Differential Diagnosis of Limb Edema The Ohio State

Differential Diagnosis of Limb Edema The Ohio State University Lymphedema Center Experience Steven M. Dean, DO, FACP, RPVI Professor of Clinical Internal Medicine Division of Cardiovascular Medicine The Ohio State University Wexner Medical Center

Disclosures • Potential Conflict: Scientific Advisory Board - Tactile Medical

Causes of Limb Edema OSU PT/Lymphedema clinic experience (2012 -2015): n = 472 • Phlebolymphedema-36% • Cancer/Rx (Lower extremities)-23% • Mixed phlebolymphedema (CA/lipedema/primary lymphedema)16% • Lipedema/lipo-lymphedema-10% • Primary lymphedema-8% • Other (7%) Preliminary Data

Emedicine 2016 - “In the industrialized world, the most common causes of secondary lymphedema are malignancy and its treatment. ”

“The most common form of lymphedema worldwide may be filarial infection but the most common in the Western world is phlebolymphedema” Farrow. Phlebolymphedema- A Common Underdiagnosed & Undertreated Problem in the Wound Care Clinic. J Am Col CWS 2010; 2: 14 -23

Most common secondary cause of Lower Extremity Lymphedema? Phlebolymphedema

Phlebolymphedema

Foot/toe swelling is NOT required to make a diagnosis of lower extremity [phlebo]lymphedema!

…lymphatic failure is responsible for all forms of peripheral edema. .

“All chronic edema indicates an inadequacy or failure of lymph drainage…” The Journal of Clinical Investigation http: //www. jci. org Volume 124 Number 3 March 2014

All edema including chronic venous insufficiency is actually lymphedema!

Always Bilateral Symmetrical Feet/Toe Sparing

Trunk is spared

Lymphedema vs Lipedema

Massive Localized Lymphedema [MLL] • “Pseudotumors” • “Pseudosarcomas ” Brewer 2011 Ann Plast Surg 41 pts; average weight 421 lb [160 -619]

Other “Hybrid” Limb Swelling

Lipedema with secondary lymphedema “Lipo-lymphedema”

Lipedema with secondary phlebolymphededema “Lipo-phlebolymphedema”

Lipedema with secondary phlebolymphedema “Lipo-phlebolymphedema”

Lipedema with foot sparing secondary phlebolymphedema “Lipo-phlebolymphedema” Photo courtesy of Dr. John aka“Jerry” Bartholomew

“Lympho-lipedema”

Lipedema with secondary phlebolymphedema “Lipo-phlebo-lymphedema”

• Phlebolymphedema, not cancer and its associated treatment, is the most common cause of secondary lower extremity lymphedema • Foot swelling is not required to make a diagnosis of phlebolymphedema • All edema is lymphedema! • Hybrid forms of limb swelling are common