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And you thought you were done with pimples

WHAT IS IT?

Lymphedema is a buildup of a fluid called lymph and protein in the tissues under the skin. Lymph accumulates when there is an obstruction to normal flow causing swelling, usually in an arm or leg. The lymph system is similar to the blood system in its network of vessels that carry lymph fluid throughout the body.

Trauma to lymphatic tissue by surgery or radiotherapy is the main cause of lymphedema in the context of cancer. It can result from surgery and/or radiation therapy during treatment for cancers of the breast, abdomen, melanoma, connective tissues (sarcomas) and the pelvic area, as well as lymphomas, in both men and women. Lymphedema may also be the result of infection, such as dermatophytosis in the foot.

Cancer tumors also can block the lymph vessels, especially in people with prostate cancer or lymphoma.

IF I HAVE CANCER WILL I DEVELOP LYMPHEDEMA?

Not necessarily. The most frequent cases occur in women with breast cancer; 10% to 25% of breast cancer patients will develop lymphedema. While most cases are mild, approximately 400,000 women cope daily with some degree of disfigurement, discomfort, and sometimes disability because of arm and hand swelling.

Because of improvements in radiation and surgical techniques (such as removing smaller samples of lymph nodes), lymphedema is less common today than it use to be. Lymphedema develops in about one in four breast cancer patients who have a mastectomy with lymph-node dissection. The risk doubles for those who also receive radiation treatments to the underarm area.

Radical prostatectomy, a procedure that removes the prostate gland, seminal vesicles and sometimes the nearby pelvic lymph nodes, can lead to lymphedema .One type of Kaposi’s sarcoma is called the lymphadenopathic form that can spread throughout the body and may aggressively involve lymph nodes, viscera, and occasionally the GI tract – resulting in a kind of lymphedema. 

SENTINEL LYMPH NODE BIOPSY

If breast cancer spreads, it first goes to the lymph nodes under the arm. That's why women with breast cancer have these nodes examined. Until recently, surgeons would remove as many lymph nodes as possible, but this greatly increased the risk of lymphedema. More recently, a growing number of physicians have begun focusing on finding the sentinel nodes — the first nodes to receive the drainage from breast tumors and therefore the first to show evidence of cancer’s spread. Experts believe that if a sentinel node is removed and found to be healthy, then the chance of finding cancer in any of the remaining nodes is very small and no other nodes need to be removed. This spares as many as 75% of women who have no evidence of tumor spread to the axillary nodes the risk of complications, especially lymphedema.

WHEN DOES IT DEVELOP?

Lymphedema can appear any time after surgery or radiation treatment including many years later.

When the condition develops very soon after surgery, it is usually mild, and goes away within one to two weeks. It can also develop six to eight weeks after surgery or radiation. Again, this type of lymphedema usually goes away in a few weeks. 

Unfortunately, the more common form of lymphedema in cancer survivors develops slowly over time. It may show up many months or even years after treatment ends and swelling can range from mild to severe. In most cases however, lymphedema appears between six and 12 months after treatment. While people who have many lymph nodes removed and radiation therapy have the highest risk of developing lymphedema, some high-risk patients won’t develop the condition.

WHEN TO CALL A PROFESSIONAL

Patients should contact a physician if they had a mastectomy, lower abdominal surgery or radiation treatments in the past, and the affected limb becomes red, painful or hot, or if it develops open sores or areas of broken skin. Doctors should be consulted especially if there is a fever in addition to swelling.

Diagnostic Tests

Usually, no specific testing is necessary to diagnose lymphedema, but tests may be done such as a blood count that can identify signs of infection. Ultrasound may be ordered to look for blood clots, which can cause swelling. Computed tomography (CT) may be used to find a tumor that could be blocking lymph vessels. In addition, there are more specialized tests that can identify lymph flow and lymph vessel abnormalities. 

Symptoms

The first signs of lymphedema can be a change in a patient’s arms or legs or other affected area such as the groin. Initially, skin will remain soft, but if the problem continues, the limb may become hot and red and the skin hard and stiff. The lymph fluid that collects in the tissues can be very uncomfortable, but pain is not always present. Early symptoms of lymphedema may include: 

  • A feeling of tightness around the arm on the area that was treated for cancer,
  • Decreased flexibility in a hand, elbow, wrist, fingers, or leg,
  • Difficulty fitting into clothing,
  • Tight fit of a ring, wristwatch, bracelet, or shoe,
  • Weakness, pain, aching or heaviness in the arm, legs, or feet,
  • Skin that looks shiny, has fewer folds, and feels stiff or taut,
  • A dull ache in the affected limb,
  • A feeling of tightness in the skin of the affected limb,
  • Difficulty moving a limb or bending at a joint because of swelling and skin tightness,
  • Pitting (small indentations left on the skin after pressing on the swollen area)

In most cases, only one arm or leg is affected. If the leg is involved, swelling usually begins at the foot, then progresses upward toward the ankle, calf and knee.

Severity

The severity is directly related to the extent of surgery and radiation treatment to the lymph nodes. Severity and general risk of developing lymphedema seems to increase with obesity, weight gain and infection in the affected area. 

TREATMENTS

Lymphedema has no cure so treatment focuses on reducing the symptoms. Treatment has varied from virtually no treatment to surgery, but there are various practical methods to deal with the condition, including elevation of the limb (in the first year only), compression garments (no greater than 20-30 mm Hg), certain types of massage and exercises, pneumatic compression devices (controversial), and other types of physical therapy. Experts also recommend keeping the affected limb clean, dry and lubricated.

The National Lymphedema Network (www. Lymphnet.org) encourages massage by an specially certified expert in lymphedema massage.. In many cases, patients can also be trained to massage themselves to improve the flow of lymph fluids. 

