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ARM OR LEG SWELLING AFTER CANCER

Arm and Leg Swelling After Cancer

With the advent of better and more effective cancer treatments, the survival rate for all cancers has risen dramatically. With this progress, a new and often misunderstood and misdiagnosed complication has arisen.

Many cancer survivors , having overcome cancer, find themselves with sudden and often unexplained swelling, usually of the arms or of the legs.

This swelling occurs because of one of several factors.

First, the swelling begins after lymph nodes have been removed for cancer biopsies.

Second, the swelling may start as a result of radiation damage to either the lymph nodes and/or the lymph system.

Due to either the removal of lymph nodes or damage to the lymph system, your body is no longer able to rid itself of excess fluids. The fluids collect in the limbs effected and swelling begins.

This swelling is called lymphedema and it can effect either your leg or your arm. The swelling that occurs is permanent, and while it is not curable it is treatable.

Hopefully, in the future with radiological scans becoming more sensitive and with increased use of such techniques such as the small needle biopsy, we can put an end to this epidemic of secondary lymphedema from cancer biopsy.

Permanent Leg or Arm Swelling

In the situation of any permanent leg swelling whether the cause is known or unknown, the diagnoses of lymphedema must be considered

There are several groups of people who experience leg or arm swelling from known causes, but it doesn't go away or unknown causes where the swelling can actually get worse as time goes by.

Group One

This group includes those who have had the injuries, infections, insect bites, trauma to the leg, surgeries or reaction to a medication. When this swelling does not go away, and becomes permanent it is called secondary lymphedema.

Group Two

Another extremely large group that experiences permanent leg or arm swelling arecancer patients, people who are morbidly obese, or those with the condition called lepedema. What causes the swelling to remain permanent is that the lymph system has been so damaged that it can no longer operate normally in removing the body's waste fluid.

In cancer patients this is the result of either removal of the lymph nodes for cancer biopsy, radiation damage to the lymph system, or damage from tumor/cancer surgeries.

This is also referred to as secondary lymphedema.

Group Three

Group three consists of people who have leg or arm swelling from seemingly unknown reasons. There may be no injury, no cancer, no trauma, but for some reason the leg simply is swollen all the time.

The swelling may start at birth, it may begin at puberty, or may begin in the 3rd, 4th or even 5th decade of life or sometimes later.

This type of leg or arm swelling is called primary lymphedema. It can be caused by a genetic defect, malformation or damage to the lymph system while in the womb or at birth or be part of another birth condition that also effects the lymph system.

This is an extremely serious medical condition that must be diagnosed early, and treated quickly so as to avoid painful, debilitating and even life threatening complications. Treatment should NOT include the use of diuretics.

WHAT IS LYMPHEDEMA?

Lymphedema is defined simply as an accumulation of excessive protein rich fluid in the tissues of the leg. The accumulation of fluid causes the permanent swelling caused by a defective lymph system.

A conservative estimate is that there may be 1-2 million people in the United States with some form of primary lymphedema and two to three million with secondary lymphedema.

WHAT ARE THE SYMPTOMS OF LYMPHEDEMA?

If you are an at risk person for arm lymphedema there are early warning signs you should be aware of. If you experience any or several of these symptoms, you should immediately make your physician aware of them.

1.) Unexplained aching, hurting or pain in the arm

2.) Experiencing “fleeting lymphedema.” This is where the limb may swell, even slightly, then return to normal. This may be a precursor to full blown arm lymphedema.

3.) Localized swelling of any area. Sometimes lymphedema may start as swelling in one area, for example the hand, or between the elbow and hand. This is an indication of early lymphatic malfunction.

4.) Any arm inflammation, redness or infection.

5.) You may experience a feeling of tightness, heaviness or weakness of the arm.

The symptoms for leg lymphedema are very similar to ones for the arm.

HOW IS LYMPHEDEMA TREATED?

The preferred treatment today is decongestive therapy. The forms of therapy are complete decongestive therapy (CDT) or manual decongestive therapy (MLD), there are variances, but most involve these two type of treatment.

It is a form of massage therapy where the leg is very gently massaged to actually move the fluid out of the leg and into an area where the lymph system still functions normally.

