Treating and managing lymphoedema

Resection Specimens and the Types of Surgery

Sentinel node biopsy approximately two-thirds of symptomatic and the majority of screening breast cancers are node negative. Axillary surgery in these cases would not be indicated if it could be predicted so as to avoid any risk of morbidity such as arm pain and lymphoedema. Lymphatic mapping and sentinel node biopsy is a new minimally invasive technique to identify patients with axillary node involvement. The sentinel node is defined as the first node to receive drainage from the tumour and is identified by injecting a vital blue dye, a radiocolloid or both around the area of the tumour just prior to surgery. A small incision is made in the axilla and a hand-held gamma probe or direct visual inspection used to identify the radioactive node or blue-stained lymphatic channels leading to a blue lymph node. The node is then excised and undergoes detailed histological examination which can involve multiple slices, section levels and the use of immunohistochemistry. Studies have reported...

Clinical Presentation

A variety of dysplastic preinvasive lesions, of both squamous and glandular type, are commonly encountered within the cervix. These are usually picked up because of an abnormal cervical smear, performed in the United Kingdom as part of the NHS cervical screening programme. These abnormalities are often associated with and due to infection by human papilloma virus (HPV). Other symptoms related to cervical pathology include watery vaginal discharge and postcoital and intermenstrual bleeding. With advanced cervical tumours invading the bladder or rectum there may be urinary or bowel symptoms. Large tumours can protrude through the external cervical os into the vagina. Small cervical tumours may be asymptomatic. With advanced tumours the ureters can become obstructed with resultant hydronephrosis and renal failure - lymphoedema and deep venous thrombosis may also occur.

Signs symptoms and diagnosis

When KS resolves, either spontaneously or following therapy, it often leaves gray-brown to light brown hyperpigmentation for months to years (post-inflammatory hyperpigmentation), caused by hemosiderin deposits from extravasated erythro-cytes. The accompanying lymphedema can also persist for a similar length of time, particularly on the lower legs.

Clinical Presentations Requiring Palliative Management

Urinary symptoms can result from ureteral or bladder obstruction or hematuria. Edema of the genitalia and lower extremities can result from lymphatic obstruction. Pain and other symptoms can result from metastatic involvement of the pelvic bones and lumbosacral plexus.

Complications And Prognosis

The main complications from wide local excision are superficial infection, wound dehiscence, and cosmetic defect. Risk of tumor recurrence after excision with appropriate margins is low. Complications of SNB are also local in nature infection, seroma, injury to nerves, and dehiscence. The risk of lymphedema is minimal in the head and neck lymphatic basins.

The Extremities

Amputation is the most obvious long-term effect of surgery on the extremities, but many other cancer operations also require sampling of regional lymph nodes. Lymphedema is a not uncommon late effect of these procedures. While this may have no noticeable downstream effects, like in colorectal cancer, when it involves dissection of lymph nodes draining the extremities, as in axillary dissection for breast cancer or a groin dissection in melanoma, it risks leaving patients without sufficient lymphatic drainage from a limb. The resultant lymphedema may take several years to become clinically apparent as fluid accumulation in the tissues is initially restricted by counteracting hydrostatic pressure within those tissues. As the tissues stretch and expand, however, the lymphedema accelerates. Functional disability from stiffness, pain, limited range of motion, and predisposition to cellulitis (which can further damage lymphatics and exacerbate lymphedema), coupled with the cosmetic effects,...

Tertiary Lesions

Hidradenitis Suppurativa

Severe axillary involvement with limitation of Fig. 3.9. Pubic lymphoedema in HS arm mobility a limb, particularly abduction of the arm (see Fig. 3.8) or even produce a lymphatic obstruction with oedema (see Fig. 3.9). It is however of note that lymph node enlargement and or inflammation is generally absent, except in cases of acute superinfection with lymphangitis.