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The Identification and Management of Oncologic

Treatment-Related Lymphedema

Tammy E. Mondry, PT, DPT, MSRS, CLT-LANA

Objectives

At the end of this course, the participant will be able to:

• Perform risk assessment for lymphedema

• Instruct patient in arm and leg care guidelines

• Identify lymphedema in the oncology patient population

• Determine when referral to a lymphedema specialist is appropriate

Anatomy and Physiology of the Lymphatic System

• Purpose of the lymphatic system

• Lymph fluid

• Lymph vessel

• Lymph node

• Quadrants

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Initial Lymph Collector

http://philschatz.com/anatomy-book/contents/m46563.html

Lymph Vessels

http://www.nature.com/nature/journal/v438/n7070/fig_tab/nature04480_F1.html

Lymph Vessels

http://www.fgf.uk.com/content/lymphaticsystem

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Lymphangion

http://openi.nlm.nih.gov/detailedresult.php?img=3284143_rsif20110751-g2&req=4

Lymph Node

http://www.organicbodyandsoul.com/Limphatic.htm

Nodal Basins

http://patient.info/diagram/lymphatic-system-diagram

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Drainage of the Lymphatic System

What is Lymphedema?

• An abnormal accumulation of protein-rich fluid due to a low volume (mechanical) insufficiency of the lymphatic system

Classifications

• Primary vs. Secondary

• Lymphedema Praecox (onset at puberty)

• Lymphedema Tarda (onset after age 35)

• Benign vs. Malignant

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Effects of Oncologic Treatments

• Surgery (excision of lymph nodes)

• Sentinel Lymph Node Biopsy

• Lymph Node Dissection

• Radiation Therapy

• Areas at risk for development of edema

Risk Factors

• More Advanced Disease

• Age

• Higher Number of Nodes Removed

• HTN

• Increased BMI

• Radiation Therapy

Incidence Rate

• Incidence of Breast Carcinoma-Related Lymphedema ranges from 6% -30%

• Onset may be delayed several decades

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Incidence Rate

Breast Edema 6-48%

•Lumpectomy 6%

•SLNBx + XRT 23%

•ALND + XRT

•Node Negative 35%

•Node Positive 48%

Incidence Rate

Lower Extremity Lymphedema

• Cervical Cancer 21-49%

• Endometrial 11%

• Vulvar 6-12%

• Prostate 25-66%

• Melanoma 1.7-53%

Lymphedema versus Edema

Lymphedema

• Disease process

• Localized

• High protein edema

• Progressive without adequate treatment

• Diagnosed through patient history and clinical observation

Edema

• Symptom of a condition (CHF, CVI, Immobility)

• Generalized or Localized

• Inflammatory reactions

• Hypoproteinemia

• Kidney, liver or thyroid disease

• Malnutrition

• Excessive bleeding

• Chronic draining wounds

• Excessive burns

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Clinical Presentation of Lymphedema

• Heaviness, tightness, aching, discomfort

• Intermittent swelling in a portion of the limb or the entire limb

• Pitting edema

• Swelling is worse as the day progresses

Compounding Factors

• Infection

• Inflammatory Disorders

• Obesity

• Psychosocial Issues

• Lymphangiosarcoma

Diagnosis of Lymphedema

• Diagnosis

- Medical History

- Stemmer’s Sign

• Differential Diagnosis

- Rule out DVT

- Rule out Malignant Lymphedema

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Diagnostic Imaging

• Lymphoscintigraphy

• MRI

• CT Scan

• Ultrasound

Clinical Assessment

• Stemmer Sign

• Girth Measurements

• Water Displacement Testing

• Perometry

• Bioimpedance

• Digital Photography

Stemmer Sign

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Girth Measurements

Volumeter

Perometer

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Bioimpedance

• L-Dex U400

http://www.impedimed.com/products/l-dex-u400/

American Physical Therapy Association Classification

• Mild (less than 3 cm differential)

• Moderate (3 to 5 cm differential)

• Severe (5-plus cm differential)

International Society of Lymphology Classification

• Stage 0 – Subclinical or Latency Stage

• Stage I – Reversible Lymphedema

• Stage II – Spontaneously Irreversible Lymphedema

• Stage III – Lymphostatic Elephantiasis

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Stage IReversible Lymphedema

Stage IReversible Lymphedema

Stage II – Spontaneously Irreversible Lymphedema

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Stage II – Spontaneously Irreversible Lymphedema

Stage II – Spontaneously Irreversible Lymphedema

Stage III – Lymphostatic Elephantiasis

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Stage III – Lymphostatic Elephantiasis

Stage III – Lymphostatic Elephantiasis

Stage III – Lymphostatic Elephantiasis

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Management of Lymphedema

• Prevention

• Preoperative Evaluation

• Baseline girth / volume measurements

• Note risk factors

• Preoperative Education

• Arm or Leg Care Guidelines

Goals of Treatment

• There is not a cure for lymphedema

• Decongest the affected limb

• Prevent / eliminate infections

• Maintain normal or near normal limb size

Treatment Options

• Vasopneumatic Sequential Compression Pump

• Surgical Options

• Low Level Laser Therapy

• HivaMat

• Diet / Medications

• Diuretics

• Coumarin

• Antibiotics

• Elevation

• Compression Garments (Day / Night)

• Complete Decongestive Therapy

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Intermittent Pneumatic Compression

• Comparing Types of Pumps (examples)

