○ Cancer of any lymph nodes: Cancer sometimes spreads to the lymph nodes in the neck, chest, underarm, pelvis, or abdomen. ○ Filariasis: This infection occurs in tropical countries and leads to elephantiasis. Larvae transmitted by mosquitoes live in the lymphatic system. Secondary lymphedema can develop at any time following a disruptive event. Cases have been reported from immediately following an event to as many as 30 years later. In the United States, the largest proportion of lymphedema cases is among women who have had breast cancer surgery, especially those who also have radiation therapy following Symptoms Symptoms of secondary lymphedema may be temporary and then go away. This “transient lymphedema” lasts less than six months and is characterized by pitting edema, characterized by the tissue’s maintaining an indentation after being pressed. 4 Symptoms may occur immediately following an event such as surgery to remove the lymph nodes. The affected limb may be warm and slightly red, but it improves within a week with elevation. Even if someone has had temporary lymphedema that resolved, chronic lymphedema may occur later. Thus, these individuals remain at risk for chronic lymphedema. A person in the early stages of developing chronic lymphedema may have no swelling but may have a sensation of heaviness, pain, tingling, or numbness in a limb. As the condition progresses, symptoms include swelling, decline in skin integrity, loss of motion, and decrease in quality of life. Many physicians have found classifying the level of severity to be useful for several purposes, such as when referring a patient to another specialist or to a physical therapist. However, a single classification system has not been agreed on. The three stages described below are those established by the International Society of Lymphology. Other grading systems are similar, but some add a fourth, subclinical grade before these three symptomatic stages: ● Stage I: This mildest stage of lymphedema is characterized by “pitting” of the tissue, meaning that if you press the skin with the fingertips, the depressed area holds the indentation. There is no hardening of the skin in this stage. Swelling of a limb is minor and goes away if the limb is elevated. Risk factors All individuals who have sustained one of the common causes of secondary lymphedema listed above are at risk for developing lymphedema. No one knows why some individuals develop lymphedema and others don’t. Millions of people have surgery or radiation therapy, for example, but not all develop lymphedema. Each of them is at risk for developing it, but at present health professionals are unable to accurately predict who will develop the condition. The following risk factors have been identified as conditions, activities, or occurrences that make it more likely that someone who has sustained one of the body insults such as surgery or radiation therapy will develop lymphedema at some point: ● Aggressive massage: Vigorous massage produces microtrauma to tissues that can lead to inflammation and swelling. In an individual with a normal lymphatic system, these changes do not have lasting effects, but for an individual at risk for lymphedema, deep massage is a risk factor and is contraindicated. ● Age: Although the scientific evidence is not entirely clear on this issue, data seem to show that the older a person is when sustaining an insult to the lymphatic system, such as radiation, the more likely he or she is to develop lymphedema. The likely explanation is that the aging of the circulation system makes it less efficient and less capable of managing the lymphatic fluid load. 5
lymph removal. The more lymph nodes a woman has removed, the higher the risk. Because of this, the modern trend toward removing only sentinel lymph nodes and leaving other lymph nodes intact is helpful in reducing the incidence of lymphedema. Discrepancies in diagnosis and reporting make it difficult to know the overall incidence, but researchers found that 42 percent of women who have had both surgery and radiation following breast cancer developed lymphedema. For women who had surgery only, the prevalence was 13 percent.2 Worldwide, incidence of lymphedema is estimated at 140–250 million cases. 3 The biggest contributor to the prevalence of lymphedema worldwide is filariasis. ● Stage II: In this stage, the swelling does not subside with limb elevation. Late in Stage II, the tissues might not stay depressed when you press on it, because the tissues have begun to harden. ● Stage III: The swollen limb is very large, and the swelling is irreversible without reconstructive surgery. This stage is sometimes referred to as elephantiasis. The tissue is hard and unresponsive, and the skin has a grotesque appearance and is discolored and hard to the touch. There is a profound loss of function. Infections are most common in Stages II and III. As lymphedema progresses, the involved areas swell more and more, and mobility is impaired. As the tissues became fibrotic, the flow of blood and oxygen to the area is reduced. The build-up of the protein-rich lymph fluid provides a rich medium for the growth of bacteria. This makes the swollen limbs susceptible to infection through any cut or scratch – even an insect bite. Such an infection is known medically as lymphangitis. Repeated infections can cause scarring, which further damages the lymphatic system, making the tissue vulnerable to more swelling and infection. A characteristic of advanced chronic lymphedema is fibrosis, the hardening of the tissues caused by recurring infections and scarring. Thus, an unfortunate cycle of chronic and sometimes worsening lymphedema occurs. Chronic lymphedema can cause fatigue because of the size and weight of the affected extremity. Lifestyle can also be affected. Daily activities may be moderately or severely impaired. Individuals may be embarrassed by their appearance, and they may become depressed. ● Obesity and weight gain: Because excess body fat is associated with an increased load on the circulation and lymphatic system, obesity is believed to increase the risk for lymphedema, although definitive epidemiological data don’t yet exist to support the relationship between obesity and lymphedema. New scientific studies continue to shed light on this area. For example, a study in breast cancer patients showed that obesity increases the risk of developing lymphedema after lymph nodes are removed, 6 and another showed that gaining weight following a cancer diagnosis is an especially high risk factor. 7 Thus, clients should be advised to achieve or maintain normal weight to avoid this risk. ● Infection: Infection can be the initial cause of lymphedema, but in addition it increases the risk of developing lymphedema following one of the other causes, such as radiation therapy or surgery. ● Airplane travel or scuba diving: Changes in pressure allow fluid to pool in the extremities. Thus, the lowered cabin pressure on a plane may worsen a compromised lymphatic system, and scuba diving has been reported to lead to onset of lymphedema symptoms. ● Heat: Hot packs, saunas, hot tubs, and hot weather are examples of factors that can trigger lymphedema symptoms. ● Scratches and breaks in the skin: Cuts, contusions, and even insect bites can cause inflammation or lead to infection that can worsen lymphedema symptoms.
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Book Code: MTX1323
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