Summary: Obesity increases the risk of upper extremity lymphedema following treatment for breast cancer and can cause lower extremity lymphatic dysfunction in extremely obese individuals. We report the first patient with obesity-induced upper extremity lymphedema. A 62-year-old man with a previous body mass index (BMI) of 105.6, presented with a BMI 60.3 following weight loss. He complained of lymphedema of all 4 extremities, which was confirmed by lymphoscintigraphy. Because the upper limbs are more resistant to lymphedema than the lower extremities, a higher BMI threshold may be necessary to cause upper extremity lymphatic dysfunction

Greene, Arin K.

Maclellan, Reid A.

Plastic & Reconstructive Surgery Global Open

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 Obesity-induced Upper Extremity Lymphedema  (Article begins on next page)The Harvard community has made this article openlyavailable.Please share how this access benefits you. Your storymatters.Citation Greene, Arin K., and Reid A. Maclellan. 2013. “Obesity-induced Upper Extremity Lymphedema.” Plastic andReconstructive Surgery Global Open 1 (7): e59.doi:10.1097/GOX.0b013e3182a96359.http://dx.doi.org/10.1097/GOX.0b013e3182a96359.Published Version doi:10.1097/GOX.0b013e3182a96359Accessed February 17, 2015 2:49:47 AM ESTCitable Link http://nrs.harvard.edu/urn-3:HUL.InstRepos:13347437Terms of Use This article was downloaded from Harvard University's DASHrepository, and is made available under the terms andconditions applicable to Other Posted Material, as set forth athttp://nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of-use#LAA www.PRSGO.com  1Lymphedema is a chronic, incurable condition caused by the anomalous development of the lymphatic system (primary lymphedema) or injury to lymphatic vasculature (secondary lymph-edema). The disease affects millions of persons worldwide and most commonly involves the extremi-ties. Fluid accumulates in the interstitial space, caus-ing enlargement of the affected area. Complications of lymphedema include psychosocial morbidity, in-fection, functional disability, skin changes, and ma-lignant transformation.1Primary lymphedema is idiopathic, rare, and typi-cally presents during infancy, childhood, or adoles-cence. Secondary lymphedema is the most common cause of the disease and usually results from either a parasitic infection or following nodal radiation and lymphadenectomy. Recently, we have shown that ex-treme obesity may be a novel cause of lymphedema.2 Patients with a body mass index (BMI) greater than 59 were found to have lower extremity lymphedema, whereas obese individuals with a BMI between 30 and 53 had normal lower extremity lymphatic func-tion.2 Patients in this study were referred for lower extremity lymphedema, and thus, only the lymphatic function of their legs was studied. We now report the first patient with obesity-induced lymphedema in-volving the upper limbs.CASE REPORTA 62-year-old man was referred to our Lymphede-ma Program with bilateral upper and lower extrem-ity lymphedema (Fig. 1). He was 5 feet 10 inches tall (179  cm) and weighed 420 pounds (191  kg); his BMI was 60.3. He had lost weight by dieting over the previ-ous 10 years since he was at his maximum weight of 736 pounds (BMI, 105.6). He complained of difficul-ty using his extremities and periodic infections of his lower limbs. His medical history was significant for a herniated disk, asthma, chronic obstructive pulmonary disease, transurethral resection of the prostate, and herniorrhaphy. His medications included lisinopril, percocet, and diazepam. Other than his BMI, he did not have any risk factors for lymphedema (eg, primary lymphedema, penetrating trauma, lymphadenecto-my, and radiation). On physical examination, he had pitting edema of all 4 extremities. To determine his extremity lymphatic function, he underwent lympho-scintigraphy, which is 100% specific and 92% sensitive for lymphedema.3–6 His lymphoscintigram showed lym-phatic dysfunction of all 4 extremities, with delayed Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.Obesity-induced Upper Extremity LymphedemaFrom the Department of Plastic and Oral Surgery, Lymph-edema Program, Boston Children’s Hospital, Harvard Medi-cal School, Boston, Mass.Received for publication August 17, 2013; accepted August 17, 2013.Copyright © 2013 The Authors. Published by Lippincott Williams & Wilkins on behalf of The American Society of Plastic Surgeons. PRS Global Open is a publication of the American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.DOI: 10.1097/GOX.0b013e3182a96359Arin K. Greene, MD, MMSc Reid A. Maclellan, MD, MMScGreene and MaclellanSummary: Obesity increases the risk of upper extremity lymphedema fol-lowing treatment for breast cancer and can cause lower extremity lym-phatic dysfunction in extremely obese individuals. We report the first patient with obesity-induced upper extremity lymphedema. A 62-year-old man with a previous body mass index (BMI) of 105.6, presented with a BMI 60.3 following weight loss. He complained of lymphedema of all 4 extremities, which was confirmed by lymphoscintigraphy. Because the up-per limbs are more resistant to lymphedema than the lower extremities, a higher BMI threshold may be necessary to cause upper extremity lym-phatic dysfunction. (Plast Reconstr Surg Glob Open 2013;1:e59; doi: 10.1097/GOX.0b013e3182a96359; Published   online 23 October 2013.)Case RepoRt2PRS GO • 2013transit to the inguinal and axillary lymph nodes. The patient was managed with static and pneumatic com-pression and was referred to a bariatric center.DISCUSSIONObesity, which affects one third of the population in the United States,7 negatively affects lymphatic function. Not only does obesity increase the risk of lymphedema following lymphadenectomy and radi-ation