Texas Medical Center News


Vol. 20, No. 15		August 15, 1998

Lymphedema - A New Emphasis on Treatment

by GAY ELLIOTT McFARLAND
The University of Texas-Houston Health Science Center

Most of us have experienced puffy fingers after eating highly salted food or after a healthy, heart-pumping aerobic workout. And certainly many of us have had "big foot" after a long airplane trip or temporary swelling after an insect bite. All perfectly normal, says Dr. Caroline Fife, associate professor of anesthesiology at The University of Texas-Houston Medical School and the director of the Hermann Center for Wound Healing.

Brenda Amerson, manual lymph drainage therapist,
wraps patient Rebecca McCoy's arm after a massage treatment.

But think about what it would be like to have a bulging arm or leg that was always two, three, even five times its normal size. According to a number of lymphedema organizations, an estimated 2.5 million Americans and 150 million people worldwide suffer from a disease called lymphedema, a painful, disfiguring, sometimes deadly disease characterized by excessive swelling.

Lymphedema refers specifically to the kind of swelling caused by the blockage of the lymphatic channels which are located throughout the body, says Dr. Fife.

The two broad categories of lymphedema are primary and secondary lymphedema. "Primary lymphedema - which is genetic - occurs in a fraction of the lymphedema cases in the United States. More common is secondary lymphedema," she says. "In third world countries, lymphedema is caused by parasitic infection because of poor sanitation. In our country, however, the most common cause is a result of surgery and treatment for breast, prostate and reproductive organ cancers."

The lymph glands are the first place surgeons look to see if the cancer has spread, says Dr. Fife. While they are trying to fight off infection, they can also harbor cancer. In addition to surgery, radiation therapy is also known to cause the condition in at least 20 percent of those who receive it.

Lymphatic fluid, a protein-rich fluid produced by the lymphatic system to fight infection, is filtered through the lymph glands as it circulates through narrow vessels, removing bacteria, toxins and dead cells. When the glands have been injured or removed, filtration of the fluid can become abnormal. The fluid accumulates in the tissue causing lymphedema.

In the Hermann Lymphedema Management Program, "at least 60 percent of our patients are self-referred women who have had breast cancer. And though the literature says that about 30 percent of post-mastectomy patients will have this condition, I think that figure is exceedingly low."

The symptoms of lymphedema include tightness and swelling, joint immobility and pain. In addition, long term effects can include obesity, skin changes, massive infections, open wounds and the risk of a cancer called lymphangiosarcoma. Without treatment, the symptoms can gradually progress through three stages. Stage I, reversible lymphedema, is characterized by swelling which is usually reduced with simple elevation of the limb. There is also pitting of the skin when it is depressed.

Stage II is referred to as spontaneously irreversible lymphedema and is marked by an increase in fibrous tissue and progressive skin hardening. There are frequent infections, increased swelling, and the skin no longer pits when depressed.

Stage III, lymphostatic elephantiasis, shows an extreme increase in swelling and the limb becomes "like a tree trunk," says Dr. Fife. The skin hardens and large protrusions can appear. If a person with lymphedema contracts cellulitis - an infection of the skin which can be gotten from a mosquito bite, a cut, or trauma to the skin - the results can be fatal. "Cellulitis is marked with a high fever and can further worsen the edema," says Dr. Fife.

"The lymphatic system is the unsung hero of the body because it is designed to act much like a storm sewer." She explains: The arteries take blood from the heart to the tissues and veins and bring it back from the tissues to the heart. The circulatory system is designed so that little capillaries in the tissues have small pore-like holes which allow the protein-rich lymph (the fluid part of the blood) to leak out on purpose and bathe all the cells so they can get nutrients and wash away their waste products. The lymphatics collect the fluid and bring it into increasingly larger and larger channels until it is finally returned through a large duct in the chest, back into the main circulatory system."

But when the system dams up, the trouble begins, she says. "Because more people are surviving cancer than in years past, there are more cases of lymphedema. Many patients are told that lymphedema is just the price they must pay for beating the first disease." But Dr. Fife and Dr. Latisha Smith, assistant professor of anesthesiology at UT-Houston Medical School, along with two highly trained manual lymph drainage (MLD) therapists, Brenda Amerson and Susan Harrelson, beg to disagree.

