«2. Awareness and Prevention 7 2.1 Risk factors for clinical lymphoedema 7 2.2 Prevention and early detection at the sub-clinical level 9 2.3 ...»
Prevention of clinical
Early detection and
A guide for health professionals
1. Introduction 1
1.1 Aim of this booklet 1
1.2 What is lymphoedema? 2
1.3 Anatomy of the lymphatic system 3
1.4 Epidemiology 5
2. Awareness and Prevention 7
2.1 Risk factors for clinical lymphoedema 7
2.2 Prevention and early detection at the sub-clinical level 9
2.3 Lifestyle and prevention 10 2.3.1 Skin and nail care tips 10 2.3.2 Diet and healthy weight 11 2.3.3 Physical activity 11 2.3.4 Travel, sun and heat 12 2.3.5 Positioning of the limb to prevent constriction 13
3. Presentation and Stages of Lymphoedema 14
3.1 Presentation of lymphoedema 14
3.2 Stages of lymphoedema 15
3.3 Problems arising from lymphoedema 16
4. Cellulitis 18
4.1 Definition 18
4.2 Clinical features of cellulitis 19
4.3 Management of acute cellulitis 20 4.3.1 Hospital admission 20 4.3.2 Management at home 22 4.3.3 Antibiotic regimes 23
4.4 Antibiotics “in case” - Travel and holidays 24
4.5 Antibiotics during lymphoedema therapy 24
4.6 Recurrent cellulitis 24 4.6.1 Antibiotic prophylaxis 25
5. Self-care 26
5.1 Simple self care exercises 26
5.2 Simple lymphatic drainage 29
6. References 35
7. Links to Additional Information 39
1.1 Aim of this Booklet This booklet provides an opportunity for healthcare professionals, working with cancer patients, to refresh their knowledge in preventing cancer related clinical lymphoedema and in providing self-help advice for patients. The recognition of lymphoedema and intervention at its earliest stage are essential to prevent progression.
This booklet also reviews the anatomy of the lymphatic system and the pathophysiology of cancer related lymphoedema, focusing on the prevention, early detection and treatment of cellulitis.
The impact of lymphoedema on patient health is often underestimated. It is an independent predictor of reduced quality of life even when other factors such as socioeconomic status, decreased range of limb motion, age, and obesity are taken into account.1 Lymphoedema can also have a negative impact on social wellbeing, resulting in additional burdens for cancer survivors.2 Therefore the prevention of clinical lymphoedema is a priority for health professionals.
This initiative is part of the NCCP Survivorship Programme.
1.2 What is Lymphoedema?
Lymphoedema is the build up of excess protein-rich lymph fluid in body tissues due to lymphatic insufficiency or obstruction of lymphatic drainage back into the bloodstream.3 The affected area can become swollen and distorted in shape. This can result in pain, heaviness, discomfort, impairment of movement and it impacts on daily activities4 (Figures 1 and 2 show clinical lymphoedema).
Primary lymphoedema is related to congenital malformation of the lymphatic channels.
Secondary lymphoedema results from illness or treatment that obstructs lymphatic drainage. Cancer related lymphoedema can occur due to the physical location of a tumour, or as a result of investigations or treatments, e.g. lymph node excision and /or radiation.
Lymphoedema is most commonly associated with breast, gynaecological and urological cancers but it can also occur in patients who have had head and neck cancer, melanoma, sarcoma and lymphoma. Lymphoedema can occur in the trunk, in addition to the limbs. For example, radiation therapy to the chest wall can result in lymphoedema of the trunk.5, 6 Figure 1. Figure 2.
Source: Lymphoedema Causes - Diseases and Conditions - Mayo Clinic 2 www.mayoclinic.org/diseases-conditions/lymphedema/basics/causes/con-20025603
1.3 Anatomy of the Lymphatic System The lymphatic system is integral to the immune system. It drains and transports ‘waste materials’ from interstitial tissues to the blood stream, including cell products such as protein, water and fat. These materials are filtered by lymph nodes before entering the venous system. Lymph is a clear-to-white
fluid made of:
• White blood cells, especially lymphocytes
• Fluid from the intestines, called chyle, which contains proteins and fats.7
The lymphatic system includes:
• Primary or superficial lymphatic vessels that form a complex network of lymphatic capillary channels in the skin
• The primary lymphatic vessels drain into larger, secondary lymphatic vessels located in the sub-dermal space.
