LYMPHADEMA
PAMELA J. SCHLEMBACH, MD
MD ANDERSON CANCER CENTER
LYMPHADEMA
•
Lymphedema
• swelling that occurs when fluid
drained by the lymph vessels
does not flow out of the arm,
hand, chest and upper back,
groin, legs- on the side of your
surgery
LYMPHADEMA
What is lymphedema?
• Lymphedema may affect just one arm or
leg, or it may occur in both arms or both
legs.
• The lymph fluid is full of protein, which makes
lymphedema hard to treat.
• The protein acts as a magnet for more
swelling, and it encourages infection.
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What is the lymphatic system?
• The lymphatic system• Major part of the immune system,
• Fights disease
• Fights infection
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What is the lymphatic system?
• The lymphatic system makes and moves
lymph fluid around the body. The lymphatic
system has three jobs:
• • Remove extra fluid from body tissues.
• • Absorb fat and move it to the blood.
• • Defend the body against disease by
making white blood cells.
LYMPHADEMA
• Functions parallel to the circulatory system
• Consists of lymph vessels, lymph nodes, and lymphoid
tissues.
• The most important role• absorb and transport large molecules (including protein and
cellular debris) which are too large to be collected by veins
and venous capillaries.
• This lymph fluid is then transported to lymph nodes that
act as “filtering stations” in the body.
• In the lymph nodes, cells from the body’s natural
defense system, called lymphocytes, help fight bacteria
and viruses.
LYMPHADEMA
• Networks of the lymphatic system are situated in several areas of the
body with a specific drainage pathway for each individual area.
• Superficial Lymph Nodes Include:
• Axillary: Located under each arm, these nodes receive fluid from the arm, chest,
back, and breast tissue.
• Inguinal: Located at the bend of the hip, these nodes receive fluid from the leg, lower
abdomen, gluteal region, and external genitals.
• Deep Lymph Nodes Include:
• Supraclavicular: Located at the neck just above the collar bones, this important node
group receives fluid from the head and shoulders. If indicated, the treatment of these
lymph nodes precedes all other treatment.
• Deep Abdominal/Pelvic Nodes: The abdomen is richly invested in lymph nodes—they
surround the organs and intestines. These nodes also receive fluid from the superficial
inguinal area as well. Congestion in this area alone can cause swelling in the lower
extremities, abdomen, and genitalia.
• Lymphatic tissue is found in other areas of the body including the tonsils,
spleen, intestinal wall, and bone marrow.
.
NORMAL LYMPHATICS
Networks of the lymphatic system
are situated in several areas of the
body with a specific drainage
pathway for each individual area.
EXAMPLE OF LYMPHADEMA
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What causes lymphedema?
• There are two types of lymphedema:
• Primary- People are born with primary
lymphedema.
• Seen at birth or later during puberty or adulthood.
EXTREME FORMS OF PRIMARY LYMPHADEMA
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• Secondary• More common
• Related to infection, injury or trauma
involving the arm or leg.
• Occur years after surgery or radiation
treatment
• May not necessarily be related to a
recurrence of cancer.
BREAST CANCER TREATMENT CAN CAUSE LYMPHADEMA
LYMPHADEMA
• Occurs when
• lymph nodes removed during surgery
• treated with radiation
• cancer has spread to lymph nodes.
TYPICAL AFTER SURGERY AND RADIATION YEARS AGO
NEGLECTED LYMPHADEMA
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Lymphedema and the Risk of Malignancies
• Angiosarcoma
• Rare form of a malignant tumor
• Result of long-standing lymphedema.
• Upper or lower extremities and has a tendency to
metastasize quickly.
• Bruise-like discoloration
LYMPHADEMA
Screening and Measurement for Early Detection of Breast Cancer Related
Lymphedema
• Life-long risk for the development of lymphedema.
• Early detection of lymphedema allows for early intervention
• Intervention prevent or slow progression of lymphedema to a
chronic, harder-to-treat stage.
• Patient education regarding the signs and symptoms of
developing lymphedema
LYMPHADEMA
Screening and Measurement for Early Detection of Breast Cancer Related
Lymphedema
• Objective measurement of arms is needed to promote early
detection and improve patient outcomes.
LYMPHADEMA- PREVENTION
LYMPHADEMA- PREVENTION
• Prevent tiring the arm:
• Avoid carrying heavy objects, moving heavy
furniture or doing activities that cause excessive
force or strain on the affected side.
