What is lymphoedema? ◦ Accumulation of lymphatic fluid in interstitial tissues ◦ Results from abnormal functioning of the lymph system How is it categorised? ◦ Primary ◦ Secondary
Feeling of tightness and heaviness in a limb Altered sensation, such as pins and needles, shooting pains or feeling of heat Joint discomfort due to the swelling, e.g. elbow, knee Tenderness in the groin of an affected leg Changes in temperature of the limb or affected skin Reduced range of movement
History Examination ? Lymphoscintigraphy Need to distinguish from lipoedema ◦ Bilateral leg swelling ◦ Nearly always Females ◦ Spares the feet ◦ Not pitting ◦ Can develop lipolymphoedema
Primary ◦ Underdevelopment ◦ Inherited Secondary ◦ Trauma ◦ Cancer ◦ Radiotherapy ◦ surgery
Secondary PrimarySecondary Damaged lymphatic system is usually present at birth (underdevelopment) Chronic venous disease. Venous hypertension and secondary damage * 70-80% cases femaleSurgery Age of onset varies, at birth 10%, before 35yrs 80%, after 35yrs 10% Radiotherapy Commonest sites – legs, arms, genitals, face. Trauma/injury Reduced mobility/muscle contraction
How common is lymphoedema after surgery for breast cancer (WLE + ANC or mastectomy)? ◦ 14-42% Why do some develop it after minimal surgery? ◦ Not fully known, ongoing research ◦ ? Pre-disposing factors
No cure. Aim reduce the swelling and keep it to a minimum. Treat in early stages If a cause is found then the cause needs to be treated, e.g. cancer. Complex Physical (Lymphatic/Lymphoedema) Therapy (C.P.T./C.L.T.). This regimen consists of 4 main parts. Skin care – emollients, keratolytics to remove hard, dead skin. Simple lymphatic drainage – gentle massage, move the swelling out of the affected area. The patient or carer taught technique. Compression bandaging Compression bandaging Exercise and movement – specially designed programme, maximising lymph drainage without over exertion
Manual Lymphatic Drainage – ◦ specialised form massage by trained therapist. Move the skin in specific directions based on the underlying anatomy and physiology of the lymphatic system. Multi-Layer Lymphoedema Bandaging Drug therapy ◦ research as to the effectiveness of drug therapy in lymphoedema. Benzopyrenes including flavonoids have been used. Coumarins used. Surgery – ◦ rare. ?benefit for eyelid or genital swelling. Only surgeons who have experience with lymphoedema and the lymphatic system should perform surgery
Cellulitis ◦ Prevention ◦ Prompt treatment British Lymphology Society Consensus Document ◦ http://www.lymphoedema.org/Menu3/consensus_o n_cellulitis_aug_10.pdf
Management of cellulitis in lymphoedema – at home with oral antibiotics 1. Amoxicillin 500 mg 8 hourly for at least 14 days. 2. Add Flucloxacillin 500 mg 6 hourly if Staphylococcus aureus infection is suspected e.g. folliculitis, pus formation or crusted dermatitis is present. 3. If patient is allergic to Penicillin, use Clindamycin 300 mg 6 hourly for at least 14 days
If a patient fails to improve on this regimen or is systemically very unwell, admission to hospital for intravenous antibiotics is recommended. Prophylactic antibiotics (Penicillin V or Erythromycin) ◦ considered in patients who develop recurrent episodes of cellulitis (=2 per year). Management of the lymphoedema is also reviewed, as a reduction in limb volume is associated with a reduced incidence of cellulitis (Ko et al, 1998).
Leeds Lymphoedema service (Bexley/Wharfedale) ◦ http://www.lymphoedemaleeds.co.uk/ http://www.lymphoedemaleeds.co.uk/ UK lymph.com ◦ http://www.uklymph.com/ http://www.uklymph.com/ Cellulitis consensus document: http://www.lymphoedema.org/Menu3/consensus_on_cellulitis_aug_10.pdf http://www.lymphoedema.org/Menu3/consensus_on_cellulitis_aug_10.pdf Lymphoedema Framework (2006 a). Best Practice for the Management of lymphoedema. International consensus. London: MEP Ltd NHS Evidence – supportive and pallitaive care. ◦ http://www.library.nhs.uk/palliative/ViewResource.aspx?resID=271133 http://www.library.nhs.uk/palliative/ViewResource.aspx?resID=271133 Ko DSC, Lerner R, Klose G et al (1998). Effective treatment of lymphoedema of the extremities. Arch. Surg. 133: 452-458.