Primary and secondary lymphatic vessels run parallel to the superficial veins
• The lymphatic vessels then drain into a deeper third layer located in the subcutaneous fat
• An intramuscular system of lymphatic vessels runs parallel to deep arteries and drains muscular compartments and joints. (Figure 3) Primary lymphatic vessels lack a muscular wall and do not have valves. The secondary and subcutaneous lymphatic vessels have muscular walls and valves which aid active, unidirectional lymphatic flow.
Figure 3. Anatomy of the lymphatic system
Lymphatic System Anatomy - Medscape Reference http://emedicine.medscape.com/article/1899053-overview
1.4 Epidemiology Patients treated for cancer have a lifetime increased risk of developing lymphoedema. It can develop within days or after many years.8 There are little consistent data on incidence and prevalence. This is probably due to variations in definition, diagnosis and measurement, recording and reporting, and patient characteristics. Prevalence appears to be increasing as cancer survival improves.
Most research on incidence describes upper limb
lymphoedema after breast cancer treatment:
• The overall incidence of breast cancer related lymphoedema is reported as ranging from 8%-56% after two years.9 Patients who had sentinel node biopsy instead of axillary node clearance have a greatly reduced risk, even with radiation therapy, at 4-17%10
• In 80% of patients with lymphoedema, onset occurred within 3 years of surgery. The remainder developed lymphoedema at a rate of 1% per year.11 Lower limb lymphoedema most often occurs after treatment for gynaecological and prostate cancers, lymphoma and melanoma:12, 13
• The greatest prevalence of gynaecological related lower limb lymphoedema is after treatment of vulval cancer (36%) and the lowest prevalence is for ovarian cancer (5%).14 It has been reported that 12-54% of patients with head and neck cancer develop secondary lymphoedema.15 A review of 47 studies involving 7,779 cancer survivors, with various cancer diagnoses (melanoma (15 studies), gynaecology (22 studies), genitourinary (8 studies), head and neck (1 study) and sarcoma (1 study)) reported an overall lymphoedema incidence rate of 15.5%16 (Table 1). Lymphoedema associated with sarcoma treatment is reported to range from 19% to 30%.17 Table 1
2. Awareness and Prevention
2.1 Risk Factors for Clinical Lymphoedema Patients who had cancer surgery or radiation therapy may be at risk of developing lymphoedema. Symptoms may occur anytime e.g. immediately post operatively onwards, with the highest risk in the first one–two years. Healthcare professionals should advise patients of the risk and provide them with advice on prevention and early detection.
Risk factors can be categorised as:
1. Disease related
• Stage of a tumour and its location
• Recurrence of a tumour or spread to the lymph nodes.
2. Treatment related
• Extent of lymph node dissection. While lymphoedema can occur after sentinel node biopsy (4-17%), it is usually milder
• Drain/wound infection
• Seroma formation
• Scar formation, fibrosis and radiation therapy related dermatitis
• Radiation therapy to the lymph nodes
• Cording (axillary web syndrome - AWS), sometimes develops as a side effect of sentinel lymph node biopsy or axillary lymph node dissection
• Trauma to the affected limb, e.g. BP monitors and injection to the affected limb.
3. Patient related
• High BMI 30 kg/m2
• Older age groups (65 years of age)
• Poor mobility
• Compromised circulation
• Inability to control early signs of lymphoedema at the sub-clinical level
• Previous cellulitis.
2.2 Prevention and Early Detection at the Sub-Clinical Level Prevention of clinical lymphoedema should begin before
commencing cancer treatment by:
• Identifying high risk patients
• Advising the patient and family of the potential risk of lymphoedema
• Highlighting the importance of prevention, risk reduction and early recognition
• Advising on a healthy diet and referral to dietician, if required
• Demonstrating preventive exercises and encouraging these post-operatively
• Demonstrating self management techniques, for example, skin care and simple lymphatic drainage (Section 5)
• Encouraging safe resumption of physical and recreational activity.
Simple prevention tasks encourage patients to take an active role early in their recovery and to know when to seek medical advice.
