News Author: Nick Mulcahy
CME Author: Charles Vega, MD, FAAFP
Disadur : Dicky Budiman, MD
January 26, 2009 — Oncologists who are alert to the signs and symptoms of cancer and cancer-treatment–related lymphedema can have a large impact on its course, because the chronic condition can be minimized if recognized and treated early, according to a review article on lymphedema published in the January/February issue of CA: A Cancer Journal for Clinicians.
However, oncologists are generally too busy to oversee the care of lymphedema themselves, and hence should become familiar with resources that can help connect patients with lymphedema-management specialists, said lead author Brian D. Lawenda, MD, clinical director of radiation oncology at the Naval Medical Center, in San Diego, California.
"We don't have the time to manage the care for lymphedema. Therefore, my colleagues and I recommend that clinicians be aware of referring specialists in their area who are experts in the diagnosis and management of lymphedema," Dr. Lawenda said in an interview with Medscape Oncology.
Dr. Lawenda also noted that oncology patients at risk for lymphedema should receive pretreatment evaluation that includes baseline girth and volume measurements of limbs. He emphasized the importance of prevention education, which includes a discussion of risk factors, and arm and leg care guidelines.
Pretreatment patient evaluation and education are not well used by clinicians, suggested Dr. Lawenda.
"Oncology patients are left with a lot of side effects of treatment. We commonly see lymphedema, but unfortunately it does not get a lot of discussion [by oncologists]. As result, it can be a surprise to patients," he said.
Who's Most at Risk?
The most common causes of lymphedema in the United States are surgery and radiation therapy for the treatment of cancer. The most common etiology is the impaired flow of lymph fluid through the draining lymphatic vessels and lymph nodes, write Dr. Lawenda and his coauthors, Tammy Mondry, DPT, a physical therapist at New Horizons Physical Therapy, in San Diego, and an expert on managing the condition, and Peter Johnstone, MD, chair of the Department of Radiation Oncology at the Indiana University School of Medicine, in Indianapolis.
Lymphedema is most commonly reported after breast cancer treatment but can result from the treatment of cervical, endometrial, vulvar, head and neck, and prostate cancers, and of sarcomas and melanoma. Lack of standardized definitions and measurement techniques for the disorder make an accurate incidence rate of cancer-treatment-related lymphedema difficult to determine, say the authors.
However, the likelihood of lymphedema by cancer type and related treatment has been established.
For instance, with regard to breast cancer, the frequency of breast edema ranges from 6% to 48% when surgery and radiation therapy are combined. The frequencies tend to be at the higher ends of the range when a lymph node dissection and radiation therapy are performed.
Increased body mass index and tumor location in the upper outer quadrant are other factors that have been reported to significantly increase the risk for breast lymphedema. Also, 1 study (Lymphat Res Biol. 2005;3:208-217) found that women older than 60 years had a higher likelihood of lymphedema (41.2%) than women younger than 60 years (30.6%). Approximately 15% of patients with a bra cup size of A or B developed breast edema, whereas approximately 48% of patients with a bra cup size of C, D, or DD presented with edema.
In general, patients tend to be at highest risk for cancer-treatment–related lymphedema when a large number of lymph nodes are removed, radiation and surgery are combined as treatment, or an infection in a limb that has been operated on develops, said Dr. Lawenda.
Recognizing Lymphedema
The signs and symptoms of lymphedema include, in a limb, a feeling of heaviness or tightness, aching or discomfort, restricted range of motion, and swelling (partial or total). Swelling might also occur in the adjacent upper quadrant of the trunk.
Lymphedema patients usually do not have severe pain, and skin color and temperature are generally normal. The swelling is typically unilateral and can include the dorsum of the hand or foot. A deepening of the natural skin folds can occur.
Patients can also present with a Stemmer sign, in which the skin of the dorsum of the fingers and toes cannot be lifted or can only be lifted with difficulty.
Evaluation for the condition should involve a close inspection of the skin, a gauging of pain level, and a review for the Stemmer sign. Photography and measurements of limb girth and volume are recommended, if possible. Generally, when a limb volume has increased by 10%, lymphedema is likely present, note the authors.
Lymphedema is considered "reversible" if a patient presents with very soft pitting edema with no fibrosis, write the authors. Prolonged elevation will lead to a complete resolution of the swelling. Nevertheless, lymphedema is not curable and will require treatment and ongoing care in all cases.
As lymphedema progresses, the outcomes from any treatment are less optimal because of adipose and fibrotic changes within the tissue. Furthermore, infections become more common, as do fibrosis and other skin changes, such as papillomas, cysts, fistulas, and hyperkeratosis.
The risk for lymphedema is lifelong, Dr. Lawenda and his colleagues emphasize. The onset can occur at the time of treatment or decades later. In any case, an examination must rule out recurrent or metastatic disease causing tumor blockage of the lymphatic system and deep vein thrombosis.
