Lymphedema

Lymphedema is a condition caused by a compromised lymphatic system or lymphatic obstruction which results in localized fluid retention and tissue swelling. It is a common side effect of cancer treatments. If left untreated, lymphedema can cause serious complications including severe disfigurement, disability, pain, and in some cases, even death.

Lymphedema is a medical condition affecting an estimated 1.5 to 5+ million future Medicare Beneficiaries who are not currently receiving treatment from Medicare according to the current medical standard of care. Medicare is spending billions of dollars every year treating largely preventable lymphedema-related cellulitis.

Estimates of lymphedema patients in the U.S. range from 3 million (primary and secondary lymphedema) to 6 million (including mixed lymphedema and venous insufficiency).

There are more than 9.6 million individuals in the United States today who are cancer survivors (living with, and beyond cancer). Of which 61 % of cancer survivors are 65 years of age and older. Of breast cancer patients 10 to 40 % of all breast cancer with arm pit (axillary) lymph node dissection and inguinal node dissection patients will develop lymphedema over their lifetime

A Journal of Clinical Oncology study found that Lymphedema boosted two-year, postoperative medical costs by $14,877 to $23,167, the additional cost came from office visits, treatments for infections and mental health services, including prescriptions for antidepressants. Cost estimates for the treatment of lymphedema exceed $110 Billion annually.

Many cancer survivors, having overcome cancer, find themselves with sudden and often unexplained swelling, usually in the arms or legs. With cancer patients this is the result of either removal of the lymph nodes for cancer biopsy, radiation damage to the lymph system, or damage from tumor/cancer surgeries. This swelling occurs because of one of many factors:

The inflammation and swelling begins after lymph nodes have been removed for cancer biopsies.
The inflammation and swelling may start as a result of radiation damage to either the lymph nodes and/or the lymph system.

There are several groups of people who experience leg or arm inflammation/swelling (edema) from known causes due to either the removal of lymph nodes or damage to the lymph system. In addition, there is a subset of people with unknown causes where the swelling can actually get worse as time goes by. This type of inflammation is called Lymphedema.

Lymphedema is a chronic disease that requires lifelong management. In some cases, lymphedema improves with time. Nevertheless, some swelling is usually permanent.

The term lymphadema comes from the lymphatic system, which helps manage the immune system’s function to protect the body from foreign substances and infections. The lymphatic system includes an extensive network of lymph vessels and lymph nodes. The lymphatic system work in a far different manner than the circulatory system:

Excess fluid is collected from the space between tissues in the body and moves through the lymph vessels. Lymphatic fluid isn’t pumped through the body like blood, but instead is “pushed” through the lymph system as the vessels are compressed by surrounding muscles.

Filters called lymph nodes remove certain harmful substances from the lymph fluid, such as bacteria and debris. The fluid from most tissues or organs is filtered through one or more lymph nodes before draining into the bloodstream.

Lymphedema refers to swelling that generally occurs in one of your arms or legs. Although lymphedema tends to affect just one arm or leg, occasionally both arms and both legs may be swollen.

Types and stages of Lymphedema

There are two types of lymphedema, primary and secondary and secondary lymphedema is more common than primary lymphedema:

Primary lymphedema is rare and is generally a birth defect caused by the absence of or irregularities with certain lymph vessels.

Secondary lymphedema occurs as a result of a blockage or removal of lymph nodes that alters the flow of lymph fluid through the lymphatic system and can develop from an infection, cancer, surgery, scar tissue from surgery or a traumatic injury, trauma, a blood clot in a vein (deep vein thrombosis or DVT), radiation, or cancer treatments.

Lymphedema develops in a number of stages, from mild to severe and is referred to by stages:

Stage 1 (spontaneously reversible): Skin tissue is still at the “pitting” stage, which means that when pressed by fingertips, the area indents and holds the indentation. Usually, upon waking in the morning, the limb(s) or affected area is normal or almost normal size.

Stage 2 (spontaneously irreversible): The tissue now has a spongy consistency and is “non-pitting,” meaning that when pressed by fingertips, the tissue bounces back without any indentation forming). Fibrosis found in Stage 2 lymphedema marks the beginning of the hardening of the limbs and increasing size.

Stage 3 (lymphostatic elephantiasis): At this stage the swelling is irreversible and usually the limb(s) is/are very large. The tissue is hard (fibrotic) and unresponsive; some patients consider undergoing reconstructive surgery called “debulking” at this stage.

Who Develops Lymphedema?

People who have had any of the any of the procedures listed below can be at risk for developing lymphedema:

• Simple mastectomy in combination with arm pit (axillary) lymph node removal. Lumpectomy in combination with axillary lymph node removal.
• Modified radical mastectomy in combination with axillary lymph node removal.
• Combined cancer surgery and radiation therapy to a lymph node region (such as the neck, armpit, groin, pelvis or abdomen).
• Radiation therapy to a lymph node region.
• Lymphedema can occur within a few days, months, or years after surgery.
• Surgeries that may lead to lymphedema include coronary artery by-pass grafts along with hip and knee replacements.

