Lymph Edema

8/3/2019 Lymph Edema

1/51

Lymphedema in Cancer


2/51

Facts

Arteries arterioles capillaries venules

veins.

In contrary, peripheral lymphatics dead ended.

Originate in distal-most tissues of skin, muscles,

visceral organs, lung, and intestine.

Lie within neurovascular bundles.

Lymph flow centripetal (distal proximal). Lympahtics not present in

Avascular - epidermis, hair, nails, cartilage & cornea

Vascular brain & retina


3/51

Anatomy

Lymphatic transport system

I. Superficial system drains skin & SC tissues.

II. Deep subfascial - drains muscles, joints, synovial

sheaths & bones

III. Visceral - drains small intestine, spleen, liver,

thymus & lungs.


4/51

Collecting vessels

Prelymphatic tissue channels

Tiny vascular structures

No endothelium

Collect lymph

Lymph capillaries

Valveless

Single cell layer of continuously overlapping

endothelial cells.

Fibrous strands anchor to surrounding tissue fibrils

Regulate flow by alternatively stretching and relaxing


5/51

Lymph capillary


6/51

Collecting vessels

Lymph precollectors

1 layer of muscle cells & collagenous fibers.

Unicuspid/ bicuspid valves maintain centripetal flow.

Dispersed 6 to 20 cm apart

Initiate lymphatic flow

Lymph collectors

Main transporter of lymph

Resemble vascular structures

Intima endothelial lining

Media muscle cells & collagen fibers

Adventitia collagen fibers extending into tissues.


7/51

Collecting vessels

Lymph collectors

Nourished by vasa vasora

Part lying between valves lymphangion

Sympathetic & parasympathetic supply spontaneouscontractions.


8/51

Lymph nodes

Lymph nodes

Total 600 700, most in abdomen & neck.

Kidney shape

Many afferent lymph vessels enter from convex

surface.

1 or 2 efferent lymphatic vessels exit from hilum

Arterioles, venules & nerves enter and exit from hilum


9/51

Lymph nodes

Lymph nodes

Concentrate lymph to half

Filter high molecular proteins, fats, cellular debris,

foreign organisms, viruses & bacteria.

Macrophages, plasma cells & lymphocytes initiate

immune response.

Lymphocyte, monocyte maturation.


10/51

Lymph ducts

Lymph ducts

Largest transport structures

As progress, space between valves , tunica media

thickens & nerve endings .


11/51

Functions of lymphatic system

Transport lymph from periphery to large veins of

neck.

Maintain homeostasis

Fluid volumes

pH

Electrolytes

Immune regulation


12/51

Lymph/ Interstitial fluid

Forms in inter-cellular space

Serum = Blood (RBCs + platelets)

Contents

96% Water +

proteins, lipids, carbohydrates, enzymes, glucose,

urea, hormones, dissolved gases (carbon dioxide,

oxygen), cells (lymphocytes, macrophages),

unwanted toxins, bacteria and viruses, cellular debris,and other bodily wastes

Colloids - sodium, potassium, chloride, calcium,

phosphorous, magnesium, and zinc or copper.


13/51

Edema

Amount of interstitial fluid increases and the area

becomes swollen with excess fluid.

Increase fluid discharge

From the arteriovenous capillaries, such as trauma or

infection

Decreases its reabsorption into lymphatics


14/51

Causes of lymphedema

Primary

Lymphatics cannot propel lymph

Alteration/ deficiency within lymphatic collecting or

transport systems. Milroy disease (Hereditary Lymphedema Type I)

Meige disease (Hereditary Lymphedema Type II)

Lymphedema praecox

Lymphedema tardum

Lymphangioma


15/51


Secondary lymphedema

Infection

Filariasis (MC), erysipelas, lymphogranuloma venerum,

scrofula. Inflammation

SLE, RA, Graves disease.

Chronic venous insufficency

Venous disease in legs chronic damage to veins and their

valves valve failure reflux pressure on normal

veins and damage to surrounding tissues and lymphatics


16/51


Secondary lymphedema

Hypoalbuminemia

albumin osmotic (oncotic) pressure reabsorption

of interstitial fluid into venous capillaries chronic B/Lswelling

Glomerulonephritis, nephrotic syn., extensive burns,

kwahshiorkar, liver cirrhosis.

Drug induced

NSAIDs, antihypertensives, hypoglycemics, etc.