Medications

There are no medications to treat lymphedema. Diuretics have been found to be ineffective and may actually exacerbate the condition. Other medicines have been tried, but there is no clear evidence of significant effectiveness with any particular drug. 

MILD LYMPHEDEMA: 

Elevating the arm or leg above the level of the heart(during the first year) and flexing it frequently are basic methods to manage the condition. Since elevation is impractical except for short periods, patients should be fitted with an elastic sleeve, covering the arm or leg. 
A significant reduction in edema (swelling) has been reported after wearing elastic sleeves for 6 consecutive hours per day. Using these garments during exercise, physical activity, and especially air travel is recommended, since air travel seems to exacerbate the condition. 
If the legs are affected, avoid periods of prolonged standing. If working or standing a lot, a doctor may prescribe special graduated compression stockings to wear throughout the day. A doctor may also suggest a protein-rich, low-salt diet for those who are over-weight or obese. 

MODERATE TO SEVERE: 

For people with moderate to severe lymphedema in the legs, doctors prescribe pneumatic compression devices to be used at home to help reduce limb swelling. The “pneumatic stockings” are worn every day for an hour or two to reduce the swelling. Once the swelling has been reduced, a person may still need to wear elastic stockings up to the knee every day from the moment of rising until bedtime. 

For lymphedema in the arm, pneumatic sleeves--like pneumatic stockings--can be used every day to reduce the swelling; elastic sleeves may also be needed.

Others recommend a special type of massage therapy called manual lymph drainage. Antibiotics also may be prescribed to prevent or treat infection in the affected limb. Since skin infections can be more serious in people with lymphedema, a person may need to have antibiotics administered intravenously in the hospital during an infection.

Complex Decongestive Therapy

More serious cases of lymphedema can be treated with Complex Decongestive Therapy by a physical therapist or other health care professional, who has special training. Complex Decongestive Therapy consists of skin care, massage, special bandaging, exercise, and fitting for a compression sleeve. Seeking and getting treatment early should lead to a shorter course of treatment to get the lymphedema under control. While most insurance companies will pay for this treatment, some do not.

Someone certified in the procedure should perform Manual Lymph Drainage (MLD). 
In the case of lymphedema of the arm, the procedure involves a type of massage that moves built up fluid around the blocked vessels and across the chest to the other side of the body where the lymphatic system is still in tact. Usually the healthy area will be “worked” first. After each treatment, the effected area is carefully bandaged with a special layered wrap that looks like an ace bandage but is made of a different fabric. The wrap is important for keeping the effected limb de-congested. An average course is 15 daily treatments of 60 to 90 minutes each. After a MLD course of treatments, the patients will wear a compression garment every day. The patient should be measured for a new compression sleeve every six months or so. Sometimes a yearly MLD treatment course is recommended as a kind of “tune up.”

PREVENTING COMPLICATIONS

Because lymphedema development may occur even after several decades, patients should monitor themselves for signs of lymphedema and report any changes to their physicians. 
Prevention is important and can require daily attention to manage the symptoms of swelling in particular. Arm and hand precautions are based on two key ideas: (1) Do not increase lymph production, which is directly proportional to blood flow, and (2) do not increase blockage to lymph system. Therefore, patients should avoid excessive heat, infections, and overly-strenuous arm exercises which would increase blood flow in the arm and thereby increase lymph production.

MANAGING LYMPHEDEMA

Patients should follow these suggestions to manage their lymphedema: 

  • Avoid puncturing or injuring the skin in any way. Use first aid care if there is a break in the skin.
  • Avoid vaccinations, injections, blood pressure monitoring, blood drawing, and intravenous administration in the arm affected.
  • Avoid tight-fitting clothing or jewelry.
  • Avoid heat, such as with sunburns or tanning, baths, and saunas.
  • Avoid strenuous exertion, but do exercise while wearing compression garments.
  • Exercise, But Avoid Muscle Strain

It is important to use your affected limb for normal everyday activities, yet overuse can cause lymphedema to occur in some people. Follow these suggestions whenever possible: 

  • Use affected arm or leg as normally as possible until fully healed, about 4 to 6 weeks after surgery or radiation treatment. 
  • Exercise regularly but do not strain the arm or leg. Before any strenuous exercise, such as weightlifting or tennis, talk with a doctor, nurse, or physical therapist about specific goals and limitations to decide what level of activity is right. Ask if a fitted sleeve or stocking should be worn during strenuous activities or while flying. 
  • If an arm or leg starts to ache, lie down and elevate it. 
  • Avoid vigorous, repeated activities, heavy lifting, or pulling. 
  • Watch for early signs of infection: rash, red blotches, swelling, increased heat, tenderness, or fever. Call a doctor right away if there are signs of infection.
  • Experts also recommend that those with lymphedema avoid any trauma to the area affected.
  • Trauma includes extreme temperature changes, repetitive movements against resistance (pushing or pulling), heavy lifting, and excessive exercise. 

For More Information

American Cancer Society

The American Cancer Society held an international conference on lymphedema in 1998 in New York City. It involved 60 of the world’s leading experts and included a forum of more than 250 breast cancer survivors, leaders of breast cancer advocacy groups, and others. The conference report plus a lymphedema resource guide are available as a book from the ACS at cancer.org. (See below for title.)

National Lymphedema Network

The National Lymphedema Network is a charitable organization with an international scope. Founded in 1988, the Network’s mission is to provide education and guidance to patients and health care professionals. The Network promotes standardizing quality treatment for lymphedema patients. In addition, the organization supports research into the causes and possible alternative treatments for this “often incapacitating, often-neglected condition.”


Sources:


This page was last edited on 06/26/2008
Written by Rachael Myers Lowe, cancerpage.com
Reviewed by Susan Frank RN MSN OCS, Quality Oncology


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