Managing Lymphedema
Once lymphedema is diagnosed, treatment should begin immediately. The goal of treatment is to decrease the excess limb volume as much as possible and to maintain the limb at its smallest size. This reduces the amount of stagnant fluid in the tissues, thereby potentially preventing or eliminating infections. The first step in treatment is referral to a physical therapist, note the authors, to quantify the amount of edema in the limb and establish a baseline.
The gold-standard treatment for lymphedema is complete decongestive therapy, say the authors, which consists of a treatment and maintenance phase; the latter is life-long and principally involves self-care that includes skin care, wearing a compression garment, and exercise. Other nonsurgical treatments are manual lymph drainage and compression.
Low-level laser therapy and microsurgical lymphatic-venous anastomoses can also be effective treatment, say the authors.
The challenge for the patient and oncologist is to find "reputable" healthcare providers who are certified in caring for the condition and can help make treatment decisions and deliver care, said Dr. Lawenda. In their article, the authors list several nonprofit organizations with lymphedema expertise that can provide help in connecting patients with caregivers. The organizations include the American Cancer Society, the Circle of Hope Lymphedema Foundation, the Lymphedema Research Foundation, the Lymphology Association of North America, and the National Lymphedema Network.
The researchers have disclosed no relevant financial relationships.
CA Cancer J Clin. 2009;59:8-24.
Clinical Context
Lymphedema is a common diagnosis that is divided into 2 general classifications: primary and secondary. Primary lymphedema is the result of abnormalities in the lymphatic system and is less common than secondary lymphedema.
In the United States, the most common cause of secondary lymphedema is breast cancer treatment. Although lumpectomy alone is associated with rates of lymphedema of 0% to 3%, adding axillary lymph node dissection and radiation therapy increases this rate to 10.7% to 42.4%. Treatment of other cancers also promotes lymphedema. Cervical cancer treatment with surgery and radiation can promote lymphedema in 21% to 49% of patients, and complete dissection of prostate cancer plus radiation therapy is associated with rates of lymphedema of 66%.
The current review examines the diagnosis and management of lymphedema.
Study Highlights
Lymphedema can be divided into 4 stages:
Stage 0: Lymphedema is latent after damage to the lymphatic system, and patients are usually asymptomatic.
Stage I: Lymphedema produces soft, pitting edema, which is reversible with elevation of the limb.
Stage II: Edema is associated with intradermal fibrosis, which reduces the ability of the skin to pit. Edema no longer resolves with limb elevation.
Stage III: There is significant increase in the severity of the fibrotic response, tissue volume, and skin changes such as papillomas, cysts, fistulas, and hyperkeratosis.
Stemmer sign, in which the skin of the dorsum of the fingers and toes is relatively difficult to lift when pinched vs the unaffected side, may be present in limbs affected by stage II or stage III lymphedema.
Secondary lymphedema may occur immediately after injury to the lymphatic system, or decades later. Clinicians should consider the possibility of physical blockage of the lymphatic system by tumor as well as deep venous thrombosis when evaluating a patient with possible lymphedema.
No curative treatment of lymphedema has been reported, so prevention and early therapy are critical. Clinicians should perform baseline assessments of limb girth before procedures to later assess the possibility of lymphedema. However, there are currently no accepted standards of lymphedema with regard to girth and volume.
Low-level laser therapy has demonstrated promising results in reducing lymphedema in 2 small placebo-controlled trials.
Complete decongestive therapy can reduce lymphedema volume by 50% to 60% and is considered the gold standard for treatment of lymphedema. This treatment begins of an acute phase of therapy consisting of skin and nail care, manual lymph drainage, compression bandaging, and therapeutic exercise.
Manual lymph drainage requires light application of pressure for 30 to 60 minutes over not only the affected limb, but over other parts of the lymphatic system as well. Patients are massaged in a distal-to-proximal direction to stimulate lymphatic flow.
A compression bandage is worn constantly during the acute phase of complete decongestive therapy. The bandage consists of padding material and short-stretch bandages.
Exercise during the acute phase of complete decongestive therapy consists of limb range-of-motion exercises, possibly combined with diaphragmatic, deep breathing.
General contraindications to complete decongestive therapy include acute infection, deep venous thrombosis, and congestive heart failure. The issue of whether this treatment may stimulate dormant tumor cells and worsen cancer is controversial.
The maintenance phase of complete decongestive therapy contains the same 4 elements of the acute phase, but manual lymph drainage may be performed by the patient, compression banding may be limited to waking hours, and exercise should include aerobic and low-load resistance exercise. Maintenance therapy can last a lifetime.
Pearls for Practice
Lymphedema can be classified into 4 stages, beginning with a latent phase. In stage I disease, edema is reversible with prolonged elevation, but stages II and III are associated with increased fibrosis and Stemmer sign.
