-20.09
Adami, M ........................................................................ O-20.01
Adami, M ....................................................................... O-06.06
Adánek, J ........................................................................ O-24.05
Adriaenssens, N ................................O-10.01, O-14.02, O-14.03
Agostini,F....................................................................... O-27.03
Akamatsu, F E ................................................................ O-07.01
Akbari, A .........................................................................O-06.04
Akbari, M E .....................................................O-06.04, O-30.02
Akcali, Y .......................................................................... P-11.10
Akl, T ...............................................................................O-23.01
Akopyan, A. A. ................................................................ P-29.11
Alitalo, K ........................................................O-20.03, RT-01.03
Alitalo , K .......................................................................... KN-05
Amore, M ..........................................O-02.01, O-02.05, O-12.06
Amore, M A .................................................................... O-04.01
Ancukiewicz, M ..................O-11.06, O-14.08, P-11.12, P-11.13
Andrade, M .....................................................................O-07.01
Andry,G.......................................................... O-22.05, O-22.06
Ansari, M ........................................................................ O-06.04
Anttila, M ........................................................................O-10.05
Aoba, T .............................................................................P-14.12
Apkhanova,T..................................................................P-29.09
Apkhanova, T V ............................................................. O-11.03
Armer, J ........ O-08.02, O-09.02, O-14.05, O-16.01, O-16.02, O
-16.03, O-16.04, P-10.09
Artamonova, E ................................................................O-28.06
Ashforth, K ..................................................................... O-30.01
Askew, R ..........................................................................O-16.07
Austin, M .........................................................................O-16.03
Axelsson, R ......................................................................O-18.08
B
Badtieva, V A ..................................................................O-11.03
Bahadori, A .....................................................................O-29.02
Baker, P ...........................................................................O-19.07
Ballah, D ..........................................................................O-05.05
Barbosa, L .......................................................................O-04.01
Bardakov, V G ................................................................O-11.03
Bastidas, E ....................................................................... P-14.14
Baumeister, R .............................. O-20.02, RT-01.01, RT-03.01
Baumeister, R G H ......................................................... O-28.02
Becker, M ........................................................................O-05.06
Beith, J ............................................................. O-01.05, O-10.08
Belgrado, J P ....................................................O-18.05, O-22.02
Beom, J .............................................................................P-14.10
NAME NUMBER
Bernas, M .........................................................................P-14.14
Bertelli, M ....................................................................... O-27.03
Birkballe, S .......................................................O-16.06, P-09.07
Birrell, S .......................................................................... O-06.01
Boccardo, F ......O-06.06, O-14.01, O-20.01, O-21.01, RT-03.02
Bohlen, H G ..................................................................... P-04.07
Bosman, J ........................................................................O-12.01
Bourgeois,P.........................KN-07, O-22.02, O-22.05, O-22.06
Bracale, P ........................................................................ O-22.02
Braun, D ..........................................................................O-04.01
Brice, G ............................................................................O-04.02
Bridenbaugh,E...............................................................O-28.04
Brorson, H .....O-02.04, O-15.03, O-17.04, O-18.06, O-19.08, O
-20.05, O-20.08, O-26.05, O-26.06, RT-01.04, RT-03.03
Brouwer, E ......................................................................O-06.03
Buttner, P ........................................................................O-13.04
Buyl,R.............................................................................O-10.01
C
Cahill, A .......................................................................... O-05.05
Cakala, M .......O-23.04, O-29.07, O-30.05, O-30.06, O-30.07, P
-03.12, P-03.12
Campisi, C .....O-02.05, O-06.06, O-14.01, O-14.01, O-14.01, O
-20.01, O-21.01, O-21.01, O-21.01, RT-03.02
Campisi, C C .................................. O-06.06, O-20.01, RT-03.02
Campisi, C S ...................................O-06.06, O-20.01, RT-03.02
Cappelino, F ..O-03.04, O-04.03, O-05.04, O-11.01, O-15.01, O
-22.04, O-27.03, O-29.03
Cappellino,F...................................................................O-15.06
Cardone, M ... O-03.04, O-04.03, O-05.04, O-11.01, O-15.01, O
-15.06, O-22.04, O-27.03, O-29.03
Casabona, F .................................................................... O-06.06
Cecchin, S ........................................................................O-27.03
Chachaj,A....................................................... O-03.05, O-14.07
Chang,D.......................................................... O-02.06, O-18.03
Chang,T .........................................................................O-21.06
Chanwimalueang,N........................................ O-29.06, P-29.15
Chanwimalueang , N ....O-11.09, O-12.05, O-18.07, O-24.02, P
-13.07
Chatterjee,V...................................................................O-23.01
Chiang, Y J ..................................................................... O-14.05
Childs, E ..........................................................................O-28.04
Christiaens, M R .............................................................O-06.05
Christiansson, I ...............................................................O-14.04
Christiansson , I ..............................................................O-11.07
Ciucci, J L ....................................................................... O-12.06
Connell, F ........................................................................O-04.02
Cormier, J ......................... O-14.05, O-16.03, O-16.07, O-18.02
Cosentino, J .....................................................................O-30.01

AUTHOR INDEX
NAME NUMBER
Cote, G .............................................................................O-23.01
Cwikla, J ......................................................................... O-22.08
D
Dahl , M ...........................................................................O-24.03
Dalen, K ...........................................................................O-20.08
Daley,S............................................................................ P-14.14
Damstra, R ........................................O-11.02, O-26.04, O-26.07
Damstra, R J ...... O-01.02, O-06.03, O-11.05, O-25.02, O-26.01
