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Lymphedema (PDQ®)

Management

Prevention

Education

Ideally, prevention should begin before treatment, by educating the patient and family in a sensitive fashion about the potential risk of developing lymphedema. Proceeding in this way may diminish a breast cancer survivor’s dissatisfaction with the educational information received about lymphedema, and could serve as a foundation for making decisions and coping with lymphedema, should it develop later.[1] Patients should be taught to recognize the early signs of edema because treatment outcomes may be significantly improved if the problem is detected early.[2]

Exercise

Refer to the Exercise does not increase risk of lymphedema onset subsection in the Risk Factors section of this summary for more information.

Other preventive measures

Generally anecdotal recommendations for taking preventive measures include the following:

Hygiene: Skin and Nail Care

  • Maintain meticulous skin hygiene and nail care to prevent a portal of entry for infection which may result in cellulitis.
  • Cut toenails straight across; see a podiatrist as needed to prevent ingrown nails and infections.
  • Use skin moisturizers and topical antibiotic solutions after small breaks in the skin, such as paper cuts.
  • Use sunscreen and suntan gradually.
  • Wear cotton socks; keep feet clean and dry.
  • Wear gardening and cooking gloves and use thimbles for sewing.
  • Avoid going barefoot outdoors.
  • Avoid blood draws (including finger sticks), vaccinations, or intravenous lines in the affected arm.
  • Use the unaffected extremity to test temperatures (e.g., for bath water or cooking), as sensation may be diminished.
  • Be aware of the signs of infection (fever, swelling, redness, pain, and heat) and see a physician for evaluation immediately.

Extremity Positioning

  • Keep the arm or leg elevated above the level of the heart when possible.
  • Avoid constrictive pressure on the affected arm or leg.
    • Do not cross legs while sitting.
    • Wear loose jewelry and clothes with no constricting bands.
    • Carry a handbag on the opposite arm.
    • Do not use elastic bandages and stockings with constrictive bands.
    • Do not sit in one position for longer than 30 minutes.

Avoiding the Pooling of Blood in the Involved Extremity

  • Avoid rapid circular movements that cause centrifugal pooling of fluid in distal parts of the limb.
  • Avoid local application of heat to the limb, which may increase blood flow.
  • Do not maintain the limb in a gravity-dependent position for long periods of time.
  • Avoid tight-fitting clothing or blood pressure monitoring in the affected arm, which could cause a tourniquet effect and obstruct lymph flow.

Treatment

The goal of lymphedema treatment centers on controlling limb swelling and minimizing complications; the underlying lymphatic vessel interruption cannot be corrected. Because clinical trials evaluating pharmacologic measures are generally not found to be effective, nonpharmacologic measures are the mainstay of treatment, with the goal of maximizing the activities of daily living, decreasing pain, increasing range of motion, and improving function.

Exercise

Nonfatiguing exercises may induce sufficient muscle contraction to move lymph into terminal lymphangioles and reduce swelling. Aerobic exercise may also increase the tone of the sympathetic nervous system, which causes the lymph collector vessels to pump more vigorously.[3] Multiple studies indicate that exercise, including upper-body exercise, is safe for women with breast cancer–related lymphedema.[4]

There is also evidence that slowly progressive weight lifting among women with previously diagnosed breast cancer–related lymphedema leads to a reduction by half of the likelihood of a clinically meaningful exacerbation of lymphedema (a flare-up) that requires treatment by a physical therapist.[5][Level of evidence: I] A group of 141 breast cancer survivors with lymphedema were randomly assigned to a twice-weekly, year-long weight-lifting intervention (N = 71) or to a wait-list comparison group (N = 70). The intervention started with 13 weeks of supervised training with little to no resistance; the amount of weight lifted was increased very gradually and only if there was no change in lymphedema symptoms or swelling. The participants all wore well-fitting, custom-made compression garments that were replaced 6 months into the intervention period. Women with breast cancer–related lymphedema should be guided to work with a certified fitness professional or physical therapist to learn the proper biomechanical form for upper-body weight-lifting exercises before undertaking this program on their own. (The specifics of the intervention are available to certified fitness professionals and physical therapists through the National Lymphedema Network.) Further research is needed to develop a version of this intervention that can be broadly disseminated.

One small pilot study has examined the safety of an intervention similar to that described above in cancer survivors with lower-extremity lymphedema secondary to melanoma or gynecologic or urological cancers. In this uncontrolled pilot study, 20% of participants developed a cellulitic infection within the first 2 months after starting a slowly progressive weight-lifting regimen.[6] Further research is needed to determine whether weight-lifting is a safe exercise modality for cancer survivors with lower-extremity lymphedema.