With these massage treatments, swelling is reduced and then the patient is fitted with a pre-measured custom pressure garment to keep the swelling down and/or is taught to use compression wraps to maintain the leg size.

WHAT ARE SOME OF THE COMPLICATIONS OF LYMPHEDEMA?

1. Infections such as cellulitis, lymphangitis, erysipelas. This is due not only to the large accumulation of fluid, but it is well documented that lymphodemous limbs are localized immunocompromised.

2. Draining wounds that leak lymphorrhea which is very caustic to surrounding skin tissue and acts as a port of entry for infections.

3. Increased pain as a result of the compression of nerves usually caused by the development of fibrosis and increased build up of fluids.

4. Loss of Function due to the swelling and limb changes.

5. Depression - Psychological coping as a result of the disfigurement and debilitating effect of lymphedema.

6. Deep venous thrombosis again as a result of the pressure of the swelling and fibrosis against the vascular system. Also, can happen as a result of cellulitis, lymphangitis and infections.

7. Sepsis, Gangrene are possibilities as a result of the infections.

8. Possible amputation of the limb.

9. Pleural effusions may result if the lymphatics in the abdomen or chest are to overwhelmed to clear the lung cavity of fluids.

10. Skin complications such as splitting, plaques, susceptibility to fungus and bacterial infections.

11. Chronic localized inflammations.

CAN LYMPHEDEMA BE CURED?

No, at the present time there is no cure for lymphedema. But it can be treated and managed and most of the complications can be avoided. Life with lymphedema can still be active and full, with proper treatment, patient education, and patient life style adaptation.

For extensive information on lymphedema, please visit our home page:

Lymphedema People

http://www.lymphedemapeople.com

© Copyright 2005 by Pat O'Connor and Lymphedema People. Use of this information for educational purpose is encouraged and permitted. It must be available free and without charge and not used for financial renumeration or gain. Please include an acknowledgement to the author and a link to Lymphedema People. See also our copyright policy on the welcome page.

Lymphedema

This patient summary is adapted from the summary on lymphedema written by cancer experts for health professionals. This and other credible information about cancer treatment, screening, prevention, supportive care, and ongoing clinical trials, is available from the National Cancer Institute. Lymphedema is a swelling of a part of the body, usually an arm or leg, that is caused by the buildup of lymph. Lymph is a nearly colorless fluid that travels throughout the lymphatic system and carries cells that help fight infection and disease. Lymphedema can be caused by cancer or the treatment of cancer. This brief summary describes lymphedema, its causes and treatment.

OVERVIEW

Lymphedema is the buildup of lymph in the tissues, mainly in the fat just under the skin, and is caused by a problem in the lymphatic system. Lymphedema is an abnormal collection of too much tissue protein, fluid (edema), chronic inflammation, and thickening and scarring of connective tissue.

The lymphatic system is made up of vessels that are similar to blood vessels, but it carries lymph instead of blood. Unlike the blood system, which circulates through every part of the body, the lymphatic system drains lymph away from each part of the body. The lymphatic system collects fluid and protein from body tissues and returns it to the blood stream. Proteins and substances too big to fit into veins are moved through the lymphatic system. Edema may occur when these substances are in excess and the lymphatic system becomes overwhelmed or blocked.

Lymphedema is categorized as either primary or secondary. Primary lymphedema is a rare inherited condition in which lymph nodes and lymph vessels are absent or abnormal. Secondary lymphedema is usually caused when the lymphatic system is blocked or cut and may be caused by infection, cancer, or scar tissue. The most frequently affected lymph nodes are in the pelvis and legs or under the arms.

