Patient education: Lymphedema after cancer surgery (Beyond the Basics)
- Babak Mehrara, MD
Babak Mehrara, MD
- Associate Professor of Surgery
- Cornell Weill Medical Center
- Section Editors
- Patricia A Ganz, MD
Patricia A Ganz, MD
- Section Editor — Cancer Survivorship
- UCLA Schools of Medicine and Public Health
- Jonsson Comprehensive Cancer Center
- Eduardo Bruera, MD
Eduardo Bruera, MD
- Section Editor — Non Pain Symptoms: Assessment and Management
- Professor of Oncology
- University of Texas, MD Anderson Cancer Center at Houston
Lymphedema is swelling caused by a buildup of fluid and fat that happens most commonly in the arms, legs, or face in patients who have been treated for cancer. Lymphedema is one of the most troubling complications that can develop after cancer surgery. Many patients find that lymphedema worsens the physical and emotional strain of living with (or following treatment for) cancer.
The risk of developing lymphedema depends upon the type of surgery performed, individual patient factors such as obesity or weight gain after surgery, treatment factors such as radiation or some types of chemotherapy, and complications after surgery, including infections or fluid collections (called "seromas").
More detailed information about lymphedema, written for healthcare providers, is available by subscription. (See 'Professional level information' below.)
WHAT IS LYMPH?
Lymph is a clear fluid that contains mostly protein and white blood cells (the blood cells that fight infection). Lymphatic vessels drain lymph fluid from the body's tissues and organs. The fluid is filtered through lymph nodes (also called glands) and eventually drains into the bloodstream (figure 1).
WHO GETS LYMPHEDEMA?
Generally speaking, patients who undergo more extensive surgery that includes removal of lymph nodes or who have radiation therapy to the area where lymph nodes are located are more likely to develop lymphedema. However, even the removal of a single lymph node (ie, a "sentinel lymph node") comes with a small risk. Also, some patients can develop lymphedema even when lymph nodes are not removed, if the lymphatic system in the skin is injured from extensive surgery and radiation (eg, those who are treated for a certain type of tumor, called sarcoma). Most patients who develop lymphedema do so within two to three years after their surgery, but it is important to note that the risk remains over a person's lifetime and increases with trauma or injury to a limb.
The initial symptoms of lymphedema may include any or all of the following in the treated limb or tissues:
●A heavy sensation or an aching discomfort
●Fatigue with use
●Numbness or tingling
In some cases, these symptoms develop before swelling is noticeable. Let your doctor or nurse know as soon as possible if you have any of these symptoms; recognizing and treating lymphedema in the early stages reduces its severity and can help prevent worsening of these symptoms over time.
Impact of lymphedema — While lymphedema is usually not a life-threatening condition, it can have a major impact on your quality of life. A change in how your limb looks can be distressing as well as painful.
●After breast cancer surgery, having a swollen or misshapen arm may increase the worry about how it looks.
●If lymphedema affects the ability to use your arm or leg, this can affect your quality of life, particularly if it is your dominant arm (eg, right arm if you are right-handed).
●Lymphedema can reduce tissue healing and occasionally causes chronic pain. For these reasons, prevention and early treatment of lymphedema are recommended.
●The limb with lymphedema can develop cellulitis, a skin infection that requires antibiotics and possible hospitalization.
If you develop lymphedema many years after surgery or have worsening lymphedema, contact your doctor or nurse immediately.
As mentioned above, the risk of lymphedema is higher in people who have multiple lymph nodes removed (for example, in an axillary lymph node dissection, a procedure in which most or all of the nodes in the underarm area are removed). In some cases, doctors can instead remove only one or a few lymph nodes (called a sentinel lymph node biopsy); this reduces the risk of lymphedema. This may not be an option in some cases, such as if the nodes have already been found to contain cancer cells.
If you have not yet developed lymphedema, monitor your limb by taking arm or leg measurements as instructed by your doctor. Although there are no measures that will prevent lymphedema with certainty, there are some things you can do to that can help reduce severity if it develops.
To avoid trauma and/or injury to the affected limb:
●Keep your skin clean. Wash with a mild soap every day.
●Be careful with your nails. Don't pick at the skin around your nails or cut your cuticles.
●Use lotion to keep your skin from getting dry and cracked.
●Use an electric razor instead of a razor blade to shave.
●Always use sunscreen when you go outside.
