Treating and managing lymphoedema

Lymphedema Clinical Summary

Lymphedema occurs from obstruction of lymphatic channels and is associated with malignancy, radiation, trauma, surgery, inflammation, infection, parasitic invasion, paralysis, renal insufficiency, congestive heart failure, cirrhosis, and malnutrition. Lymphedema is characterized by painless pitting edema, fatigue, increase in limb size (particularly during the day), and presence of lymph vesicles. The skin becomes thickened and brown in the late stages. Cellulitis, deep venous thrombosis (DVT), lymphangitis, traumatic hematoma, right heart failure, tuberculosis, and lymphogranuloma venereum should be considered when the diagnosis of lymphedema is made. Imaging techniques of the lymphatic system include radionuclide imaging (lymphoscintigraphy), which is the preferred method, and lymphangiography.


Lymphedema is a disorder characterized by insufficiency of the lymphatic system, which leads to accumulation of a protein-rich fluid in the tissues and to a disfiguring and disabling swelling of the extremities. In the chronic condition the patients also suffer from tissue fi-brosis, adipose degeneration, impaired wound healing, and susceptibility to infections (Witte et al. 2001). Non-inherited secondary or aquired lymphedema develops when the lymphatic vessels are damaged, for example, by surgery or radiation therapy, or obstructed by filarial infection. Inherited primary lymphedema is usually due to hypoplasia or aplasia of the superficial or subcutaneous lympatic vessels. In some families of hereditary lymphedema, heterozygous missense mutations were found in the VEGFR-3 gene. All the lymphedema-associated mutations inactivated the tyrosine kinase domain and therefore led to insufficient VEGFR-3 signaling (Irrthum et al. 2000 Karkkainen et al. 2000). However, primary lymphedemas...

Imaging the Complications of Surgery

Radical inguinal node dissection in particular has a high incidence of complications, including wound infection, skin necrosis, wound dehiscence, lymphoedema, and lym-phocele.13 Imaging can sometimes be used to distinguish an abscess from hematoma, seroma, or lymphocele on CT or MRI, infection often results in a thicker, enhancing wall and heterogenous contents (sometimes with air).105 However, aspiration is often diagnostic in groin collections, with ultrasound guidance if necessary.

Laser Treatment Cryotherapy and Photodynamic Therapy

Carbon dioxide (CO2) and Neodymium yttrium aluminium garnet (Nd YAG) lasers have been used as first-line therapy with reasonable response rates and good cosmetic and functional results. The CO2 laser is typically used at a power setting between 15 and 20 W, and has a penetration of 2-2.5 mm. Direct focusing of the beam allows it to be used as a scalpel to excise tissue for histological analysis. Ablation sites generally heal in 3-4 weeks. The Nd YAG laser is typically used with the power set between 24 and 60 W. It has a tissue penetration of 4-6 mm, but causes tissue coagulation and therefore prevents histological diagnosis and a risk of understaging the disease. Larger lesions can be treated using this laser, but ablation sites can take up to 2-3 months to heal (Fig. 5.11). Treatment with either of these lasers is usually well tolerated, with minor complications ranging from minor pain and bleeding at treatment sites, to preputial lymphoedema in those patients who have retained...

T MAkinen and K Alitalo

Blood and lymphatic vessels together form a circulatory system, which allows the transportation of metabolic substances, cells, and proteins in the body. A major role of the lymphatic vasculature is to return an excess of the protein-rich interstitial fluid to the blood circulation. In addition, the lymphatic vasculature is an important part of the immune system, as it filters lymph and its antigens through the lymph nodes. Lymphatic vessels also serve as one of the major routes for absorption of lipids from the gut (Witte et al. 2001). Until recently, studies of the lymphatic vessels were hampered due to the lack of specific markers, but recently several such markers have been identified. In addition, recent studies have indicated an important role for the lymphatic vessels in certain developmental disorders, such as lymphedema, and as a route for the metastasis of malignant tumors. These findings have brought lymphatic vascular biology to the forefront of cardiovascular research.

The Surgical Management of Advanced Metastatic Inguinal Disease

Wound closure can be combined with a sartorius muscle transposition in order to cover the exposed femoral vessels. However, it is debatable as to whether the sartorius transposition reduces the lymph drainage postoperatively.3 1 Other techniques which have been described include the use of an omental flap in order to reduce the risk of lymphoedema.32

Impact of Breast Disease on the Patient

The patient pictured in Figure 16-8 had inflammatory carcinoma of her left breast, with massive lymphedema of the left arm. The patient had noticed that her arm had been swelling for the past few months, and she now needed support to raise it. She presented to the clinic complaining only about the heaviness of her arm. When examination revealed the breast lesion, she stated that she had noticed the breast changes ''only a few days ago.'' This is another example of denial of illness (see also the patient shown in Fig. 2-1).