Damstra, R. J. ..................................................O-19.06, O-20.07
Damstra, R.J. ..................................................................O-13.05
Danilevskaya, O. V. ...........................O-18.04, P-29.11, P-29.12
Danoff, J ..........................................................................O-17.03
Dawson, R ........................................................ O-14.06, O-17.06
De Cian, F ........................................................ O-06.06, O-14.01
De Ridder, M .................................................................. O-14.02
De Vries, D ...................................................................... O-14.06
Deltombe, T H ................................................. O-26.02, O-29.01
Demidova, E. Y U. ...........................................................P-29.12
Demiguel - Jimeno, J M .................................................O-30.04
Demirtas, Y ......................................................O-20.06, O-27.05
Desaki, J .......................................................................... O-03.07
Dewilde, J ........................................................................O-22.02
Devoogdt,N.....................................................................O-06.05
Diana, S ........................................................................... O-15.02
Dimakakos, E. .................................................................O-21.02
Dixon, J ........................................................................... O-23.05
Doi, K ...............................................................................O-11.08
Domaszewska - Szostek, A ............................................ P-03.12
Domaszewska - Szostek, A ...............O-22.08, O-23.03, P-03.12
Dósa - Rácz, É ...............................................................RT-02.02
Douglass,J....................................................... O-06.01, O-12.08
Duarte - Alfonso, E ......................................................... P-14.13
Durlik, M ............................ O-23.04, O-24.06, P-03.12, P-03.12
E
Ebrahimi, M ....................................................................O-06.04
Edgar,J........................................................................... O-05.05
Ekataksin, W .O-11.09, O-11.09, O-12.05, O-12.09, O-18.07, O
-24.02, O-29.06, P-02.07, P-11.11, P-13.07, P-29.15
Erős, G .............................................................................O-07.02
Ezaki, T .............................................................O-03.07, P-27.06
NAME NUMBER
F
Failla, A ......... O-03.04, O-04.03, O-05.04, O-11.01, O-15.01, O
-15.06, O-22.04, O-29.03
Faulkner, M .................................................................... O-23.05
Feldman, J .......................................................................O-16.03
Felmerer, G ....................................... O-19.02, O-24.01, P-24.07
Finnane, A .......................................................................O-08.03
Fiorentino, A ......O-03.04, O-11.01, O-15.01, O-15.06, O-27.03
Forner - Cordero, I ...........................O-13.06, O-30.04, P-14.13
Fouka, G. .........................................................................O-21.02
Freccero, C ........................ O-17.04, O-19.08, O-20.05, O-26.06
Freccero, C .....................................................................O-26.05
French, J ..........................................................................O-10.08
Frick, A ............................................................ O-20.02, O-28.02
Friedman, D ....................................................................O-06.06
Fujino,T..........................................................................O-06.07
Föeldi, E .......................................................................... O-18.01
Földi, E .............................................................................P-24.07
G
Galbraith, C ....................................................................O-23.02
Garcia - Saez, R ...............................................................P-14.13
Gashev, A ........................................................................ O-23.01
Gasheva, O .......................................................................P-04.07
Genette, A ........................................................................O-29.01
Geraerts, I ....................................................................... O-06.05
Gerber, L ......................................................... O-17.02, O-17.03
Gerhard, M ..................................................................... O-11.08
Gershenwald, J ............................................................... O-14.05
Gersman, A ......................................................O-30.08, O-30.08
Gersman, A ......................................................O-30.08, O-30.08
Gevorgyan,A..................................................................O-24.04
Gogia,S........................................................................... O-24.06
Gordon, S ..........................................O-10.03, O-13.04, O-17.05
Gottrup,F....................................................................... O-16.06
Greene, A ......................................................... O-05.01, O-05.02
Gruvsved Andersson, Å ..................................O-04.05, O-04.06
Gubina, M ....................................................................... O-27.04
Guerrini, A ......................................................................O-27.03
Guoling,C....................................................................... O-02.03
Gutierrez - Delgado,M..................................................O-13.06
195

AUTHOR INDEX
NAME NUMBER
196
H
Haag O Agga,M.............................................................O-04.03
Habarov, D ......................................................................O-19.09
Habibi, M ........................................................................ O-29.05
Haghighat,S......................O-06.04, O-29.02, O-29.05, O-30.02
Haji Mollahoseini,F.......................................................O-29.05
Hamadé, A ...................................................................... O-21.04
Hanboon, B K ................................................................. O-11.09
Hansson, E ...................................................................... O-02.04
Hardy,M.........................................................................O-22.02
Hasegawa,H................................................................... O-12.02
Hawro, R ..........................................................O-03.05, O-14.07
Hayes,S............................. O-01.01, O-01.07, O-08.04, O-08.06
Hayes, S C ....................................................................... O-08.03
Heerkens, Y ..................................................... O-10.02, O-16.05
Heidenreich, B ............................................................... O-06.01
Hendrickx, A ...................................................................O-01.02
Heppner,P...................................................................... O-08.02
Hidding,J......................................................... O-16.05, P-06.09
Hoch, J .............................................................................O-19.05
Homaei , F .......................................................................O-06.04
Honkonen, K .................................................................RT-01.03
Horneij,E........................................................................ P-01.08
Hosono, M ......................................... O-19.01, O-22.07, P-29.10
Houdová, H ..................................................................... O-19.05
