Lymphatic fistulas: obliteration by low-dose radiotherapy.
BACKGROUND
Lymphatic drainage from the surgical wound is an uncommon but challenging complication of surgical intervention. Protracted lymphorrhea contributes to morbidity, favors infections and results in a prolonged hospital stay. Treatment options include surgical ligation and, more conservatively, leg elevation, continuous local pressure, subatmospheric pressure dressings, and low-dose radiotherapy. This study examines the efficacy of low-dose radiotherapy.


METHODS
17 patients (19 fistulas) with lymphorrhea following vena saphena harvesting (n = 7), femoropopliteal bypass (n = 3), varicose vein surgery (n = 2), hip arthroplasty (n = 3; five fistulas), shunt surgery (n = 1), and piercing (n = 1) were referred for external radiotherapy. Depending on the depth of the fistula, orthovoltage (n = 12), electrons (4-11 MeV; n = 2) or photons (8 MV; n = 3) were used. Fractions between 0.3 Gy and 2 Gy were applied; the individual total dose depended on the success of the radiotherapy, i. e., the obliteration of the lymph fistula, and varied from 1 to 12 Gy.


RESULTS
In 13 out of 17 patients complete obliteration of the fistula was achieved. Interestingly, this was achieved in nine of the ten patients irradiated with total doses of </=3 Gy and with fraction sizes ranging from 0.3 to 0.5 Gy. In one patient with hip arthroplasty, only two out of three fistulas disappeared after 12 Gy and in a further three cases no distinct benefit was observed after 2.4 Gy, 8 Gy, and 10.5 Gy, respectively. No treatment-related side effects occurred.


CONCLUSIONS
Radiotherapy represents an efficacious and economical treatment option in cases of persistent lymphorrhea and is able to reduce the risk of secondary infection, to decrease the duration of hospitalization, and to reduce overall costs for the individual patient. Daily scoring of treatment efficacy is recommended, because radiotherapy can be terminated as soon as lymphorrhea has stopped. Very low total doses with 0.3-0.5 Gy fraction size are recommended up to a maximum of 10-12 Gy in nonresponders.
Mayer
Ramona
R
Department of Radiation Oncology, Medical University of Graz, Austria. ramona.mayer@meduni-graz.at
Sminia
Peter
P
McBride
William H
WH
Stranzl
Heidi
H
Prettenhofer
Ulrike
U
Fruhwirth
Johannes
J
Poschauko
Johann
J
D000368:Aged; D017577:Cutaneous Fistula / Q000209:etiology / Q000532:radiotherapy*; D019583:Dose Fractionation, Radiation; D005260:Female; D006801:Humans; D008206:Lymphatic Diseases / Q000209:etiology / Q000532:radiotherapy*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000532:radiotherapy*; D011878:Radiotherapy / Q000379:methods*; D011879:Radiotherapy Dosage; D012189:Retrospective Studies; D016896:Treatment Outcome