A DELAY in the diagnosis of lymphoedema can cost patients the opportunity for better outcomes in treatment and long-term management of a condition that has no cure.
Currently, cancer services recognise that secondary lymphoedema can occur as a result of cancer treatment and are taking this on board as part of patient survivorship programs.
However, for primary lymphoedema, which is often missed among the large number of chronic oedemas especially in older people, we need to recognise the importance of early diagnosis by the patient’s primary carer — usually their GP — who is well equipped to diagnose the disorder in the early stages.
In 2002, the Australasian Lymphology Association (ALA) published its Lymphoedema National Service Equity Survey (available by contacting firstname.lastname@example.org), reporting a 9-year delay from onset to diagnosis for primary lymphoedema compared with diagnosis within 6 months of breast cancer related lymphoedema. This is the only report undertaken in Australia to examine diagnostic delay for primary lymphoedema, and today there is little evidence to suggest that things have improved.
We know that the lymphatics are the dominant route for the recycling of tissue fluid. Chronic oedema, from whatever cause, persists because the lymphatics are overloaded or compromised either by damage or primary insufficiency. Although the possible cause for overload needs to be found and treated, if there is no cause determined, “think lymphoedema”.
So, what should physicians look for? Professor Peter Mortimer, a UK expert in the diagnosis and treatment of lymphoedema, recommends that if a patient presents with persistent swelling in the feet and/or legs lasting more than 3 months, especially if asymmetric, “think lymphoedema”.
If the swelling remains after elevation and diuretic but tends to improve with mobility, “think lymphoedema”. On examination, Stemmer’s sign — an inability to pinch up a thin fold of skin at the base of the second toe — is pathognomic of lymphoedema.
Cellulitis is a major complication, because the lymphoedema area is effectively immunocompromised. We know that one in five patients presenting for limb cellulitis have lymphoedema and one in 10 patients with lymphoedema will have at least one episode of cellulitis.
If not systemically unwell, oral antibiotics (penicillins, cephalosporins or, if allergic, clindamycin) taken early and continued for 2 weeks are recommended but many patients may require hospitalisation. Cellulitis, in turn, can further damage the lymphatics.
The diagnostic test for lymphoedema is the lymphosctinigram, which can be performed by most nuclear medicine services. However, when ordering a Doppler scan to exclude a venous thrombosis as a cause of leg swelling, it is worthwhile asking the sonographer to comment on the subcutaneous tissue as it could be a lymph problem.
If no deep vein thrombosis is found, lymphoedema may be suggested by the appearance of characteristic thickening and honeycombing of this layer.
There are no specific medications or operations recommended for primary lymphoedema but an early diagnosis allows patients the benefit of simple self-massage and compression, and exercise including hydrotherapy to control and even reverse the condition.
Keeping the areas cool, the skin clear of infections and moisturised, and not prescribing diuretics or calcium channel blockers, which slow lymphatic pumping, can be very worthwhile measures that can offer patients far better long-term outcomes.
Dr Helen Mackie is a consultant in rehabilitation medicine and medical director of the Mt Wilga Private Hospital Lymphoedema Service. She is also medical advisor to the Australasian Lymphology Association.
To locate an accredited lymphoedema practitioner in your area visit the National Lymphoedema Practitioner Register website. Further information is available at the ALA website including information on early signs, symptoms and treatment.
Posted 10 April 2012