Gradient pressure garments

Gradient pressure garments (also known as lymphedema sleeves or stockings) generate greater pressures distally than proximally, which enhances mobilization of edema fluid. Some patients may require custom-made sleeves to achieve an appropriate fit. The use of these garments may be especially important at high altitudes, such as during air travel, because the ambient atmospheric pressure is less than the outlet transcapillary pressure within the superficial tissues, which can lead to worsening edema.

Bandages

Bandaging involves the use of inelastic material to discourage reaccumulation of lymph by reducing capillary ultrafiltration and optimizing the efficacy of the intrinsic muscle pump. Bandaging may change an initially resistant limb to one with less edema, resulting in decreased limb volume and allowing a garment to be applied successfully.[7][Level of evidence: I]

Skin care

The goal of skin care is to minimize dermal colonization by bacteria and fungus, especially in the crevices, and hydrate the skin to control dryness and cracking.

Complex decongestive therapy

Complex decongestive therapy is a multimodality program that consists of manual lymphedema drainage therapy, low-stretch bandaging, exercises, and skin care.[8] This approach has been recommended as a primary treatment by consensus panels and as an effective therapy for lymphedema unresponsive to standard elastic compression therapy.[9,10]

Complex decongestive therapy is divided into two successive phases. The first phase consists of intensive treatment to allow substantive reduction of lymphedema volume. The second phase consists of maintenance treatment at home. Compliance with the use of the elastic sleeve and low-stretch bandage has been found to be an important determinant of success with maintenance therapy at home.[8] Complex decongestive therapy has also been shown to improve lymphedema following groin dissection.[11] Patients should be referred to a properly trained therapist for optimal results.

Intermittent external pneumatic compression

Intermittent external pneumatic compression may also provide additional improvement with lymphedema management when used adjunctively with decongestive lymphatic therapy. One small randomized trial of 23 women with new breast cancer–associated lymphedema found an additional significant volume reduction when compared with manual lymphatic drainage alone (45% vs. 26%).[12][Level of evidence: I] Similarly, improvements were also found in the maintenance phase of therapy. Concerns regarding the use of intermittent pneumatic compression include the optimum amount of pressure and treatment schedule and whether maintenance therapy is needed after the initial reduction in edema.[13][Level of evidence: I] There is a theoretical concern that pressures higher than 60 mmHg and long-term use may actually injure lymphatic vessels.

Pharmacologic therapy

No chronic pharmacologic therapy is recommended for patients with lymphedema. Diuretics are typically of little benefit and may promote intravascular volume depletion because the lymphedema fluid cannot be easily mobilized into the vascular space. Coumarin is associated with significant hepatotoxicity and has not been found to have any benefit in controlled trials.[14] Antibiotics should be used promptly for patients with evidence of cellulitis; intravenous use may sometimes be required for severe cellulitis, lymphangitis, or septicemia.

Weight loss

The results of a small randomized trial have suggested that breast cancer–related lymphedema may improve with weight loss.[15][Level of evidence: I] The mechanism by which obesity may predispose to lymphedema is unclear, but proposed mechanisms include an increased risk of postoperative complications, including infection, reduced muscle pumping efficiency, and separation of lymphatic channels by subcutaneous fat.[15] A larger, longer-term weight-loss intervention in cancer patients with lymphedema (including those with lower-extremity disease) is warranted to further explore weight loss for disease management.

Low-level laser therapy

Studies suggest that low-level laser therapy may be effective in reducing lymphedema in a clinically meaningful way for some women.[16][Level of evidence: I][17,18] Two cycles of laser treatment were found to be effective in reducing the volume of the affected arm, extracellular fluid, and tissue hardness in approximately one-third of patients with postmastectomy lymphedema at 3 months posttreatment.[16] Suggested rationales for laser therapy include a potential decrease in fibrosis, stimulation of macrophages and the immune system, and a possible role in encouraging lymphangiogenesis.[16]

Surgery

Surgery is rarely performed on patients who have cancer-related lymphedema. The primary surgical method for treating lymphedema consists of removing the subcutaneous fat and fibrous tissue with or without creation of a dermal flap within the muscle to encourage superficial-to-deep lymphatic anastomoses. These methods have not been evaluated in prospective trials, with adequate results for only 30% of patients in one retrospective review. In addition, many patients face complications such as skin necrosis, infection, and sensory abnormalities.[19] The oncology patient is usually not a candidate for these procedures. Other surgical options include the following:

  • Microsurgical lymphaticovenous anastomoses, in which the lymph is drained into the venous circulation or the lymphatic collectors above the area of lymphatic obstruction.
  • Liposuction.
  • Superficial lymphangiectomy.
  • Fasciotomy.