The early recognition and treatment of cellulitis is essential to prevent progression to clinical lymphoedema. Information on cellulitis prevention, recognition and treatment is outlined in Section 4.
2.3 Lifestyle and Prevention A lower incidence of lymphoedema has been found in patients who exercise regularly, receive lymphoedema education before treatment, and perform preventive self-care activities.18 2.3.1 Skin and Nail Care Tips Meticulous skin hygiene and nail care are essential to reduce
the risk of bacterial and fungal infection and the risk of cellulitis:
• Cut toenails straight across; see a chiropodist, as needed, to prevent ingrown nails and infections
• Only use electric razors or depilatory creams for hair removal
• Avoid dry, cracked or flaky skin. Use good quality bland unperfumed moisturiser, pH neutral, to keep the skin supple and moist
• Cracked areas of skin should be washed, with soap and water and dried carefully
• Damaged skin should be cleaned and covered with a dry dressing until it heals. Clean and change the bandage regularly
• Topical antibiotic solutions can be used to treat small breaks in the skin, for example, paper cuts
• Wear cotton socks; keep feet clean and dry
• Wear gardening and oven gloves
• Use a thimble for sewing
• Avoid going barefoot outdoors
• Avoid having blood tests (including finger sticks), vaccinations, intravenous lines or blood pressure monitoring in the affected limb
• Avoid exposure to extreme heat or cold - use the unaffected extremity to test temperatures (e.g. for bath water or cooking)
• Use insect repellent
• Be alert for the signs of infection (fever, swelling, redness, pain, and heat) and see your GP if you suspect infection.
2.3.2 Diet and Healthy Weight The risk of lymphoedema increases in those who are overweight or obese. Maintaining a normal weight and eating a healthy diet are an important part of healthy survivorship.
2.3.3 Physical Activity Gentle limb exercises should begin as soon as possible after surgery and continue during other treatments e.g. radiation therapy or chemotherapy. The exercises should be slow and methodical (Section 5). If there is pain the exercises can be reduced but not stopped. These exercises will stimulate lymph flow from the limb and reduce the risk of lymphoedema. They will also improve the range of movement and limb strength and will facilitate proper positioning of the limb in patients receiving radiation therapy.
Gentle and moderate physical activity does not increase the risk of lymphoedema. In the past, patients at risk of lymphoedema were advised to avoid using the affected limb as it was thought that removal of lymph nodes altered the response of the affected area to inflammation, infection, injury, and trauma. However, low level exercise has a different effect on the body than higher intensity exercise e.g. swimming is beneficial. Extreme exercise will promote inflammation and injury and should be avoided in patients at risk for lymphoedema. By contrast, slowly progressive, carefully controlled exercises are beneficial.19, 20 2.3.4 Travel, Sun and Heat Additional precautions are recommended during long journeys
and in hot weather:
• The affected area should be gently exercised and elevated, where possible
• Never stay sitting for long periods when travelling. Move about, where possible
• Drink plenty of water during hot weather
• Wear long sleeved cotton garments to protect the limbs from bites or burns
• Use of sun screen (minimum of SPF 15 – 30)
• Do not use a sauna or a hot tub or put the affected limb into a very hot bath
• Never use a sunbed.
2.3.5 Positioning of the Limb to Prevent Constriction Keep the arm or leg elevated above the level of the heart when possible.
Avoid constricting the affected limb.21 People with leg lymphoedema should avoid conditions which cause stasis.
Stasis refers to sitting or standing for a long period of time without moving, changing position, or elevating the legs.
Excessive constriction refers to tightening or squeezing in a manner that restricts lymph flow through that area or causes
tissue trauma, therefore:
• Avoid crossing legs while sitting
• Do not sit in one position for longer than 30 minutes
• Wear well fitting comfortable shoes
• Carry a handbag on the opposite arm
• Wear loose jewellery and clothes with no constricting bands
• Do not use elasticated bandages or tight clothing e.g.
socks/stockings with constrictive tops
• Avoid local application of heat to the limb, as this may increase blood flow
• Avoid blood pressure monitoring on the affected arm
• Wear a professionally fitted comfortable bra.
3. Presentation and Stages of Lymphoedema