LYMPHADEMA- PREVENTION
• Long car trips or airplane flights:
• −Drink plenty of water.
• - Stand and/or stretch when it is safe to do so.
• − Do arm and breathing exercises every two
hours.
• − Elevate the arm with pillows.
LYMPHADEMA PREVENTION
• Avoid cuts and scratches to the hand
and arm.
LYMPHADEMA PREVENTION
Avoid cuts and scratches to the
hand and arm.
-Long-sleeved shirts while doing work (such as
gardening) that may cause scratches or cuts.
Wear heavy gloves
LYMPHADEMA PREVENTION
Avoid cuts and scratches to the
hand and arm.
• -Electric shaver when shaving under the arm to
prevent razor cuts.
LYMPHADEMA PREVENTION
Avoid cuts and scratches to the hand
and arm.
• − Use a thimble to protect against puncture wounds
while sewing.
• − Use a cutting board while chopping or slicing foods.
• − Avoid shelling shrimp or crawfish with your bare hands.
• − Use insect spray to help prevent insect bites.
• − Treat cuts, burns, insect bites and scrapes immediately.
• - Thoroughly wash injured site, apply an antibacterial
ointment and cover with a bandage.
LYMPHADEMA PREVENTION
Avoid cuts and scratches to the
hand and arm.
− Use insect spray to help prevent insect bites.
LYMPHADEMA-PREVENTION
• Avoid needle insertions in your affected arm.
• Use your healthy arm for blood draws, and
when receiving vaccinations or injections.
• If you need a medical procedure on your
affected arm, such as removing skin growths,
ask your cancer doctor first.
LYMPHADEMA-PREVENTION
Avoid excessive heat, such as saunas,
whirlpool spas or extremely hot
showers.
LYMPHADEMA-PREVENTION
Keep the arm cool in hot weather.
• − Do not sunbathe.
• − Stay in air-conditioned places.
• − Place the arm under cool running
water.
• − Place cool towels over the arm.
LYMPHADEMA-PREVENTION
Prevent burns to the arm.
• − Use long padded mitts near
the oven, grill or fireplace.
• − Protect the arm from sunburn
• - Wear long sleeves.
BURNS CAN CAUSE INFECTION EASILY
LYMPHADEMA PREVENTION
Avoid harsh detergents or deodorants.
• Wear rubber gloves :
• hands will be in water for an extended
length of time
• in contact with harsh chemicals (such as
cleaning solutions).
LYMPHADEMA PREVENTION
Keep hands and cuticles soft.
− Apply a moisturizing lotion after washing to prevent
your hand from becoming chapped, dry or cracked.
LYMPHADEMA/ PREVENTION
• − Do not cut the cuticle on your hand.
• Use a cuticle softener cream and gently
ease the cuticle back with a cottontipped swab.
• −Keep your nail edges smooth
• - Do not bite your fingernails.
• − Use your own instruments when you get a
manicure.
LYMPHADEMA
Check your fingernails for signs of a fungal infection
(i.e., discoloration, thickening, crumbling edges, or
cracks)
LYMPHADEMA PREVENTION
Treat injuries and infection
• − Treat cuts, burns, insect bites and
scrapes immediately.
• - Thoroughly wash injured site,
apply an antibacterial ointment
and cover with a bandage.
NEGLECTING THE SYMPTOMS
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Prevent trapping more fluid in the arm on the side of
your surgery.
• − Blood pressure taken, use the opposite arm.
• If both sides have been treated, ask your doctor for
advice.
• − Wear loose-fitting jewelry or watches with
adjustable bands on the affected arm.
• − Wear properly fitted bras to avoid trapping fluid in
the chest wall and arm.
• − Do not wear tight or elastic shirt sleeves.
LYMPHADEMA/ PREVENTION
• Weight Loss
LYMPHADEMA
• Height, weight, and body mass index (BMI).
• Elevated BMI is associated with increased risk of
developing lymphedema.
• Overweight =BMI ≥ 25 -referred to a qualified
professional for nutrition education.
• Obese =BMI ≥ 30 -referred to a qualified professional
for nutrition counseling and evaluation for potential
weight reduction program.
LYMPHADEMA/ PREVENTION
• Weight Loss
• Obesity can increase the risk of lymphedema.
• Weight loss is achieved by:
• increasing physical activity moderately reducing total
calorie intake.
