LYMPHADEMA PAMELA J. SCHLEMBACH, MD MD ANDERSON CANCER CENTER LYMPHADEMA • Lymphedema • swelling that occurs when fluid drained by the lymph vessels does not flow out of the arm, hand, chest and upper back, groin, legs- on the side of your surgery LYMPHADEMA What is lymphedema? • Lymphedema may affect just one arm or leg, or it may occur in both arms or both legs. • The lymph fluid is full of protein, which makes lymphedema hard to treat. • The protein acts as a magnet for more swelling, and it encourages infection. LYMPHADEMA What is the lymphatic system? • The lymphatic system• Major part of the immune system, • Fights disease • Fights infection LYMPHADEMA What is the lymphatic system? • The lymphatic system makes and moves lymph fluid around the body. The lymphatic system has three jobs: • • Remove extra fluid from body tissues. • • Absorb fat and move it to the blood. • • Defend the body against disease by making white blood cells. LYMPHADEMA • Functions parallel to the circulatory system • Consists of lymph vessels, lymph nodes, and lymphoid tissues. • The most important role• absorb and transport large molecules (including protein and cellular debris) which are too large to be collected by veins and venous capillaries. • This lymph fluid is then transported to lymph nodes that act as “filtering stations” in the body. • In the lymph nodes, cells from the body’s natural defense system, called lymphocytes, help fight bacteria and viruses. LYMPHADEMA • Networks of the lymphatic system are situated in several areas of the body with a specific drainage pathway for each individual area. • Superficial Lymph Nodes Include: • Axillary: Located under each arm, these nodes receive fluid from the arm, chest, back, and breast tissue. • Inguinal: Located at the bend of the hip, these nodes receive fluid from the leg, lower abdomen, gluteal region, and external genitals. • Deep Lymph Nodes Include: • Supraclavicular: Located at the neck just above the collar bones, this important node group receives fluid from the head and shoulders. If indicated, the treatment of these lymph nodes precedes all other treatment. • Deep Abdominal/Pelvic Nodes: The abdomen is richly invested in lymph nodes—they surround the organs and intestines. These nodes also receive fluid from the superficial inguinal area as well. Congestion in this area alone can cause swelling in the lower extremities, abdomen, and genitalia. • Lymphatic tissue is found in other areas of the body including the tonsils, spleen, intestinal wall, and bone marrow. . NORMAL LYMPHATICS Networks of the lymphatic system are situated in several areas of the body with a specific drainage pathway for each individual area. EXAMPLE OF LYMPHADEMA LYMPHADEMA • LYMPHADEMA What causes lymphedema? • There are two types of lymphedema: • Primary- People are born with primary lymphedema. • Seen at birth or later during puberty or adulthood. EXTREME FORMS OF PRIMARY LYMPHADEMA LYMPHADEMA • Secondary• More common • Related to infection, injury or trauma involving the arm or leg. • Occur years after surgery or radiation treatment • May not necessarily be related to a recurrence of cancer. BREAST CANCER TREATMENT CAN CAUSE LYMPHADEMA LYMPHADEMA • Occurs when • lymph nodes removed during surgery • treated with radiation • cancer has spread to lymph nodes. TYPICAL AFTER SURGERY AND RADIATION YEARS AGO NEGLECTED LYMPHADEMA LYMPHADEMA Lymphedema and the Risk of Malignancies • Angiosarcoma • Rare form of a malignant tumor • Result of long-standing lymphedema. • Upper or lower extremities and has a tendency to metastasize quickly. • Bruise-like discoloration LYMPHADEMA Screening and Measurement for Early Detection of Breast Cancer Related Lymphedema • Life-long risk for the development of lymphedema. • Early detection of lymphedema allows for early intervention • Intervention prevent or slow progression of lymphedema to a chronic, harder-to-treat stage. • Patient education regarding the signs and symptoms of developing lymphedema LYMPHADEMA Screening and Measurement for Early Detection of Breast Cancer Related Lymphedema • Objective measurement of arms is needed to promote early detection and improve patient outcomes. LYMPHADEMA- PREVENTION LYMPHADEMA- PREVENTION • Prevent tiring the arm: • Avoid carrying heavy objects, moving heavy furniture or doing activities that cause excessive force or strain on the affected side. LYMPHADEMA- PREVENTION • Long car trips