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Winchester Hospital Oncology Rehabilitation Department

Three to five million patients in the United States are affected by lymphedema. Secondary lymphedema maydevelop in cancer survivors due to a disruption of lymph flow from the cancer itself or the cancer treatment.Lymphedema is most commonly seen after breast cancer treatment but can develop in other patients whohave undergone cancer treatment. Without intervention, lymphedema may lead to progressive swelling,fibrosis of the soft tissues, and infection.

**Evaluating Lymphedema in Cancer Survivors

• Early diagnosis and treatment oflymphedema is essential for successful management.• With breast cancer treatment, those at highest risk have had both surgery and axillary radiation therapy.• Further risk factors for developing lymphedema in the breast cancer population include:

o Tumor located in upper quadranto Postoperative axillary trauma, infection, hematoma, or seromao Axillary lymph node dissectiono Axillary radiation (especially after axillary lymph node dissection)o Large number of positive lymph nodeso Higher body weighto Infectiono Injury

Clinically Assessing Lymphedema: Physical Examination DocumentationSpecific evaluation tests should be considered to clinically assess and document lymphedema including:

• Skin inspection• Girth measurements• Presence or absence of pitting edema

o The depth of the pitting edema can be noted by pushing gently with two fingers on the affected limb• Presence or absence of Stemmer Sign

o A Stemmer Sign is performed by grasping the skin on the dorsal surface of the affected distalextremity. A positive Stemmer sign is the inability to grasp the skin of the dorsum ofthe hand, or thesecond digit of the foot, and indicates clinical lymphedema

• Description of tissue consistency (presence or absence of fibrosis)• Presence or absence of pain (reported by patient and to palpation and range of motion)

Early stages oflymphedema are usually marked by non painful swelling. Later stage symptoms mayprogress to pain, nerve compression, numbness, or weakness.

Measuring LymphedemaMany clinicians use limb girth measurements when evaluating lymphedema. In general, upper extremitycircumferential tape measurements are taken and documented at points to be determined by clinician. Forexample;

1. Metacarpal-phalangeal joints/ thumb web space2. Wrists3. IO em distal to the lateral epicondyles / olecranon4. 15 em proximal to the lateral epicondyles /olecranon

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*A 2 em or greater difference between extremities is significant and may indicate lymphedema.If available, preoperative measurements can be helpful as a baseline for postoperative measurements to ruleout swelling due to the operation or treatment rather than lymphedema.

Stages and Clinical PresentationsThe International Society of Lymphology defines four stages oflymphedema along with their clinicalpresentation:

St Clinical P tat'- ---0: Subclinical, with no evidence on • Patient may complain of limb heaviness but therephysical exam are no clinical signs or evidence of swelling1: Early Stage, with swelling and • Patient complains of nonpainful swelling.pitting edema • Exam reveals swelling, soft tissue (no fibrosis),

and pitting edema.• Considered "reversible" - swelling may be relieved

with elevation overnight followed by worseningthroughout the day

2: More advanced, with fibrosis • Patient has swelling, fibrosis, and nonpittingresulting in nonpitting edema edema.

• Considered "spontaneously irreversible"-symptoms do not improve with elevation

• Stemmer sign usually positive3: Elephantiasis, with huge limbs and • Increased swelling, fibrosis, and other skinskin changes changes such as hyperkeratosis, cysts, and

papillomas

Differential Diagnosis of Single Limb LymphedemaWhen evaluating lymphedema patients, there are some differential diagnoses to be considered and warrantreferral back to a physician or oncologist. These include:

• Cellulitis• Deep vein thrombosis• Recurrent malignancy• Trauma with soft tissue swelling• Chronic venous insufficiency

