Catherine Holley, RN Operating Room Nurse Massachusetts General Hospital

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1 Operating Room Nurse Massachusetts General Hospital March 13, 2019

2 What is Lymphedema? Swelling (edema) that occurs due to injury or impairment of the lymphatic system Causes: Anything that disrupts the flow of lymph fluid through the lymphatic vessels and/or the lymph nodes Build up of protein-rich lymph fluid

3

4 An estimated 3-5 million (some studies say closer to 10 million) Americans, and hundreds of millions worldwide, suffer from lymphedema and lymphatic diseases. More people suffer from these diseases in the United States than suffer from Multiple Sclerosis, Muscular Dystrophy, ALS, Parkinson's disease, and AIDS -- combined.

5 Don t confuse lymphedema with lipedema.

6 LIPEDEMA Chronically progressive disease, almost exclusively in women. Painful fat disorder, 11% women in hips/lower bodies estimated 17 million US / 370 million worldwide

7 Lymphedema vs Lipedema

8 Understanding Lymphedema Quick review of circulatory system

9 Circulatory System Arteries / Veins Closed system Circulating system External pump heart Fairly set volume Lymphatics Open ended One way No pump, dependent on muscles Capacity can increase up to 10x

10 Lymphatic System Tonsils cluster of nodes Thymus WBC s recognize foreign invaders Spleen lymphocytes antibodies Lymph nodes Lymph vessels Thoracic Duct R Lymphatic Duct Bone Marrow RBC, PLT, & infection fighting cells

11 Image provided by Xiaolei Liu (Guillermo Oliver's lab)

12 Lymphatic System The Basics Network of tissues and organs, removing toxins/wastes from body body s pool vacuum! Body s immune system / fighting infection Lymph flow is dependent on muscle contraction (no pump) Over 3 LITERS of lymph fluid produced daily Over 600 nodes in body

13 What is Lymph Fluid? 96% water protein cell debris bacteria waste products clear, straw color

14 Important Facts Unclear who will develop lymphedema (LE) Can be immediate but often onset is delayed 1-5 years after insult, or even decades later No cure. Chronic, life long disease In US, highest incidence: breast CA surgery with axillary lymph node dissection > 500,000 Breast Cancer survivors with LE

15 Types of Lymphedema Primary >40 rare disorders are assoc with primary lymphedema Congenital / hereditary Absent or abnormal lymphatics Birth: Milroy s disease (auto-dom) Teens: lymphedema praecox Adults: lymphedema tarda Secondary 22% non-cancer related 68% cases are cancer related Damage/injury to lymph system Surgery any surgery! Lymph node dissection - cancer Radiation therapy Burns / Trauma Infection

16 National Cancer Institute 2015 Lymphedema is one of the most poorly understood, relatively underestimated, and least researched complications of cancer or its treatment.

17 Incidence of Cancer-Related Secondary Lymphedema Cormier, et al 2010 Melanoma 16% Head/Neck 4% Pelvic Dissections 22% Breast with radiation 49% Breast 10-20% Radiation Therapy 31% Gynecology 20% Sarcoma 30% Genitourinary 10% Overall cancer-related incidence is 15.5%

18 Review of Node Clusters Major clusters of lymph nodes: Cervical Axillary Inguinal Vertebral Intestinal Pelvic Abdominal

19 Secondary: Surgical Risks ANY Damage to Lymphatic Tissue Scrotum Gynecologic surgery GU surgery Orthopedic procedures Trauma Infection / Cellulitis Lymph node dissection Radiation therapy Burns Vascular surgery Tumor resection Venous ligation

20 Stage O Latency, at risk Stages of Lymphedema Stage I Pitting Reversible edema, reduces with elevation Stage II Non-pitting Irreversible edema Fibrosis and scarring Doesn t improve with elevation Stage III Elephantiasis Hardening of dermis, papillomas of skin

21 Stage I Treatment Biggest problem is accurate diagnosis. Early evaluation and treatment with manual lymph drainage (MLD). MLD along with compression can prevent progression of disease. Use of pneumatic pump may be recommended. Patient education and adherence is vital. Lymphedema Treatment Options Stage II Treatment Complete Decongestive Therapy (CDT) 4-6 weeks long, 2 hours/session MLD with multi-layer bandaging. Patient education about exercise, nail care and lifelong adherence.

22 Four Layers of Bandaging Stockinet Soft roll bandages Foam padding Short stretch bandages

23 CDT: Daily Process

24 After CDT Treatment Preventing re-accumulation of lymph fluid Self Care routine Compression Pump Daily manual lymph drainage (MLD) Custom compression garments or multi-layer wrapping Vigilance. Every. Single. Day.

25 Breast Cancer Related (BCRL) incidence as low as 10%, up to 49% with radiation (Cormier, et al 2010) Before lymphedema treatment (complete decongestive therapy) 4 weeks after treatment Neglected lymphedema after mastectomy Examples of custom compression to reduce lymph fluid accumulation

26 Examples of Custom Compression

27 Lymph Node Transfer Surgical Options lymph nodes are taken from a healthy part of your body and placed to the area affected with lymphedema. Lympho-venous Bypass small lymph vessels are connected to small veins nearby to improve the flow of lymph fluid. Liposuction removes the fat in the affected area that can accumulate in the later stages of lymphedema.

28 Cellulitis Infections a constant threat for patients Chronic, often non-healing wounds Recurrent hospitalizations Antibiotics Limited mobility Out of work Medical costs

29 Patient education and compliance are critical components to the successful management of lymphedema

30 Reality of a Lymphedema Life Constant threat of infection Pain Clothing / shoes Self image / self esteem Isolation / depression Sexuality / body image Cancer diagnosis No end in sight. discouragement, frustration, anger Financial impact

31

32 Join us Saturday May 18! The 1 st Annual 5K Walk/Run to raise awareness and fight lymphedema and lymphatic disease. Visit LymphWalk.org

33 Questions?

Catherine Holley, RN Operating Room Nurse Massachusetts General Hospital

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