Integrative Modalities

Manual lymphedema therapy

Manual lymphedema therapy, a type of massage technique, involves the use of a very light superficial massage with gentle, rhythmic skin distention, ideally limited to pressures of approximately 30 mmHg to 45 mmHg.[3] In comparison to many other massage techniques, manual lymphedema therapy is very light to the touch. The strokes often feel like a “brushing” technique. Manual lymphedema therapy decreases congested lymph nodes by directing it to the circulatory and lymphatic system.[3] Manual lymphedema therapy begins on unaffected areas to direct the lymph away from the affected extremity.

A limited number of trials have been conducted among women with breast cancer who are experiencing lymphedema. These trials have reported significant reductions in limb volume when manual lymphedema therapy is administered as the sole intervention or as an adjunct to standard of care.[20-22][Level of evidence: I] However, large randomized controlled trials are needed to confirm these preliminary findings.

Manual lymphedema therapy should be introduced in a closely supervised medical setting, by a clinician specifically trained in manual lymphedema therapy.[23] No adverse events have been reported in the pilot studies that administered manual lymphedema therapy to women with breast cancer. The reported adverse events are associated with the general discipline of massage therapy and are largely related to treatments delivered by unlicensed massage therapists or treatments that include deep and rigorous massage techniques. Manual lymphatic therapy, also known as manual lymphatic drainage, can be taught to patients for self-care.

Despite the safety profile, the following special precautions should be considered when massage therapy is delivered to individuals with cancer:

  • Avoid directly massaging any open wounds, hematomas, or areas with skin breakdown.
  • Avoid directly massaging tumors that are apparent on the skin surface.
  • Avoid massaging areas with acute deep venous thrombosis.
  • Avoid directly massaging radiated soft tissue when the skin is sensitive.[24]

Additional integrative modalities have been under investigation for their role in the treatment of secondary lymphedema. Selenium has been studied in clinical trial NCT00188604, and acupuncture and moxibustion have been studied in clinical trial LJMC-AMWELL-SL as treatments for lymphedema.

Refractory Lymphedema and Complications

If lymphedema is massive and refractory to treatment, or has an onset several years after the primary surgery without obvious trauma, a search for other etiologies should be undertaken. Of particular importance is exclusion of the recurrence of tumor or the development of lymphangiosarcoma, which should be excluded with computed tomography or magnetic resonance imaging. The complication of lymphangiosarcoma is classically seen in the postmastectomy lymphedematous arm (Stewart-Treves syndrome). The mean time between mastectomy and lymphangiosarcoma is 10.2 years, with a median survival of 1.3 years. Clinically, the lesions of lymphangiosarcoma may initially appear as blue-red or purple with a macular or papular shape in the skin. Multiple lesions are common; subcutaneous nodules may appear and should be carefully evaluated in the patient who has chronic lymphedema.[25]