Erysipelas St Anthonys Fire

The most common complaints during the acute infection are pain, fever, chills, and swelling of the skin. Infants, young children, and older adult patients are the groups most often affected, with a peak incidence at age 60 to 80. Erysipelas may become a red, indurated, tense, and shiny plaque with sharply demarcated margins. Local inflammatory signs, such as warmth, edema, and tenderness, are universal. Lymphatic involvement is manifested by a peau d'orange look to the skin, with sharp borders and regional lymphadenopathy. More severe infections may include numerous vesicles or bullae, petechiae, and even skin necrosis. Streptococci cause erysipelas in as many as 80 of cases, with two thirds of those caused by group A and 25 by group G streptococci. S. aureus has been implicated in cases of recurrent erysipelas secondary to lymphedema. Atypical forms have been caused by Streptococcus pneumoniae, Klebsiella pneumoniae, Yersinia enterocolitica, and Moraxella spp. and should be...

Management of Complications

Despite the use of elastic stockings, lymphedema can still develop in approximately 10 of patients, especially those in whom extensive surgery together with radiation therapy was necessary because of the burden of disease. Supporting therapy includes lymph massage and compression therapy. Surgical therapy using lymphatic-venous anastomosis have not been entirely successful. Legs with lymphedema are infection prone, especially with streptococcus A bacteria, leading to erisypelas. At the author's institution antibiotic prophylaxis with monthly penicillin depots is strongly advised after two bouts of erisypelas-like infections.

Search strategy for adverse effects

Adverse effects or Mastectomy complications or (ii) the adverse event itself may be indexed, together with the nature of the intervention, for example, Gastrointestinal Hem-orrhage and Aspirin , or Lymphedema and Surgery or (iii) occasionally, an article may be indexed only under the adverse event, for example, Hemorrhage chemically-induced.

Making the Patient Comfortable Splints Pillows Cushions Commodes and Beds

Many types of splints or supports for joints and the spine are available that can help prevent movement-related pain. When walking is painful or difficult, the safety of a walker can increase self-confidence, and many find that leaning forward on them eases back pain. Pain from swelling (lymphedema) can be reduced by using wraps. Pressure stockings or sleeves can also improve function in this setting and after limb pain from a deep venous thrombosis (DVT or blood clot). Simply wrapping a painful joint in an empty plastic bag sealed to the skin with tape can elevate the temperature around the joint by trapping the body's own heat. If moving an arm, a leg, or even the back is very painful, talk to the doctor about whether splinting would reduce the pain. When joints or muscles are weak or paralyzed, a variety of splints are used to provide support and reduce pain. Pain in the spine is common in patients with prostate cancer, breast cancer, or a tumor that has spread to the spine and...

Management of Clinically Node Negative cN0 Patients

Patients undergoing inguinal lymph node dissections can suffer from troublesome lower limb lymphedema which is refractory to conservative treatment. However, the development of nanoparticles which encourage tissue regeneration will be invaluable in the management of lymphedema.

A44 Common medical terms used to describe symptoms and signs of heart and blood vessel disorders

Oedema the presence of abnormally large amounts of fluid in the intercellular tissue spaces of the body and usually means demonstrable accumulation of excessive fluid in the subcutaneous tissues. Oedema may be localized, due to venous or lymphatic obstruction or to increased vascular permeability (which may follow stings from insects), or it may be more widespread due to heart failure or renal disease. Collections of oedema fluid are designated according to the site, for example ascites (peritoneal cavity), hydrothorax (pleural cavity), and hydropericardium (pericardial sac). Oedema due to heart failure is usually first detected as a swelling around the ankles (ankle oedema). Oedema may also occur in the back in front of the end of the spinal cord (sacral area), where it is referred to as sacral oedema.

A81 Common symptoms associated with disease of the kidneys

Oedema the presence of abnormally large amounts of fluid in the intercellular tissue spaces of the body, usually applied to demonstrable accumulation of excessive fluid in the subcutaneous tissues. Oedema may be localized, due to venous or lymphatic obstruction or to increased vascular permeability, or it may be systemic due to heart failure or renal disease. Collections of oedema fluid are designated according to the site, for example ascites (peritoneal cavity), hydrothorax (pleural cavity), and hydropericardium (pericardial sac).