What Are the Symptoms of Lymphedema?

It is important to react quickly to the symptoms of lymphedema listed below. Prompt treatment can help get the condition under control. Do not delay and call your health care provider right away. Untreated, lymphedema can lead to increased swelling and a hardening of the skin and supporting muscle tissue this will result in decreased function and mobility in the affected limb.

Lymphedema can lead to chronic infections and other illnesses; therefore seeking medical attention at the earliest signs of any symptoms of lymphedema is extremely important.

If you notice any persistent swelling in your arm or leg, hands, fingers, shoulders, or chest. The swelling may occur for the first time after a traumatic event (car accident, sudden fall or trauma to an arm or leg for example), after an infection in the area of the body that was treated for cancer, or after an airplane trip lasting more than three hours.

Other potential signs of lymphedema:

• A heavy sensation in the arms or legs.
• Skin that has tightness to it resulting from excess edema.
• Rigidity in the hand, wrist, or ankle.
• Difficulty fitting into clothing in one specific area.
• A sudden tight-fitting bracelet, watch, or ring that wasn’t skintight before.
• Restricted range of motion in your arm or leg
• Aching or discomfort in your arm or leg
• Recurring infections in your affected limb(s)
• Hardening and thickening of the skin on your arm or leg

How Is Lymphedema Diagnosed?

Lymphedema is diagnosed after a careful evaluation of your medical history, including past surgeries and medical treatments, reviewing current medications and symptoms, along with a complete physical exam. Sometimes, additional tests such an MRI, CT scan or Doppler ultrasound may be needed.

Treatment options for Lymphedema

Lymphedema treatments vary, depending on the stage and cause of the illness. If the initial signs and symptoms of swelling are caused by infection, antibiotics can be prescribed. Other treatments may include compression bandaging, proper skin care and diet, cold compression garments, exercises, and a gentle form of skin stretching/massage that manually allows for lymphatic drainage performed by a certified massage therapist trained in lymphatic therapy.

Other things that may help:

• Light exercises that require you to move your affected limb may encourage movement of the lymph fluid out of your limb.

• Wrapping your arm or leg with an Arctic Ease Cryotherapy® Wrap. Cold compression wraps such as Arctic Ease® wrapped around your entire limb encourage lymph fluid to flow back out of your affected limb and toward the trunk of your body. When bandaging your arm or leg, start by making the bandage tightest around your fingers and toes. Wrap the bandage more loosely as you move up your arm or leg. A trained lymphedema therapist can show you how to wrap your limb.
• Massage. Using a massage technique called manual lymph drainage may encourage the flow of lymph fluid out of your arm or leg. Manual lymph drainage involves special hand strokes on your affected limb to gently move lymph fluid to healthy lymph nodes, where it can drain. Avoid massage therapy if you have a skin infection, active cancer, blood clots or congestive heart failure. In addition, keep away from have a massage on areas of your body that have received radiation therapy.
• Pneumatic compression. Wear a plastic sleeve over your affected arm or leg, the sleeve is connected to a pump that intermittently inflates the sleeve, putting pressure on your limb. The inflated sleeve moves lymph fluid away from your fingers or toes, to healthy lymph nodes, where it can drain.
• Compression garments. Compression garments include long sleeves or stockings made to compress your arm or leg to encourage the flow of the lymph fluid out of your affected limb.

Complete decongestive therapy (CDT) is when several of the treatments listed above are combined. CDT should be avoided with people who have high blood pressure, diabetes, paralysis, heart failure, blood clots or acute infections.

In cases of severe lymphedema, surgery may need to be considered to remove excess tissue in your arm or leg. While this reduces severe swelling, however, surgery will not cure lymphedema.

How Can I Help Prevent Lymphedema?

Lymphedema can be prevented or controlled if it develops by maintaining good nutrition habits, incorporating regular exercise into your daily routine and practice good hygiene to avoid infections.

In addition, avoid tight fitting clothes, shoes or jewelry; after breast cancer surgery avoid heavy lifting with the affected arm (even a purse or bag). Also avoid injections or blood drawing on the side where you had lymph nodes removed and have blood pressure checked on the unaffected arm.

It is also extremely important to report any signs of an infection no matter how minor to your healthcare providers. Symptoms can include the following: redness, swelling, a skin rash or blistering on the side of your body where you had lymph nodes removed, or a temperature over 100 degrees. These warning signs of infection may be an early sign of lymphedema and should be treated immediately.

Tips to assist in maintaining good nutrition, which may also help:

• Try to eliminate or reduce foods high in salt and fat from your diet.

• Have a goal to include at least two to four servings of fruits and three to five servings of vegetables in diet daily.
• Add foods high in fiber such as whole-grain breads, cereals, pasta, rice, fresh fruits, and vegetables to your diet
• Drink plenty of water each day to flush your body of toxins
• Maintain your ideal body weight. A registered dietitian or your health care provider can help calculate your ideal body weight.
• Avoid alcoholic beverages.