●If an arm is affected, wear gloves when gardening, cooking, or doing other things that could hurt your skin.
●If a leg is affected, wear hard-soled shoes when outside.
●If you do get a small cut, scrape, or bite on your arm, hand, leg, or foot, clean it well with soap and water and apply an antibiotic cream. Call your doctor or nurse as soon as possible if it does not heal quickly or if you have signs of an infection.
TREATMENT OF ESTABLISHED LYMPHEDEMA
If you notice symptoms of lymphedema, contact your doctor or nurse. Other causes of limb swelling, such as deep vein thrombosis or cancer recurrence, need to be excluded before lymphedema therapy can begin. There is no cure for lymphedema once it is established. The main goals of treatment are to control swelling, relieve symptoms, and prevent the swelling from worsening over time. A therapy program that combines massage, skin care, exercise, and compression garments (compression bandages or a lymphedema sleeve or stocking) is recommended. Rarely, devices that forcefully compress the affected limb may be used.
Treatment should begin as soon as possible. A healthcare provider or program with expertise in treating lymphedema can be especially helpful.
For patients who have lymphedema, in addition to the measures listed above, there are things you can do to help keep it from getting worse over time. Below are the most important things you can do.
●To limit swelling:
•Do not wear clothing that restricts flow to and from the limb, and avoid activities that could interfere with lymph flow (eg, using a pelvic harness for rock climbing could constrict flow from the lower limb).
•Wear compression garments (special sleeves or stockings) to limit swelling. Garments that are made to measure and prescribed by your doctor or physical therapist are most effective.
•Keep your weight under control – Excessive weight gain or being overweight can worsen lymphedema and may limit the effectiveness of compression garments.
•Visit a lymphedema therapist – Some physical therapists are trained in a special kind of massage that can help with lymphatic drainage.
●Try to do some exercise and weight training – These activities have been shown to reduce the severity of lymphedema, improve overall fitness, and help with weight control.
●If one of your arms is affected, avoid medical procedures that puncture the skin, if at all possible, in that arm. In addition, avoid continuous blood pressure monitoring on the affected arm. Blood pressure can be taken in the opposite arm or, if both arms are affected, in one of your legs.
●Contact your doctor or nurse if the affected arm or leg develops a rash; becomes red, blistered, painful, or warm to the touch; or if you get a fever (temperature greater than 100.4ºF or 38ºC). These symptoms could signal a possible infection that could cause the beginning or worsening of lymphedema.
SURGERY FOR LYMPHEDEMA
There are several surgical procedures that can treat lymphedema in certain situations:
●Lymphedema surgery – In some cases, a surgical procedure can help improve lymphatic drainage or remove excess fatty tissue. Options may include:
•Lymph node transplantation – This is an operation in which healthy lymph nodes are removed from one area of the body and transplanted to the limb with lymphedema. These lymph nodes can reestablish the lymphatic circulation of the limb and improve symptoms.
•Lymphovenous bypass – This is another type of surgery in which lymphatic vessels are connected to small adjacent veins, bypassing the area where the lymphatic vessels were damaged.
These two types of procedures are most useful in people with early-stage lymphedema and require consultation with a qualified and experienced surgeon.
●Liposuction – This is a procedure in which excess fatty tissue is removed from the limb with lymphedema using a cannula (a thin tube). This procedure is most useful for patients with advanced disease in whom large amounts of excess fat have been deposited in the limb.
Your doctor or nurse can talk to you about what your treatment options might be based on your individual situation.
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Breast cancer guide to diagnosis and treatment (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
The following organizations also provide reliable health information.
●National Lymphedema Network
●National Cancer Institute
●Cancer.Net: The official patient information website of the American Society of Clinical Oncology
●National Comprehensive Cancer Network
●American Cancer Society
●National Library of Medicine
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- Langer I, Guller U, Berclaz G, et al. Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: a prospective Swiss multicenter study on 659 patients. Ann Surg 2007; 245:452.
- Bertelli G, Venturini M, Forno G, et al. An analysis of prognostic factors in response to conservative treatment of postmastectomy lymphedema. Surg Gynecol Obstet 1992; 175:455.
- Rockson SG, Miller LT, Senie R, et al. American Cancer Society Lymphedema Workshop. Workgroup III: Diagnosis and management of lymphedema. Cancer 1998; 83:2882.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.