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Lymphedema

General

According to etiology, there are two general classifications of lymphedema primary and secondary lymphedema. Primary lymphedema is caused by deficient or faulty development of the lymph system. Secondary lymphedema occur as a complication from trauma or diseases which damage the lymphatic vessels or lymph nodes. The primary cause of lymphedema in the western world, is impaired or disrupted flow of lymph fluid caused by cancer or cancer treatment (secondary lymphedema).

Lymphedema occurs when the transport capacity of the lymph system is reduced significantly.
The swelling is caused by an accumulation of fluid (rich in protein) in the tissue, due to reduced drainage of lymph fluid (1,2). The swelling is often chronic. A lymphedema can lead to pain/discomfort and changes in the soft tissues in the affected area (fibrosis) (3,4). Lymphedema occurs most often during the first 2-3 years after cancer treatment (5 6). Without treatment, lymphedema can lead to progressive swelling.

In some cancer treatment the lymph nodes and fatty tissue are removed, most often in the axilla, pelvis and the groin. This treatment causes damage to the lymphatic wessels and reduces the number of lymph nodes. The subsequent reduced capacity for drainage of lymph fluid in the arm and leg may result in lymphedema.

Radiation therapy may cause tissue scarring and fibrosis. The combination of surgery and radiation therapy to the axilla additionally increases the risk of developing lymphedema.

Cancer related lymphedema can also occur due to metastasis in areas where blocking the central lymph vessels in advanced disease.

Factors which may increase the risk for developing lymphedema are:

  • obesity
  • infection in the area where lymphedema occurs
  • overheating/sunburn
  • trauma of the arm/leg on the operated side

Indications for treatment

Lymphedema in the arm/hand, breast, leg, groin, face and neck after treatment of:

  • breast cancer where axillary dissection is performed
  • gynecologic cancer where the lymph nodes in the pelvis or the groin are removed
  • melanoma where the lymph nodes in the axilla or the groin are removed
  • lymphoma and cancer of the head and neck region where lymph nodes in the neck region are removed
  • prostate cancer where the lymph nodes in the pelvis or the groin are removed
  • sarcoma where lymph nodes are removed

Without treatment the lymphedema can increase in size. This may cause skin changes (fibrosis), increased swelling and therefore more discomfort in the area (3).

Contraindications

Absolute
  • acute infections, local or general (erysipelas)
  • arterial insufficiency with risk of necrosis
  • thrombosis and embolism
Relative

Untreated cancer disease, heart failure, or kidney failure

Goal

  • reduce lymphedema
  • relieve tormenting side effects
  • improve function 
  • prevent complications such as skin changes and inflammation in the area (erysipelas)

References

1. Rockson SG. Diagnosis and management of lymphatic vascular disease. J Am Coll Cardiol 2008;52:799-806.
2. Lawenda BD, Mondry TE, Johnstone PAS. Lymphedema: (Review) A primer on the identification and management of a chronic condition in oncologic treatment. CA Cancer J Clin 2009;59:8-24.
3. Mortimer PC. The patophysiology of lymphedema. Cancer 1998;83(12 Suppl American): 2798-802.
4. Erickson VS, Pearson ML, Ganz PA, Adams J, Kahn KL. Review: Arm edema in breast cancer patients. J Natl Cancer Inst 2001;93:96-111.
5. Nesvold IL, Dahl AA, Løkkevik E, Mengshoel AM, Fosså SD. Arm and shoulder morbidity in breast cancer patients after breast-conserving therapy versus mastectomy. Acta Oncol 2008;47:835-842.
6. Norman SA, Russel Locario A, Potashnik SL, et al (2009) Lymphedema in breast cancer survivors: incidence, degree, time course, treatment, and symptoms. J Clin Oncol 2009;27:390-397.
7. Johansen J, Overgaard J, Blichert Toft M, Overgaard M. Treatment morbidity associated with the management of the axilla in breast-conserving therapy. Acta Oncol 2000;39:349-54

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