治疗淋巴水肿(1)

Recognizing Lymphedema Is Vital in Assisting Oncology Patients 认识淋巴水肿有助于肿瘤患者治疗 January 21, 2009 — Oncologists who are alert to the signs and symptoms of cancer and cancer-treatment-related lymphedema can have a large impact on its course, because the chronic condition can be minimized if recognized and treated early, according to a review article on lymphedema published in the January/February issue of CA: A Cancer Journal for Clinicians. 依据2009年1月21日发在《临床癌症杂志》1/2月刊上关于淋巴水肿的一篇回顾性文章，提醒肿瘤专家警惕癌症和癌症治疗相关的淋巴水肿的体征和症状可以影响癌症的进程，因为如果尽早的认识和治疗，这种慢性过程可以最小化。 However, oncologists are generally too busy to oversee the care of lymphedema themselves, and hence should become familiar with resources that can help connect patients with lymphedema-management specialists, said lead author Brian D. Lawenda, MD, clinical director of radiation oncology at the Naval Medical Center, in San Diego, California. 这篇文章的第一作者——加利福尼亚圣地亚哥海军医疗中心放疗主任Brian D. Lawenda博士说：“肿瘤专家往往由于过于忙碌而忽视淋巴水肿的治疗，因此应该帮助病人联系处理淋巴水肿的专家。” "We don't have the time to manage the care for lymphedema. Therefore, my colleagues and I recommend that clinicians be aware of referring specialists in their area who are experts in the diagnosis and management of lymphedema," Dr. Lawenda said in an interview with Medscape Oncology。 Lawenda博士在肿瘤学医学网景的一次采访中说：“我们没有时间去处理淋巴水肿。因此，我同事和我建议临床医生要意识到向善于诊断和处理淋巴水肿的专家咨询。” Dr. Lawenda also noted that oncology patients at risk for lymphedema should receive pretreatment evaluation that includes baseline girth and volume measurements of limbs. He emphasized the importance of prevention education, which includes a discussion of risk factors, and arm and leg care guidelines. Lawenda博士同时也提到存在发生淋巴水肿危险的肿瘤患者应该进行包括淋巴的基线长度和测量体积的治疗前评估。他强调治疗前评估的重要性，包括风险因素的讨论和四肢的护理指导。 Pretreatment patient evaluation and education are not well used by clinicians, suggested Dr. Lawenda Lawenda博士谈到临床并没有很好的对患者进行治疗前和教育。 "Oncology patients are left with a lot of side effects of treatment. We commonly see lymphedema, but unfortunately it does not get a lot of discussion [by oncologists]. As result, it can be a surprise to patients," he said. 他说：“肿瘤患者的治疗会遗留很多副作用。我们通常会看到淋巴水肿，但不幸的是它未得到肿瘤专家的大量讨论。因此，对于病人这会成为一个意外。” Who's Most at Risk? 谁是最危险的呢？ The most common causes of lymphedema in the United States are surgery and radiation therapy for the treatment of cancer. The most common etiology is the impaired flow of lymph fluid through the draining lymphatic vessels and lymph nodes, write Dr. Lawenda and his coauthors, Tammy Mondry, DPT, a physical therapist at New Horizons Physical Therapy, in San Diego, and an expert on managing the condition, and Peter Johnstone, MD, chair of the Department of Radiation Oncology at the Indiana University School of Medicine, in Indianapolis. 在美国造成淋巴水肿的最常见的原因是癌症治疗中的外科手术和放疗。 Lawenda博士和其他作者——圣地亚哥新视野物理治疗机构的物理治疗师Tammy Mondry和印第安纳波利斯的印第安纳大学医学院放疗系主任Peter Johnstone博士——认为最常见的病因是淋巴管和淋巴结分泌的淋巴液的通路被损害了。 Lymphedema is most commonly reported after breast cancer treatment, but can result from the treatment of cervical, endometrial, vulvar, head and neck, and prostate cancers, and of sarcomas and melanoma. Lack of standardized definitions and measurement techniques for the disorder make an accurate incidence rate of cancer-treatment-related lymphedema difficult to determine, say the authors. 