• Foods that are naturally low in calories include:
• fruits, vegetables, grains, low-fat dairy products and lean
proteins like chicken breast, fish, soy, beans and legumes.
• The federal recommendation for physical activity
for weight loss is 60 to 90 minutes on most days of
the week.
LYMPHADEMA
• Nutrition Guidelines
• Fruits, vegetables and fiber and limit salt, fat and
sugar.
• According to the United States Department of
Agriculture, a healthy diet also includes whole
grains, low-fat dairy products and lean proteins.
• Foods high in fat and added sugar should be
limited because they are high in calories and can
contribute to weight gain and obesity.
OBESITY AND LYMPHADEMA ARE LINKED
EXERCISE FOR PREVENTION
LYMPHADEMA/ PREVENTION
• Exercise
• Several research studies have found that a program
of gradually increasing exercise supervised by a
certified lymphedema therapist — meaning you
start gently and intensify slowly over time — is not
likely to increase the risk of lymphedema.
LIGHT ARM EXERCISE
LYMPHADEMA/ PREVENTION
• Exercise
• Exercise is a key component of any diet but can
also help minimize lymphedema.
• The USDA recommends exercising for at least 30
minutes on most days of the week to benefit overall
health.
• Moving the arms and legs can help move fluid out
of the limbs and prevent swelling.
• Aerobic activities like swimming, bicycling and
jogging on the treadmill to improve cardiovascular
health and increase movement of the extremities
LYMPHADEMA/ PREVENTION
• Sodium
• Sodium (salt) can worsen lymphedema
• Refraining from adding salt to food while cooking or
at the table.
• Avoid high-sodium foods like
• processed foods, deli meats, canned vegetables
and soups, condiments, frozen or convenience
entrees, savory snacks, certain cheeses, premarinated meats and fast food.
LYMPHADEMA
Call your doctor immediately if your arm, hand,
upper back or chest shows signs of infection. These
can include the following.
• • Red streaks on the arm or chest wall
• • Red, warm, or unusually hard, swollen, or painful
arm, hand, upper back, or chest wall
• • A feeling of heaviness or constant aching in the
arm or chest wall
• • Elevated body temperature (fever)
LYMPHADEMA
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Stage 0 Lymphedema (Non-Visible, Latency)
• Lymphedema can develop very slowly
• Protein molecules can accumulate beneath the
skin and “pull” extra water into the affected area
• Sensations of heaviness or fatigue in the limb or
region.
• Despite a “normal” measurement of tissue or limb
sizes in that area
• This stage should not be ignored—instead, prompt
treatment will reduce the risk of worsening edema.
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Stage 1 lymphadema
• Puffy appearance of the hand
• Pushing on the skin—referred to as “pitting” edema.
• Difficult to see veins on the top of the hand or foot.
• Improve at night but return during the day.
• Elevation of the affected area may temporarily
help reduce the edema
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Stage 2 lymphedema
• Swelling takes on a spongy consistency and
“pitting” is less present.
• Does NOT respond to elevation.
• Fibrosis, or scar tissue
• Gradual thickening of the tissues on the limb as it
increases in size.
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• At this stage, the skin typically becomes very dry and scaly
and the limb or other affected body region becomes very
large. There may be fluid leaking from the limb and skin
infections are common. The weight of the limb can be
debilitating. Excess skin projections (including blisters) can form
to attempt to contain the fluid, and these projections pose an
even greater infection risk.
• While these stages are all different, they are continuous. When
lymphedema remains untreated, it will progress. Treatment of
lymphedema focuses on halting this progression while also
improving the symptoms. Specifically, treatment focuses on
reduction of fluid volume but also on softening tissue fibrosis,
reducing risk of infection, and maintaining or enhancing the
function of the limb.
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Does lymphedema go away?
• Although there are cases when lymphedema has
suddenly gone away and not come back, most
patients always have it and need long-term
treatment.
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• How is lymphedema treated?
The physical therapist will evaluate you and create a
treatment plan.
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• Physical therapists provide a comprehensive
program to help manage lymphedema that
includes:
• Education
• Special exercises
• Compression bandaging
• Manual lymphatic drainage therapy
• Fitting of compression garments.
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• Massage –
• Two basic types of massage are used to treat
lymphedema:
• 1. Manual lymph draining -precise and gentle form of
massage moves fluid to other parts of the body.
• 2. Soft tissue mobilization (or myofascial release) loosen scar tissue and other tightness that might
contribute to the swelling.