or airplane flights: • −Drink plenty of water. • - Stand and/or stretch when it is safe to do so. • − Do arm and breathing exercises every two hours. • − Elevate the arm with pillows. LYMPHADEMA PREVENTION • Avoid cuts and scratches to the hand and arm. LYMPHADEMA PREVENTION Avoid cuts and scratches to the hand and arm. -Long-sleeved shirts while doing work (such as gardening) that may cause scratches or cuts. Wear heavy gloves LYMPHADEMA PREVENTION Avoid cuts and scratches to the hand and arm. • -Electric shaver when shaving under the arm to prevent razor cuts. LYMPHADEMA PREVENTION Avoid cuts and scratches to the hand and arm. • − Use a thimble to protect against puncture wounds while sewing. • − Use a cutting board while chopping or slicing foods. • − Avoid shelling shrimp or crawfish with your bare hands. • − Use insect spray to help prevent insect bites. • − Treat cuts, burns, insect bites and scrapes immediately. • - Thoroughly wash injured site, apply an antibacterial ointment and cover with a bandage. LYMPHADEMA PREVENTION Avoid cuts and scratches to the hand and arm. − Use insect spray to help prevent insect bites. LYMPHADEMA-PREVENTION • Avoid needle insertions in your affected arm. • Use your healthy arm for blood draws, and when receiving vaccinations or injections. • If you need a medical procedure on your affected arm, such as removing skin growths, ask your cancer doctor first. LYMPHADEMA-PREVENTION Avoid excessive heat, such as saunas, whirlpool spas or extremely hot showers. LYMPHADEMA-PREVENTION Keep the arm cool in hot weather. • − Do not sunbathe. • − Stay in air-conditioned places. • − Place the arm under cool running water. • − Place cool towels over the arm. LYMPHADEMA-PREVENTION Prevent burns to the arm. • − Use long padded mitts near the oven, grill or fireplace. • − Protect the arm from sunburn • - Wear long sleeves. BURNS CAN CAUSE INFECTION EASILY LYMPHADEMA PREVENTION Avoid harsh detergents or deodorants. • Wear rubber gloves : • hands will be in water for an extended length of time • in contact with harsh chemicals (such as cleaning solutions). LYMPHADEMA PREVENTION Keep hands and cuticles soft. − Apply a moisturizing lotion after washing to prevent your hand from becoming chapped, dry or cracked. LYMPHADEMA/ PREVENTION • − Do not cut the cuticle on your hand. • Use a cuticle softener cream and gently ease the cuticle back with a cottontipped swab. • −Keep your nail edges smooth • - Do not bite your fingernails. • − Use your own instruments when you get a manicure. LYMPHADEMA Check your fingernails for signs of a fungal infection (i.e., discoloration, thickening, crumbling edges, or cracks) LYMPHADEMA PREVENTION Treat injuries and infection • − Treat cuts, burns, insect bites and scrapes immediately. • - Thoroughly wash injured site, apply an antibacterial ointment and cover with a bandage. NEGLECTING THE SYMPTOMS LYMPHADEMA Prevent trapping more fluid in the arm on the side of your surgery. • − Blood pressure taken, use the opposite arm. • If both sides have been treated, ask your doctor for advice. • − Wear loose-fitting jewelry or watches with adjustable bands on the affected arm. • − Wear properly fitted bras to avoid trapping fluid in the chest wall and arm. • − Do not wear tight or elastic shirt sleeves. LYMPHADEMA/ PREVENTION • Weight Loss LYMPHADEMA • Height, weight, and body mass index (BMI). • Elevated BMI is associated with increased risk of developing lymphedema. • Overweight =BMI ≥ 25 -referred to a qualified professional for nutrition education. • Obese =BMI ≥ 30 -referred to a qualified professional for nutrition counseling and evaluation for potential weight reduction program. LYMPHADEMA/ PREVENTION • Weight Loss • Obesity can increase the risk of lymphedema. • Weight loss is achieved by: • increasing physical activity moderately reducing total calorie intake. • Foods that are naturally low in calories include: • fruits, vegetables, grains, low-fat dairy products and lean proteins like chicken breast, fish, soy, beans and legumes. • The federal recommendation for physical activity for weight loss is 60 to 90 minutes on most days of the week. LYMPHADEMA • Nutrition Guidelines • Fruits, vegetables and fiber and limit salt, fat and sugar. • According to the United States Department of Agriculture, a healthy diet also includes whole grains, low-fat dairy products and lean proteins. • Foods high in fat and added sugar should be limited