淋巴水肿最常见于胸部肿瘤治疗后，但也可见于颈部、子宫内膜、外阴、头颈和前列腺等部位的癌症以及肉瘤和黑素瘤治疗后。作者们认为针对这种情况由于缺乏规范定义和处理技术导致癌症治疗后相关的淋巴水肿的精确发生率难以确定。 However, the likelihood of lymphedema by cancer type and related treatment has been established 但是，可能导致淋巴水肿的癌症类型和相关治疗已经建立。 For instance, with regard to breast cancer, the frequency of breast edema ranges from 6% to 48% when surgery and radiation therapy are combined. The frequencies tend to be at the higher ends of the range when a lymph node dissection and radiation therapy are performed. 例如像胸部肿瘤，如果合并手术和放疗，胸部水肿的概率从6%到48%，如果切除一个淋巴结同时放疗，水肿的发生率将会处于上述范围的高端。 Increased body mass index and tumor location in the upper outer quadrant are other factors that have been reported to significantly increase the risk for breast lymphedema. Also, one study (Lymphat Res Biol. 2005;3:208-217) found that women older than 60 years had a higher likelihood of lymphedema (41.2%) than women younger than 60 years (30.6%). Approximately 15% of patients with a bra cup size of A or B developed breast edema, whereas approximately 48% of patients with a bra cup size of C, D, or DD presented with edema. 已报道的可明显增加发生胸部淋巴水肿危险的因素还包括较高的体重指数以及肿瘤的生长位置在外上象限。另外一项研究（《淋巴生物研究》杂志，2005;3:208-217）也表明60岁以上的妇女发生淋巴水肿的几率(41.2%)高于60岁以下的妇女(30.6%)。胸罩罩杯为A或B的病人发生淋巴水肿的几率大约为15%，而胸罩罩杯为C、D或DD的病人发生几率为48%。 In general, patients tend to be at highest risk for cancer-treatment-related lymphedema when a large number of lymph nodes are removed, radiation and surgery are combined as treatment, or an infection in a limb that has been operated on develops, said Dr. Lawenda. Lawenda博士说：“一般来说，手术与放疗结合，并且大量的淋巴结被切除或者手术后的肢体感染扩散都会使病人高发与癌症治疗相关的淋巴水肿” Recognizing Lymphedema 认识淋巴水肿 The signs and symptoms of lymphedema include, in a limb, a feeling of heaviness or tightness, aching or discomfort, restricted range of motion, and swelling (partial or total). Swelling might also occur in the adjacent upper quadrant of the trunk. 淋巴水肿的症状和体征包括肢体感觉沉重或紧绷，疼痛或不适，制动，并且肿胀（部分或全部）。肿胀可能会发生在临近上象限的躯体部分。 Lymphedema patients usually do not have severe pain, and skin color and temperature are generally normal. The swelling is typically unilateral and can include the dorsum of the hand or foot. A deepening of the natural skin folds can occur. 淋巴水肿的病人通常没有很严重的疼痛，皮色和皮温一般也是正常的。肿胀一般为单侧并包括手背和足背。皮肤的自然褶皱可能加深。 Patients can also present with a Stemmer sign, in which the skin of the dorsum of the fingers and toes cannot be lifted or can only be lifted with difficulty. 病人表现为Stemmer征阳性，即手指和脚趾背部的皮肤不能提起或者只能很困难的提起。 Evaluation for the condition should involve a close inspection of the skin, a gauging of pain level, and a review for the Stemmer sign. Photography and measurements of limb girth and volume are recommended, if possible. Generally, when a limb volume has increased by 10%, lymphedema is likely present, note the authors. 情况的评估应该包括皮肤的严格检查，疼痛水平的测量，Stemmer征的检查。如果可能的话拍摄和测量淋巴的尺寸和体积并记录。作者提示一般淋巴体积增长10%，淋巴水肿就有可能出现。 