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Massive Localized Lymphedema: A Case-control Study of Patients With and Without Obesity-Induced Lymphedema
Reid A. Maclellan, MD, MMSc, David Zurakowski, PhD, Frederick D. Grant, MD, Arin K. Greene, MD, MMSc.
Boston Children's Hospital / Harvard Medical School, Boston, MA, USA.

Background: Massive localized lymphedema (MLL) is an area of skin and subcutaneous overgrowth associated with obesity. The purpose of this project was to determine whether MLL results from obesity-induced lymphedema (OIL), and to characterize the prevalence and risk factors for the condition.

Methods: Patients evaluated in our Lymphedema Program between 2009 and 2016 were reviewed for obese individuals [body mass index (BMI) >30] who had lower extremity lymphatic function evaluated by lymphoscintigraphy. Candidate variables included age, gender, infection history, BMI, duration of lymphedema, and lymphoscintigraphy findings. An association between candidate variables and the presence of MLL was determined using multivariable logistic regression.

Results: Seventy-one patients were included: Group 1 (n=43) had normal lymphatic function and did not exhibit MLL [BMI 40.4 (range 30-62)]; Group 2 (n=28) had OIL and 61% developed MLL (p<0.0001). Masses involved the thigh (n=16; unilateral = 6, bilateral =10), genitalia (n=3), and suprapubic area (n=2). More severe lymphatic function by lymphoscintigraphy was associated with worse MLL findings. Patients with a BMI>61 had a 21 times greater odds of developing MLL versus a BMI <61 (p=0.003). Gender, patient age, duration of lymphedema, and infection were not associated with the development of MLL (p=0.1).

Conclusions: MLL is a consequence of OIL and affects approximately one-half of obese patients with lower extremity dysfunction; a BMI >61 significantly increases the risk. Obese individuals should be referred to a bariatric weight-loss center before their BMI reaches a threshold that causes OIL and MLL.

Figure: Increasing BMI causes lower extremity lymphatic dysfunction and elevates the risk of developing MLL. Left. Patient with a BMI of 44 exhibits a normal lymphoscintigram with inguinal lymph node uptake of technetium Tc-99m sulfur colloid 45 minutes after injection into the feet (normal transit time is ≤ 45 minutes). Center. Subject (BMI = 52) has OIL without MLL (no inguinal uptake of tracer at 1 hour images). Right. Individual with a BMI of 60 has OIL and MLL of the thighs (no inguinal uptake of tracer at 1 hour images).

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