Lymphedema: Symptoms and Treatments

What is lymphedema?

“Lymphedema is swelling of a part of the body – usually the extremities of the upper or lower limbs – caused by the accumulation of lymph in the subcutaneous tissues. This accumulation results from a transient or permanent incapacity of the lymphatic system and collecting canals to participate in the purification and drainage of the limbs”says Dr. Ariel Toledano.

In summary, lymphedema is an accumulation of lymph in the tissues, which causes swelling of the limb or several limbs as symptoms. When the lymphatic vessels are damaged or clogged, the lymphatic fluid cannot be properly drained and accumulates in the tissues, causing swelling. Lymphedemas are not so much diseases but rather symptoms of lymph dysfunction.

As a reminder, the lymph nodes are tiny organs whose purpose is to filter the lymphatic fluid. They are located throughout the body, but “clusters” can be found just under the skin, in the neck, under the arms, and in the groin. Lymph nodes make up the lymphatic system, which is one of the body’s defense mechanisms against the spread of infection and cancer.

The lymph is a clear liquid composed of water, white blood cells, proteins and lipids that have been filtered out of blood vessels. Some of this fluid will be reabsorbed by the blood vessels, but the rest will go to the lymphatic vessels. The lymph then passes through the lymph nodes, sort of collection centers where damaged cells, infections, and cancerous cells are filtered out and then destroyed. If there are too many cancer cells present, the volume of the lymph nodes begins to swell.

What are the causes of lymphedema?

There are two types of lymphedema:

• the primary lymphedema : of unknown origin, primary lymphedema affects 1 in 10,000 people, 80% of women, with a peak incidence at puberty. He touches mainly the legs and results in 80% of cases from a distal obliteration, which affects the lower part of the legs. “This type of lymphedema progresses slowly; it is often limited to one side and mainly affects the back of the foot”, says Dr. Toledano. In 10% of cases, it is a proximal obliteration which is in question. “At this stage, this type of primary lymphedema affects both men and women; unilateral, it begins at any age, thanks to a bite or an infection in particular, then evolves very quickly, in one or two months.” The remaining 10% correspond to primary lymphedema with congenital aplasia“relatively rare abnormalities that appear at birth”;
• the secondary lymphedema appears as a result of trauma to the lymphatic network. The majority of cases are observed in the arms, in women who have undergone lymph node dissection as part of breast cancer treatment (20% of cases). Secondary lymphedema can also affect the legs, especially after treatment with surgery or radiation therapy for prostate cancer, lymphoma, bladder or ovarian cancer. Trauma to the venous network can also give rise to lymphoedema in the lower limbs: this is called functional lymphedema or veno-lymphatic edema. “Normally, the lymphatic system supplements the venous system”, reminds Dr. Toledano ; “when the latter is deficient, it is overworked, sometimes to such an extent that it finds itself overwhelmed. It is not uncommon for a patient suffering from venous insufficiency to also present lymphatic insufficiency”.

What are the symptoms of lymphedema?

Swelling of the volume of the affected area is the main symptom of lymphedema. When it concerns the lower limb, it is initially limited to the back of the foot; but over time and without treatment, it can go up to the ankle and then to the calf in a second phase, warns the vascular doctor. “This edema is called depressible, that is to say that we can leave an imprint in the skin. Over time, in the absence of treatment, the lymphatic fluid continues to accumulate in the tissues, causing ever greater swelling and then the development of fibrosis in the dermis. This is evidenced by Stemmer’s sign: if you pinch the 2nd toe between two fingers, they fail to get closer as the edema is fibrotic.

Lymphedema is rarely painful (unless there are complications or secondary infections) but can lead to a feeling of heaviness in the affected limbs. “People rarely complain.” reports the vascular doctor. “Most often, they consult because the edema prevents them from putting on their shoes”.

In addition to oedemas, this inefficiency of the lymphatic system can expose increased risk of infections. “In addition to its role in recycling body waste, lymph is also involved in the development and strengthening of immunity. When the lymphatic system is affected, a person has a greater risk of developing infections such as erysipelas, fungal infection, or lymphangitis in the affected limb. It is therefore recommended to limit its use in order to prevent any risk of injury or sting which could constitute an entry point for an infectious germ; are also prescribed antibiotics for prophylaxis“says Dr. Toledano.

In general, a simple clinical examination associated with an interrogation of the patient is sufficient for the general practitioner or the vascular doctor to make the diagnosis of lymphedema.

The doctor can prescribe Additional tests like a Doppler echo in order to determine whether the attack concerns exclusively the lymphatic system or is associated with venous insufficiency. More precise, a lymphoscintigraphy or a Lymphatic MRI will allow the doctor to establish a map of the entire lymphatic network and assess the extent of the damage. “These examinations make it possible to draw up a precise initial assessment which will give the doctor information on the chances of possible improvement.explains Ariel Toledano.

In terms of medication, the therapeutic arsenal for treating lymphedema is limited. “You can possibly prescribe proanthocyanidin oligomers (or oligo-proanthocyanidins – OPC) based on grape seed extracts or flavonoids, especially in the event of associated venous insufficiency, but the effectiveness is very relative”.

The main treatment for lymphedema is symptom relief by wearing a restraint (a sleeve for the arm, stockings or a compression bandage of class 3 minimum for the leg), to which we associate manual lymphatic drainage and pressotherapy. “In this case, lymphatic drainage is prescribed and reimbursed by health insurance. It must be performed by a physiotherapist trained in this technique., warns Dr. Toledano. The regular practice of physical activity completes the treatment. It is this regularity of care applied over the long term that will overcome lymphedema, warns the specialist. “The patient must be aware that lymphedema is a chronic pathology that requires regular care.. At the present time, no surgery exists to treat this pathology.

In summary, the treatments for lymphedema are:

• manual lymphatic drainage : it helps to raise the lymph to the heart and thus reduce lymphedema. Specifically, trained physiotherapists and healthcare professionals apply slow pressure along the lymphatic system;
• Compression bandages : multilayer compression bandages are used in the first stage of treatment, to complete lymphatic drainage, and allow a pressure effect on the lymph;
• The elastic compression : the elastic compression maintains the effects of natural lymphatic drainage and compression bandages. It ensures that the lymph does not accumulate again;
• Treatment by hospitalization : some angiology departments offer intensive treatments during hospitalization, where there is natural lymphatic drainage, elastic compression and physiotherapy.

If in doubt, do not hesitate to turn to a health professional who will be able to direct you towards the most appropriate treatments.

Dr. Ariel Toledano is a vascular doctor (Paris) and author of the book Take care of your legs (Editions du Cerf).