Lymphedema management

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Abstract

Lymphedema, defined as the abnormal accumulation of protein rich fluid dysfunction of the lymphatic system, is a common sequela of cancer therapy. The incidence is highest among patients who have undergone resection and irradiation of a lymph node bed. Recently, increased attention has been focused on the modification of anticancer therapies in an effort to minimize lymphatic compromise. Sentinel lymph node biopsy is an example of a surgical procedure developed to preserve lymphatic function. Concurrent with the development of less invasive treatments, the field of lymphedema management has evolved rapidly over the past decade. Combined manual therapy, often referred to as complex decongestive physiotherapy (CDP), has emerged as the standard of care. CDP combines compression bandaging, manual lymphatic drainage (a specialized massage technique), exercise, and skin care with extensive patient education. Case series collectively describing a mean 65% volume reduction in over 10,000 patients attest its efficacy. Pneumatic compression pumps were historically widely used to control lymphedema. Their use as an isolated treatment modality is now rare. Reliance on pumps diminished with the recognition that they may exacerbate truncal and genital lymphedema, as well as injure peripheral lymphatics when applied at high pressures. Many noncompressive approaches, particularly the use of benzopyrone medications and liposuction, continue to be used abroad.

Section snippets

Modifications of primary cancer therapy

Breast cancer can be used as a model to show how early detection and treatment modification can assist in the prevention of lymphedema. Advanced nodal disease at diagnosis is a known risk factor for lymphedema because of the need for extensive axillary surgery, increased chemotherapy, and additional radiation therapy to the axilla.4, 5, 6

Arm edema is associated with the degree of axillary dissection and the use of axillary radiation therapy.7, 8 The incidence of lymphedema increases with more

Manual lymphatic drainage

Manual lymphatic drainage (MLD) is a highly specialized massage technique designed to enhance the sequestration and transport of lymph. Specific stroke duration, orientation, pressure, and sequence characterize MLD. Through gentle, rhythmic skin distension, congested lymph is directed through residual functioning lymphatics into intact nodal basins. MLD permits elimination of congested truncal lymph by shifting it to lymphotomes (anatomic regions drained by a specific lymph node bed) with

Surgical procedures for lymphedema

Many operations have been used over the past century to improve the status of the lymphedematous upper limb. The list of the diverse operations attempted for this disabling condition in the past decades suggests that none are successful. Philosophically these can be loosely grouped as (1) recreation or imitation of lymphatic channels, (2) bridging the lymphedematous area to normal lymphatic areas, and (3) resections or debulking of lymphedematous tissue.

The most biologically based operation,

Medications

Diuretics are routinely initiated to treat lymphedema. Although many patients experience an acute reduction in swelling with diuretics, they are not recommended in the long-term management of lymphedema.82 These medications exert their therapeutic influence by reducing blood capillary pressure. This alters the interplay of forces that dictate net fluid movement across the endothelium, reducing ultrafiltration. Unfortunately, although use of diuretics may curtail the accumulation of lymph fluid,

Future directions

Increasing investigative attention is being paid to the development of novel lymphedema treatment approaches. The identification of vascular endothelial growth factor receptor as the defective gene in several families afflicted with congenital lymphedema has paved the way for gene therapy trials.105, 106 These are currently in the incipient stages. Hyperbaric oxygen therapy has also received attention as a means of curbing radiation-induced fibrosis of lymphatics and thereby preserving drainage.

Conclusion

Lymphedema remains a significant, long-term problem for many cancer survivors. Although numerous surgical and pharmacological interventions have been scrutinized, none offer unequivocal benefit and many are plagued by deleterious side effects. At present, multimodal manual therapy is the standard of care. The combination of MLD, remedial exercises, skin care, and compressive bandaging, referred to as complete decongestive physiotherapy, has been shown to be effective in numerous large case

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