リンパ浮腫とリハ栄養

リンパ浮腫とはリンパ液がたまったために生じるむくみのことです。一次性と二次性（子宮がん、乳がん、前立腺がんの術後や放射線療法後に続発するもの）がありますが、ほとんどは二次性です。

根治的な治療方法はありませんが、複合的理学療法（スキンケア、医療徒手リンパドレナージ、圧迫療法、圧迫下での運動療法の組み合わせ）が最も有効と言われています。

最近のレビュー論文では、複合的理学療法は有効だが、個々の治療でみると、包帯による圧迫療法は有効、リンパドレナージは不明、スキンケア、運動、弾性スリーブ装着は比較研究なしという結果でした。

Devoogdt N, et al: Different physical treatment modalities for lymphoedema developing after axillary lymph node dissection for breast cancer: a review. Eur J Obstet Gynecol Reprod Biol. 2010 Mar;149(1):3-9.

栄養に関して言えば、リンパ液は皮下組織を流れますので、皮下脂肪が多いとリンパ液の流れが悪くなりむくみやすくなります。つまり、肥満がリンパ浮腫の大きなリスク因子の1つであり、減量によってリンパ浮腫をある程度改善することも可能です。

実際、リンパ浮腫患者の減量に関するRCT論文は2つあり、いずれも栄養管理による体重減少はリンパ浮腫の治療に効果があるという結果です。

リハ栄養的には、食事療法とウォーキングやレジスタンストレーニング（患肢以外）を併用することで、より体重減少とリンパ浮腫の改善を期待できると考えます。もちろん複合的理学療法も行ったうえでの話になります。

1つ目の論文は、エネルギー摂取量減少群、脂質摂取量減少群、コントロール群の3群で24週後に比較。前2群で有意に体重が減少。リンパ浮腫の上肢の容積には有意差はないが、体重減少とリンパ浮腫の上肢の容積の減少に相関ありという結果です。かなり弱い結論になります。

①Clare Shaw et al: Randomized Controlled Trial Comparing a Low-Fat Diet With a Weight-Reduction Diet in Breast Cancer-related Lymphedema. Cancer 2007;109:1949–56.

BACKGROUND. Obesity is considered a risk factor for lymphedema of the arm resulting from breast cancer treatment (BCRL) as well as a poor prognostic factor in response to lymphedema treatment. The aim of the study was to compare the effect of 2 dietary interventions on excess arm volume in BCRL.
METHODS. A total of 64 women with BCRL were randomized to 1 of 3 groups for 24 weeks: 1) weight reduction through reduced energy intake; 2) low-fat diet with no change in energy intake (isoenergetic); 3) control group with no dietary change from habitual intake.
RESULTS. The primary outcome measure was arm volume at 24 weeks. Results showed significant reductions in body weight (P=0.006), body mass index
(P=0.008), and skinfold thickness measured at 4 sites (P=0.044) in the weightreduction and low-fat groups compared with controls. A slightly greater, but not significant (P=0.605), fall in excess arm volume occurred in the dietary groups but a significant correlation between weight loss (irrespective of group) and a reduction in excess arm volume (r: 0.423; P=0.002) was demonstrated.
CONCLUSIONS. Weight loss, whether through reduced energy intake or low-fat diet, appears to be helpful in the treatment of breast cancer-related lymphedema.

2番目の論文は減量に関する食事のアドバイスを行った群と一般に健康的な食事に関する冊子を渡した群で12週後に比較。前者で有意にリンパ浮腫の上肢の容積、体重、BMIが減少が得られたという結果です。こちらのほうが強い結論になります。

②Clare Shaw, et al: A Randomized Controlled Trial of Weight Reduction as a Treatment for Breast Cancer-related Lymphedema. Cancer 2007;110:
1868–74.

BACKGROUND. Obesity is considered a risk factor for the development of breast cancer-related lymphedema of the arm and as a poor prognostic factor in response to lymphedema treatment. The objective of this study was to examine weight reduction as a treatment for breast cancer-related lymphedema.
METHODS. Twenty-one women with breast cancer-related lymphedema were randomized either to receive dietary advice for weight reduction or to receive a booklet on general healthy eating. They were monitored for 12 weeks.
RESULTS. The primary outcome measure was arm volume at 12 weeks. The results indicated a significant reduction in swollen arm volume at the end of the 12-week period (P=0.003) in the intervention weight-reduction group. There was a significant reduction in body weight (P=0.02) and body mass index (P=0.016) in the weight-reduction group at the end of the 12-week study period.
CONCLUSIONS. Weight loss achieved by dietary advice to reduce energy intake can reduce breast cancer-related lymphedema significantly.