because they are high in calories and can contribute to weight gain and obesity. OBESITY AND LYMPHADEMA ARE LINKED EXERCISE FOR PREVENTION LYMPHADEMA/ PREVENTION • Exercise • Several research studies have found that a program of gradually increasing exercise supervised by a certified lymphedema therapist — meaning you start gently and intensify slowly over time — is not likely to increase the risk of lymphedema. LIGHT ARM EXERCISE LYMPHADEMA/ PREVENTION • Exercise • Exercise is a key component of any diet but can also help minimize lymphedema. • The USDA recommends exercising for at least 30 minutes on most days of the week to benefit overall health. • Moving the arms and legs can help move fluid out of the limbs and prevent swelling. • Aerobic activities like swimming, bicycling and jogging on the treadmill to improve cardiovascular health and increase movement of the extremities LYMPHADEMA/ PREVENTION • Sodium • Sodium (salt) can worsen lymphedema • Refraining from adding salt to food while cooking or at the table. • Avoid high-sodium foods like • processed foods, deli meats, canned vegetables and soups, condiments, frozen or convenience entrees, savory snacks, certain cheeses, premarinated meats and fast food. LYMPHADEMA Call your doctor immediately if your arm, hand, upper back or chest shows signs of infection. These can include the following. • • Red streaks on the arm or chest wall • • Red, warm, or unusually hard, swollen, or painful arm, hand, upper back, or chest wall • • A feeling of heaviness or constant aching in the arm or chest wall • • Elevated body temperature (fever) LYMPHADEMA LYMPHADEMA Stage 0 Lymphedema (Non-Visible, Latency) • Lymphedema can develop very slowly • Protein molecules can accumulate beneath the skin and “pull” extra water into the affected area • Sensations of heaviness or fatigue in the limb or region. • Despite a “normal” measurement of tissue or limb sizes in that area • This stage should not be ignored—instead, prompt treatment will reduce the risk of worsening edema. LYMPHADEMA LYMPHADEMA Stage 1 lymphadema • Puffy appearance of the hand • Pushing on the skin—referred to as “pitting” edema. • Difficult to see veins on the top of the hand or foot. • Improve at night but return during the day. • Elevation of the affected area may temporarily help reduce the edema LYMPHADEMA LYMPHADEMA Stage 2 lymphedema • Swelling takes on a spongy consistency and “pitting” is less present. • Does NOT respond to elevation. • Fibrosis, or scar tissue • Gradual thickening of the tissues on the limb as it increases in size. LYMPHADEMA LYMPHADEMA • At this stage, the skin typically becomes very dry and scaly and the limb or other affected body region becomes very large. There may be fluid leaking from the limb and skin infections are common. The weight of the limb can be debilitating. Excess skin projections (including blisters) can form to attempt to contain the fluid, and these projections pose an even greater infection risk. • While these stages are all different, they are continuous. When lymphedema remains untreated, it will progress. Treatment of lymphedema focuses on halting this progression while also improving the symptoms. Specifically, treatment focuses on reduction of fluid volume but also on softening tissue fibrosis, reducing risk of infection, and maintaining or enhancing the function of the limb. LYMPHADEMA- LYMPHADEMA Does lymphedema go away? • Although there are cases when lymphedema has suddenly gone away and not come back, most patients always have it and need long-term treatment. LYMPHADEMA • How is lymphedema treated? The physical therapist will evaluate you and create a treatment plan. LYMPHADEMA . • Physical therapists provide a comprehensive program to help manage lymphedema that includes: • Education • Special exercises • Compression bandaging • Manual lymphatic drainage therapy • Fitting of compression garments. LYMPHADEMA • Massage – • Two basic types of massage are used to treat lymphedema: • 1. Manual lymph draining -precise and gentle form of massage moves fluid to other parts of the body. • 2. Soft tissue mobilization (or myofascial release) loosen scar tissue and other tightness that might contribute to the swelling. • Sometimes massage taught to patients or family members. MANUAL DRAINAGE LYMPHADEMA • Exercise – • Stretching exercises to loosen up the tissues in the area • Special exercises to help move the fluid. TREATMENT