Hsu, W .............................................................................O-21.06
Hyngstrom,J.................................................................. O-14.05
Iida, T .............................................................................. O-11.08
Iker, E ..............................................................................O-22.03
Immink, M ...................................................................... O-12.08
Inayama,Y...................................................................... P-14.12
Isakoff, S J .........................................O-11.06, O-14.08, P-11.13
Ivanchev, K ..................................................................... O-05.06
Jacomo, A L .................................................................... O-07.01
Jain, P ...O-24.06, O-29.07, O-30.05, O-30.06, O-30.07, P-20.10
Janda, M ......................................................................... O-08.03
Janda, M ........................................................................ O-08.06
Jarolím, L ........................................................................O-24.05
Jasinski, R ........................................................O-03.05, O-14.07
Jeffery,S..........................................................................O-04.02
Jense, E ............................................................................O-26.06
Jeon, J Y ............................................................P-09.05, P-26.08
Jeong, J Y ........................................................................ P-09.08
Jodkowska, A .................................................. O-03.05, O-14.07
I
J
NAME NUMBER
Johansen, M ....................................................................O-20.08
Johansson, B ....................................................................P-29.13
Johansson, K ....... O-01.06, O-01.07, O-08.01, P-01.08, P-08.07
Johansson , K ..................................................................O-24.03
Johnston, M .................................................................... O-28.01
Jonsson, A ........................................................................P-08.07
Jönsson, C ....................................................................... O-01.06
K
Kalemikerakis, J. ............................................................O-21.02
Kallen, M .........................................................................O-16.07
Kandamany,N................................................................O-19.04
Kaneda, K ........................................................................P-02.07
Karami , M ......................................................................O-29.02
Karlsmark, T ....................................................O-16.06, P-09.07
Karlsson, K ......................................................................P-29.13
Katorkin, S ......................................................................O-21.05
Keeley,V.......................................................... O-06.08, O-25.03
Kemény,L......O-07.02, O-10.04, O-15.02, RT-02.02, RT-02.02
Khadem Maboudi, A A ..................................................O-29.02
Khajornsaksumeth,W...................................................O-11.09
Khananyan, N.A. ............................................................O-18.04
Kilbreath, S ......................................................O-01.05, O-10.08
Kim, B H .......................................................................... P-14.11
Kim, H J ...........................................................................P-26.08
Kimata, Y ........................................................................O-18.03
Kindt, N ...........................................................................O-22.02
Kitahara, S ......................................................................O-03.07
Klernäs, P ........................................................................O-08.01
Klinkert, P. ....................................... O-13.05, O-19.06, O-20.07
Koba - Wszedybyl,M.....................................................O-03.05
Koba - Wszędybył,M.....................................................O-14.07
Kobayashi,N...................................................................O-06.07
Koelmeyer,L.................................................................. O-10.08
Kombantsev, E ............................................................... O-19.09
Komulainen, M ...............................................................O-10.05
Konenkov, V ................................................................... O-27.04
Kong, E H ........................................................................ P-14.11
Konno, H ..........................................................O-21.03, O-23.07
Koshima, I .......................................................................O-11.08
Krag,C............................................................................O-23.06
Krieger,C........................................................................O-21.04
Kristjanson,L.................................................................O-08.01
Kudo, A ............................................................................P-14.12
Kukushkin, G ................................................................. O-28.06
Kula, M ............................................................................ P-11.10
Kulikov, I ........................................................................ O-27.04
Kurieva, F ........................................................ O-12.04, O-28.06

AUTHOR INDEX
NAME NUMBER
Kurnikova, I .................................................... O-12.04, O-28.06
Kärki, A ........................................................... KN-08, RT-03.04
L
Lacerda, M ...................................................................... P-29.14
Lahtinen, T ..................................................................... O-10.05
Lamote, J .......................................... O-10.01, O-14.02, O-14.03
Lamprou, D A A .............................................................O-26.01
Lamprou, D A. A. ............................ O-13.05, O-19.06, O-20.07
Lamprou, D- A A ............................................................O-26.07
Lauret - Roemers, M ......................................................O-25.05
Lavagno,R...................... O-14.01, O-20.01, O-21.01, RT-03.02
Lee, J ................................................................ O-10.08, O-14.05
Lee, M J ...........................................................................O-01.05
Lee, S J ............................................................................P-09.08
Lee, S J .............................................................. P-09.05, P-26.08
Leflor, J ........................................................................... O-16.07
Lehn - Hogg,M...............................................................O-21.04
Leong,S.............................................................................KN-03
Leunen, K ........................................................................O-06.05
Levin, Y .............................................O-12.04, O-28.05, O-28.06
Levy,E............................................................. O-17.02, O-17.03
Lglass,E.......................................................................... O-22.03
Lievens, P ..........................................O-10.01, O-14.02, O-14.03
Lindman, H ..................................................................... P-29.13
Linnell, J .......................................................................... P-01.08
Liu, N ................................................................O-05.03, O-22.01
Liu, Z ................................................................................P-03.09