Physical Appearance

Of large auricles, cubitus valgus, short fourth metacarpals and metatarsals, distal palmar triaxial radii, narrow hyper-convex nails, and pigmented cutaneous nevi.162,227 Infants with Turner syndrome exhibit lymphedema with loose skin of the neck, puffiness of the dorsum of the hands and feet, and low hairlines.131,162 Congenital heart disease is much more frequent in patients with Turner syndrome with webbing of the neck than in patients with Turner syndrome without webbing,40,131 and coarctation of the aorta is eight times as frequent when Turner syndrome is accompanied by webbing of the neck.131 Noonan syndrome (Turner phenotype with normal genotype) (see Fig. 8-11) is only occasionally accompanied by coarctation of the aorta163 and rarely by ascending aortic aneurysm.162,195,204

Sex Chromosomal Abnormalities

Turner's syndrome, a form of gonadal dysgenesis resulting from a 45,X karyotype (X-chromosomal monosomy), is characterized by female phenotype, short stature, a shieldlike chest, a short and sometimes webbed neck, low- set ears, high-arched palate, small mandible, and sexual infantilism. y The frequency of 45,X in female live births is 0.1 to 0.6 per 1000. A variety of other malformations can be associated, including congenital lymphedema, particularly of the hands and feet, cardiac and renal defects, skeletal anomalies, and abnormalities of the nails. An increased number of pigmented nevi has also been reported. Other disorders have been associated with this disorder, including Hashimoto's thyroiditis, obesity, inflammatory bowel disease, and rheumatoid arthritis. Nerve deafness occurs in approximately half the patients, and olfactory as well as taste deficits have been described. Eighteen percent of patients studied in one series were mentally retarded, although this high prevalence...

Clinical Manifestations and Pathology

Once the filarial larva settles in a human lymph channel and begins to mature, it provokes a localized response consisting of lymph vessel dilation and a slowing of lymph flow through that worm-occupied channel. With time the host body responds immunologically, sending eosinophils, plasma cells, and macrophages to the sites of infection. Lymphangitis (inflammation of lymph channels) usually results in swelling, redness, and pain, and, when the lymph vessels become hypertrophied, in varices. Fibrosis of the vessel occurs, trapping and killing the adult worm, which is absorbed or calcified. Obliteration of the lymph vessel forces extravasation of lymph into the tissue space, where it accumulates and causes the typical lymphedema of filarial elephantiasis. The swelling can become quite large, consisting of lymph, fat, and fibrotic tissue under tightly stretched and thickened skin (Beaver et al. 1984 Manson-Bahr and Bell 1987).

Structure and Physiology

The lymphatic system is an extensive vascular network and is responsible for returning tissue fluid (lymph) back to the venous system. The extremities are richly supplied with lymphatic tissue. Lymph nodes, many of which are located between major proximal joints, aid in filtering the lymphatic fluid before it enters the blood. The most important clinical symptoms of lymphatic obstruction are lymphedema and lymphangitis.

Examination of the Lymphatic System

Lymphedema Lymphangitis is lymphatic spread manifested by thin red streaks on the skin. Obstruction to lymphatic flow produces lymphedema, which is usually indistinguishable from other types of edema. In Figure 16-8, the patient has marked lymphedema of her left arm secondary to inflammatory breast carcinoma.

Evaluate for Retraction Phenomenon

If a mass is detected, molding of the skin may be useful to determine whether the retraction phenomenon is present. The examiner should elevate the breast around the mass. Dimpling may occur if a carcinoma is present. Figure 16-19 demonstrates the technique of molding and its result in a patient with carcinoma of the breast. Notice the marked dimpling of the breast. This patient also had metastatic lesions of breast carcinoma on her arm, together with lymphedema. She presented to the clinic stating that she had discovered the swollen arm the day before.

The Role of Radiotherapy in the Management of Urethral Cancer

The complication rates following radiotherapy range between 16 and 20 . Currently dose reduction without compromising tumor control appears to be the best way of reducing the morbidity associated with this treatment.914 The complications following radiotherapy include penile lymphoedema and urethral stricture disease for anterior lesions. For posterior urethral tumors there is a risk of fistula formation with the bladder or rectum.

Surgical Techniques of Lymphadenectomy 981 Inguinal Lymphaden ectomy

Transected and the muscle together with its overlying fascia is sutured to the inferior margin of the inguinal ligament. Excellent coverage of the femoral vessels is achieved with no long-term sequelae. The saphenous vein can also be spared, if possible, in order to minimize postoperative lymphedema. After performing the dissection, the skin edges are carefully inspected any area with doubtful viability should be excised. There are no comparative studies on the use of antibiotics but it seems reasonable to give prophylactic antibiotics at the time of surgery, as this type of surgery should be considered a contaminated procedure, because of coexisting inflammatory reactions within the lymph nodes. Along with the general recommendations for prophylactic antibiotics, the authors' group gives one dose at the start of anesthesia. Prior to closing the wound, suction drains are inserted in order to prevent lymphocele formation and also increase the chance of primary wound healing....