FOR LYMPHADEMA PHYSICAL THERAPY LYMPHADEMA Compression garments – Elastic fabric garments, similar to a girdle or support stocking, put pressure on the arm or leg to help move fluid and keep new fluid from collecting. LYMPHADEMA Bandaging – • Cotton, low-stretch bandages apply constant pressure on the limb. • Bandaging is usually combined with other methods of treatment. WRAPPING FOR LYMPHADEMA LYMPHADEMA Medicine – Sometimes doctors prescribe antibiotics or other medicines as part of the treatment plan. LYMPHADEMA • Various herbal remedies purported to heal venous vasculature, reduce inflammation and aid in detoxification may be recommended. • • • • • Horse chestnut Coumarin Grape Seed Extract Bromelain Witch Hazel • BUT-Herbal remedies are not to be substituted for treatment recommendations by a trained medical doctor. LYMPHADEMA Special compression garments purchased DEVICES USED TO TREAT LYMPHADEMA LYMPHADEMA How are doctors treating lymphedema with surgery? • Lymphaticovenular bypass, which redirects the lymph fluid to small veins • Vascularized lymph node transfer, which promotes new lymphatic vessels to grow • Both procedures allow for improved drainage, which can lessen the lymphedema. • Your doctor can talk with you about which procedure he or she recommends. LYMPHADEMA Who may have this procedure? • Ask your doctor about the surgery. • Patients who have had less severe lymphedema for a shorter time tend to have better results. • What should I expect from this procedure? • Many patients improve; however, every patient is different. • Does not help every patient. • Do not expect a complete cure. • What does this procedure involve? • Four to six hours while under general anesthesia. LYMPHADEMA Lymphaticovenular Bypass • The doctor makes multiple small cuts (incisions) about 1 inch long in the affected arm or leg. • ospital stay is less than 24 hours. • Lymph node Transfer • Using microsurgery, the doctor removes lymph nodes from your neck or groin area and then reattaches them in the affected arm or leg. • A hospital stay is usually about four days. LYMPHADEMA • The Benefits of Water for Lymphedema • Lymphedema patients should drink plenty of water. • The opposite (drinking less water) may seem true, but drinking more water is important because lymph fluid has high protein content. • Need water to move protein. • Having more water available means “protein traffic” moves better. LYMPHADEMA • Other Great Benefits of Water: • It Helps You De-Stress: Stress takes a toll on all your basic body systems and when you’re dehydrated the effects are magnified. • Drinking water will provide you with more energy, ease tension, slow breathing, and reduce the strain on your heart. • It Helps You Lose Weight: Choosing water instead of sodas and other caloric beverages is a great start to a healthy diet. • Plus, when you’re well hydrated, your body works more efficiently and will enhance aspects of weight loss, like digestion and muscle function when you exercise. LYMPHADEMA • Other Great Benefits of Water: • You’ll Be Less Likely To Get Sick: Hydration keeps your mucus membranes in top working order – they’re gatekeepers to the natural defense system that helps keep out germs such as cold and flu viruses. • It Keeps You Looking Young: Water acts as a natural moisturizer to the skin, preventing it from drying out, helping to maintain its elasticity and giving it a general healthy, glowing appearance. • Boosts Mood and Brain Power: Even mild dehydration is associated with feelings of anger, depression, and confusion. • LYMPHADEMA • Psycho-Social Complications • Lymphedema is disfiguring and sometimes painful and disabling. • It can negatively impact the emotional, vocational, recreational and financial aspects of the patient's life. • Most patients are able to continue a normal life; however, some patients experience depression, anxiety, and impairments related to their intimate, work, and social relationships LYMPHADEMA • Lymphedema Awareness D-Day • National Lymphedema Awareness "D" Day: March 6th • Each year, on March 6, the National Lymphedema Network and the lymphedema community nationwide celebrate Lymphedema Awareness "D" Day, a special day set aside to honor inspirational lymphedema patients: those who have contributed to the community or who have shown great courage in their struggle with disease. LYMPHADEMA •Look for it •Manage it •Be proactive THANK YOU • Thank you! QUESTIONS?