Lymphedema: Early recognition and treatment

By DIANA JEAN C. ROXAS, MD

A year after Clem’s breast surgery and chemotherapy treatment, she noticed an unusual swelling on her left arm. She ignored it at first, thinking that it would go away on its own. She dismissed it as “pagmamanas” or simple water retention. However, as months went by, the swelling did not subside. In fact, it looked like it had worsened because her left arm had already become visibly larger than her right arm.

Clem was referred by her oncologist to a vascular medicine specialist at St. Luke’s Medical Center for Lymphedema assessment.

Lymphedema is an abnormal accumulation of lymphatic fluid beneath the skin that is caused by damaged or blocked lymphatic system. The lymphatic system is part of the circulatory system. It consists of lymphatic vessels, lymph nodes and other organs such as the spleen and tonsils, whose function is to maintain the body’s fluid balance and ward off infections.

Lymphedema occurs most commonly in the arms or legs but it may also occur in other parts of the body such as the breast, trunk, abdomen, head, neck, or genitals.

When Clem’s lymph nodes were removed after her mastectomy, the lymphatic fluids could not flow out properly from her arms to the rest of her body because fluid drainage in her arm had been compromised. This has caused fluid retention and swelling.

Clem is just one of the 24 to 49 percent of breast cancer patients who eventually develop lymphedema after surgery. However, not only mastectomy patients develop this problem. Four to 28 percent of patients who undergo removal of breast lumps and 4 to 17 percent of patients who have sentinel lymph node biopsy and radiation therapy eventually develop lymphedema. Some 60 to 67 percent of vulvar cancer patients and approximately 40 percent of cervical cancer patients who have surgery may also manifest limb swelling. In fact, any form of surgery that involves the removal of the lymph nodes can predispose patients to develop this condition.

In some cases, lymphedema can be caused by parasites that infest the lymph nodes, a condition called “filariasis.” People can also be born with abnormalities of the lymphatic system, known as congenital or primary lymphedema.

Left untreated, body parts afflicted by lymphedema could balloon to enormous sizes, which patients might find unpleasant and distressing. But more than being an aesthetic problem, lymphedema could lead to serious complications. The fluids that accumulate could cause tissue fibrosis, causing hardening and discoloration of the affected part of the body.

Lymphedema could also result to infections such as cellulitis, a bacterial infection that causes skin sores, which spread rapidly to surrounding areas of the skin. It can also cause lymphangitis that may make lymphnodes tender and painful. In very few instances, long standing lymphedema can cause a form of cancer known as lymphoma or lymphangiosarcoma.

The clinical diagnosis of lymphedema is usually done by measuring limb circumference using tape measure or other devices that estimate the volume of the limb. However, this method is far from being accurate as it cannot detect the early onset of lymphedema. By the time lymphedema is detectable using this method, irreversible complications would have already set it.

St. Luke’s Medical Center- Global City’s Cancer Institute has made available its Lymphedema Service, which aims to promote the early detection and treatment of this common but under-recognized disorder. It is equipped with the FDA approved low frequency impedance device called the L- DEX machine that can detect early stages of lymphedema. L- DEX screening is a safe and painless procedure, similar to ECG that compares the travel of electrical signals between affected and unaffected limbs. It works under the pretext that limbs with fluid retention would conduct electricity more than an unaffected limb. The machine generates values for normal, subclinical (no swelling but with feeling of tightness), mild (there is swelling but it goes away when the limb is elevated), moderate (hardening of skin, swelling does not go away when limb is elevated), and severe ( acute swelling, does not go away when limb is elevated; hardening and thickening of skin) lymphedema. Patients who are at risk for cancer related lymphedema can also be screened prior to surgery and followed up to assess the effectiveness of the treatment.

Once lymphedema is diagnosed, patients are referred to the Department of Physical Medicine and Rehabilitation for Complete Decongestive Therapy (CDT), the standard of care for lymphedema. This treatment consists of the use of compression garments, multi-layered bandaging, physical exercises, manual lymphatic drainage, segmental pneumatic compression pumps using the Lymphapress Machine, and low level laser therapy to reduce swelling and hardening of the skin.

When lymphedema is ignored for a long time and complications have already set in, the patient may be referred for surgical intervention. Thus, early recognition is vital to avoid unwanted and life-threatening complications and provide the patient non-surgical treatment options to manage their condition.