• Bio Compression Systems

• Tactile Medical

• Contraindications and Considerations

• Insurance Coverage

Bio Compression Systems, Inc

Bio Vest with One Arm

Model SC-2004 Sequential Circulator

http://www.biocompression.com/Home.aspx

Tactile Medical

Flexitouch System Upper Extremity Flexitouch System Lower Extremity

http://www.tactilemedical.com/products/flexitouch/flexitouch-mechanism-of-action/

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Surgical Options

• Lymphatic bypass procedures

• Reductive procedures

• Lymph Node Transfer

• Liposuction

• Experimental Procedures

Low Level Laser Therapy

http://www.riancorp.com/Products/low-level-laser-therapy-lllt.html

Electrical Stimulation

•HivaMat (Histological Variable Manual Technique)

•Deep Oscillation

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Diet and Medications

• Heart Healthy Diet

• Diuretics

• Coumarin (Benzopyrone)

• Antibiotics

Compression Garments

• Day use garments

• Night use garments

• Selecting garments based on patient functional ability

Day Use Garments

• Juzo, Jobst, Solaris, CircAid / Medi, LympheDIVAs, Sigvaris, Solidea, JoViPak, Farrow Medical, Reid Sleeve

• Circular Knit versus Flat Knit

• Off-the-Shelf versus Custom made

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Night Use Garments

Complete Decongestive Therapy (CDT)

Two Phase Therapy• Treatment Phase

• One hour

• Five times per week

• Two to four weeks

• Maintenance Phase

• Lifetime of daily maintenance

• Six month reassessments

Contraindications for CDT

• Relative Contraindications

• HTN

• Paralysis

• Diabetes

• Bronchial asthma

• Absolute Contraindications

• Acute infection

• DVT

• CHF

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Relative Contraindications

• Hypertension

• Paralysis

• Diabetes

• Bronchial Asthma

Absolute Contraindications

• Acute Infections

• Congestive Heart Failure (CHF)

• Deep Vein Thrombosis (DVT)

Treatment Phase

• Skin / Nail Care

• Manual Lymph Drainage (MLD)

• Compression Bandaging

• Therapeutic Exercise

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Skin and Nail Care

• Avoid injections and blood draws in the affected arm

• Have blood pressure checked in the unaffected arm

• Avoid heavy lifting with the affected arm

• Report to your MD if you have any signs of infection

Manual Lymph Drainage

•Manual technique to facilitate lymph flow

• Increases pumping rate up to ten times (100-120 times /min)

MLD Compared to Massage

MLD

• Manual Technique

• Focus on Connective Tissue

• Gentle Pressure

• Working and Resting Phase

Traditional Massage

• Manual Technique

• Focus on Muscle Tissue

• Considerable Pressure

• Increases Lymphatic Load

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Manual Lymph Drainage

Compression Bandaging

•Multilayer bandage

•Worn 24 hours per day during the treatment phase

•Short Stretch Bandages

Muscle / Joint Pump

Resting Pressure Working Pressure

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Therapeutic Exercise

•Exercise performed after compression bandages are applied

• Increases pumping rate up to ten times

• Facilitates Muscle Joint Pump

Maintenance Phase

• Skin / Nail Care

• Self –MLD

•Compression Garments

•Home Exercise Program

•Girth and Volume Reassessment

Compression GarmentsSleeve, Gauntlet, Glove, Stocking

•Manufacturers

•Compression Class

• 30-40mmHg

• Life of the Garment

• Six Months

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When Does CDT Fail?

• Malignant lymphedema

• Associated illnesses

• Lack of compliance

• Insufficient treatment

Palliative Care

• Provide Comfort

• Relief of Symptoms

• Maintain Function

• Lymphorrhea

Stage I – Reversible Lymphedema

Pre Post

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Stage I – Reversible Lymphedema

Pre Post

Stage II – Spontaneously Irreversible Lymphedema

Pre Post

Stage II – Spontaneously Irreversible Lymphedema

Pre Post

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Stage III – Lymphostatic Elephantiasis

Post

Pre

Lymphedema Lower Extremity

Pre-Treatment Post-Treatment

Lymphedema Lower Extremity

Pre-Treatment Post-Treatment

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Truncal Lymphedema

Pre-Treatment Post-Treatment

Head / Neck Lymphedema

Pre-Treatment Post-Treatment

Patient Education

Arm and Leg Care Guidelines

• Skin Care

• Modification of Activity and Lifestyle

• Avoid Limb Constriction

• Use of Compression Garments

• Avoid Extreme Temperatures

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Skin Care

• Avoid Cutting or Clipping Cuticles

• Avoid Punctures to the skin

• Wear gloves when gardening or using household cleaners

• Avoid injury

• Be aware of signs of infection

(red, hot, swollen, painful, fever or flu-like symptoms)

Activity and Lifestyle

• Activity or Exercise (gradually increase duration and intensity)

• Frequent Rest Periods for Limb Recovery

• Avoid Limb Constriction

• Avoid Extreme Temperatures

Activity and Lifestyle

• Avoid Prolonged Standing and Sitting

• Well-Fitted Footwear and Hosiery

• Compression Garments During Air Travel

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Lymphedema and Exercise

• Cardiopulmonary warm up and cool down

• Flexibility Exercises

• Resistive Exercise

• Aerobic Exercise

LANA Certification

• 135 hours of CDT training

• Licensed PT, PTA, OT, COTA, RN, MD, DO, ATC, DC, Massage Therapist

• https://www.clt-lana.org/

Resource

National Lymphedema Network

www.lymphnet.org