Acute versus chronic lymphedema There are several types of lymphedema. The first type is acute, temporary, and mild lymphedema that occurs within a few days after surgery that has involved the cutting of lymphatic vessels. It usually gets better within a week after keeping the affected arm or leg raised and by pumping the muscle that is associated with the affected limb (for example, making a fist and releasing it). The second type of lymphedema is acute and painful and occurs 4-6 weeks after surgery. This type of lymphedema is caused by swelling of the lymphatic vessels. It is treated by keeping the affected arm or leg raised and taking anti-inflammatory drugs. The third type of lymphedema is an acute form involving the skin, often occurring after an insect bite or minor injury or burn. It may occur on an arm or leg that is chronically swollen. This third form of edema is treated by keeping the arm or leg raised and by taking antibiotics. The fourth and most common form of lymphedema is slow and painless and usually occurs 18-24 months after surgery to remove a tumor or lymph nodes. If it develops later, it may mean that the tumor is coming back.

Acute lymphedema is a temporary condition that lasts less than 6 months. The skin indents when touched and stays indented, but there is no hardening of the skin. A patient may be more likely to develop lymphedema if he or she has surgical drains that leak protein into the surgical site; inflammation; no movement of the arm or leg; or a temporary lack of lymphatic function in one area of the body.

Chronic lymphedema is the hardest of all types of edema to treat. The damaged lymphatic system of the affected part of the body is not able to handle the increased fluid. This may happen when a tumor recurs or grows in an area of lymph nodes; when infection and/or injury of the lymphatic vessels occurs; when there is lack of movement of the arm or leg; after radiation therapy or surgery; with medical conditions such as diabetes, kidney problems, high blood pressure, congestive heart failure, or liver disease; or when preventive measures have not been taken after surgery. Lymphedema may also occur when cancer or cancer treatment causes loss of appetite, nausea, vomiting, depression, anxiety, or problems with metabolism.

A patient who is developing lymphedema will have soft, pitting edema that is helped by raising the arm or leg and by wearing elastic support garments. Continued problems with the lymphatic system cause fluid to flow back into the tissues, and the condition may become worse. This causes pain, heat, redness, and swelling as the body tries to get rid of the extra fluid. The skin becomes hard, stiff, and non-pitting and is no longer helped by raising the arm or leg or using elastic support.

Patients with lymphedema are more susceptible to infection. No effective treatment is yet available for patients with advanced chronic lymphedema. Edema may reoccur more easily in patients who have had lymphedema.

Risk factors

Factors that can lead to the development of lymphedema include radiation therapy to the area where the lymph nodes were surgically removed, problems after surgery that cause inflammation of the arm or leg, being overweight, the number of lymph nodes removed in surgery, and being elderly.

Patients who are at risk for lymphedema are those with:

- Breast cancer if they have received radiation therapy or had lymph nodes removed. Radiation to the underarm area after the lymph nodes have been removed increases the occurrence of lymphedema. This also include men who have experienced male breast cancer.

- Melanoma of the arms or legs if the patient has had lymph nodes removed from the underarm area and/or received radiation therapy.

- Prostate cancer treated by radiation therapy to the whole pelvis or by surgery.

- Cancer of the female reproductive tract that is advanced, treated with surgery to remove the lymph nodes, or treated with radiation therapy.

- Cancer that has spread to the lower abdomen, such as metastatic ovarian, testicular, colorectal, pancreatic, or liver cancer. The pressure from the growing tumor can destroy the lymphatic vessels and block lymphatic drainage.

Diagnosis

Specific criteria for diagnosing lymphedema do not yet exist. About half of patients with mild edema describe their affected arm or leg as feeling heavier or fuller than usual. To evaluate a patient for lymphedema, a history and physical examination of the patient should be completed. The history should include any past surgeries, problems after surgery, and the time between surgery and the onset of symptoms of edema. Any changes in the edema should be determined as well as any history of injury or infection. Knowing the medications a patient is taking is also important for diagnosis.

Management

Prevention Patients at risk for lymphedema should be identified early, monitored, and taught self-care. A patient may be more likely to develop lymphedema if he or she eats an inadequate diet, is overweight, is inactive, or has other medical problems. To detect the condition early, the following should be examined: weight, measurements of the arms and legs; protein levels in the blood; ability to perform activities of daily living; history of edema, previous radiation therapy, or surgery; and other medical illnesses, such as diabetes, high blood pressure, kidney disease, heart disease, or phlebitis (inflammation of the veins).

