LYMPHEDEMA

Lymphedema is a subcutaneous accumulation of protein rich fluid due to damaged or blocked lymphatic vessels.

Causes – It is most commonly seen in the arms of postmastectomy patients, or following radiotherapy to the axilla (and this can occur 10 years after treatment, even when there is no evidence of recurrence of cancer). Pelvic malignancy can cause lymphedema in one or both legs. Initially the edema is pitting, but the subcutaneous tissues eventually become thickened, fibrosed and leathery. Recurrent cellulitis can occur, causing further damage to lymphatics.

Management options – A daily regime of medical management can give good results, sometimes even with long standing lymphedema. The effect of treatment is monitored by measuring limb circumference (at fixed points) and recording the data.

Diuretics are seldom helpful.

Reducing the size of a heavy, aching, disfiguring arm or leg almost always improves the patient’s morale.

Ms. E. MacT., 48, with advanced melanoma and a lymphedematous leg, had compression therapy which reduced the above knee circumference by 5 inches over 2 weeks. She said, “This treatment has helped me more than anything I’ve had done.”

Medical management involves:

1. Bandaging

2. Compression stockings and sleeves

3. Sequential compression pump

4. Massage and exercise

5. Skin care advice

6. Prophylactic antibiotics

1. Bandaging is necessary:

• To reduce swelling

• To treat swollen fingers

• If there is lymph leakage

• If there is pain in the arm

A good method is to:

• Apply a full-length non-elastic cotton sleeve (to avoid skin creases when bandaging).

• Apply a narrow bandage to each finger (starting distally) and back to the wrist (leaving the palm free).

• Pad arm creases with cotton wool (especially elbow crease and back of the hand)

• Pad whole arm with foam sheet or Webril

• Bandage the arm with an elastic bandage.

• Apply a second (wider) cotton sleeve over the elastic bandage (so it does not catch on clothing).

It takes about an hour to teach the technique to a willing family carer. The bandages should ideally be re-applied every day over a 2-week period to gradually reduce swelling. Careful measurement of the arm is important to monitor reduction of swelling.

After a regime of bandaging, maintenance therapy with a support sleeve and daily use of a compression pump at home will be sufficient for several weeks. Bandaging may have to be repeated (perhaps for 2 weeks every 6 weeks).

2. Light surgical compression stockings and sleeves can be used to maintain a good fit and keep pace with reduction in limb size. Proper fitting is necessary. In severe cases these have to be worn continuously and only removed for bathing, and will need to be worn indefinitely. It is best to use use garments designed to apply a pressure of about 25mm Hg. Finger swelling can be made worse by a compression sleeve and requires time consuming finger bandaging. Satisfactory elastic gloves are not yet available.

3. Compression pump – Only a minority of patients need pneumatic compression, which can speed the initial rate of improvement, but does not necessarily lead to a better outcome. It can be useful as maintenance therapy between bandaging programs.

The compression pump stimulates lymphatic flow. The Jobst single chamber system has been superseded by multichambered intermittent sequential machines. The usual recommended pressure is 50mm Hg, but some patients need to start around 30mm Hg and build up to 50mm Hg over 2 to 3 days. The limb may require 4 to 6 hours per day if it has become hardened (usually in 1 to 2 hour treatment periods). Smaller pumps are available for home use.

Compression is unlikely to be effective if there is swelling beyond the root of the limb (in the chest wall or lower abdomen).

4. Massage and exercises – Normal lymph flow depends on body movements and can be encouraged by skin massage to increase the flow in proximal skin lymphatics. Daily self-massage of the skin of the chest and abdomen for 15 minutes can help to reduce swelling. Daily limb exercises will improve circulation and reduce joint stiffness. Massage and exercise should be routinely used in conjunction with bandaging and compression garments.

5. Skin care – Daily skin hydration (with aqueous cream as a soap substitute) is important. With gross swelling sensation is reduced and skin damage and ulceration can easily occur, so the limb should be kept away from excessive heat, detergents or hard objects. (Patients should be advised to use oven, washing-up and gardening gloves if an arm or hand is affected, and to avoid carrying heavy objects.)

6. Prophylactic antibiotics are indicated if cellulitis has occurred more than once. Fungal infections in skin creases also require treatment with anti-fungal cream. Avoid venipuncture or using a blood pressure cuff on an affected arm.

Diuretics – In gross lymphedema there can be a secondary venous component with some of the edema due to immobility and loss of muscle pumping. A diuretic may slightly reduce tissue tension but is rarely helpful.

High dose steroids can occasionally relieve early edema due to recurrent pelvic malignancy, but in most cases are ineffective.

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.