References

  1. Ridner SH: Pretreatment lymphedema education and identified educational resources in breast cancer patients. Patient Educ Couns 61 (1): 72-9, 2006. [PUBMED Abstract]
  2. Markowski J, Wilcox JP, Helm PA: Lymphedema incidence after specific postmastectomy therapy. Arch Phys Med Rehabil 62 (9): 449-52, 1981. [PUBMED Abstract]
  3. Petrek JA: Commentary: prospective trial of complete decongestive therapy for upper extremity lymphedema after breast cancer therapy. Cancer J 10 (1): 17-9, 2004.
  4. Schmitz KH: Balancing lymphedema risk: exercise versus deconditioning for breast cancer survivors. Exerc Sport Sci Rev 38 (1): 17-24, 2010. [PUBMED Abstract]
  5. Schmitz KH, Ahmed RL, Troxel A, et al.: Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med 361 (7): 664-73, 2009. [PUBMED Abstract]
  6. Katz E, Dugan NL, Cohn JC, et al.: Weight lifting in patients with lower-extremity lymphedema secondary to cancer: a pilot and feasibility study. Arch Phys Med Rehabil 91 (7): 1070-6, 2010. [PUBMED Abstract]
  7. Badger CM, Peacock JL, Mortimer PS: A randomized, controlled, parallel-group clinical trial comparing multilayer bandaging followed by hosiery versus hosiery alone in the treatment of patients with lymphedema of the limb. Cancer 88 (12): 2832-7, 2000. [PUBMED Abstract]
  8. Vignes S, Porcher R, Champagne A, et al.: Predictive factors of response to intensive decongestive physiotherapy in upper limb lymphedema after breast cancer treatment: a cohort study. Breast Cancer Res Treat 98 (1): 1-6, 2006. [PUBMED Abstract]
  9. Didem K, Ufuk YS, Serdar S, et al.: The comparison of two different physiotherapy methods in treatment of lymphedema after breast surgery. Breast Cancer Res Treat 93 (1): 49-54, 2005. [PUBMED Abstract]
  10. Koul R, Dufan T, Russell C, et al.: Efficacy of complete decongestive therapy and manual lymphatic drainage on treatment-related lymphedema in breast cancer. Int J Radiat Oncol Biol Phys 67 (3): 841-6, 2007. [PUBMED Abstract]
  11. Hinrichs CS, Gibbs JF, Driscoll D, et al.: The effectiveness of complete decongestive physiotherapy for the treatment of lymphedema following groin dissection for melanoma. J Surg Oncol 85 (4): 187-92, 2004. [PUBMED Abstract]
  12. Szuba A, Achalu R, Rockson SG: Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema. A randomized, prospective study of a role for adjunctive intermittent pneumatic compression. Cancer 95 (11): 2260-7, 2002. [PUBMED Abstract]
  13. Dini D, Del Mastro L, Gozza A, et al.: The role of pneumatic compression in the treatment of postmastectomy lymphedema. A randomized phase III study. Ann Oncol 9 (2): 187-90, 1998. [PUBMED Abstract]
  14. Loprinzi CL, Barton DL, Jatoi A, et al.: Symptom control trials: a 20-year experience. J Support Oncol 5 (3): 119-25, 128, 2007. [PUBMED Abstract]
  15. Shaw C, Mortimer P, Judd PA: Randomized controlled trial comparing a low-fat diet with a weight-reduction diet in breast cancer-related lymphedema. Cancer 109 (10): 1949-56, 2007. [PUBMED Abstract]
  16. Carati CJ, Anderson SN, Gannon BJ, et al.: Treatment of postmastectomy lymphedema with low-level laser therapy: a double blind, placebo-controlled trial. Cancer 98 (6): 1114-22, 2003. [PUBMED Abstract]
  17. Kozanoglu E, Basaran S, Paydas S, et al.: Efficacy of pneumatic compression and low-level laser therapy in the treatment of postmastectomy lymphoedema: a randomized controlled trial. Clin Rehabil 23 (2): 117-24, 2009. [PUBMED Abstract]
  18. Ahmed Omar MT, Abd-El-Gayed Ebid A, El Morsy AM: Treatment of post-mastectomy lymphedema with laser therapy: double blind placebo control randomized study. J Surg Res 165 (1): 82-90, 2011. [PUBMED Abstract]
  19. Chilvers AS, Kinmonth JB: Operations for lymphoedema of the lower limbs. A study of the results in 108 operations utilizing vascularized dermal flaps. J Cardiovasc Surg (Torino) 16 (2): 115-9, 1975 Mar-Apr. [PUBMED Abstract]
  20. McNeely ML, Magee DJ, Lees AW, et al.: The addition of manual lymph drainage to compression therapy for breast cancer related lymphedema: a randomized controlled trial. Breast Cancer Res Treat 86 (2): 95-106, 2004. [PUBMED Abstract]
  21. Williams AF, Vadgama A, Franks PJ, et al.: A randomized controlled crossover study of manual lymphatic drainage therapy in women with breast cancer-related lymphoedema. Eur J Cancer Care (Engl) 11 (4): 254-61, 2002. [PUBMED Abstract]
  22. Andersen L, Højris I, Erlandsen M, et al.: Treatment of breast-cancer-related lymphedema with or without manual lymphatic drainage--a randomized study. Acta Oncol 39 (3): 399-405, 2000. [PUBMED Abstract]
  23. Ernst E: Massage therapy for cancer palliation and supportive care: a systematic review of randomised clinical trials. Support Care Cancer 17 (4): 333-7, 2009. [PUBMED Abstract]
  24. Gecsedi RA: Massage therapy for patients with cancer. Clin J Oncol Nurs 6 (1): 52-4, 2002 Jan-Feb. [PUBMED Abstract]
  25. Tomita K, Yokogawa A, Oda Y, et al.: Lymphangiosarcoma in postmastectomy lymphedema (Stewart-Treves syndrome): ultrastructural and immunohistologic characteristics. J Surg Oncol 38 (4): 275-82, 1988. [PUBMED Abstract]
  • Updated: July 30, 2014