Learn more about the medical cases the doctors of SGH have faced
By Meg Marinis, Director of Medical Research
Cancer in more than one place. A mastectomy. An oophorectomy. Experimental therapies. A prognosis of six months to live… Jeez. Carrie's been through A LOT these last eight years. It's amazing that she survived all that. But is it strange that after pulling through years of disease and difficult treatments that she wants to be BACK in the hospital? Asking for more treatment? Because her arms are big??
It's not strange at all. It's not that "her arms are big." Carrie suffers from a serious condition called lymphedema – swelling that typically affects the arms or legs due to a blockage in the lymphatic system. This blockage prevents lymph fluid from draining well, allowing it to build up, and causes the swelling in the limbs. The condition can be extremely painful, and many former breast cancer patients have claimed that lymphedema is even worse than the cancer itself.
What does the lymphatic system do?
The lymphatic system is a vital part of the immune and circulatory systems, helping to keep a person healthy. It circulates the protein-rich "lymph fluid" throughout the body, picking up bacteria, viruses, and waste. The fluid carries these substances back to the lymph nodes where specific cells filter out the waste products out of the body.
There are two kinds of lymphedema: Primary and Secondary.
Primary lymphedema, rare and most frequently diagnosed in women, stems from problems that occurred during the development of the lymphatic system. It can be present at birth, develop at the onset of puberty, or appear in adulthood. In many cases, the cause is unknown, but studies have shown an association with vascular anomalies such as hemangioma, lymphangioma, Port Wine stain, and Klippel Trenaury.
Secondary lymphedema can come from any condition or procedure that damages or removes the lymph nodes or vessels. Our patient Carrie developed it due to having breast cancer surgery, which included the removal of lymph nodes from her armpits to see if the cancer had spread. Other causes include radiation treatment, cancer, and infection.
Besides swelling in the arms or legs, lymphedema can present with the following symptoms:
- Feeling of heaviness or tightness in the arm or leg.
- Restricted range of motion in the arm or leg.
- Recurring infections in the affected limb.
- Thickening and hardening of the skin on arm or leg.
According to the National Lymphedema Network, the condition can also be described in three stages:
- At Stage 1, the affected tissue remains in the "pitting" phase – when pressed by fingertips, the area indents and holds the indentation. When the patient wakes up in the morning, the limb seems almost normal.
- Once the lymphedema reaches Stage 2, the tissue is "non-pitting" – when pressed by fingertips, the area bounces back and does not remain indented. Also, the affected area of the limb begins to harden and increase in size.
- Once the symptoms escalate to Stage 3, the swelling is usually determined to be irreversible. The affected limb can be quite large with hard and unresponsive tissue. At this point, patients begin to consider surgical treatment.
Left untreated, the fluid build-up can cause a number of complications.
Lymphedema can lead to tissue channels increasing in size and number; it may reduce the oxygen availability in the transport system; it can interfere with wound healing; and it provides a culture medium for bacteria that results in infections such as cellulitis and lymphangitis. Some studies have shown that lymphangiosarcoma (a rare form of soft tissue cancer) results from the most serious and untreated cases of lymphedema. Signs of this cancer include blue-red or purple marks on the skin.
Lymphedema does not have a definitive cure, but several treatments exist to help manage the affected limb.
- Doctors may recommend specific exercises for the affected limb to try and improve movement of the lymph fluid.
- A certain technique of wrapping the limb has been shown to encourage the flow of liquid. Therapists advise that the bandage should be tighter around the fingers or toes.
- Manual lymph drainage is a type of massage in which gentle hand strokes to the limb may move fluid. Doctors suggest avoiding this treatment if the patient has a skin infection, active cancer, blood clots, congestive heart therapy, or has previously undergone radiation therapy to the affected area.
- Pneumatic compression or compression garments has also shown promising results in alleviating the fluid build-up.
For more severe cases of lymphedema, doctors will present surgical options to the patient such as procedures to remove excess tissue from the affected limb or the newer lymph node transfer that Mark and Jackson gave to Carrie. The lymph node transfer still remains experimental, but many patients have reported success post-operatively.
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