LYMPHEDEMA

DEPARTEMEN KARDIOLOGI DAN KEDOKTERAN VASKULAR

FK USU/RSUP.H.ADAM MALIK MEDAN

What is Lymphedema ?
Swelling of a body part, usually a limb, due to
accumulation of lymph fluid from obstructed
flow of the lymphatics
Primary lymphedema is due to a congenital
deformity of the lymphatic system:
Lymphedema congenita present at birth
Lymphedema praecox develops in childhood or
adolescence
Lymphedema tarda develops in adulthood

Secondary Lymphedema
Secondary lymphedema usually results from a
trauma to the lymphatic system
Surgery
Radiation therapy
Tumor compression/obstruction
Traumatic injury
Infection
Lymphoproliferative disease
Tumor/cancer involvement

What is the lymphatic system ?

Retrieves proteins filtered out of the circulatory
system by capillaries and returns them to the
venous system for circulation
The lymphatic system originates as lymph
capillaries in the spaces between cells
The capillaries join to form larger vessels called
the lymphatics

Lymphatic System (continued)

The lymphatics are joined together by lymph
nodes which act as filters and empty into the
right lymphatic duct or the thoracic duct
Lymphatics:
smaller diameter and thinner walls than veins or
arteries
contain valves like veins to assist with lymph flow
also are aided by skeletal muscle contractions and
pulsatile movements of surrounding blood vessels
to assist with lymph flow

How does it occur ?

Decreased lymph flow from lymphatic damage
results in increased protein concentration in the
interstitial fluid
With increased protein concentration, fluid is
shifted into the interstitial space due to oncotic
pressure
With fluid accumulation in the interstitial space,
swelling/edema occurs in that body part

How does it occur ? (continued)

Lymphatic damage and fluid stasis also leads to
scar tissue/fibrosis development with collagen
and fibrin deposition to vessel walls, therefore
further blocking lymph flow
Fluid stasis increases susceptibility to infection
with cycle initiated for further lymphatic
damage

Manual
Lymphatic
Drainage

How frequently does it occur ?

Affects 1 % of the US population over 2
million people usually from breast cancer
treatment
Post-mastectomy: 25.5 %
Post-mastectomy with axillary lymph node
dissection and radiation therapy: 38.3 %
Further increased with obesity and/or infection

How frequently does it occur ?

(continued)
May also see with:
lymphoma
prostate cancer
melanoma
Hodgkins disease
ovarian cancer
Cushings disease
Systemic lupus erythmatosus

Even more common in third world countries

due to prevalence of parasitic infections

Types of lymphedema
Acute:
mild, transient form
occurring within days of surgery
resolving within first weeks

Painful:
occurs 4 to 6 weeks after surgery
frequently associated with phlebitis or lymphangitis

Erysipeloid:
occurs with chronic form after local trauma

Types of lymphedema
(continued)
Chronic:
more insidious and painless form
occurs 18 to 24 months after surgery after gradual
development of fibrous tissues

Dependent:
occurs with fluid overloading conditions such a renal
failure or cardiovascular diseases
more involving dependent or inactive extremities

Physiologic consequences
from lymphedema
Decreased
circulating blood
volume

Decreased cardiac
output

Decreased effective
arterial blood volume

Increased renin/
aldosterone/
angiotensin II levels

Increased plasma
volume with
increased transudate

Increased distal
tubular reabsorption
of Na with retention
of water and Na

What is seen clinically ?

Edema of the involved anatomy
Pain can, but not always may be, present
more common with infection

Usually no skin ulcerations are seen

if present, more consistent with chronic venous
insufficiency

If erythema, must consider infection

Thickening, hardening or doughiness of the
subcutaneous tissue
Seldom are skin changes seen

Lymphedema Location

Are diagnostic tools

appropriate
?
Lymphangiography has been used in past to
evaluate, however:

rarely is it required due to strong correlation with

history and exam for diagnosis
anatomical information gained has no impact on
treatment
can frequently exacerbate the condition

If clinical suspicion, venogram or venous

doppler can rule out presence of thrombosis
Best tools remain detailed history and exam

What happens if not treated ?