Lopez - Agustin,M.........................................................O-13.06
Lotfi - Tokaldany ,M..................................... O-29.02, O-30.02
Lubarsky,M.................................................... O-19.09, O-27.04
Luwan, W ........................................................ O-02.03, O-07.03
M
Mackie, H .........................................................................P-29.08
Mackie, H .......................................................................O-20.04
Maegawa,J........................................O-19.01, O-22.07, P-29.10
Maksimov, V ...................................................................O-27.04
Mano, Y ............................................................O-21.03, O-23.07
Manokaran, G ..................................O-13.01, O-13.02, O-13.03
Mansour, S ......................................................................O-04.02
Marchenko, A. I. ..............................................O-18.04, P-29.12
Marchenko , A. I. ............................................................ P-29.11
Marcovecchio, L ............................................................. O-12.06
Maria, D A ...................................................................... O-07.01
Marshall, M .................................................................... O-18.02
Martin, K ........................................................................ O-18.01
Martin, R .........................................................................O-16.07
NAME NUMBER
Martinez , R .................................................................... O-04.01
Martino, M .......................................................O-10.02, O-16.05
Masia, J ........................................................................... O-19.03
Matthews, M ....................................................O-10.03, O-17.05
Mavili, E ...........................................................................P-11.10
Mayrovitz,H...................................................................O-09.03
Mc Fetridge,L................................................................ O-10.06
Mc Garvey,C..................................................................O-17.02
Mcewen, M ......................................................................O-10.07
Mcgarvey,C....................................................................O-17.03
Meddings - Blaskett,O.................................................. O-23.02
Meier - Vollrath, I ....................... O-15.04, RT-02.03, RT-02.04
Meiklejohn,J.................................................................. O-08.04
Melrose, W .....................................................................O-13.04
Mendoza, A ..................................................................... O-12.06
Merrett, S ........................................................................O-12.07
Michel, P ..........................................................................O-21.04
Michelini, S ....O-03.04, O-04.03, O-05.04, O-11.01, O-15.01, O
-15.06, O-22.04, O-27.03, O-29.03
Michelotti, L ....................................................................O-04.03
Mihara, M ....................................................................... O-11.08
Miller, C L .......................... O-11.06, O-14.08, P-11.12, P-11.13
Milov, V ...........................................................................O-28.06
Mirzaei, HR .................................................................... O-06.04
Mitsuda, M ...................................................................... P-13.07
Miura, M ..........................................................................P-14.12
Moneta, G ......O-03.04, O-05.04, O-11.01, O-15.01, O-15.06, O
-29.03
Moore, J ........................................................................... P-04.07
Morikawa, S ....................................................................O-03.07
Mortimer, P ......................................KN-04, O-04.02, RT-02.01
Moseley,A.......................................................................O-06.01
Mosti, G ...........................................................................O-25.01
Mosti, H ..........................................................................O-26.04
Mungovan,K.................................................................. O-14.05
Munnoch, A ......................................O-06.02, O-19.07, O-29.04
Munnoch, D .................................................................... O-19.04
Munoz - Langa,J........................................................... O-30.04
Munro, K .........................................................................O-19.04
Mushnikova, N. Y U. ......................................................O-18.04
Månsson, S ...................................................................... O-18.06
197

AUTHOR INDEX
NAME NUMBER
198
N
Nagahama,K...................................................................P-14.12
Nagai,T........................................................................... O-23.01
Nagao,T...........................................................................P-14.12
Najafi,M......................................................................... O-06.04
Narushima, M .................................................................O-11.08
Nazemi, F ........................................................................ O-30.02
Neklyudova, P. S. ............................................................ P-29.11
Nemes, A ....................................................................... RT-02.02
Németh, I B ..................................................................... O-07.02
Neven, P ...........................................................................O-06.05
Niemi, T ...........................................................................O-20.03
Nieuwenhuijsen, A T M ..................................................P-14.09
Nilsson Wikmar, L ..........................................................P-29.13
Nimaev, V .........................................................O-19.09, O-27.04
Nishiyama,M..................................................................O-23.07
Nitiwarangkul,W...........................................................O-18.07
Niu, C ....................O-03.06, O-03.08, P-03.09, P-03.10, P-03.11
Notohamiprodjo,M........................................................O-20.02
Nuutinen, J ......................................................................O-10.05
Nørregaard,S...................................................O-16.06, P-09.07
O
O' Toole, J ........................................................................P-11.12
O' Toole , J ....................................................... O-14.08, P-11.13
O' Toole,, J ......................................................................O-11.06
Obermair, A .....................................................O-08.03, O-08.06
Obringer,G.....................................................................O-21.04
Oh, B M ............................................................................P-14.10
Ohkuma, M .........O-03.02, O-03.03, O-27.02, O-30.03, P-13.07
Ohlin, K ..............O-17.04, O-19.08, O-20.05, O-26.05, O-26.06
Ohtani, O ......................................................................... P-14.12
Okada, E ......................................................................... O-02.02
Okudela, K .......................................................................P-14.12
Olszewski, W .O-23.04, O-24.06, O-29.07, O-30.05, O-30.06, O
-30.07, P-03.12, P-03.12, P-20.10
Olszewski, W L ................................. O-22.08, O-23.03, P-19.10
Oshima, A ....................................................................... O-11.08