Treating Lymphedema in Cancer Survivors

Lymphedema is not believed to be curable but treatment is based on the fact that patients who have swellingwith a pitting edema and thus, little or no fibrosis respond to compression. Treatment options andexpectations for resolution or improvement depend largely on the stage:

o Stage 0: patients can be given compression garments and education, usually no need for moreextensive treatment

o Stage 1: ideal patients to treat, usually respond to compression therapyo Stage 2: may respond to treatment, should be given a trialo Stage 3: exceedingly difficult to treat, may need support and information about living with

lymphedema as a chronic disease

Possible Treatment Interventions [or Lymphedema

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o Manual lymph drainageo Pneumatic pumpso Oral pharmaceuticalso Low- level laser therapyo Compression bandagingo Compression garmentso Limb exerciseso Limb elevationo Surgeryo Complex decongestive therapy (CDT)

Complex decongestive therapy, CDT, is considered the gold standard of treatment and its componentsinclude:

• Manual lymph drainage (MLD)• Compression bandaging• Exercise• Skin care• Education for patient self- management• Elastic compression garments

Typically CDT is initiated weeks to months after surgery to ensure postoperative swelling is not the issue.Ideally, treatment is done daily until the patient's swelling is resolved or improved. A typical timeframe fornecessary therapy is three to eight weeks.

o The goals of CDT include:• Reduce swelling (edema)• Increase lymph drainage• Reduce fibrosis (if possible)• Improve skin condition• Improve patient's ability to function• Educate patient about self care for this condition

Untreated or partially treated lymphedema may result in the progression of swelling and stage, as well as,joint immobility, non-healing wounds, life threatening infections, and amputation.

Clinical Decision Making

New onset Lymphedema

Records reviewed and physician has cleared patient to begintreatment

Physician has not yet cleared patient to begin treatment-referpatient back to physician for work up/clearance

Evaluation includes description of skin and edema, limb girth,fibrosis, stemmer sign, and pain

a diagnosis confirmed and stage documented inchart

Begin complete decongestive therapy (CDT)

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Lymphedema and ExerciseExercise has enormous physical and emotional benefits when it comes to healing and improving dailyfunction, quality of life, and in preventing future illnesses. Additionally, most recent breast cancer studieshave demonstrated that judicious, gradually progressing exercise is reasonable and does not cause orexacerbate lymphedema.

• Exercises used in complex decongestive therapy include active, repetitive, non-resistive motion of theinvolved body part.

a These exercises can enhance the efficiency of the muscle pump and likely promote venousand lymphatic flow while significantly reducing limb swelling.

• Studies found (15) patients gained perceptions of improved quality of life post CDT treatment as wellas improved physical functioning, social functioning, and reduction in pain with decreased limbvolume.

• Flexibility exercises, including gentle stretching, may help preserve joint range of motion andimprove lymph and venous flow.

• Aerobic exercises are safe with lymphedema patients and promote cardiovascula.r fitness and weightmanagement, which may help promote lymph and venous flow

• Resistive exercises started at a low level and gradually increased may improve lymphedema whenperformed with proper compression garments and bandages.

a One study instructed a group of breast cancer survivors in progressive twice weekly weightlifting exercises. The subjects reported fewer symptoms, were stronger, and had fewerexacerbations of their lymphedema compared to the control group (23).

Supervised Exercise Checklist:Prescribing exercises for cancer survivors with lymphedema should be done by experts who have extensivetraining in this diagnosis and remain in consideration of differential diagnoses. The following outlinesrehabilitation clinicians' guidelines for implementing exercise treatment:

• Obtain medical clearance• Take pre-exercise measurements• Instruct patient to wear compression garment including glove or gauntlet• Begin exercise at low level• Progress gradually• Avoid excessive resistance, repetition, and/or fatigue• Stop or adjust for discomfort and/or increased swelling• Retake measurements after exercise and before and after every subsequent visit

Guidelines for Preventing Lymphedema:Once lymph reduction resolves or plateaus, patients are educated in proper long term self care, including:

• Taking good care of one's skin and nails• Avoiding trauma or injury to the at risk limb• Gradually becoming more physically active• Avoiding limb constriction such as with blood pressure cuffs, tight jewelry, etc• Avoiding temperature extremes• The use of compression garments (esp. for exercise or travel)

* *Adapted from Survivorship Training And Rehabilitation CSTAR) modules.

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