Complete decongestive therapy for lymphedema consists of skin and nail care, manual lymph drainage, compression bandaging, and therapeutic exercise.
However, oncologists are generally too busy to oversee the care of lymphedema themselves, and hence should become familiar with resources that can help connect patients with lymphedema-management specialists, said lead author Brian D. Lawenda, MD, clinical director of radiation oncology at the Naval Medical Center, in San Diego, California.
"We don't have the time to manage the care for lymphedema. Therefore, my colleagues and I recommend that clinicians be aware of referring specialists in their area who are experts in the diagnosis and management of lymphedema," Dr. Lawenda said in an interview with Medscape Oncology.
Dr. Lawenda also noted that oncology patients at risk for lymphedema should receive pretreatment evaluation that includes baseline girth and volume measurements of limbs. He emphasized the importance of prevention education, which includes a discussion of risk factors, and arm and leg care guidelines.
Pretreatment patient evaluation and education are not well used by clinicians, suggested Dr. Lawenda.
"Oncology patients are left with a lot of side effects of treatment. We commonly see lymphedema, but unfortunately it does not get a lot of discussion [by oncologists]. As result, it can be a surprise to patients," he said.
Who's Most at Risk?
The most common causes of lymphedema in the United States are surgery and radiation therapy for the treatment of cancer. The most common etiology is the impaired flow of lymph fluid through the draining lymphatic vessels and lymph nodes, write Dr. Lawenda and his coauthors, Tammy Mondry, DPT, a physical therapist at New Horizons Physical Therapy, in San Diego, and an expert on managing the condition, and Peter Johnstone, MD, chair of the Department of Radiation Oncology at the Indiana University School of Medicine, in Indianapolis.
Lymphedema is most commonly reported after breast cancer treatment but can result from the treatment of cervical, endometrial, vulvar, head and neck, and prostate cancers, and of sarcomas and melanoma. Lack of standardized definitions and measurement techniques for the disorder make an accurate incidence rate of cancer-treatment-related lymphedema difficult to determine, say the authors.
However, the likelihood of lymphedema by cancer type and related treatment has been established.
For instance, with regard to breast cancer, the frequency of breast edema ranges from 6% to 48% when surgery and radiation therapy are combined. The frequencies tend to be at the higher ends of the range when a lymph node dissection and radiation therapy are performed.
Increased body mass index and tumor location in the upper outer quadrant are other factors that have been reported to significantly increase the risk for breast lymphedema. Also, 1 study (Lymphat Res Biol. 2005;3:208-217) found that women older than 60 years had a higher likelihood of lymphedema (41.2%) than women younger than 60 years (30.6%). Approximately 15% of patients with a bra cup size of A or B developed breast edema, whereas approximately 48% of patients with a bra cup size of C, D, or DD presented with edema.
In general, patients tend to be at highest risk for cancer-treatment–related lymphedema when a large number of lymph nodes are removed, radiation and surgery are combined as treatment, or an infection in a limb that has been operated on develops, said Dr. Lawenda.
Recognizing Lymphedema
The signs and symptoms of lymphedema include, in a limb, a feeling of heaviness or tightness, aching or discomfort, restricted range of motion, and swelling (partial or total). Swelling might also occur in the adjacent upper quadrant of the trunk.
Lymphedema patients usually do not have severe pain, and skin color and temperature are generally normal. The swelling is typically unilateral and can include the dorsum of the hand or foot. A deepening of the natural skin folds can occur.
Patients can also present with a Stemmer sign, in which the skin of the dorsum of the fingers and toes cannot be lifted or can only be lifted with difficulty.
Evaluation for the condition should involve a close inspection of the skin, a gauging of pain level, and a review for the Stemmer sign. Photography and measurements of limb girth and volume are recommended, if possible. Generally, when a limb volume has increased by 10%, lymphedema is likely present, note the authors.
Lymphedema is considered "reversible" if a patient presents with very soft pitting edema with no fibrosis, write the authors. Prolonged elevation will lead to a complete resolution of the swelling. Nevertheless, lymphedema is not curable and will require treatment and ongoing care in all cases.
As lymphedema progresses, the outcomes from any treatment are less optimal because of adipose and fibrotic changes within the tissue. Furthermore, infections become more common, as do fibrosis and other skin changes, such as papillomas, cysts, fistulas, and hyperkeratosis.
The risk for lymphedema is lifelong, Dr. Lawenda and his colleagues emphasize. The onset can occur at the time of treatment or decades later. In any case, an examination must rule out recurrent or metastatic disease causing tumor blockage of the lymphatic system and deep vein thrombosis.
