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Fluid in the Arms or Legs (Lymphedema), ASCO's curriculum


This section has been reviewed and approved by the PLWC Editorial Board, 05/05

Lymphedema is the abnormal buildup of fluid in an arm or leg due to a blockage in the lymphatic system, the series of channels and nodes (small sacs of infection-fighting cells) that carries lymph (a colorless fluid) through the body. The lymphatic system helps fight infections and other diseases.

There are two types of lymphedema: primary and secondary. Primary lymphedema is a rare, natural disorder of the lymph system. More often, people with cancer develop secondary lymphedema. Lymphedema can develop immediately after surgery or radiation therapy, or it can develop months or years later. About 15% of women who have radical mastectomies (removal of the breast, underarm lymph nodes, and lining of the chest muscles) develop lymphedema. The most common causes of secondary lymphedema include the following:

  • Surgery to remove the lymph nodes, especially for breast cancer, prostate cancer, or melanoma
  • Radiation therapy to the lymph nodes
  • Metastatic cancer (cancer that has spread from its primary location)
  • Bacterial or fungal infection
  • Injury to the lymph nodes
  • Other diseases involving the lymph system

Lymphedema can be acute (lasting no more than six months) or chronic (lasting years). Acute lymphedema usually develops a few days or weeks after radiation therapy or surgery and lasts less than six months. As the body heals and normal lymph fluid motion resumes, the swelling usually goes away. Chronic lymphedema occurs when the lymphatic system changes and can no longer meet the body's demands for fluid drainage. It can happen immediately after surgery or radiation therapy or months or years after cancer treatment. There is no cure for chronic lymphedema.

Doctors describe lymphedema according to its grade:

  • Grade I means that the skin indents when it is pressed, elevating the affected limb helps reduce the swelling, and there is no visible evidence of scarring.
  • Grade II means that the skin does not indent when it is pressed, elevating the affected limb does not help the swelling, and there is moderate to severe scarring.
  • Grade III is irreversible lymphedema. The skin has hardened, the affected body part has swelled in size and volume, and the skin has changed texture.

Symptoms

People with lymphedema may experience the following symptoms:

  • Slow, painless swelling that begins in the hands or feet and progresses toward the trunk
  • "Heavy" feeling in the arms or legs
  • Rings, watches, or clothes that become too tight
  • Tight or shiny skin
  • Skin that does not indent at all when pressed, or hardened skin
  • Hyperkeratosis (thicker skin)
  • Skin that may look like an orange peel (swollen with small indentations)
  • The development of small warts or blisters that leak clear fluid

If you are concerned about any of these symptoms, please talk with your doctor.

Diagnosis

Some doctors may be able to diagnose lymphedema by observing symptoms alone. However, some tests may be needed to confirm a diagnosis, plan treatment, and rule out other causes of lymphedema.

  • The doctor may measure your arms or legs to monitor swelling or may calculate the volume of fluid that has built up by placing the arm or leg into a water tank.
  • Ultrasound (an imaging test that uses sound waves to create a picture of the inside of the body) helps the doctor see the flow of the lymph system.
  • Lymphoscintigraphy is a reliable procedure for confirming a diagnosis of lymphedema. The lymph system is injected with a radioactive substance. A camera takes pictures of this substance, which shows the pattern of lymph drainage.
  • A computerized tomography (CT or CAT) scan creates a three-dimensional picture of the inside of the body with an x-ray machine, and a magnetic resonance imaging (MRI) test uses a magnetic field instead of an x-ray to produce detailed images of the body. These tests can show the placement and pattern of the lymph system and whether a tumor or other mass is obstructing the flow of the lymph system.

It is important to make sure that other illnesses are not causing the swelling. The doctor may perform other tests to rule out heart disease, blood clots, infection, liver or kidney failure, or an allergic reaction.

Treatment

Treatments for lymphedema are designed to reduce swelling, prevent it from getting worse, prevent infection, and improve the use and appearance of the arm or leg. Talk with your doctor about the best way to manage lymphedema. Treatments for lymphedema include the following:

Elevation. Keeping an affected limb elevated can often help reduce swelling and encourage draining through the lymph system. However, it is often not practical to maintain an elevated position over time.

Massage. A specialized technique called manual lymphatic drainage can help reduce swelling. The results are better the earlier massage begins. Your doctor or nurse can refer you to someone trained in this technique.

Exercise. Exercising can improve the flow of the lymph system, strengthen muscles, and improve the body's ability to absorb protein. Exercising should be done while wearing a compression garment or bandage (see below).

Compression. Compression garments or bandages apply pressure to the limb and encourage draining through the lymph system and are useful in preventing further swelling. There are different types of compression garments or bandages:

  • Compression bandages wrap the affected limb and are usually used during the treatment phase because the limb changes size.
  • Compression garments are elastic sleeves for the arm or leg that can be custom-fitted. These are generally used during the maintenance phase once size of the limb stays the same.
  • Pneumatic compression uses a machine to apply pressure to the arm or leg.

All compression devices apply the most pressure furthest from the body and less pressure closer to the body.

Hygiene. Preventing infection from developing around lymphedema can prevent it from getting worse. Washing the area often with soap and using alcohol-free lotions may help. Antibiotic or antifungal drugs can also help prevent infections.

Low level laser treatments (LLLT). A small number of trials have found LLLT could provide some relief of postmastectomy lymphedema, particularly in the arms.

Treatments that are not usually recommended include the following:

  • Diuretics, medicines that lower the amount of water in the body
  • Surgery to repair the lymph system.

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