What is Lymphoedema? Incidence and Prevalence

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1 What is Lymphoedema? Incidence and Prevalence North of England Cancer Network Lymphoedema Conference - A problem shared 8 March 2013 Dr Andrew Hughes Consultant in Palliative Medicine

2 Outline 1) What is lymphoedema? 2) Causes of Chronic oedema 3) How common is lymphoedema? 4) Why A problem shared?

3 What is lymphoedema? Tissue swelling due to a failure of lymphatics Does this differ from other causes of oedema? Lymphoedema vs Chronic oedema?..does it matter?

4 St Oswald's Lymphoedema service ACUTE OEDEMA.heart failure, DVT, cellulitis, angio-oedema. etc OEDEMA Lipoedema CHRONIC OEDEMA OEDEMA IN PATIENTS WITH ADVANCED DISEASE Secondary to Lymphatic cancer / treatment, infection, trauma or any of other causes Primary Lymphovenous stasis (dependent) Venous Post thrombotic Insufficiency Lymphoedema 2 ry to treatment 2 ry to LN involvement Venous oedema 2 ry to DVT, IVCO, SVCO, venous compression Lympho-venous oedema pelvic / axillary mass albumin / dependent oedema

5 Functions of the lymphatic system Return of fluid from interstitial spaces back to the circulation. Mopping up proteins - return to circulation Transport of other substances: waste products fats / enzymes / hormones Role in immune system - infection / cancer

6 Oedema (= excess fluid in the interstitial space) occurs when Net Capillary Filtration Rate exceeds Lymph Drainage P c Interstitial space p p P c Capillary bed Initial Lymphatic Capillary bed = Net fluid movement

7 Interstitial space P i i i P i P c p Capillary bed p P c Capillary filtration rate depends on 1) the pressure within the capillary (Hydrostatic pressure) 2) the protein concentration (Colloid Osmotic pressure) 3) Surface Area 4) Capillary permeability Net flow is into interstitial space even at the venous end

8 Interstitial space P i i Eg: low albumin Advanced disease, nephrotic syndrome, P c p malabsorption, liver disease Capillary bed Capillary filtration rate depends on i p P i Raised venous pressure from DVT, P c venous stasis, right heart failure, Na + /water retention 1) the pressure within the capillary (Hydrostatic pressure) 2) the protein concentration (Colloid Osmotic pressure) 3) Surface Area 4) Capillary permeability Infection, inflammation Net flow is into interstitial space even at the venous end

9 Osmotic (Oncotic) Pressure Protein molecules Movement of water molecules Net Movement of fluid Semi-permeable membrane

10 Lymph flow depends on effective anatomy and functioning of the lymphatics Lymphatic system has to be anatomically effective Blocked or damaged by cancer, trauma, radiotherapy, infection. Overloaded by excess capillary filtration and unable to compensate P c Interstitial space p p P c Capillary bed Initial Lymphatic P i i i P i P c p Capillary bed p P c

11 Superficial lymphatics Deep lymphatics Thoracic duct Cisterna Chyli Superficial lymph nodes Deep lymph nodes

12 Initial lymphatics - superficial Blind ended vessels Single layer of endothelium No muscle - passive, collapsed when empty Attached to surrounding structures by anchoring filaments Opens and takes in fluid in response to movement of surrounding tissues

13 Anchoring filaments Skin Muscle

14 Lymphatic vessels Collectors Layer of smooth muscle One-way valves forming heart-shaped segments (lymphangion) Peristaltic movements propel fluid towards thoracic duct Deep breathing creates negative pressure in the chest and siphons fluid towards thoracic cavity

15 Lymphangions with one way valves The more the lymphangion fills up, the harder it squeezes lymph onwards Until.. The wall becomes overstretched, and it looses its elasticity Protein escapes into the wall and damages it further, leading to failure of lymphatic propulsion A secondary lymphatic component develops on top of the oedema already there.

16 Lymph nodes Occur in superficial and deep chains Some fluid is reabsorbed within the lymph nodes (post-nodal lymph has higher protein concentration.) Processing of antigens Addition of lymphocytes Efferent trunks from lower limbs transport lymph into the Cisterna Chyli and thoracic duct.

17 Summary of causes of oedema 1) Excess capillary filtration a) Venous back pressure DVT, venous stasis, RHF b) Low Albumin Na + /water retention c) Inflammation leads to excess interstitial fluid AND further damage to the superficial lymphatics 2) Impaired Lymphatic Drainage a) PRIMARY absence, hypoplasia, hyperplasia b) SECONDARY damage due to cancer, infection, surgery, RT or loss of compensatory mechanisms

18 How common is lymphoedema? Prevalence difficult to confirm due to confusion in diagnosis 75% of lymphoedema is non-cancer related 25% cancer related Breast cancer related lymphoedema = 14% of all referrals Primary lymphoedema: 1 in 33,000 (Baskerville 1989)

19 How common is lymphoedema? Breast cancer: prevalence reported 12-60% 28% (Mortimer et al 1996) even with sentinel node biopsies 6% still develop lymphoedema Pelvic cancer: Vulvectomy and LN dissection: 70% Cervical Cancer: 40% (Werngren-Elgstrom 1994) LN dissection for melanoma: 26% (Papachristou 1997) Identification of those at risk with appropriate advice: Risk Reduction, prevention and early treatment

20 How common is lymphoedema? Overall prevalence of Chronic Oedema / Lymphoedema Wandsworth study (Moffat et al 2003) All ages: 1.33 per 1,000 > 65: 5 per 1,000 Derby study (Moffat et al 2012) All ages: 3.99 per : : 28.6 NECN = 3.2 million population => 12,000 patients

21 How common is lymphoedema? Hospital in-patients: 26% have chronic oedema (Moffat et al 2012) 20-30% of lymphoedema patients develop cellulitis In : 45,522 in patient admissions for cellulitis costing 87 million (NHS Instituite for Innovation and Improvement) Hospice in-patients: 41% of patients reported it as being one of their top 3 priorities (Trent Hospice Audit Group 1996)

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23 Myth or Reality??

24 Myth or Reality??

25 Myth or Reality??

26 Myth or Reality??

27 Myth or Reality??

28 Myth or Reality??

29 Myth or Reality??

30 Current provision within NECN NECN SURVEY OF LYMPHOEDEMA PROVISION IN THE NORTH OF ENGLAND services offering from ½ to 5 days/week 5 are hospice based 9 services have one or more lymphoedema specialists. Categories of lymphoedema treated: At Risk 15/17 (88%) Mild/Moderate/Un-complicated 16/17 (94%) Moderate/Severe/Complicated 12/17 (71%) Oedema in advanced disease 12/17 (71%)

31 Caseload: Current provision within NECN 4181 patients on caseloads across the 15 services 73% of patients with cancer related lymphoedema 22% of patients with Non-Cancer/Other lipoedema Referrals Apr March referrals across 14 services 824 with cancer related Lymphoedema (52%) 575 Non Cancer related Lymphoedema (36%) 144 Other Lipoedema (9%) 43 Not Stated (3%)

32 So. Whose problem is it? Everyone s! The person with lymphoedema, Their families and carers. Community nursing and medical staff Hospital services Lymphoedema services Clinical Commissioning groups!!!