Lymphedema

Medical quality assurance by Dr. Albrecht Nonnenmacher, MD at June 29, 2016
StartDiseasesLymphedema

The lymphatic system is responsible for fighting infection and is an important part of the immune system. Lymphedema is swelling commonly occurring in the arms or legs due to a lymphatic system blockage. The blockage causes a build-up of lymphatic tissue in the surrounding tissues.

Contents

Definition & Facts

"Edema" literally means swelling and "lymph" refers to the lymphatic system. Lymphedema is often a complication of cancer treatment. Lymphedema occurs in approximately 20% of patients who have axillary (armpit) lymph node removal according to the American College of Surgeons. According to the American Cancer Society, 90% of women who develop lymphedema do so within the first three years of breast cancer treatment.

Symptoms & Complaints

Lymphedema normally manifests as swelling. Due to the swelling, the patient may have decreased range of motion in the affected extremity.

Pain, aching, and general discomfort are felt with lymphedema. Patients commonly report feeling an itchy feeling similar to "bugs crawling all over."

The recommended time to make an appointment with a physician is immediately after the swelling or discomfort is noted. Quick intervention, before soft tissue damage, allows for the best outcome.

Causes

The most common cause of lymphedema is lymph node dissection and/or removal. Lymph nodes are commonly removed to prevent the spread of breast cancer or to test the lymph nodes for cancerous cells. When the lymph nodes are removed, the lymphatic pathways can become overwhelmed with the build-up of lymph and shift the fluid into surrounding tissues, resulting in edema or swelling. According to the American Cancer Society, post-mastectomy patients are most vulnerable to lymphedema within the first year following their lymph node and/or breast removal.

Radiotherapy for cancer treatment also damages the lymphatic system by permanently damaging tissue. Cancer cells and tumors may cause a blockage in the lymph pathways as well. Another common cause of lymphedema is infection because infectious agents can block the flow of lymph.

Lymphedema can also be a congenital disorder which is known as "primary lymphedema." There are different types of congenital lymphedema. They include Milroy's disease, which is the abnormal formation of lymph nodes from infancy. Meige lymphedema (also known as Meige disease) occurs in pubescent-aged and/or pregnant patients. Meige is uncommon but usually occurs before age 35. After age 35, a rare type of congenital late-onset lymphedema may occur called lymphedema tarda.  

Lymphedema may affect certain people more so than others. Those with rheumatoid arthritis or who are obese may be at greater risk. Psoriatic arthritis is a type of arthritis that people who psoriasis can develop. This condition may also be a risk factor for lymphedema.

Diagnosis & Tests

Depending on the patient's past medical history, such as lymph node removal operations, lymphedema may be diagnosed based on signs and symptoms. Otherwise, diagnostic imaging such as MRIs, CT scans, and ultrasounds are used. MRI shows soft tissue with extensive detail and can reveal any damage or trauma to the tissues.

A specialized test called lymphoscintigraphy involves the patient's blood vessels being injected with a contrast dye. The machine scans the blood vessels as the dye moves through, making it easier to see blockages of fluid.

If lymphedema is believed to be congenital, genetic testing may be done. Measurements of the volume of the affected extremity are used to determine the severity of lymphedema. These can be accomplished by using a tape measurement.

Treatment & Therapy

According to the National Lymphedema Network, treating lymphedema is based on complete decongestive therapy which is also known as CDT. It has two phases: the first phase attempts to reduce the swelling in the limbs and the second phase attempts to maintain that reduction and improve the patient's overall quality of life.

Reducing swelling in the limbs takes the form of several techniques that utilize similar mechanisms. Manual lymph drainage is similar to a type of massage that involves a therapist manipulating the congested lymphatic tissue through the skin and attempting to direct it towards areas that are not blocked.

Compression bandaging is also involved which attempts to create pressure in certain parts of the swollen limb in order to move congested fluid into open vessels and pathways. Similarly, compression socks help the flow of excessive lymph out of the extremity. Intermittent pneumatic compression sleeves are worn on the affected extremity, hook up to a pump, and inflate periodically to move lymph fluid. The sleeves feel like a massage and are very beneficial to patients with lymphedema.

Exercises are important to treating lymphedema. Light exercise helps to keep blood moving through the vessels, preventing back-up of fluid. Heavy exercise is not advised immediately following lymph node operations because the blood flow increase also increases the chance of lymphedema. Exercises can target the arm or the leg.

With severe and persistent lymphedema, surgery may be recommended to remove tissue in the affected extremity. Surgery does not cure the condition and is considered a last resort because of the many risks it carries. Types of surgery used to treat lymphedema are liposuction and microsurgical reconstruction.

Living a healthy lifestyle is important to managing this chronic condition. Eating well, exercising daily, sleeping regularly, and reducing stress all play their part in improving a person's quality of life.

Having a support system is beneficial when dealing with this chronic condition. Attending group meetings or becoming involved with an online community can help the patient know they are not alone. They are able to share their struggles, receive tips from other patients, and connect with other people whose lives have been affected by lymphedema.

Prevention & Prophylaxis

As lymphedema is often a consequence of cancer treatment, all cancer patients should be aware of the risks posed by lymphadenectomies and other cancer treatments that may cause lymphedema. Unfortunately, many cancer patients have to pursue life-saving treatment despite these risks and are left without much of a choice. To the extent that obesity is a risk factor, steps should be taken to maintain a healthy weight.

The recommended way to prevent lymphedema from worsening is by avoiding using the affected extremity as much as possible. Diagnostic tests such as drawing blood, administering injections, or taking blood pressure should be performed on an unaffected limb. Hospitals have bracelets that say "limb alert" to notify staff members to use the other limb.

The affected limb should be protected from cuts or scrapes to prevent the risk of infection. People with lymphedema should avoid wearing tight clothes which would constrict blood flow. If the affected limb is on the lower portion of the body, shoes should be worn at all times to prevent injuries.

Consistent skin and fingernail care helps prevent infection and injuries in the extremities. Education on self-care is important to cope with the life-long ramifications of this illness. Lymphedema patients need to have education on their disease in order to properly treat and prevent complications.