• Sometimes massage taught to patients or family
members.
MANUAL DRAINAGE
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• Exercise –
• Stretching exercises to loosen up the
tissues in the area
• Special exercises to help move the fluid.
TREATMENT FOR LYMPHADEMA
PHYSICAL THERAPY
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Compression garments – Elastic fabric garments,
similar to a girdle or support stocking, put pressure on
the arm or leg to help move fluid and keep new fluid
from collecting.
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Bandaging –
• Cotton, low-stretch bandages apply constant
pressure on the limb.
• Bandaging is usually combined with other methods
of treatment.
WRAPPING FOR LYMPHADEMA
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Medicine –
Sometimes doctors prescribe antibiotics or other
medicines as part of the treatment plan.
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• Various herbal remedies purported to heal venous
vasculature, reduce inflammation and aid in
detoxification may be recommended.
•
•
•
•
•
Horse chestnut
Coumarin
Grape Seed Extract
Bromelain
Witch Hazel
• BUT-Herbal remedies are not to be substituted for
treatment recommendations by a trained
medical doctor.
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Special compression garments
purchased
DEVICES USED TO TREAT LYMPHADEMA
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How are doctors treating lymphedema with surgery?
• Lymphaticovenular bypass, which redirects the
lymph fluid to small veins
• Vascularized lymph node transfer, which promotes
new lymphatic vessels to grow
• Both procedures allow for improved drainage,
which can lessen the lymphedema.
• Your doctor can talk with you about which
procedure he or she recommends.
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Who may have this procedure?
• Ask your doctor about the surgery.
• Patients who have had less severe lymphedema for a
shorter time tend to have better results.
• What should I expect from this procedure?
• Many patients improve; however, every patient is
different.
• Does not help every patient.
• Do not expect a complete cure.
• What does this procedure involve?
• Four to six hours while under general anesthesia.
LYMPHADEMA
Lymphaticovenular Bypass
• The doctor makes multiple small cuts (incisions)
about 1 inch long in the affected arm or leg.
• ospital stay is less than 24 hours.
• Lymph node Transfer
• Using microsurgery, the doctor removes lymph
nodes from your neck or groin area and then
reattaches them in the affected arm or leg.
• A hospital stay is usually about four days.
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• The Benefits of Water for Lymphedema
• Lymphedema patients should drink plenty of water.
• The opposite (drinking less water) may seem true,
but drinking more water is important because
lymph fluid has high protein content.
• Need water to move protein.
• Having more water available means “protein
traffic” moves better.
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• Other Great Benefits of Water:
• It Helps You De-Stress: Stress takes a toll on all your basic
body systems and when you’re dehydrated the effects are
magnified.
• Drinking water will provide you with more energy, ease
tension, slow breathing, and reduce the strain on your
heart.
• It Helps You Lose Weight: Choosing water instead of sodas
and other caloric beverages is a great start to a healthy
diet.
• Plus, when you’re well hydrated, your body works
more efficiently and will enhance aspects of weight loss, like
digestion and muscle function when you exercise.
LYMPHADEMA
• Other Great Benefits of Water:
• You’ll Be Less Likely To Get Sick: Hydration keeps your
mucus membranes in top working order – they’re
gatekeepers to the natural defense system that helps keep
out germs such as cold and flu viruses.
• It Keeps You Looking Young: Water acts as a natural
moisturizer to the skin, preventing it from drying out, helping
to maintain its elasticity and giving it a general healthy,
glowing appearance.
• Boosts Mood and Brain Power: Even mild dehydration is
associated with feelings of anger, depression, and
confusion.
•
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• Psycho-Social Complications
• Lymphedema is disfiguring and sometimes painful and
disabling.
• It can negatively impact the emotional, vocational,
recreational and financial aspects of the patient's life.
• Most patients are able to continue a normal life;
however, some patients experience depression, anxiety,
and impairments related to their intimate, work, and
social relationships
LYMPHADEMA
• Lymphedema Awareness D-Day
• National Lymphedema Awareness "D" Day: March
6th
• Each year, on March 6, the National Lymphedema
Network and the lymphedema community
nationwide celebrate Lymphedema Awareness "D"
Day, a special day set aside to honor inspirational
lymphedema patients:
those who have contributed to the community or
who have shown great courage in their struggle
with disease.
LYMPHADEMA
•Look for it
•Manage it
•Be proactive
THANK YOU
• Thank you!
QUESTIONS?