1. Jenny Smith 3 November 2010

2.  Provide a brief overview of what is meant by lymphoedema and the current recommended management

3.  Define what is meant by the term ‘lymphoedema’  Describe characteristic features  List the two main types and the commonest causes  Explain the recommended management

6.  What is lymphoedema? ◦ Accumulation of lymphatic fluid in interstitial tissues ◦ Results from abnormal functioning of the lymph system  How is it categorised? ◦ Primary ◦ Secondary

7.  Feeling of tightness and heaviness in a limb  Altered sensation, such as pins and needles, shooting pains or feeling of heat  Joint discomfort due to the swelling, e.g. elbow, knee  Tenderness in the groin of an affected leg  Changes in temperature of the limb or affected skin  Reduced range of movement

8.  History  Examination  ? Lymphoscintigraphy  Need to distinguish from lipoedema ◦ Bilateral leg swelling ◦ Nearly always Females ◦ Spares the feet ◦ Not pitting ◦ Can develop lipolymphoedema

9.  Primary ◦ Underdevelopment ◦ Inherited  Secondary ◦ Trauma ◦ Cancer ◦ Radiotherapy ◦ surgery

10.  Secondary PrimarySecondary Damaged lymphatic system is usually present at birth (underdevelopment) Chronic venous disease. Venous hypertension and secondary damage * 70-80% cases femaleSurgery Age of onset varies, at birth 10%, before 35yrs 80%, after 35yrs 10% Radiotherapy Commonest sites – legs, arms, genitals, face. Trauma/injury Reduced mobility/muscle contraction

11.  How common is lymphoedema after surgery for breast cancer (WLE + ANC or mastectomy)? ◦ 14-42%  Why do some develop it after minimal surgery? ◦ Not fully known, ongoing research ◦ ? Pre-disposing factors

12.  No cure.  Aim reduce the swelling and keep it to a minimum.  Treat in early stages  If a cause is found then the cause needs to be treated, e.g. cancer.  Complex Physical (Lymphatic/Lymphoedema) Therapy (C.P.T./C.L.T.). This regimen consists of 4 main parts.  Skin care – emollients, keratolytics to remove hard, dead skin.  Simple lymphatic drainage – gentle massage, move the swelling out of the affected area. The patient or carer taught technique.  Compression bandaging Compression bandaging  Exercise and movement – specially designed programme, maximising lymph drainage without over exertion

13.   Manual Lymphatic Drainage – ◦ specialised form massage by trained therapist. Move the skin in specific directions based on the underlying anatomy and physiology of the lymphatic system.  Multi-Layer Lymphoedema Bandaging  Drug therapy ◦ research as to the effectiveness of drug therapy in lymphoedema. Benzopyrenes including flavonoids have been used. Coumarins used.  Surgery – ◦ rare. ?benefit for eyelid or genital swelling. Only surgeons who have experience with lymphoedema and the lymphatic system should perform surgery

14.  Cellulitis ◦ Prevention ◦ Prompt treatment  British Lymphology Society Consensus Document ◦ http://www.lymphoedema.org/Menu3/consensus_o n_cellulitis_aug_10.pdf

15.  Management of cellulitis in lymphoedema – at home with oral antibiotics  1. Amoxicillin 500 mg 8 hourly for at least 14 days.  2. Add Flucloxacillin 500 mg 6 hourly if Staphylococcus aureus infection is suspected e.g. folliculitis, pus formation or crusted dermatitis is present.  3. If patient is allergic to Penicillin, use Clindamycin 300 mg 6 hourly for at least 14 days

16.  If a patient fails to improve on this regimen or is systemically very unwell, admission to hospital for intravenous antibiotics is recommended.   Prophylactic antibiotics (Penicillin V or Erythromycin) ◦ considered in patients who develop recurrent episodes of cellulitis (=2 per year). Management of the lymphoedema is also reviewed, as a reduction in limb volume is associated with a reduced incidence of cellulitis (Ko et al, 1998).

17.  Leeds Lymphoedema service (Bexley/Wharfedale) ◦ http://www.lymphoedemaleeds.co.uk/ http://www.lymphoedemaleeds.co.uk/  UK lymph.com ◦ http://www.uklymph.com/ http://www.uklymph.com/  Cellulitis consensus document: http://www.lymphoedema.org/Menu3/consensus_on_cellulitis_aug_10.pdf http://www.lymphoedema.org/Menu3/consensus_on_cellulitis_aug_10.pdf  Lymphoedema Framework (2006 a). Best Practice for the Management of lymphoedema. International consensus. London: MEP Ltd  NHS Evidence – supportive and pallitaive care. ◦ http://www.library.nhs.uk/palliative/ViewResource.aspx?resID=271133 http://www.library.nhs.uk/palliative/ViewResource.aspx?resID=271133  Ko DSC, Lerner R, Klose G et al (1998). Effective treatment of lymphoedema of the extremities. Arch. Surg. 133: 452-458.

18. Thank You