Oshiro, H ......................................................................... P-14.12
Ostergaard,P..................................................................O-04.02
Oyama,K.........................................................................P-13.07
NAME NUMBER
P
Palkó, A ........................................................................... O-10.04
Pallotta, O ....................................................................... O-10.07
Pallotta, O J .................................................................... O-10.06
Paltrinieri, E ................................................................... O-04.01
Panova, I ......................................................................... O-28.06
Papendieck,C................................................................. O-04.01
Park, J ..............................................................................P-09.04
Partsch, H ...........O-25.01, O-26.01, O-26.03, O-26.04, O-26.07
Passariello, F .................................................... O-07.06, P-09.06
Perbeck, L ....................................................................... O-18.08
Peterson, P ...................................................................... O-18.06
Pettersson, L ....................................................................P-08.07
Pfalzer, L ..........................................................O-17.02, O-17.03
Phillips,J.........................................................................O-04.04
Pikalov, M ....................................................................... O-28.05
Pilch, U .............................................................O-03.05, O-14.07
Piller, N ..........O-01.04, O-06.01, O-10.07, O-12.07, O-12.08, O
-14.06, O-17.01, O-17.06, O-23.02, RT-01.02
Piller, N B .........................................................O-10.06, O-12.01
Pinelli, L .......................................................................... O-27.03
Pissas, A ...........................................................................O-24.04
Piyaman,P...........O-11.09, O-24.02, O-29.06, P-02.07, P-29.15
Polsachev , V. I. .............................................................. O-18.04
Ponomareva, E. Y U. ...................................................... P-29.12
Pons, G ............................................................................ O-19.03
Poon, K ............................................................................O-20.04
Postriganova, N. D. ......................................................... P-29.12
Povestchenko, A ..............................................................O-27.04
Puglisi,D......................................................................... O-22.04
Puglisi,M........................................................................ O-06.06
Pyykönen,J.....................................................................O-10.05
Q
Qin, L ................................................................ O-03.08, P-03.10
R
Raad, R A ........................................................................ P-11.13
Radmer Jensen, M .......................................................... P-09.07
Rahbar, E .........................................................................P-04.07
Rasmussen, J ...................................................................O-18.02
Refshauge,K....................................................O-01.05, O-10.08
Rel - Monzo, P ................................................................ O-30.04
Reneker, J ....................................................................... O-16.02
Reul - Hirche, H ..............................................................O-08.06
Reynders,T.....................................................................O-14.02
Rice, J ...............................................................O-06.01, O-14.06
Riches, K ...........................................O-06.08, O-25.03, O-25.06

AUTHOR INDEX
NAME NUMBER
Rockson , S ......................................................................O-27.01
Rodionova, O .................................................................. O-28.06
Romaldini, F ................................................................... O-22.04
Ross, M ............................................................................O-14.05
Rubio - Maicas, C ........................................................... P-14.13
Russell, T A .........................O-11.06, O-14.08, P-11.12, P-11.13
Ryan,T.............................................................................. KN-06
Ryan, T J .........................................................................O-03.01
Saarikko , A .................................................................... O-20.03
Saaristo, A .....................................................................RT-01.03
Saeed, H ...........................................................................O-17.01
Saez, H .............................................................................O-16.07
Saito, T ............................................................. O-21.03, O-23.07
Sakuragi,N..................................................................... O-06.07
Salusri, C .........................................................................O-05.04
Samarin, M ..................................................................... O-17.01
Samkharadzé, T ............................................................. O-21.04
Sanderson, P ................................................................... O-08.05
Sandsborg,A................................................................... P-01.08
Sano, M ............................................................ O-21.03, O-23.07
Santi, P ............................................O-06.06, O-20.01, RT-03.02
Santi, P L ......................................................... O-14.01, O-21.01
Schainfeld , R ..................................................................O-14.08
Schaverien, M ................................................................. O-06.02
Schmeller, W ................................O-15.05, RT-02.03, RT-02.04
Schmitz, K ........................... KN-02, O-01.01, O-01.03, O-01.07
Schoevaerdts, J C ............................................O-26.02, O-29.01
Semple,J......................................................................... O-28.01
Semprebene,A................................................................O-22.04
Seo, K S ............................................................. P-09.04, P-14.10
Setou, M .......................................................................... O-21.03
Sevick - Muraca, E ......................................................... O-18.02
Shanley,K........................................................ O-20.04, P-29.08
Sharikov, Y ..................................................................... O-28.06
Shimazu, Y .......................................................................P-14.12
Shimizu, K ........................................................ O-03.07, P-27.06
Shumkov, M ....................................................................O-19.09
Shyu,C..............................................O-16.01, O-16.02, O-16.04
Si, Y .................................................................................. P-03.10
Sierakowski, K ................................................................O-01.04
Silva, A Q ........................................................................ O-07.01
Sim, Y J ................................ P-09.05, P-09.08, P-14.11, P-26.08
Simanin, R. A. ................................................................. P-29.11
Simpson,M..................................................................... O-04.02
Skolny, M N ........................O-11.06, O-14.08, P-11.12, P-11.13
