終末期の悪性軟部腫瘍症例に生じたリンパ浮腫に対し症状緩和を得られた2例

Symptom Relief for Lymphedema-caused Malignant Soft Tissue Tumors in Two Patients with Advanced Stage Disease

はじめに

　続発性リンパ浮腫は，悪性腫瘍の外科治療に伴うリンパ節郭清や放射線治療によりリンパ管系に輸送障害を生じ，組織間隙に過剰な水分貯留や皮膚病変をみる疾患である^1）．

　終末期のがん患者に生じたリンパ浮腫は，運動障害，疼痛を生じ，患者のQOL（Quality of life）に重大な影響を与えるが，これまで終末期の軟部肉腫症例に生じたリンパ浮腫に対する治療の報告はない．

　終末期の浮腫は腫瘍の直接浸潤等によるリンパ流路の障害により生じる場合と全身的な要因，腎不全，心不全，低アルブミン血症など複数の要因により生じる場合があるが，原疾患あるいは転移巣の局所治療が困難なことが多く，通常は難治性である．

　我々は終末期の軟部肉腫症例に生じたリンパ浮腫に対して，緩和治療の一環として複合的治療を取り入れることで患者の自覚症状，心理的苦痛が改善し結果的にQOLの向上をもたらすことができた．

　代表的な2例を中心に我々の取り組みを報告する．

Abstract : Limb lymphedema is a serious complication following surgery or radiation therapy for malignant soft tissue tumors. We have recently experienced two cases where we provided symptomatic relief for lymphedema as part of palliative care for patients with sarcoma in the advanced stage. For the treatment of lymphedema, complex physical therapy (manual lymphatic drainage, compression, and exercise therapy), elevation of the affected limb, and skin care were carried out after ruling out the presence of deep venous thrombosis. Inelastic bandaging provides containment and effectively arrests the progression of swelling that stretches the skin. Since obstructive masses interrupt the entire lymphatic quadrants, lymphatic drainage is focused on creating a collateral flow in the truncal territories and in the limb. No complications associated with treatment were observed. In spite of refractory edema due to disease progression in both cases, the swelling of the affected limb or patients' subjective symptoms were temporarily improved by the treatment. While aiming to reduce swelling, the provision of comfort, relief from pain or other swelling-related symptoms, and maintenance or restoration of function are desirable and beneficial outcomes. Palliative therapy for lymphedema may lead to an improvement of the quality of life (QOL) of patients with sarcoma in the advanced stage.