Masterclass GUIDES

Introduction

Lower extremity lymphedema is an under recognized and under managed clinical condition. Too often unrecognized, the correct diagnosis of lymphedema is essential for appropriate clinical management.1,2 Often undermanaged, or potentially mismanaged through the liberal use of diuretics, the result can lead to secondary unintended consequences and result in progressive adipose deposition, tissue fibrosis, increasing limb volume, heaviness, functional difficulties,increased susceptibility to recurrent episodes of cellulitis, and overall higher healthcare utilization.

This Masterclass Guide provides an overview of this condition in clinical practice.

What is Lymphedema?

Assessment of Lymphedema

■ Lymphedema is the result of a loss of the finely tuned balance of microvascular tissue fluid production and recovery through the lymphatic vasculature, chronic inflammation, and loss of integrity of the lymphatic endothelial cell GCX 3-7

■ Primary lymphedema is due to a genetic mutation resulting in abnormal lymphatic vascular development causing either a structural or functional abnormality that impairs proper drainage of lymphatic fluid, and is further categorized as congenital (identification based upon abnormalities identified shortly after birth), praecox (abnormalities identified most often during teenage years or early adulthood), or tarda (typically occurring after age 35) 3

■ Due to the challenges associated with accurately diagnosing lymphedema, clinicians should carefully consider the differential diagnosis. Patients can be broadly segregated by those with unilateral asymmetric or bilateral leg edema, and by acuity of onset

Acute onset unilateral leg edema

■ Consider DVT and evaluate using duplex ultrasonography. If DVT has been excluded, patients should be evaluated for musculoskeletal injury or cellulitis, which should be evident based on history and physical exam findings

Bilateral leg edema

■ The differential diagnosis includes medication-induced edema, acute heart failure, end-stage renal disease, and bilateral DVT. Common medicationinduced edema is often forgotten within the differential, yet is well described in the literature. Clinicians should closely examine medication lists as a significant proportion of patients now take antihypertensive medications commonly associated with edema (Table 1) 8

Unilateral leg edema

■ The differential diagnosis includes chronic venous insufficiency, chronic lymphedema, Baker’s cyst, May-Thurner syndrome, pelvic tumor, complex regional pain syndrome, syndromic limb hypertrophy (Klippel-Trenaunay syndrome and Proteus syndrome), and poor calf contractility (radiculopathy, stroke). Duplex ultrasonography can be helpful to identify chronic venous insufficiency and Baker’s cyst