It is important that the patient know about his or her disease and the risk of developing lymphedema. Poor drainage of the lymphatic system due to surgery to remove the lymph nodes and/or radiation therapy may make the affected arm or leg more susceptible to serious infection. Even a small infection may lead to serious lymphedema.

Patients should understand the dangers of developing lymphedema and should be taught about arm, leg, and skin care after surgery and/or radiation therapy (see Table I below). It is important that this care continues for life, since lymphedema can occur 15 or more years after surgery. Breast cancer patients who follow instructions about skin care and proper exercise after mastectomy are less likely to experience lymphedema.

Lymphatic drainage is improved during exercise, therefore exercise is important in preventing lymphedema. Breast cancer patients should do hand and arm exercises after mastectomy. Patients who have surgery that affects pelvic lymph node drainage should do leg and foot exercises. The doctor determines how soon patients should start exercising after surgery. Physical therapists should develop an individual exercise program for the patient.

Better recovery occurs when lymphedema is discovered early, so patients should be taught to recognize the early signs of edema and to tell the doctor about any of the following symptoms: feelings of tightness in the arm or leg; rings or shoes that don't fit; weakness; pain, aching, or heaviness; redness, swelling, or signs of infection.

Patient Teaching Guide

1. Use an electric razor for shaving -wear gardening and cooking gloves; use thimbles for sewing -take care of nails; do not cut cuticles

2. Legs -keep the feet covered when going in the ocean -keep the feet clean and dry; wear cotton socks -cut toenails straight across; see a podiatrist

3. Either arms or legs -suntan gradually; use sunscreen -clean cuts with soap and water, then use antibacterial ointment -use gauze wrapping instead of tape -talk to the doctor about any rashes -avoid needle sticks of any type in the affected arm or leg -avoid extreme hot or cold, such as, ice packs, heating pads -do not overwork the affected arm or leg

4. Do not put too much pressure on the arm or leg: -do not cross legs while sitting -wear loose jewelry; wear clothes without tight bands -carry a handbag on the unaffected arm -do not use blood pressure cuffs on the affected arm -do not use elastic bandages or stockings with tight bands -do not sit in one position for more than 30 minutes

5. Watch for signs of infection, such as redness, pain, heat, swelling, fever. Call the doctor immediately if any of these signs appear.

6. Do exercises regularly to improve drainage.

7. Keep regular follow-up appointments with the doctor.

8. Check all areas of the arms and legs every day for signs of problems: -measure around the arm or leg periodically or if the limb seems swollen -use a tape measure at two consistent places on the arm or leg -tell the doctor if the limb suddenly gets larger

9. The arm or leg may be less sensitive. Use the unaffected limb to test temperatures for bath water or cooking.

10. Eat a well-balanced diet.

Treatment

Lymphedema is treated by mechanical methods and with medication. Mechanical methods include raising the arm or leg, wearing custom-fitted clothes that apply controlled pressure, cleaning the skin carefully to prevent infection, and controlling body weight. When used, pressure garments should cover the entire area of edema. For example, a stocking that only reaches the knee can become tight and cause problems if there is edema in the thigh. Pumps on the arm and leg that give intermittent pressure are very helpful. The cuff is inflated and deflated according to a controlled time cycle. This increases fluid flow in the veins and lymphatic vessels and keeps fluid from collecting in the arm or leg.

Antibiotics may be used to treat and prevent infections. Other types of drugs such as diuretics or anticoagulants are generally not helpful, and may even worsen the problem.

Finding the exact cause of the swelling and treating it correctly is important. Edema often leads to infection, which then increases protein deposits in the tissues. If an infection is diagnosed, appropriate antibiotics should be given. Blood clots should be ruled out, since massage and therapy to encourage drainage may make the clots more dangerous. If blood clots are found, they should be treated with medication.

Coumarin was once used in some foods and medications in the United States. Coumarin was found to cause liver damage, and its use in foods and drugs in the United States has been banned since the 1950's.

Coumarin has been studied to determine if it is effective in reducing the swelling caused by lymphedema. Research has not shown coumarin to be an effective treatment for lymphedema and has shown that it may cause liver damage. Coumarin is available in some countries, but has not been approved for use in the United States.