Cancer


17/51

Lymphedema in cancer

Lymphadenectomy inguinal, iliac, axillary LN

(MC non-infectious chronic unilateral swelling)

Radiation to LN chronic unilateral (U/L)

swelling

Surgery of prostate, uterus or cervix B/L

swelling

Recurrent/ metastatic malignancy Hodgkin & non-hodgkin lymphoma


18/51

History

U/L, painful, duration hours to days.

Acute DVT, cellulitis, compartment syndrome.

U/L, painless, over weeks to months.

Chronic Lymphedema, soft tissue/ vascular tumors,

AV fistulas, chronic venous insufficency.

B/L, over weeks to months.

CHF, nephrotic syn., glomerulonephritis.

Malignancy in pelvis, abdomen or retroperitoneal

space.

Advanced ca. prostate, ovary, pelvic tumors


19/51

Testing Lymphedema

Lymphoscintigraphy

Radioisotope-labeled colloid injected into web

space between first and second toes.

Gamma camera measures colloid movement as ittravels toward proximal lymph nodes

If slow progress of radioisotope, compared with

normal lower limb - hypoplasia of peripheral

lymphatics (primary lymphedema).If radioisotope escapes from main lymph channels,

especially into skin (dermal backflow) - lymph

reflux (secondary lymphedema with proximal

lymph obstruction).


20/51

Testing


21/51

Testing

Lymphedema

Lymphangiography

Rarely done

Radio-opaque lipiodol injected directly into peripheral lymphvessel x-rays monitor its proximal progress.

CT/ MRI

Subcutaneous honeycomb pattern

MRI superior also detects excess fluid


22/51

Testing


23/51

Testing

VTE

D-dimer for DVT.

U/S for deep, perforator, and superficial venous

systems of legs. Contrast venography for pelvic or abdominal

thrombus

CT for pelvic malignancies/ retroperitoneal fibrosis.

Ankle brachial pressure index (APBI) arterialinsufficiency in legs of old patients and diabetics


24/51

Staging

5 Goals to accomplish

Evaluate and identify symptoms and possible etiology.

Determine duration, extent and severity of disease.

Outline medical intervention and expected outcome.

Help patients understand disease, possible

management options, anticipated results, and

promote compliance.

Help insurance companies ascertain possibleexpenses.


25/51

Staging

Revised ISL (International Society of

Lymphology) Consensus Document 2001.

Stage I - early accumulation of fluid relatively high in

protein content and which subsides with limbelevation.

Stage II - limb elevation rarely reduces tissue swelling

and pitting is manifest.

Stage III - lymphostatic elephantiasis - skin does notpit with trophic skin changes as acanthosis, fat

deposits and warty overgrowths.

Consensus document 2003

Stage 0 Latent/ subclinical.


26/51

Staging

Stage 1 Stage 2 Stage 3


27/51

Lymphedema management

Comprehensive Decongestive Therapy (CDT) by

ISL.

Components

Manual lymph drainage

Specialized bandaging

Exercise

Skin care

Self management program


28/51


CDT goals

Improve integrity of skin, connective tissues.

Reduce/ eliminate infections

Reduce edema

Facilitate patients ability to manage themselves


29/51


CDT 2 phase treatment

Phase 1 (by trained health care professional)

manual lymph drainage

skin care (including wound care if indicated)

bandaging (specialized)

exercise (in bandages)

compression garment (if appropriate)

Phase 2 (by patient)

skin care

manual lymphatic drainage (as needed)

daytime compression garment, nighttime bandaging

exercise (in bandages or garment)

support groups


30/51


Effects of manual lymph drainage on lymphatics

lymph transport capacity volume of lymph fluid

transported proximally

frequency of lymph vessel contractions pressure in lymph collector vessels

Redirect natural flow patterns toward collateral

vessels, anastomoses, and uninvolved lymph node

regions arteriolar blood flow


31/51


Recruits functioning lymph vessels and nodes

closest to regions not adequately performing.

Regardless of site of insufficient flow, manual

work on neck, back, abdomen & uninvolvedinguinal and axillary LN.

Begin from contralateral trunk area towards

congested area.

Then continue to move from involved area to

uninvolved area.

Be light, slow & precise.


32/51


No deep strokes as in standard massage.

Rather, a specified number of light pressure

strokes without friction that directionally stretch

tissue.

Each session lasts minimum of 45 to 60 min.


33/51

MLD techniques Stationary Circles

Strokes in continuous spirals with fingertips typically

over neck, face and LN.

Pump Technique

Place palms on skin, make oval strokes with fingers

and thumbs to encourage lymph flow.


34/51

MLD techniques

Rotary Technique

Massage skin in circular motions with palms facing

down. Wrists used to apply and lessen stroke

pressure.

