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Lymphoedema

Julie-Ann MacLaren, MA, BSc (Hons), RGN, DipN (Oncology), ENB237, ENB998.

Macmillan Lecturer - Practitioner in Lymphoedema, The Royal Marsden Hospital, London and Surrey

Lymphoedema is a chronic condition, which causes patients both physical and psychosocial problems. Lymphoedema is defined as 'Swelling due to the excess accumulation of fluid in the tissues caused by inadequate lymphatic drainage' (BLS, 2001). Swelling develops when the normal production of lymphatic fluid exceeds the capacity of the lymph nodes and vessels responsible for lymphatic drainage, causing swelling to form in the interstitium of the skin.

Lymphoedema is a chronic condition, which causes patients both physical and psychosocial problems. Lymphoedema is defined as 'Swelling due to the excess accumulation of fluid in the tissues caused by inadequate lymphatic drainage' (BLS, 2001). Swelling develops when the normal production of lymphatic fluid exceeds the capacity of the lymph nodes and vessels responsible for lymphatic drainage, causing swelling to form in the interstitium of the skin.

Causes
The most common cause of lymphoedema in Western Europe is when it is secondary to cancer treatment, such as surgery or radiotherapy, which necessitates removal or obliteration of lymph node areas. Other forms of lymphoedema include 'primary' lymphoedema, caused by congenital conditions such as Milroy's disease, or filiaritic infection from mosquito bites, in the developing world.

Incidence
Estimates of the incidence of lymphoedema tend to focus on specific cancer-related lymphoedemas. Upper-limb lymphoedema following breast cancer treatment is estimated at between 25-38% (Kissin et al, 1986) according to the type of breast cancer treatment used.

Higher rates of incidence are related to the use of both surgery and radiotherapy to the axilla in treating malignant breast disease.

However, Mortimer et al (1996) estimate the prevalence of lymphoedema as 28% of all women undergoing breast cancer treatment. Werngren-Elgstrom and Lidman (1994) suggest that 40% of women undergoing treatment for cancer of the cervix develop unilateral leg swelling of 5% greater than the unaffected limb. Their research uses only a small sample group of 54 women, and has yet to be replicated on a wider scale, but may be relevant for other patient groups undergoing groin lymph node dissection or radiotherapy.

Primary lymphoedema is thought to affect 1:33,000 of the general population (Hardy and Taylor, 1999).

Presentation
Cancer-related lymphoedema presents as swelling within the limb or truncal quadrant adjacent to the area treated, or affected by cancer. Primary forms of lymphoedema may present as unilateral or bilateral limb swelling, or swelling elsewhere on the body with no apparent cause. Other causes of swelling such as hypoproteinaemia, superior vena cava (SVC) obstruction, deep vein thrombosis, active cancer or venous disease must be ruled out before starting treatment.

Mild and uncomplicated oedema is characterised as an excess limb volume of 20% or less with no genital or truncal involvement (BLS, 1999a).

It may present as soft and pitting swelling. At this stage the shape of the limb is preserved, although dry skin, caused by skin stretching, may cause problems.

Moderate to severe lymphoedema, characterised by an excess limb volume of greater than 20%, with swelling of the trunk, genital areas or digits present (BLS, 1999a), causes thickening and hardening of the skin and the promotion of skin folds which can make limbs appear misshapen.

Complications
Complications that may occur in lymphoedema are acute inflammatory episodes (such as cellulitis infection), which should be treated promptly with broad-spectrum antibiotics to prevent further lymph vessel damage.

Leaking from the affected swollen area is known as lymphorrhoea, and can occur where the surrounding skin is unable to stretch to accommodate new or existing swelling.

The volume of lymphorrhoea produced varies between patients, although it responds well to multi-layer lymphoedema bandaging, which must be performed by an appropriately skilled therapist.

Functional deficits may occur where limb swelling limits the range of movement of a limb, or where brachial plexus neuropathy is also present.

Pain must be alleviated and the causes for this identified, as lymphoedema should not itself cause acute pain.

Treatment of lymphoedema
Treatment of lymphoedema adopts a four-cornerstone approach. The modalities used are appropriate skincare, exercise, lymphatic drainage and the use of compression garments (see the box on page 93).

