Lymphedema management
Section snippets
Modifications of primary cancer therapy
Breast cancer can be used as a model to show how early detection and treatment modification can assist in the prevention of lymphedema. Advanced nodal disease at diagnosis is a known risk factor for lymphedema because of the need for extensive axillary surgery, increased chemotherapy, and additional radiation therapy to the axilla.4, 5, 6
Arm edema is associated with the degree of axillary dissection and the use of axillary radiation therapy.7, 8 The incidence of lymphedema increases with more
Manual lymphatic drainage
Manual lymphatic drainage (MLD) is a highly specialized massage technique designed to enhance the sequestration and transport of lymph. Specific stroke duration, orientation, pressure, and sequence characterize MLD. Through gentle, rhythmic skin distension, congested lymph is directed through residual functioning lymphatics into intact nodal basins. MLD permits elimination of congested truncal lymph by shifting it to lymphotomes (anatomic regions drained by a specific lymph node bed) with
Surgical procedures for lymphedema
Many operations have been used over the past century to improve the status of the lymphedematous upper limb. The list of the diverse operations attempted for this disabling condition in the past decades suggests that none are successful. Philosophically these can be loosely grouped as (1) recreation or imitation of lymphatic channels, (2) bridging the lymphedematous area to normal lymphatic areas, and (3) resections or debulking of lymphedematous tissue.
The most biologically based operation,
Medications
Diuretics are routinely initiated to treat lymphedema. Although many patients experience an acute reduction in swelling with diuretics, they are not recommended in the long-term management of lymphedema.82 These medications exert their therapeutic influence by reducing blood capillary pressure. This alters the interplay of forces that dictate net fluid movement across the endothelium, reducing ultrafiltration. Unfortunately, although use of diuretics may curtail the accumulation of lymph fluid,
Future directions
Increasing investigative attention is being paid to the development of novel lymphedema treatment approaches. The identification of vascular endothelial growth factor receptor as the defective gene in several families afflicted with congenital lymphedema has paved the way for gene therapy trials.105, 106 These are currently in the incipient stages. Hyperbaric oxygen therapy has also received attention as a means of curbing radiation-induced fibrosis of lymphatics and thereby preserving drainage.
Conclusion
Lymphedema remains a significant, long-term problem for many cancer survivors. Although numerous surgical and pharmacological interventions have been scrutinized, none offer unequivocal benefit and many are plagued by deleterious side effects. At present, multimodal manual therapy is the standard of care. The combination of MLD, remedial exercises, skin care, and compressive bandaging, referred to as complete decongestive physiotherapy, has been shown to be effective in numerous large case
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Primary lymphedema