Skördåker, A ................................................................... P-08.07
S
NAME NUMBER
Slavin, S ...........................................................................O-15.03
Smalky,K........................................................................O-16.07
Smeets, A .........................................................................O-06.05
Smith, B L ......................................... O-11.06, O-14.08, P-11.13
Smith, J ........................................................................... O-06.01
Soballe, P .........................................................................O-17.03
Soballe, P ........................................................................O-17.02
Soluyanov,M.................................................................. O-19.09
Soustelle, L ......................................................................O-24.04
Specht,M...........................................O-11.06, O-14.08, P-11.13
Speck,R........................................................... O-01.01, O-01.07
Springer,B.......................................................O-17.02, O-17.03
Springer,S...................................................................... O-20.02
Steen - Zupanc,U............................................................P-08.07
Stelmach, E ..................................................................... O-30.07
Stewart, B .......................... O-08.02, O-16.02, O-16.03, O-16.04
Stewart, B ....................................................................... P-10.09
Stoessel, J C .....................................................................O-21.04
Stout, N .............................................................O-17.02, O-17.03
Stulin , I. D. ......................................................................P-29.12
Suami, H .......................................................... O-02.06, O-18.03
Suebtrakul, P ...................................................O-11.09, O-24.02
Suominen, E .................................................. O-20.03, RT-01.03
Suzuki, M .........................................................O-21.03, O-23.07
Svensson, B ........................O-17.04, O-19.08, O-20.05, O-26.06
Svensson, B .................................................................... O-26.05
Svensson, H .......................................O-02.04, O-19.08, O-20.05
Svensson, L .................................................................... O-18.08
Syrigos, K. ......................................................................O-21.02
Syzdykova,K.................................................................. O-28.06
Szentner, K ......................................................................O-07.02
Szewczyk,K.....................................................O-03.05, O-14.07
Szolnoky,G..................... O-07.02, O-10.04, O-15.02, RT-02.02
Szuba, A ........................................................... O-03.05, O-14.07
T
Taghian, A G ...................... O-14.08, O-14.08, P-11.12, P-11.13
Taghian ,A......................................................................O-11.06
Tan, I ............................................................................... O-18.02
Tanaka, H ........................................................ O-21.03, O-23.07
Tarkowski, R ................................................... O-03.05, O-14.07
Taylor,S..........................................................................O-14.05
Teerachaisakul, M ..........................................................O-12.05
Tengrup,I....................................................................... O-11.07
Tennvall - Nittby,L........................................................O-11.07
Tervala, T ...................................................... O-20.03, RT-01.03
Thangaswamy,S.............................................................O-23.01
Theunissen, C C W .........................................................O-11.05
199

AUTHOR INDEX
NAME NUMBER
Theys,S............................................................ O-26.02, O-29.01
Thirot , J F R .................................................. O-26.02, O-29.01
Tian, H ............................................................. O-07.05, O-07.05
Tian, H ............................................................. O-07.05, O-07.05
Tian, T ............................................................................. O-28.03
Tilley,S............................................................................O-10.07
Tintner, R ........................................................................O-16.07
Tiong,J............................................................. O-20.04, P-29.08
Tobbia, D .......................................... O-19.02, O-24.01, O-28.01
Todini, M .........................................................................O-03.04
Todisco, R ....................................................................... O-03.04
Tomášek, D ..................................................................... O-19.05
Tomoeda, H .......................................O-19.01, O-22.07, P-29.10
Topalan,M...................................................... O-20.06, O-27.05
Tosaki, A ..........................................................................P-29.10
Trembath, R ....................................................................O-04.02
Truijen,S........................................................................ O-06.05
Tsai, T ..............................................................................O-21.06
Tsarapkina, A. R. .............................................O-18.04, P-29.12
Tuppurainen,M............................................................. O-10.05
200
U
Ung,O............................................................................. O-10.08
Unno, N ............................................................ O-21.03, O-23.07
Urbain, F ......................................................................... O-22.02
Urbain, F C ......................................................O-22.05, O-22.06
Urtaev, B. M. ....................................................O-18.04, P-29.11
V
Váchová, H ......................................................................O-11.04
Van De Veen, W ............................................................. O-20.08
Van Duinen, K F .............................................................O-11.05
Van Gulick - Gielink, P .................................................. P-06.09
Van Kampen,M............................................................. O-06.05
Van Parijs,H.................................................................. O-14.02
Van Ravensberg,D......................................... O-10.02, O-16.05
Vandermeeren, L ............................................ O-22.05, O-22.06
Vardaki, Z. ......................................................................O-21.02
Varga,E.........................................................O-10.04, RT-02.02
Varga,M........................................................O-10.04, RT-02.02
Verbelen, H ..................................................................... O-14.03
Veske, M ..........................................................................O-20.08
Victor, J ............................................................................P-20.10
Viehoff, P ......................................................... O-10.02, O-16.05
Viitanen, T ...................................................................... O-20.03
Vinh - Hung,V............................................................... O-14.02
Voesten, H. G. J. ...............................O-13.05, O-19.06, O-20.07
NAME NUMBER
W
Wald, M .............................O-11.04, O-19.05, O-20.09, O-24.05