Lymphedema is considered "reversible" if a patient presents with very soft pitting edema with no fibrosis, write the authors. Prolonged elevation will lead to a complete resolution of the swelling. Nevertheless, lymphedema is not curable and will require treatment and ongoing care in all cases. 作者认为如果患者表现为轻度凹陷性水肿不伴有纤维症时，淋巴水肿是“可逆的”。持续抬高患肢可以完全消除肿胀，淋巴水肿不是不可治愈的，这需要治疗和持续的护理。 As lymphedema progresses, the outcomes from any treatment are less optimal because of adipose and fibrotic changes within the tissue. Furthermore, infections become more common, as do fibrosis and other skin changes, such as papillomas, cysts, fistulas, and hyperkeratosis. 如果淋巴水肿持续进展，由于组织内的脂肪和纤维化改变，那么任何治疗的结果都不是乐观的。而且当纤维和其他皮肤改变，如乳突淋瘤、囊肿、瘘管以及角化过度，感染会更为常见。 The risk for lymphedema is lifelong, Dr. Lawenda and his colleagues emphasize. The onset can occur at the time of treatment or decades later. In any case, an examination must rule out recurrent or metastatic disease causing tumor blockage of the lymphatic system and deep vein thrombosis. Lawenda博士和他的同事强调说淋巴水肿的危险是终生的。这种隐患可以在治疗时发生，也可能是几十年以后发生。无论如何，必须排除循环或代谢疾病导致的肿瘤阻碍淋巴系统和深静脉血栓的形成。 Managing Lymphedema 淋巴水肿的处理 Once lymphedema is diagnosed, treatment should begin immediately. The goal of treatment is to decrease the excess limb volume as much as possible and to maintain the limb at its smallest size. This reduces the amount of stagnant fluid in the tissues, thereby potentially preventing or eliminating infections. The first step in treatment is referral to a physical therapist, note the authors, to quantify the amount of edema in the limb and establish a baseline. 淋巴水肿一经诊断，应该立即予以治疗。治疗的目的是尽可能的减小过大的淋巴体积，使它保持在最小的体积。这样可以减少组织内的滞留液体，可以潜在的预防和阻止感染。作者指出治疗的第一步是安排一个理疗专家去量化淋巴水肿的数量，然后建立一个基线。 The gold-standard treatment for lymphedema is complete decongestive therapy, say the authors, which consists of a treatment and maintenance phase; the latter is life-long and principally involves self-care that includes skin care, wearing a compression garment, and exercise. Other nonsurgical treatments are manual lymph drainage and compression. 作者认为淋巴水肿的金治疗方法是可降低充血的治疗，包括治疗期和维持期。维持期是终生的，主要包括皮肤护理、穿压缩衣服和锻炼等自我护理的内容。其他非外科治疗是手动压缩和引流淋巴。 Low-level laser therapy and microsurgical lymphatic-venous anastomoses can also be effective treatment, say the authors. 作者认为低水平的激光治疗和显微外科淋巴静脉吻合术也是有效的治疗方法。 The challenge for the patient and oncologist is to find "reputable" healthcare providers who are certified in caring for the condition and can help make treatment decisions and deliver care, said Dr. Lawenda. In their article, the authors list several nonprofit organizations with lymphedema expertise that can provide help in connecting patients with caregivers. The organizations include the American Cancer Society, the Circle of Hope Lymphedema Foundation, the Lymphedema Research Foundation, the Lymphology Association of North America, and the National Lymphedema Network. Lawenda博士认为病人和肿瘤专家面临的挑战是找到“好的”保健提供者——有资质照顾病人，可以帮助制定治疗并予以帮助。在文章中，作者罗列了具有淋巴水肿方面专业知识可以向病人提供帮助的非盈利组织的名单。这些组织包括美国癌症协会，淋巴水肿希望基金会，淋巴水肿研究基金会，北美淋巴学联合会以及国际淋巴水肿网络。 The researchers have disclosed no relevant financial relationships. 研究者已公开表示不存在相关的财务联系 CA Cancer J Clin. 2009;59:8-24. Abstract 《临床癌症杂志》，2009;59:8-24，摘要