Secondary lymphedema is a chronic
distressing condition which affects a significant number of women who undergo
breast cancer treatment. In simple words it is swelling of arm after breast
cancer treatment due to accumulation of protein rich interstitial fluid within
the skin and subcutaneous tissue that causes chronic inflammation and reactive
fibrosis of the affected tissues. It has a major effect on health, quality of
life, functional status, family and finances. Lymphoedema remains an important
problem with severe medical and psychological consequences.
Epidemiology of Lymphoedema
Currently secondary arm lymphedema
affects approximately 30% those who undergo breast cancer treatment (Mosely
etal.) It occurs due to dissection of lymph nodes and radiation.
Stages of lymphedema
Stage I: Oedema is soft (pitting)
No secondary tissue changes
Elevation reduces swelling
Stage II: Lymphostatic fibrosis
Hardening of the tissue (no pitting)
Frequent infections
Stage III: Extreme increase in volume and tissue texture with skin
changes
Clinical Manifestation of secondary
Lymphoedema
- Limb swelling
- Discomfort and heaviness
- Skin tight and shiny
- Skin change ( hyper keratosis
and papillomatous)
- Repeated infections
- Joint stiffness and muscle
strain
- Lymphorrhoea
Risk reducing factors for the
prevention of Lymphoedema
- Do not ignore any slight
increase of swelling in the arm, hand, fingers and neck
- Never allow injections, blood
collections, and blood pressure checking in affected arm
- Avoid vigorous, repetitive
movements against resistance with the affected arm (scrubbing, pushing,
pulling)
- Avoid heavy lifting with the
affected arm and never carry heavy hand bags on the affected extremity
- Avoid tight clothing and
jewellery and elastic band on the affected arm
- Avoid extreme temperatures.
Keep the arm protected from Sun.
- Avoid any type of trauma
(bruising, cuts, sun burn and other burns, injuries, insect bites and pet
scratches)
- Exercises are important but do
not overtire the arm at risk. If it
starts paining, lie down and elevate the limb.
- Encourage use of compression
garments while travelling by air .
- Use electric razor to remove
hair from axilla .
- Signs of infections such as
rashes, redness, blistering, increase of temperature should be noticed and
the doctor should be consulted immediately.
- Maintain an ideal body weight
with a well-balanced, low sodium, high fiber diet
Management of Lymphoedema
Complex decongestive physiotherapy (
CDP)
It includes:
- Skin care
- Compression(bandaging/hosiery )
- Massage (manual lymphatic
drainage)
- Exercises (ROM)
- Diet (low sodium high fiber diet)
Contraindications for the management
of lymphedema
- Infection
- Arterial/ venous insufficiency
- Congestive cardiac failure
- Pain
Complications of Lymphoedema
- Cellulitis –Infection of skin
- Lymphangitis- Infection of
lymphatic system
- Lymphangio sarcoma – a type of
cancer ( it is rare)
Surgical measures to treat Lymphoedema
- Lymphovenous anastamosis
- Lymphatic grafting
Lymphoedema Clinic in RCC Trivandrum
- an Overview
Regional Cancer Centre,
Thiruvananthapuram has the facility for providing post mastectomy
rehabilitation which includes shoulder mobility exercises, skin care, wound
care, drain care, diet, use of prosthesis, counseling for breast self-examination
of relatives and regular follow up
RCC has a Lymphoedema clinic in the
sixth floor functioning from 11.00am to 04.00pm on all working days. Clinic is
providing the services not only for the management of lymhoedema but the
preventive aspect of lymphedema also. All Patients undergoing breast surgery
are advised to attend lmphoedema clinic from their first review visit itself.
All patients attending the
lymphedema clinic would be assessed for Lymphoedema. All relevant history
regarding surgery will be collected. Measurements of both arms will be measured
in 12 anatomical regions (base of thumb, wrist, 4cm, 8cm, 12cm and 16cm above
from the wrist then elbow, 4cm, 8cm, 12cm and 16cm above from the elbow and
armpit). Circumference of more than 2cm in the affected arm at any point of
measurement as compared to the non-affected arm will be considered as
lymphedema such patients are advised to attend lymphoedme clinic regularly
(every 3 months).
Last year we conducted a study
regarding ‘factors contributing to secondary lymphedema among breast cancer
treated patients’. Study reveals that the highest incidence of lymphedema is
observed following breast cancer surgery particularly among those who undergo
radiation therapy following maxillary surgery. Second highest incidence of Lymphoedema
is noted in patients who had developed surgical site infections and other
recurrent infections on the affected arm. Study reveals obesity is also a main
factor for lymphedema.
Better post-operative patient
education and information and lifelong skin care and exercises could reduce the
occurrence of lymphedema. It is the responsibility of an oncology nurse to
recognize lymphedema and facilitate early treatment of this common side effect
of breast cancer therapy will improves patient’s outcome and quality of life.
Reference
- Prognostic factors for
lymphedema after primary treatment of breast carcinoma –Andrea-Herd-Smith
etal.
- Lymphoedema management –
Joachim E-Luther-USA
- National Lymphoedema Network
- Hand Book for certificate
course in Essentials of Palliative Care 4rth Edition 2011
- cancerhelp.cancer
researchuk.org/…./treatment/lymphedema-after-br…
- www.medsurgnursing.nect/ceonline/2008/article10302307
- http:/www.lymphedemapeople.com/wiki/doku.php?id=pathologyoflymphoedema
PR Sivakumary
Breast Care Nurse , RCC