"The Lymphedema Clinic utilizes what's called complex physical decongestive therapy (CPDT)," says Amerson. The treatment consists of four components which first establishes the drainage of lymph, and then maintains and improves this intense initial phase.

To drain the lymph, Amerson and Harrelson use the MLD technique - a gentle massage treatment which stimulates the lymphatics and encourages the stagnant, built-up fluid to move on out of the body through excretion. In some cases, Dr. Fife's staff also uses an electronic pumping device which simulates the motion of the lymphatic system. After MLD, Amerson says, "we bandage the arm or leg snugly. This compression therapy prevents the re-accumulation of fluid." Once maximal reduction of the swelling has been achieved, the patient is fitted with a special compression sleeve or stocking. The other two components of CPDT are meticulous hygiene to avoid infection and daily remedial exercises to improve muscle tone and help propel the flow of lymph.

There is no cure as yet for lymphedema, says Dr. Fife. But there are treatments for it.

Facts About Lymphedema

Though many health care professionals consider lymphedema a rare condition, in fact, at least 30 percent of all breast cancer survivors in the U.S. alone will contract lymphedema due to surgery or radiation. A slightly lower percentage of patients with reproductive organ and prostate cancers will also develop lymphedema.
There are two broad categories of lymphedema: primary lymphedema, which is genetic, and secondary lymphedema. In third world countries, people are more likely to get lymphedema from parasitic infections, while Americans get lymphedema from trauma to the lymphatic system.
Lymphedema is a chronic condition which cannot be cured but can be controlled with proper care. It is characterized by the swelling of a part of the body, usually an extremity, caused by the accumulation of lymph, a protein rich fluid produced by the lymphatic system to fight infection.
Lymphedema is painful, disfiguring and extremely dangerous if not treated. If a person with lymphedema contracts cellulitis - an infection of the skin which can be caused by something as innocuous as an insect bite - the infection can be fatal.
According to Dr. Caroline Fife, an associate professor of anesthesiology at The University of Texas-Houston Medical School and director of the Hermann Center for Wound Healing Lymphedema Management program, more cancer survivors have lymphedema than in years past for the simple reason that they are now living long enough to get it. Before life-saving treatments, lymphedema was, largely, a moot point.
The psychological effects of lymphedema can be devastating. "Many times the lymphedema does not occur until years after the cancer surgery. When it does, it's as distressing as having the cancer itself. It also serves as a constant reminder of cancer," says Dr. Fife.
Decongestive physical therapy called manual lymphatic drainage (MLD) massage is, to date, the most effective way to reduce and control the effects of Stages I and II lymphedema. Fife's clinic uses a combination of MLD and an electronic pumping device which simulates the flow of a normal lymphatic system and encourages drainage. MLD is followed by tight bandaging, also called compression therapy.
Persons with lymphedema should avoid tight fitting clothing and undergarments because they can hinder the flow of lymph.
Patients should avoid excessive cold or heat and sunburn.
Diet and moderate exercise are important. Brenda Amerson, an MLD therapist in the program, tutors her patients with recommendations such as:
1. Avoid high sodium foods which include many canned foods, table salt, some seafood, and salted snacks such as popcorn, chips and pretzels. The sodium ban also applies to water. If you are unsure about the sodium content of your tap water, buy bottled water, she says.
2. Drink water, water and more water to flush the toxins from the body. Limit caffeine and do not imbibe excessive amounts of alcohol.
3. In addition to maintaining a low sodium regime, choose low fat foods consisting primarily of fruit (especially watermelon, fresh pineapple and cantaloupe), fresh or frozen (not canned) vegetables and low fat protein. "One ounce of the wrong food can cause more edema," says Amerson.
4. Moderate exercise is imperative. "We give our patients lymphedema exercises and teach them how to do their own maintenance massage. It is also necessary for lymphedema patients to walk or swim or ride a bike to help reduce the fluid and then to maintain that reduction."

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