Scoop Strokes

Palms face up, fingers remain outstretched so thathands cupped to resemble a scoop. Twisting strokes

to skin encourage waste disposal.


35/51

Skin care

To avoid/ eliminate fungal and bacterial

infections.

Protein-rich fluid accumulates in

lymphedematous tissues, serves as culturemedium for pathogens circulating within body or

entering through skin lesions.

Skin conditions in lymphedema

Dry skin, hyperkeratosis, lipodermatosclerosis, fungal

infections, lymph fistulas, eczema, chronic

ulcerations.


36/51

Wound care

When integrity of skin compromised.

Compression aided care.


37/51

Bandaging

Skin elasticity partially lost tissue

hydrostatic pressure

by external support.

Support be continuous until volume reduction

stabilizes and tissues remodel with improved

functional lymphatic capacity.


38/51

Bandaging

After manual lymph drainage, skin cleansed and

protected with moisturizer.

If ulcerations, place protective dressing thatabsorbs exudate.

A specific combination of padding, foam,

protective gauze & short-stretch bandages

applied in precise layers.

Bandages be worn continuously except for time

required to cleanse, treat, or rewrap limb.

Teach the patient/ attendant.


39/51

Bandaging

Effects on lymphatic system

Support for tissues with lost elasticity.

muscle pump efficiency during activity.

rate of ultrafiltration.

facilitates colloidal protein reabsorption.

softens fibrotic tissue with localized pressure.

provides mild in tissue pressure, assisting lymph

vessels to empty. hydrostatic pressure gradient between blood and

lymphatic tissues, preventing refilling of interstitium

with fluid.


40/51

Bandaging


41/51

Types of bandages

Short stretch type

Little or no stretch

Form envelope/ cocoon around limb

In resting state, minimal but constant compression

Compression only during exercise as muscles expand

and press against wrap.

Exercise important for optimum effect.

Worn at night.


42/51

Types of bandages

Long stretch type

Highly elastic extend to 3 resting length.

High resting pressure continuous compression on

limb. Compressive forceduring exercise due to stretch

caused by muscle expansion.

Not recommended at night because high resting

pressure.Compromises arterial circulation and already compromised

tissues.


43/51

Exercises

Can be performed with bandages

Promote emptying of affected lymph regions

Assist functioning lymphatics to work more

efficiently

cardiovascular function, muscular strength,

functional capacity, and endurance.

Consider limitation in joint range of motion,muscle strength, and posture or gait deficits

while developing exercises.


44/51

Compression garment

Worn at end of intensive treatment phase if

compromised limb/ body part reached normal or

near normal size.

Most appropriate in earliest stage/ at risk.

Affect lymphatics by

Maintain hydrostatic pressure that prevents refilling of

interstitial space with lymph.

Preserve long-term reductions of limb circumference

achieved by CDT.

Continue softening of fibrotic tissues initiated during

treatment phase.


45/51

Compression pumps

Pneumatic

Effectiveness debatable.

Intermittent/ sequential compression

Capillary filtration.

Effective in palliative care.


46/51

Others

Nutritional counselling

Obesity can lymphedema

Advice and strengthen lifelong lifestyle changes.

Psychosocial Encouraging patient and attendant participation

compliance.

Address concomitant health concerns

depression, isolation, loneliness, anxiety, poor coping skills.


47/51

Surgery

Selection criteria

Failed satisfactory control of lymphedematous

process/ prevent disease progression during a year of

vigorous medical management. Serious commitment to a lifetime of maintenance.

Stage III with profound soft tissue changes, hardened

fibrosclerotic tissues with distortion, disfigurement,

and/or elephantiasis.

Recurrent sepsis >3 times during a year even with

adequate antibiotics.


48/51

46 y woman had surgery and radiation for uterine cancer.

Lymphedema in left leg confirmed by lymphoscintigram, showing

marked dermal backflow.


49/51


50/51

First association between malignancy & cancer Armand Trousseau.

Succumbed to gastric cancer developed

thrombophlebitis in upper arm. Trousseasus syn. any VTE in solid/

hematoligical malignancies.

VTE in cancer

Symptomatic 10 to 15%. Autopsy 50%.

10 to 15% patients with idiopathic TE developcancer in 2 years.


51/51

Highest incidence cancers

Lung

Pancreas

Stomach Colon

Ovaries

Date post:	06-Apr-2018
Category:	Documents
Upload:	registerpy
View:	224 times
Download:	1 times

Lymph Edema

Documents