Wallenius, I ......................................................................P-29.13
Wallmichrath, J ...............................................O-20.02, O-28.02
Wanchai, A ..................................................................... O-08.02
Wang,W......................................................................... O-28.04
Ward, L ............................. O-01.05, O-08.06, O-10.08, O-13.04
Ward, L C ....................................................................... O-09.01
Warner, J ........................................................................ O-13.04
Warren, L E .....................................................................P-11.12
Warren Peled, A .............................................................O-15.03
Washington,J..................................................................P-14.14
Waters, M ........................................................................O-10.07
Wei, Y ..............................................................................O-03.06
Weiss, J .............................................................O-29.02, O-30.02
Weiss, M ..........................................................................O-20.02
Wigg,J.............................................................................O-29.04
Wikkeling, O. R M. ........................................................ O-13.05
Wikkeling, O. R. M. ........................................O-19.06, O-20.07
Wilson, J ......................................................................... P-04.07
Witte, M ........................................................................... P-14.14
Witte, M H ........................................................................ KN-01
Wonders, T ..................................................................... O-10.07
Wongwat,P.....................................................................O-11.09
Wozniewski, M ................................................ O-03.05, O-14.07
X
Xing,Y.............................................................................O-14.05
Xu, S ................................................................. O-16.01, O-16.04
Y
Yakubson, V. V. ..............................................................O-18.04
Yamada, K ...................................................................... O-18.03
Yamamoto, N ....................................O-11.08, O-21.03, O-23.07
Yamamoto, T .................................................................. O-11.08
Yanes Chandia, P ........................................................... O-12.06
Yanli, L ............................................................................O-07.03
Yarema, I. V. ....................................................O-18.04, P-29.11
Yarema , R. I. ....................................................P-29.11, P-29.12
Yarovenko, G ..................................................................O-21.05
Yun, G J ............................................................ P-09.05, P-26.08
Yun , G J ..........................................................................P-09.08
Yunesian, M ....................................................................O-06.04
Yunesian , M ...................................................................O-30.02

AUTHOR INDEX
NAME NUMBER
Z
Zaima, N ..........................................................................O-21.03
Zaleska, M .....O-22.08, O-23.03, O-23.04, O-24.06, O-29.07, O
-30.05, O-30.06, O-30.07, P-03.12, P-03.12
Zawieja,D.........................................................O-28.04, P-04.07
Zayeri,F..........................................................................O-29.05
Zee, T ...............................................................................O-25.04
Zhang,H......................................................................... O-07.05
Zhang,J.............................. O-03.06, O-03.08, P-03.09, P-03.10
Zhang,L...........................................................................P-03.10
Zhang,Y............................. O-03.06, O-03.08, P-03.09, P-03.10
Zhang,Z...........................................................................P-03.11
Zhao, Z ................................O-03.06, O-03.08, P-03.09, P-03.10
Zhaoxi, D ..........................................................O-07.04, O-12.03
Zhiyu,L............................................................O-07.04, O-12.03
Zhu, B ..............................................................................O-18.02
Zhu, X ..............................................................................O-05.05
Zinicola, V .......................................................................O-29.03
Zou, Z ...............................................................O-28.03, O-28.03
Zou, Z ...............................................................O-28.03, O-28.03
Zvonik, M ........................................................................O-24.01
Å
Åberg,M...........................................O-05.06, O-19.08, O-20.05
NAME NUMBER
201

EXHIBITION

List of exhibitors
BSN medical / JOBST
Mr Rune Westheim
Uggledalsvägen 13
427 40 Billdal
Sweden
T +46 31 727 98 04
F +46 31 727 98 10
E rune.westheim@bsnmedical.com
BSN Medical manufacture JOBST compression garment
for lymphatic and venous diseases. We offer Custom Made
garment, RTW garments and compression bandages.
medi GmbH & Co. KG
Mr Christian Lacher
Medicusstr. 1
95448 Bayreuth
Germany
T +49 921 912-0
F +49 921 912-781
E export@medi.de
medi GmbH & Co. KG in Germany is one of the world’s
leading manufacturers of compression hosiery. medi
supplies the following products:
• medical compression stockings for treatment of venous
disorders (i.e. varicose veins, DVT, etc.)
• anti-embolism stockings for thrombosis prophylaxis in
hospitals
• lymphoedema sleeves and stockings
• elastic supports
• orthotic rigid braces for knee, hip, shoulder and back
• prosthetic products
• compression sport socks
3M Svenska AB
Ms Christina Erviken Eile
Bollstanäsvägen 3
191 89 Sollentuna
Sweden
T +46 (0)8 92 25 18
F +46 (0)8 92 22 89
E christina.erviken@mmm.com
In 3M, we have worked with compression for leg ulcers for
years. 3M has now developed a treatment for lymphoedema,
where there is considerable focus on treatment effectiveness
and quality of life of patients.
After extensive research, design and testing, 3M's
researchers developed 3 M Coban compression systems
- a breakthrough compression bandage, which may change
the procedure for intensive lymphoedema treatment.
ApodanNordic HealthCare A/S
Ms Pernille Krogh
Lergravsvej 63
Copenhagen S 2300
Danmark
T +45 3297 1555
F +45 3297 2101
E pk@apodan.dk
Apodan Nordic distributes in Denmark medical compression
products under the brands: CircAid® and Lympha Press®
Varitex NV manufactures and distributes in Europe medical
compression products under the brands: Varitex®, CircAid®
Medical Products, Lympha Press® and Eureka®
204
Bauerfeind AG
Ms. Isabell Weber
Triebeser Str. 16
07937 Zeulenroda-Triebes
Germany
T +49 (0)36628 – 66 1000
F +49 (0)36628 – 66 1999
E info@bauerfeind.com
Bauerfeind AG is one of the leading manufacturers of
medical aids such as compression stockings, supports,
orthoses and orthopedic insoles and shoes. The high-quality
products with the respected „Made in Germany“ label make
an important contribution to maintaining and restoring
health.
Bodystat Ltd
Mrs Louise Whitelegg
PO Box 50
Douglas
Isle of Man (British Isles)
T +44 (0) 1624 629 571
F +44 (0) 1624 611 544
E info@bodystat.com / louise@bodystat.com
QuadScan 4000 Two devices in one! Firstly, assess fluid shifts
in limbs with the Impedance Ratio, instantly displayed on
this portable device, identifying Intra / Extra cellular fluid
shifts. Secondly, manage the whole body, with measures
including body fat, fat-free mass, lean mass, total body
water, extra-cellular water, and more.