Psychosocial considerations

Because lymphedema is disfiguring and sometimes painful and disabling, it can create mental, physical, and sexual problems. Women who develop lymphedema after treatment for breast cancer have more mental, physical, and sexual difficulties than women who do not develop lymphedema. The added stresses associated with lymphedema may interfere with its treatment that is often painful, difficult, and time-consuming.

Coping with lymphedema in the upper body after breast cancer treatment is especially difficult for patients who have little social support. Some patients may react to the problem by withdrawing. It is also difficult for patients with painful lymphedema. Patients with lymphedema may be helped by group and individual counseling that provides information about ways to prevent lymphedema, the role of diet and exercise, advice for picking comfortable and flattering clothes, as well as emotional support.

Other treatment

Surgery for lymphedema usually results in complications and is seldom recommended to the cancer patient.

Complications

A rare but fatal complication of lymphedema is lymphangiosarcoma, a tumor of the lymphatic vessels. The average time between mastectomy and the appearance of lymphangiosarcoma is about 10 years. After a patient develops lymphangiosarcoma, the average survival time is 1.3 years.

The cause of lymphangiosarcoma is not known. It appears as one or more bluish- red bumps on the affected arm or leg. First, one purple-red, slightly raised area in the skin of the arm or leg appears. The patient usually describes it as a bruise. Later, more tumors appear, and the bumps grow. Death usually results from metastases to the lungs.

TO LEARN MORE

For more information, call the National Cancer Institute's Cancer Information Service at 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615. The call is free and a trained information specialist is available to answer your questions.

There are many other places to get information about cancer treatment and services. Check the social service office at your hospital for local and national agencies that can help with finances, getting to and from treatment, care at home, and dealing with other problems.

Write to the National Cancer Institute at this address:

National Cancer Institute Building 31, Room 10A24 9000 Rockville Pike Bethesda, MD 20892

SaintsMemorial

The Role of Lymphatics in Cancer as Assessed by Near-Infrared Fluorescence Imaging.

Dec. 2011

Rasmussen JC, Kwon S, Sevick-Muraca EM, Cormier JN. Source Center for Molecular Imaging, The Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center, Houston, 1825 Pressler St, SRB 330F, Houston, TX, 77030, USA, john.rasmussen@uth.tmc.edu. Abstract The lymphatic system is the secondary circulatory system responsible for fluid homeostasis and protein transport in the body. In addition, because the lymphatic system provides a primary pathway for cancer metastasis, lymph node involvement is routinely used as a determinant in cancer staging. Despite their importance, the lymphatics remain poorly understood, in part because of the historic lack of imaging modalities with sufficient spatial and/or temporal resolution to visualize the fine lymphatic structure and subtle contractile function. In recent years, near-infrared fluorescence (NIRF) imaging has emerged as a new imaging modality to non-invasively visualize the lymphatics and assess contractile lymphatic function in humans following administration of microdose amounts of a NIRF contrast agent. In this contribution, we first review NIRF imaging and its clinical application in sentinel lymph node mapping, intraoperative guidance, and assessing the architecture and contractile function of the lymphatics in health and in cancer-related lymphedema. We then present recent NIRF lymphatic imaging for non-invasive assessment of lymphatics both in preclinical melanoma models and in human subjects with melanoma.

SpringerLink

Preliminary development of a lymphedema symptom assessment scale for patients with head and neck cancer.

Nov 2011

Deng J, Ridner SH, Murphy BA, Dietrich MS.

Source School of Nursing, Vanderbilt University, 461 21st Ave. South, 600B Godchaux Hall, Nashville, TN, 37240, USA, jie.deng@vanderbilt.edu.

Keywords: Secondary lymphedema – Head and neck cancer (HNC) – Symptom assessment – Instrument development – Late effect

Abstract

PURPOSE: Currently, no instruments are available to assess symptoms secondary to lymphedema in patients with head and neck cancer (HNC). The study aim was to develop and conduct preliminary tests of such an instrument.