to the axilla,8–11 but it may cause the disease in extremely obese individuals (BMI, >59).2 Previously, obese patients referred to our center complained of lower extremity enlargement, and thus, only the lymphatic function of their legs was assessed using lymphoscintigraphy. The patient in this report was the first to present with upper extremity edema as well, and he was found to have lymphatic dysfunc-tion of all of his limbs. His maximum BMI of 105 was the highest of the cohort of patients managed in our Lymphedema Program. The patient we have treated with the next highest BMI (88) had bilat-eral lower extremity lymphedema but did not com-plain of upper extremity edema. A BMI threshold may exist above 88 at which point upper extremity lymphatic dysfunction might develop, similar to the threshold between 54 and 59 at which point lower extremity lymphedema seems to occur. The up-per limbs should be more resistant to developing obesity-induced lymphedema, compared with the lower extremities, because: (1) adipose deposition in obese patients preferentially affects the legs, (2) lymph drainage from the upper limbs is closer to the central venous circulation, and (3) the arms are less affected by having to transport lymph against gravity.Obesity may reduce lymphatic function by either (1) impairing the function of lymphatic vessels and/or (2) overwhelming normally functioning lymphat-ics with increased lymph production. An obese limb may compress lymphatics or the adipose tissue might cause inflammation which damages the lymphatic vasculature. Alternatively, as the size of the obese ex-tremity increases, the elevated production of lymph may overwhelm the capacity of the lymphatics to transport the fluid proximally.Obesity-induced lymphedema may prove to be the only example of lymphedema that is reversible. Follow-ing weight loss through diet or a bariatric procedure, lymphatic clearance may improve because of reduced lymph production and/or by restored function of lym-phatic vessels. If lymphatic function does not reverse following massive weight loss, then the mechanism for the disease would be less likely elevated lymph produc-tion and more likely injury to lymphatic vasculature Fig. 1. a 62-year-old man with a maximum BMI history of 105.6, presented with a BMI of 60.3 after dieting. He complained of swelling of all 4 limbs (a and D). extremity lymphoscintigraphy showed absence of tracer in the axillary (B) and inguinal nodes (e) 45 min following radiolabelled colloid injection into the hands and feet (normal transit time to the axillary and inguinal nodes is <45 min).3–6 Minimal, delayed tracer accumulation into the axillary (C) and inguinal nodes (F) occurred 2 h after injection. these findings indicated lymphatic dysfunction of all 4 extremities consistent with lymphedema.3–6   arrows indicate nodal uptake of radiolabelled tracer. 3Greene and Maclellan • Obesity-induced Upper Extremity Lymphedemawhich cannot be reversed following weight loss. If lymphedema proves to be irreversible following mas-sive weight loss, then patients should undergo a bariat-ric procedure before reaching a BMI threshold when lymphatic dysfunction occurs. Unlike other comorbid-ities that improve following weight loss (eg, diabetes, hypertension, and hypercholesterolemia), patients would continue to suffer from lymphedema.CONCLUSIONSExtreme obesity previously has been associated with lower extremity lymphedema. We present a pa-tient with a maximum BMI history of 105 who was referred with bilateral arm and leg lymphedema. Lymphoscintigraphy confirmed lymphatic dysfunc-tion of all 4 limbs. Severe obesity may be a novel cause of upper extremity lymphedema. Arin K. Greene, MD, MMScDepartment of Plastic and Oral SurgeryLymphedema ProgramBoston Children’s Hospital300 Longwood AvenueBoston, MA 02115E-mail: arin.greene@childrens.harvard.edu REFERENCES  1.  Schook CC, Mulliken JB, Fishman SJ, et al. Primary lymph-edema: clinical features and management in 138 pediat-ric patients. Plast Reconstr Surg. 2011;127:2419–2431. 2. Greene AK, Grant FD, Slavin SA. Lower extremity lymph-edema and elevated body mass in obese patients. N Engl J Med. 2012;366:2136–2137. 3. Gloviczki P, Calcagno D, Schirger A, et al. Noninvasive evaluation of the swollen extremity: experiences with 190 lymphoscintigraphic examinations. J Vasc Surg. 1989;9:683–699; discussion 690. 4. Moshiri M, Katz DS, Boris M, et al. Using lymphoscintig-raphy to evaluate suspected lymphedema of the extremi-ties. AJR Am J Roentgenol. 2002;178:405–412. 5. Szuba A, Shin WS, Strauss HW, et al. The third circula-tion: radionuclide lymphoscintigraphy in the evaluation of lymphedema. J Nucl Med. 2003;44:43–57. 6. Scarsbrook AF, Ganeshan A, Bradley KM. Pearls and pit-falls of radionuclide imaging of the lymphatic system. Part 2: evaluation of extremity lymphoedema. Br J Radiol. 2007;80:219–226. 7. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 1999–2008. JAMA 2010;303:235–241. 8. Werner RS, McCormick B, Petrek J, et al. Arm edema in conservatively managed breast cancer: obesity is a major predictive factor. Radiology 1991;180:177–184. 9. McLaughlin SA, Wright MJ, Morris KT, et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: patient perceptions and precautionary behaviors. J Clin Oncol. 2008;26:5220–5226.  10. Helyer LK, Varnic M, Le LW, et al. Obesity is a risk factor for developing postoperative lymphedema in breast can-cer patients. Breast J. 2010;16:48–54.  11. Ridner SH, Dietrich MS, Stewart BR, et al. Body mass in-dex and breast cancer treatment-related lymphedema. Support Care Cancer 2011;19:853–857.

Obesity-induced Upper Extremity Lymphedema

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Obesity-induced Upper Extremity Lymphedema

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