Managing Lymphedema
Once lymphedema is diagnosed, treatment should begin immediately. The goal of treatment is to decrease the excess limb volume as much as possible and to maintain the limb at its smallest size. This reduces the amount of stagnant fluid in the tissues, thereby potentially preventing or eliminating infections. The first step in treatment is referral to a physical therapist, note the authors, to quantify the amount of edema in the limb and establish a baseline.
The gold-standard treatment for lymphedema is complete decongestive therapy, say the authors, which consists of a treatment and maintenance phase; the latter is life-long and principally involves self-care that includes skin care, wearing a compression garment, and exercise. Other nonsurgical treatments are manual lymph drainage and compression.
Low-level laser therapy and microsurgical lymphatic-venous anastomoses can also be effective treatment, say the authors.
The challenge for the patient and oncologist is to find "reputable" healthcare providers who are certified in caring for the condition and can help make treatment decisions and deliver care, said Dr. Lawenda. In their article, the authors list several nonprofit organizations with lymphedema expertise that can provide help in connecting patients with caregivers. The organizations include the American Cancer Society, the Circle of Hope Lymphedema Foundation, the Lymphedema Research Foundation, the Lymphology Association of North America, and the National Lymphedema Network.
The researchers have disclosed no relevant financial relationships.
CA Cancer J Clin. 2009;59:8-24.
Clinical Context
Lymphedema is a common diagnosis that is divided into 2 general classifications: primary and secondary. Primary lymphedema is the result of abnormalities in the lymphatic system and is less common than secondary lymphedema.
In the United States, the most common cause of secondary lymphedema is breast cancer treatment. Although lumpectomy alone is associated with rates of lymphedema of 0% to 3%, adding axillary lymph node dissection and radiation therapy increases this rate to 10.7% to 42.4%. Treatment of other cancers also promotes lymphedema. Cervical cancer treatment with surgery and radiation can promote lymphedema in 21% to 49% of patients, and complete dissection of prostate cancer plus radiation therapy is associated with rates of lymphedema of 66%.
The current review examines the diagnosis and management of lymphedema.
Study Highlights
Lymphedema can be divided into 4 stages:
Stage 0: Lymphedema is latent after damage to the lymphatic system, and patients are usually asymptomatic.
Stage I: Lymphedema produces soft, pitting edema, which is reversible with elevation of the limb.
Stage II: Edema is associated with intradermal fibrosis, which reduces the ability of the skin to pit. Edema no longer resolves with limb elevation.
Stage III: There is significant increase in the severity of the fibrotic response, tissue volume, and skin changes such as papillomas, cysts, fistulas, and hyperkeratosis.
Stemmer sign, in which the skin of the dorsum of the fingers and toes is relatively difficult to lift when pinched vs the unaffected side, may be present in limbs affected by stage II or stage III lymphedema.
Secondary lymphedema may occur immediately after injury to the lymphatic system, or decades later. Clinicians should consider the possibility of physical blockage of the lymphatic system by tumor as well as deep venous thrombosis when evaluating a patient with possible lymphedema.
No curative treatment of lymphedema has been reported, so prevention and early therapy are critical. Clinicians should perform baseline assessments of limb girth before procedures to later assess the possibility of lymphedema. However, there are currently no accepted standards of lymphedema with regard to girth and volume.
Low-level laser therapy has demonstrated promising results in reducing lymphedema in 2 small placebo-controlled trials.
Complete decongestive therapy can reduce lymphedema volume by 50% to 60% and is considered the gold standard for treatment of lymphedema. This treatment begins of an acute phase of therapy consisting of skin and nail care, manual lymph drainage, compression bandaging, and therapeutic exercise.
Manual lymph drainage requires light application of pressure for 30 to 60 minutes over not only the affected limb, but over other parts of the lymphatic system as well. Patients are massaged in a distal-to-proximal direction to stimulate lymphatic flow.
A compression bandage is worn constantly during the acute phase of complete decongestive therapy. The bandage consists of padding material and short-stretch bandages.
Exercise during the acute phase of complete decongestive therapy consists of limb range-of-motion exercises, possibly combined with diaphragmatic, deep breathing.
General contraindications to complete decongestive therapy include acute infection, deep venous thrombosis, and congestive heart failure. The issue of whether this treatment may stimulate dormant tumor cells and worsen cancer is controversial.
The maintenance phase of complete decongestive therapy contains the same 4 elements of the acute phase, but manual lymph drainage may be performed by the patient, compression banding may be limited to waking hours, and exercise should include aerobic and low-load resistance exercise. Maintenance therapy can last a lifetime.
Pearls for Practice
Lymphedema can be classified into 4 stages, beginning with a latent phase. In stage I disease, edema is reversible with prolonged elevation, but stages II and III are associated with increased fibrosis and Stemmer sign.
Complete decongestive therapy for lymphedema consists of skin and nail care, manual lymph drainage, compression bandaging, and therapeutic exercise.