Carl Zeiss AB
Mr Peter Wallin
Box 27324
102 54 Stockholm
Sweden
T +46 (0)8-459 25 00
F +46 (0)8-660 29 35
E med@zeiss.se
Vario 700 is a visualization system that enlarges anatomical
structures and displays them with good illumination. It
enables surgeons to recognize minute details and work
with precision. Magnification is primarily important in
minimally invasive surgery.
Delfin Technologies Ltd
Mr. Aki Immonen
P.O. Box 1199, Microkatu 1
Kuopio, 70211
Finland
T +358 50 911 1199
F +358 17 222 2343
E info@delfintech.com
Delfin produces scientific instruments for skin and oedema
measurements. Used worldwide, these are accurate, reliable
and user-friendly. The MoistureMeterD and MoistureMeterD
Compact are water-specific instruments for the local and
non-invasive measurement of tissue dielectric constant
(TDC) used in lymphoedema research, early detection of
lymphoedema and assessment of treatment efficacy.

Haddenham Healthcare Ltd
International Sales
Crendon House
Long Crendon, Bucks, HP18 9BB
United Kingdom
T +44 (0)1844 208842
F +44 (0)1844 208843
E sales@hadhealth.com
Haddenham Healthcare is an independently owned
company specializing in the treatment of lymphoedema.
Haddenham is a market leader in UK, and is now rapidly
developing partnerships in international markets with its
own operation in Australia, and partnership / distribution
arrangements in Europe, North America and Asia.
Höjmed Medical AB
Mr David Erlandsson
Box 24053
104 51 Stockholm
Sweden
T +46 (0)8 41070600, +46 (0)733-424752
E info@hojmed.com
Manufacturer and distributor of medical devices in the field
of plastic, burns, reconstructive and trauma surgery.
Intramedic AB
Ms Christina Lundbäck
Vänersborgsvägen 5
746 34 Bålsta
T +46(0 171 468383
E Christina.lundback@intramedic.se
Rolf Davidsen Helseagenturer AS/Jovipak
Mr ROLF DAVIDSEN
POSTBOX 238
4291 KOPERVIK
NORWAY
T 0047 52844500
F 0047 52844509
E post@rdh.as
JOVIPAK Quality you can feel, products you can trust, for
managing lymphedema. RDH AS is a company that provides
a complete range of products for lymphedema treatment
with JoviPak, Lympha Press and Mediven compression
garments.
Juzo GmbH
Ms Petra Jakob
Juliusplatz 1
86551 Aichach
Germany
T +49 163 3901014
F +49 8251 90177151
E petra.jakob@juzo.de
Juzo is one of the leading manufacturers for compression
garments worldwide. With its production in Germany, Juzo
is celebrating its 100. anniversary in 2012 and therefore has a
precious variety of experience in compression therapy. From
tip to toe in the field of Lymphology, Phlebology and Scar
Treatment.
We are looking forward welcoming you at our booth!
Lymed Oy
Ms Marisa Palonen
Pyhäjärvenkatu 5 A
Tampere, 33200
Finland
T +358 20 779 2233
F +358 20 779 2230
E info@lymed.fi
Lymed Oy is a Finnish manufacturer of high quality
custom-made medical compression garments with 20 years’
experience. Unique, exclusively developed materials are
used in manufacturing, enabling us to design garments that
are comfortable to wear, look good and give the best possible
result in the therapy.
Solaris
Mr Dave Lischka
6737 West Washington Street, Suite 3260
West Allis, WI 53214
United States of America
T +1 (414) 918-9180
F +1 (414) 918-9189
E info@solarismed.com
With over a decade of manufacturing experience, Solaris
has become a leader in nighttime lymphedema management
and is quickly developing a reputation in venous and wound
care treatment. Solaris prides itself on its products, customer
service, and involvement in their local and lymphedema
communities. For more information, visit www.solarismed.
com.
Technovital AB
Mr Johan Wessel
Gyllenstiernsgatan 16
115 26 Stockholm
T +46 8 7656860
E info@technovital.se
“LPG ENDERMOLOGIE” is the science of cell-stimulation
proven by more than 85 scientic studies. It reactivates
dormant cellular activity by mechanically stimulating
the skin. (mechano-stimulation) Treatment of diverse
lymphologie patalogies are particulary efficient as well as
non-invasive and pain-free.
205

206

EXHIBITION MAP
Carl Zeiss, Technovital,
3x2 3x2
Jovipak
3x2
Posters
Posters
Intramedic
3x2
Solaris
3x2
Coffee
Haddenham
5x2
Coffee
Bodystat
3x2
Delfin
3x2
Lymed
3x2
Höjmed
3x2
3M
4x2,5
Lunch Area
medi
6x6
Coffee
Coffee
Coffee
Coffee
Entrance from
lecture halls and
registration area.
Juzo
4x2
Apodan
6x2
Bauerfeind
4x2,5
BSN Medical
12x4,5

23rd International
Congress of
Lymphology
September 19-23, 2011
Malmö, Sweden www.lymphology2011.com
Congress and Exhibition Office
Destination Öresund AB
Fersens väg 18 • 211 42 Malmö, Sweden
Tel +46 (0)40-300 665 • Fax +46 (0)40-918 952
lymphology2011@destinationoresund.com
www.lymphology2011.com