A cycle of fibrosis, stasis and protein
accumulation begins with progression and
worsening of edema
Increased incidence of infection
Elephantiasis may develop in final stages
In severe cases, rare complication of
lymphangiosarcoma may occur

When is treatment
appropriate ?
ALWAYS in the presence of painless swelling,
especially if greater than 2 cm
If swelling occurs after the 6 week period
following completion of treatment
ALWAYS with swelling in the months or years
after treatment, but first must rule out cancer
recurrence or metastatic disease

What are goals of treatment ?

Improve cosmesis
Preserve skin integrity
Soften subcutaneous tissues
Avoid infection or lymphangitis
Decrease limb size
Avoid contracture of the involved limb
Most importantly: patient and family education

What are treatment options ?

Medications:
Antibiotics
should always have on hand to begin treatment with
first signs of infection
should cover Gram positive organisms with most
common pathogen Group A Strep

Diuretics
can decrease water and sodium in the interstitial fluid,
but have no impact on protein status
risks usually outweigh benefits

Benzopyrones / Coumarin
stimulate proteolysis
not available in United States or FDA approved

What are treatment options ?

Mechanical interventions

elevation
protection of limb
manual lymph drainage/massage
compression garments to reduce and control edema
exercise, especially of distal musculature, to facilitate
lymph flow

Surgery: Not curative

Excisional: Charles / Homans procedure
debulking of the area to remove excess tissue to
decrease volume

Physiological:
drainage of the area via lymph to lymph or lymph to

Manual Lymphatic Drainage

Manual Lymphatic Drainage

Exercise

What types of compression are

available ?
Compression stocking
can be used for treatment and maintenance
2 pairs are appropriate to maximize hygiene
last from 4 to 6 months
can be difficult to don or doff and keep in position

Compressive wrapping
better flexibility for specific problem areas and for
specific patients
patients and families can learn technique
allow greater activity level than pumps
can be time consuming to don

Available compression
(continued)
Compression pumps

not adequate for primary therapy

do not address proximal edema
high cost with decreased compliance
less convenient for associated exercise or mobility
variable protocols dependent on brand and type but
ranges:
single chamber/uniform/intermittent compression:
30-60 mm Hg
multi-chamber/differential/sequential compression:
60-120 mm Hg

Reid sleeve
markets as being less expensive, less cumbersome and

Bandages

Compressive Bandages

Compression Garments

Sequential, Pneumatic Pumps

Intermittent Compression Devices

Contraindications
Deep vein thrombosis
Local superficial infection
Congestive heart failure
Acute pulmonary edema
Displaced or acute fractures

Skin Care and Hygiene

Lymphedema increases risk of skin breakdown,
infection, and delayed wound healing
Proper skin care
Inspection
Protection

Treatment Works

Treatment Works

Treatment Works

Terima Kasih

What can Physiatry provide for

treatment ?
Education regarding factors contributing to
lymphedema and therefore increased
compliance
Early treatment for initial or recurrent infection
Emphasize proper care of the extremity
Determination of appropriate therapy and/or
long-term compression needs

What are measures to be taken

for protection ?
Make every attempt to avoid:
cuts

scratches

hangnails

insect bites

punctures

burns

Do not irritate or handle these injuries if

they occur
No blood pressures or venipunctures in
involved limb
Liberal use of moisturizer to avoid dryness
or cracking

Measures to take (continued)

Wear protective garments for appropriate
activities:

gardening or pruning
dishwashing
baking/cooking
sewing

Immediate contact with physician if presence

of infection
Carry heavy parcels or purses on the opposite
limb
Sunscreen or long-sleeved garments for sun
exposure

Measures to take (continued)

Jewelry should not be worn on affected limb

Insect repellent for high risk exposure
Utilize electric razor for shaving
Check water temperature with other limb or
thermometer before immersion
Avoid heavy lifting or repetitive movements
with involved limb
Avoid tight-fitting garments to affected limb
Avoid climate temperature extremes