METHODS: A preliminary item pool was generated from a literature review, previous work in breast cancer-related lymphedema, and an observational study. The item pool was revised based on an expert panel's suggestions and feedback from 18 patients with HNC. The current questionnaire, the Lymphedema Symptom Intensity and Distress Survey-Head and Neck (LSIDS-H&N), was then pilot tested in 30 patients with HNC.

RESULTS: Preliminary testing (1) demonstrated feasibility, readability, and ease of use of the LSIDS-H&N and (2) identified that there was a considerable level of symptom burden in the cohort of patients in the piloting sample.

CONCLUSION: Content validity of the LSIDS-H&N was supported by the expert panel during development of the LSIDS-H&N. Further testing is ongoing.

SpringerLink

Lymphedema after breast or gynecological cancer: use and effectiveness of mainstream and complementary therapies.

Sept 2011

Finnane A, Liu Y, Battistutta D, Janda M, Hayes SC. Source School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia. anna.finnane@qut.edu.au

Abstract

OBJECTIVES: The purpose of this study was to describe the use, as well as perceived effectiveness, of mainstream and complementary and alternative medicine (CAM) therapies in the treatment of lymphedema following breast or gynecological cancer. Further, the study assessed the relationship between the characteristics of lymphedema (including type, severity, stability, and duration), and the use of CAM and/or mainstream treatment.

METHODS: This was a cross-sectional study using a convenience sample of women with lymphedema following breast and gynecological cancers. A self-administered questionnaire was sent to 247 potentially eligible women. Of those returned (50%), 23 were ineligible and 6 were excluded due to level of missing data.

RESULTS: In the previous 12 months, the majority of women (90%) had used mainstream treatments to treat their lymphedema, with massage being the most commonly used (86%). One (1) in 2 women had used CAM to treat their lymphedema, and 98% of those using CAM were also using mainstream treatments. Over 27 types of CAM were reported, with use of a chi machine, vitamin E supplements, yoga, and meditation being the most commonly reported forms. The perceived effectiveness ratings (1-7 with 7=completely effective) of mainstream (mean±standard deviation (SD): 5.3±1.5) and CAM therapies (mean±SD: 5.2+1.6) were considered high.

CONCLUSIONS: These results demonstrate that mainstream and CAM treatment use is common, varied, and considered to be effective among women with lymphedema following breast or gynecological cancer. Furthermore, it highlights the immediate need for larger prospective studies assessing the inter-relationship between the use of mainstream and CAM therapies for treatment success.

Mary Ann Liebert

Arm Swelling Common Among Young Breast Cancer Patients

The good news is that there are nearly two million breast cancer survivors in the United States , and survival rates continue to increase for patients with this disease. But the flip side is that survival can present its own set of little-known complications.

Researchers found that slightly more than half of 580 women diagnosed with breast cancer in one study experienced swelling, or lymphedema, in their arms or hands after the surgical removal of the breast or the tumor.

This swelling was persistent among nearly one-third of the women. Women with lymphedema reported their quality of life as lower than did women without the problem.

“Women don't know about lymphedema,” said Electra Paskett, the study's lead author and a professor of epidemiology and biostatistics in the School of Public Health at Ohio State University.

For most women, the swelling takes place on the same side of the body as the affected breast. And it's generally not a sign of cancer's recurrence, Paskett said. Lymphedema can be painful, as the arm becomes fluid-filled, heavy and stiff and the skin becomes tight. Affected patients may have problems using their arms or hands. They also often need to buy clothes that are otherwise too big in order to fit the swollen limb.

Lymphedema is caused by a build-up of lymphatic fluid. The lymphatic system serves as a source of immune cells and includes organs and tissues such as bone marrow, the spleen, and lymph nodes. Lymph nodes are small, round masses of tissue that filter lymphatic fluid and can also trap cancer or bacteria cells that flow through the blood.

Removing or sampling the lymph nodes during surgery is fairly common, as they can serve as a conduit by which cancer can spread throughout the body. Both lymph node removal and radiation can disrupt the flow of lymph fluid.

“The lymph system is like a freeway,” Paskett said. “If there is construction or a wreck, all of the cars back up. That's sort of what happens with lymphedema – there is a traffic jam, and the fluid gathers in the arm, hand and fingers.”

Ohio State Research

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