A fluid buildup that may collect in a person’s legs after nearby lymph vessels or lymph nodes are blocked or removed. Although lymphedema is most often associated with breast cancer, it also can develop after treatment for other types of cancer. Untreated, this stagnant fluid interferes with wound healing and provides a culture medium for bacteria that can lead to lymph node infection (lymphangitis).

If lymph nodes are removed, there is always a risk of developing lymphedema, either immediately after surgery or weeks, months, and even years later. Lymphedema also can develop if chemotherapy is unwisely administered to the side of the body on which surgery was performed or after repeated aspiration of fluid in the groin area, which often causes infection and lymphedema. Air travel also has been linked to the onset of lymphedema in patients who have had cancer surgery, probably as a result of decreased cabin pressure. This is why cancer patients should always wear a compression garment when flying.

Risk Factors

There are a number of risk factors for the development of lymphedema:

• Surgical removal of lymph nodes in the groin or pelvic regions

Radiation therapy to the groin or pelvic region

• Cancer spread to the lymph nodes in the neck, chest, underarm, pelvis, or abdomen

• Tumors in the pelvis or abdomen that block lymph drainage

• Excessive thinness or heaviness, which may delay recovery and increase risk for lymphedema

Symptoms

Lymphedema can develop in any part of the body, causing symptoms such as a full sensation in the limb, tightened skin, or decreased flexibility. In the early stages of lymphedema, a patient may experience swelling that indents with pressure but remains soft. The swelling may improve readily by supporting the leg in a raised position, gently exercising, and wearing elastic support garments.

However, continued problems with the lymphatic system cause the lymphatic vessels to expand; as lymph flows back into the body tissues, the condition worsens. This causes pain, heat, redness, and swelling as the body tries to get rid of the extra fluid. The skin becomes hard and stiff and no longer improves with raised support, gentle exercise, or wearing of elastic support garments.

Stages

Lymphedema develops in a number of stages, from mild to severe, referred to as stages 1, 2, and 3.

Stage 1 (spontaneously reversible): In the initial stage of lymphedema, tissue appears pitted when pressed by fingertips. Typically, on waking in the morning the affected area looks normal.

Stage 2 (spontaneously irreversible): In this intermediate stage, the tissue now has a spongy consistency and bounces back when pressed by fingertips, with no pitting. The area begins to harden and enlarge.

Stage 3 (lymphostatic elephantiasis): In this advanced stage, the swelling is irreversible and the affected area has usually grown quite large. The tissue is hard and unresponsive. Some patients consider reconstructive surgery (debulking) at this stage.

Acute Lymphedema

There are four types of acute lymphedema, which may be treated with different aspects of decongestive therapy, such as manual lymphatic drainage, bandaging, proper skin care and diet, compression garments, or remedial exercises.

The first type of acute lymphedema is mild and lasts only a short time, appearing immediately after surgery to remove the lymph nodes. The affected limb may be warm and slightly red but is usually not painful and improves within a week if the affected leg is supported in a raised position and the muscles in the affected limb are contracted.

The second type of acute lymphedema occurs six to eight weeks after surgery or during radiation therapy. This type may be caused by inflammation of either lymphatic vessels or veins, producing a limb that is tender, warm, and red. It is treated by keeping the limb supported in a raised position and using anti-inflammatory drugs.

The third type of acute lymphedema occurs after an insect bite, minor injury, or burn that causes an infection of the skin and the lymphatic vessels near the skin surface in a leg that is chronically swollen. The affected area becomes hot, red, and very tender. It is treated by supporting the affected leg in a raised position and using antibiotics. A compression pump should not be used and affected area should not be wrapped with elastic bandages during the early stages of infection. Mild redness may continue after the infection.

The fourth and most common type of acute lymphedema develops very slowly and may become noticeable only two years or more after surgery — or not until many years after cancer treatment. The patient may experience discomfort of the skin or aching in the neck and shoulders or spine and hips caused by stretching of the soft tissues, overuse of muscles, or posture changes caused by increased weight of the arm or leg.

Temporary vs. Chronic Lymphedema

Temporary lymphedema lasts less than six months and does not involve hardening of the skin. A patient may be more likely to develop lymphedema as a result of:

• A surgical drain that leaks protein into the surgical site;

• Inflammation;

• Inability to move the limb;

• Temporary loss of lymphatic function; or

• Blockage of a vein by a blood clot or inflammation of a vein.

Chronic (long-term) lymphedema is the most difficult of all types of swelling to treat; it occurs when the damaged lymphatic system of the affected area is not able to handle the increased need for fluid drainage from the body tissues. This may happen:

• After a tumor recurs or spreads to the lymph nodes;

• After an infection of the lymphatic vessels;

• After periods of inability to move the limbs;

• After radiation therapy or surgery;

• When early signs of lymphedema have not been controlled; or

• When a vein is blocked by a blood clot.

Patients with chronic lymphedema are at increased risk of infection. No effective treatment is yet available for advanced chronic lymphedema. Once the body tissues have been repeatedly stretched, lymphedema may recur more readily.

Prevention

Poor drainage of the lymphatic system caused by surgery to remove lymph nodes or radiation therapy may make an affected leg more susceptible to serious infection. Even a small infection may lead to severe lymphedema.

It is important that patients take precautions to prevent injury and infection in the affected arm or leg, since lymphedema can occur 30 years or more after surgery. Because lymphatic drainage is improved during exercise, exercise can help prevent lymphedema. Those who have surgery have affects pelvic lymph node drainage should do leg and foot exercises.

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