Which are essential for the forward flow of lymph fluid and for preventing the generation of high hydrostatic forces due to gravity. The intervalvular distance is approximately 6-10 cm. The lymphatic pressures can vary from less than 25 mmHg in the absence of lymphatic obstruction to over 100 mmHg during obstruction.
Squamous cell carcinoma is characterized by local invasion and regional spread, with late onset of hematogenous dissemination. Lymph node metastasis is an adverse prognostic factor for survival. However, patients with minimal involvement of the nodes have an excellent prognosis after regional lymphade-nectomy. By contrast, most patients with extensive inguinal metastases or spread to the pelvic nodes die of their disease, hence, the rationale to perform a lymph node dissection at the earliest possible moment to remove metastases at a time when they are still clinically occult. By definition, occult metastases cannot be detected by simple physical examination. Analysis at our institution has shown that the negative predictive value of normal findings at physical examination (probability of absence of metastasis with negative findings at physical examination) of the inguinal region is 88 . Lymphangiography, ultrasound, computerized tomography, and magnetic resonance imaging are all...
A mass may be part of. attached to. or free from adjacent structures, such as skin or bone. Fixation of the skin may be associated with a fine dimpling at the opening of the hair follicles resembling an orange skin when there is lymphatic obstruction ('peatt d'orange'). Such a change is most commonly due to malignant disease. Fixation to deeper structures may occur. For example, a breast tumour may become fixed to underlying muscle.
The rationale for inguinofemoral lymphadenectomy via separate incisions instead of en bloc is that dissemination to the inguinofemoral lymph nodes does not occur in continuity but by embolization 36 . Preservation of a ''skin bridge'' results in a lower frequency of postoperative wound breakdown and less risk of lymphedema of the legs. Hacker and co-workers found no difference in survival between radical vulvectomy with en bloc inguinofemoral lymphadenectomy when compared with surgery via separate incisions, whereas the morbidity was less in the latter patient group 37 . Despite this decreased morbidity, seroma and lymphadema are still frequently observed 37 . Tumor recurrence in the skin bridge has been reported 38,39 .
Despite the continued leakage of fluid, swollen ankles are essentially a nuisance, requiring looser shoes and so on, rather than a sign of a major problem. Swelling may be more noticeable in summer months because blood vessels and lymph channels dilate (swell) more when the temperature is higher. Sometimes the swelling is severe and does not go away and makes it hard to wear shoes and be comfortable. Specially trained physical therapists who are lymphedema specialists can be miraculous at getting the fluid mobilized.
Loop diuretics are used in the treatment of edema associated with CHF, cirrhosis of the liver, and renal disease, including the nephrotic syndrome. These drugs are particularly useful when a greater diuretic effect is desired. Furosemide is the drug of choice when a rapid diuresis is needed or if the patient has renal insufficiency. Furosemide and torsemide are also used to treat hypertension. Ethacrynic acid is also used for the short-term management of ascites caused by a malignancy, idiopathic edema, or lymphedema.
Turner syndrome, with a 45,X karyotype, is the only monosomy compatible with life. Even then, 98 of all fetuses with the syndrome are spontaneously aborted. The few that survive are unmistakably female in appearance (Fig. 1.12) and are characterized by the absence of ovaries (gonadal dysgen-esis) and short stature. Other common associated abnormalities are webbed neck, lymphedema of the extremities, skeletal deformities, and a broad chest with widely spaced nipples. Approximately 55 of affected women are mono-somic for the X and chromatin body negative because of nondisjunction. In 80 of these women, nondisjunction in the male gamete is the cause. In the remainder of women, structural abnormalities of the X chromosome or mitotic nondisjunction resulting in mosaicism are the cause.
The most common symptom is painless macroscopic haematuria. Irritative symptoms such as frequency, urgency and pain may signify the presence of carcinoma in situ or invasive bladder cancer. Less common complaints include loin pain from ureteric obstruction, lymphoedema owing to nodal metastatic disease and non-specific symptoms from metastatic disease.
Changes in the lymphatic system often are related to infection and may consist of inflammation and enlargement of the nodes, called lymphadenitis, or inflammation of the vessels, called lymphangiitis. Obstruction of lymphatic vessels because of surgical excision or infection results in tissue swelling, or lymphedema. Any neo-plastic disease involving lymph nodesis termed lymphoma. These neoplastic disorders affect the white cells found in the lymphatic system, and they are discussed more fully in Chapter 10.
Erysipelas and cellulitis are acute spreading infections of the skin, usually involving large confluent areas and accompanied by systemic toxicity. Erysipelas is a superficial skin infection involving the cutaneous lymphatic vessels, caused most commonly by group A streptococci and occasionally by group C or G streptococci. Erysipelas most often involves the face, has a characteristic, well-demarcated appearance with raised margins, and is accompanied by systemic symptoms of fever and chills. Streptococcal cellulitis is an acute, rapidly spreading infection that extends deeper than erysipelas and involves the skin and subcutaneous tissues. Cellulitis is generally associated with diffuse erythema, pain, swelling, lymphangitis, fever, chills, and sometimes bacter-emia. Recurrent cellulitis of the extremities occurs in persons with impaired lymphatic drainage such as in lymphedema after radical mastectomy, or phlebectomy associated with coronary artery bypass surgery (CABG). An...
Time, the lesions can enlarge and become clumped together. Lesions can be pruritic but are rarely painful. Medical attention is usually sought because of bacterial superinfection, lymphedema, bulky lesions, or for cosmetic reasons. Invasion of bone does not occur, in contrast to mycetoma.
Edema is a common symptom or finding in patients with right- or left-sided heart failure. Fluid retention in heart failure results from increased venous pressure and abnormal activity of salt-retaining hormones (see Chap. 20). In an average-sized person, 5 to 10 lb of excess fluid is required for edema to become apparent a history of recent weight gain often will correlate with a deterioration in clinical status. The amount of weight loss in response to treatment for heart failure in the past will relate to the severity of the problem. Minor degrees of edema are evident only after a period of dependency of the legs and will decrease after rest. Presacral edema may be most obvious when the patient has been at bed rest. Although edema of cardiac origin may progress to anasarca, cardiac edema rarely involves the face or upper extremities. Edema mainly affecting the face and arms is more likely to be due to venous or lymphatic obstruction by clot or neoplasm. Facial edema is a feature of...
Cellulitis is a diffuse skin infection that involves the deep dermis and the subcutaneous fat tissues. Unlike erysipelas, which demonstrates superficial skin involvement with distinct margins, cellulitis is diffuse and spreading with no distinct demarcations. Although the inciting event typically is not discernable, predisposing factors include traumatic skin lesions, including puncture wounds, lacerations, surgical wounds, and burns prior history of cellulitis dermatophyte infections, such as tinea pedis pressure ulcers eczema dermatitis vascular insufficiency lymphedema presence of a foreign body malnutrition and immunosuppressive conditions, such as diabetes mellitus and cirrhosis 22,23 . Any cutaneous surface may be involved, but the most common site of infection is the lower extremity 24,25 . In immu-nocompetent hosts, the microorganisms most commonly implicated include Gram-positive cocci such as beta-hemolytic streptococci (particularly S pyogenes) and S aureus. In...