In addition to this, the nurse need to be aware of the counselling role that is essential to help patients adjust to changes in body image and to develop the coping skills necessary for dealing with this chronic condition. u

Further information
Help and advice are available from:

- The British Lymphology Society (BLS), 1 Webb's Court, Buckhurst Avenue, Sevenoaks, Kent TN13 1LZ. Telephone: 01732740850. Web: www.lymphoedema.org/bls

- The Lymphoedema Support Network, St Luke's Crypt, Sydney Street, London SW3 6NH. Telephone: 02073510990. Web: www.lymphoedema.org/lsn

- MLD UK, PO Box 14491, Glenrothes, Fife KY6 3YE. Telephone: 01592840799. Web: www.mlduk.org.uk

- Breast Cancer Care, Kiln House, 210 New Kings Road, London SW6 4NZ. Telephone 02073842984(Admin). National Helpline: 08088006000. Web: www.breastcancercare.org.uk

SKINCARE
The aim is to improve skin condition in the area affected and protect against infection (MacLaren, 2001). Use of an emollient is necessary to moisturise, nourish and maintain the skin's integrity. Avoid unnecessary trauma to the skin surface such as cuts, scratches, bites and grazes, and treat any that occur antiseptically. Invasive therapeutic interventions in a swollen area can be a risk for swelling (Smith, 1997).

COMPRESSION
The mainstay of management is to apply compression bandaging or graduated compression garments. Multi-layer lymphoedema bandaging (MLLB) uses inelastic bandages to garner the effect of the muscle pumps in either arm or foot and calf, by providing counter-pressure against voluntary muscle activity (Todd, 2000). Bandaging is often used in a short, intensive phase to reduce limb size or preserve poor skin condition. Graduated compression garments, worn daily, encourage the movement of lymph and venous return towards the root of the limb (Kirshbaum, 1999).

LYMPHATIC DRAINAGE
This may be in the form of specialised manual lymphatic drainage (therapist-driven), or simple lymphatic drainage. It is taught to, and can be performed, by the patient, or a carer or partner. MLD UK has a register of therapists, but NHS provision is scanty.

EXERCISE
Exercise should be done in moderation, with the patient advised to start any new activities gently and avoid overexertion of the affected limb. Overexertion or sprains to a limb may exacerbate further lymph formation and increase any swelling. Gentle exercise, such as swimming, walking or cycling, is generally advised.

WHO IS AT RISK FROM LYMPHOEDEMA?
Cancer patients who have:

- Had radiotherapy to a lymph node area

- Had surgery to a lymph node region

- Have cancer recurrence/disease in a lymph node region

Non-cancer patients with:

- A family history of leg or arm swelling

- Trauma to lymphatics through infection or accident

- Lymphadenectomy for another medical condition

THE NURSE'S ROLE
Advice to patients should include the following:

- Identification of the patient who is 'at risk'

- Assistance in locating a local lymphoedema therapist - The British Lymphology Society provides a directory of services in the UK (BLS, 1999b)

- Regular use of emollients to the affected area

- Avoid trauma to the affected area

- Avoid invasive medical procedures on the affected limb/truncal area where possible

- Promote the appropriate use of compression garments as fitted by a lymphoedema therapist

- Suggest gentle limb elevation to maintain comfort and maximise drainage capacity

- Advise on normal use of limb, avoiding over exertion

- Advise on appropriate clothing and footwear

- Referral to other members of the multidisciplinary team where necessary.

British Lymphology Society (2001)Clinical Definitions. Sevenoaks: British Lymphology Society.

British Lymphology Society (1999a)Chronic Oedema: Population and Needs. Sevenoaks: BLS.

British Lymphology Society (1999b)Directory of Lymphoedema Treatment Services. Sevenoaks: BLS.

Hardy, D., Taylor, J. (1999)An Audit of Non-Cancer Related Lymphoedema in a Hospice Setting. International Journal of Palliative Nursing. 5: 1, 18-27.

Kirshbaum, M. (1999)Lymphoedema and Breast Cancer. Nursing Times Clinical Monographs, No. 38.

Kissin, M.W. Querci della Rovere, G., Easton, D., Westbury, G. (1986)Risk of Lymphoedema Following the Treatment of Breast Cancer. British Journal of Surgery 73: 7, 580-584.

MacLaren, J. (2001)Skin changes in Lymphoedema: Pathophysiology and Management Options. International Journal of Palliative Nursing. In press.

Mortimer, P.S., Bates, D.O. Brassington, H.D., Stanton, A.W.B., Strachan, D.P., Levick, J.R. (1986)The Prevalence of Arm Oedema Following Treatment of Breast Cancer. Quarterly Journal of Medicine 89: 377-380.

Smith, J. (1998)The Practice of Venepuncture in Lymphoedema. European Journal of Cancer Care 7: 97-98

Todd, J. (2000)Containment in the Management of Lymphoedema. In: Twycross, R., Jenns, K., Todd, J., (Eds.). Lymphoedema. Oxford: Radcliffe Medical Press.

Werngren-Elgstrom, M., Lidman, D. (1994)Lymphoedema of the Lower Extremities After Surgery and Radiotherapy for Cancer of the Cervix. Scandinavian Journal of Plastic Reconstructive and Hand Surgery. 28: 289-293

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