Prognosis and Adjuvant Treatment

Penile Cancer

Therapy, e.g. short-term complications like epidermolysis, and long-term effects such as lymphedema and fibrosis. Finally, the follow-up is more complicated because of the fibrotic changes, making physical examination less reliable. Although, Ravi et al. have indicated that patients with large ( 4 cm) and or fixed regional nodes may benefit from preoperative radiotherapy, the above-mentioned disadvantages outweigh the preoperative use. There are no studies available that have


EN is patchy, it involves the small bowel, mostly the jejunum, but it frequently also affects the ileum. The colon is never directly involved. There is mucosal necrosis and variable necrosis of the bowel wall, up to full thickness. The worst patches are often antimesenteric. The mesentery itself becomes thickened, shortened and odematous and often hemorrhagic. The mesenteric nodes are enlarged and hemorrhagic. At surgery, which is usually 5-10 days after consumption of the meat containing meal, there is obvious lymphatic obstruction in the damaged gut wall and mesentery. Adherent mesentery binds the thick damaged loops of bowel together. The damage in the gut is visually suggestive of vascular involvement transverse stripes of hemorrhagic injury and patches of necrosis alternate with relatively normal areas. In Thailand, the disease was called segmental infarcts of the small intestine.9 Many pathologists have described the pathology as infarction, implying death of tissue due to...

Lymph Nodes

V Lymphedema results from the accumulation of lymphatic fluid in tissues, which is caused by restricted lymphatic flow. Lymphedema is typically classified as primary or secondary. Lymphedema often results when lymph nodes or lymphatic vessels are damaged or surgically removed. A patient with breast cancer who has undergone axillary lymph node dissection or radiation therapy, or both, is at risk of developing lymphedema because of the removal or damage of the lymph nodes and small lymphatic vessels. Symptoms include persistent accumulation of a protein-rich fluid in the interstitial tissues and swelling of the upper limb on the affected side.

Yellow Nail Syndrome

Yellow nail syndrome is an uncommon disorder of unknown aetiology, characterized by the triad of yellow nails, lymphoedema and respiratory tract involvement. Vitamin E at dosages ranging from 600 to 1200 IU daily can induce a complete clearing of the nail changes. Although the mechanism of action of vitamin E in yellow nail syndrome is still unknown, antioxidant properties of alpha-tocopherol may account for its efficacy. A 5 solution of vitamin E in dimethyl sulphoxide produced marked clinical improvement in a double-blind controlled study. The efficacy of topical vitamin E, however, still needs confirmation. Oral itraconazole, 400 mg daily one week a month for several months, or oral flucouazole, may be beneficial in some cases.


Chyluria may be classified as parasitic or nonparasitic (Table 2). Various theories have been suggested to explain the cause of chyluria. Prout postulated the theory of secretion of fat from blood through the kidney (9). Mollenbroch (1670) suggested abnormal connection between lymphatic and urinary system (10). Ackerman (1863) gave the obstructive theory and suggested that the obstruction of lymphatics anywhere between intestinal lacteals and the thoracic duct may give rise to chyluria (3). The theory of lymphatic obstruction appears to be most convincing and is well supported by the existing literature (11-13). The theory of lymphatic obstruction appears to be most convincing and is well supported by the existing literature.

Physical Therapist

Rather than attempting to improve the patient's function, the goal of the palliative care physiotherapist is to help plan activity oriented to maximizing the patient's diminishing resources. This can be accomplished by active or passive range of motion exercises that the bedridden patient can perform to prevent contractures and improve circulation, massage to relax aching muscles, treatment of lymphedema, instruction in transfers or positioning, and the use of physical therapy for the alleviation of pain.

Massage Techniques

Different client groups require proper recognition before aromatherapy trials are started or aromatherapy massage is given. For example, for cancer patients, guidelines must be observed (Wilkinson et al., 1999) special care must be taken for certain conditions such as autoimmune disease (where there are tiny bruises present) low blood cell count, which makes the patient lethargic and needing nothing more than very gentle treatment and lymphoedema, which should not be treated unless the therapist has special knowledge and where enfleurage toward the lymph nodes should not be used. A general study of the clinical effectiveness of massage by Ernst (1994) used numerous trials, with and without control groups. A variety of control interventions were used in the controlled studies including placebo, analgesics, transcutaneous electrical nerve stimulation (TENS), and so on. There were some positive effects of vibrational or manual massage, assessed as improvements in mobility, Doppler flow,...