Questions and answers on "lymphoedema"

(by Mrs. Christina Jakob-Ertel, August 2016)

The topic of "lymphoedema" is incredibly important for many patients within the scope of their cancer treatment. As the lymphatic system, in contrast to the circulatory system, is something most patients are not so familiar with however, we have compiled a list of the most important questions and answers for you.

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1. What is the role of the lymphatic system?

In addition to its immunological functions, the role of the lymphatic system consists of ensuring the "cleansing" of intercellular space (interstitium). The lymphatic system removes so-called lymph-obligatory loads. These include, for example, water, cells, protein and fat.

By raising the frequency at which it operates, an intact lymphatic system can well compensate an increase in these lymph-obligatory loads triggered, for example, by an acute infection. This feature is known as a safety valve function. When required, the lymphatic system can increase its performance.

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2. What function do the lymph nodes have?

So-called regional lymph nodes are positioned in the larger lymphatic pathways of the body. This is where the lymphatic fluid is concentrated and they serve as a filter station for pathogens, cell debris and foreign bodies. Lymph nodes are generally grouped together, for example in the armpit, groin, and throat as well as around the abdomen. Each group of lymph nodes has a particular area to "cleanse". The lymph nodes in the armpit, for example, are responsible for the entire upper quadrant of the torso and parts of the breast.

3. How is lymphatic fluid transported in the vessels?

The flow of lymph through the body is supported by various forces. These include fluid pressure in the interstitium, pulsation of corresponding arteries as well as muscle contractions and movement of the viscera. The lymph is actively transported further. The larger lymph vessels contain lymphangions. Supported by a pacemaker-type function, they cause contractions in the muscle walls and force the fluid further through the vessel. This movement through the lymphatic vessel is stimulated by increased stretching. When more lymph flows into the vessel, the frequency and amplitude of pulsations increases. Stretching caused by external pressure also has a similar effect. This can be achieved this through manual lymph drainage, compression therapy and exercise.

4. Is the lymphatic system damaged in every cancer operation?

Removal of lymph nodes or radiotherapy in the lymphatic drainage area can cause damage to the lymphatic system.

5. Do all patients experience lymphoedema after a cancer operation?

No. In most cases the patient's lymphatic system can compensate the damage. The body has a number of ways of reacting to damage and averting lymphoedema. Nonetheless, unnecessary strain on the lymphatic system should be avoided after a cancer operation and there are a number of issues to consider.

The role of the lymphatic system is outlined in question 1. The lymph vessels remove different loads from the interstitium. All measures which could potentially increase these loads should subsequently be avoided. If, for example, prior to your cancer operation you regularly attended appointments with physiotherapists who treated you with Fango mud massages and then carried out a rigorous back massage, there is a strong increase in blood circulation in the tissues caused by such treatments. The lymph-obligatory fluid load increases. Consequently, the lymphatic system can now still manage to fulfil its primary function but is already so strained, it will not achieve any more.

There are many patients who never develop lymphoedema. We do not know, however, in what category you are as a patient, we do not know how capable your lymphatic system is of compensating an increase in the lymphatic load. Therefore we recommend avoiding the treatments mentioned above as well as all measures which lead to an increase in blood circulation in the affected quadrant. To be precise - such measures should no longer be applied to the quadrant of the body from which lymph nodes have been removed or where radiotherapy has been carried out in lymphatic drainage area.

6. If I experience swelling in the area which has been operated on, what needs to be done?

The first step is to arrange to see your oncologist. It is then important to initiate a DRAINAGE PHASE as quickly as possible. This means daily treatment five times per week with manual lymphatic drainage, skin care, compression therapy with short-stretch bandages and exercise therapy. This drainage phase generally lasts for 5-8 days depending on the extent of the lymphoedema.

When the arm/leg has been thoroughly drained, a MAINTENANCE PHASE follows straight after. Now you will be provided with an individually fitted, flat knit compression stocking from a specialist store. You wear this every day through to the evening and then take it off overnight.

The main aim of the MAINTENANCE PHASE is to preserve the success achieved through treatment in the DRAINAGE PHASE. Only in severe cases when there are already signs of change to the tissue, is regular lymphatic drainage necessary.

After approximately 6 months stockings tend to lose their tension. At this time, get in touch with your physiotherapist to arrange commencement of a new DRAINAGE PHASE. And then the process starts again.

7. My therapist believes that just a stocking is also adequate. Is this true?

No, unfortunately not. It is only by applying a compression bandage every day that lymphoedema will improve. In combination with exercise, the lymph-obligatory load is properly drained. The stocking is used exclusively for its effectiveness in maintenance and conservation. It is not suitable for drainage.

8. Can my doctor prescribe lymphatic drainage on a prophylactic basis if there are no signs of lymphoedema?

Investigations have shown that the lymphatic system can be impaired after a cancer operation. Manual lymphatic drainage directly affects the lymphatic vessels.In some circumstances, therefore, it is quite sensible for your doctor to prescribe a series of lymphatic drainage sessions after the surgical procedure, once you have been discharged. On the other hand, if there is no evidence of swelling or other complications the prescribing of long-term lymphatic drainage cannot be recommended as a matter of course.

9. What must I pay attention to when choosing a practice for my treatment?

The first important question to ask is whether this practice uses bandages. If you already have lymphoedema, isolated lymphatic drainage will not help you. The therapist should have completed a 4-week training course, including an examination. Please also ask to what extent this practice has experience in the treatment of lymphoedema. Lymphatic drainage should never cause any pain. Treatment always begins in healthy, adjoining areas and never directly on the affected side. Treatment is administered on the body from the front and the back. Each treatment session should last at least 45 minutes.

10. Are there any special nutritional recommendations?

There are no particular nutritional recommendations in the case of lymphoedema. Nevertheless, it is important that you eat a balanced diet and pay attention to what you eat. You can find information about healthy and balanced eating habits on this website.

11. Is it advisable to take any dietary supplements?

Please seek advice on this question from your doctor. Once blood tests have been carried out it may be advisable to take certain dietary supplements such as selenium and vitamin D. You should only do this after blood tests have been taken as you can otherwise cause yourself a lot of harm.

12. Is there a limitation on the sports that I choose to do?

It goes without saying that all types of sports in which there is a high risk of injury are not beneficial for the lymphatic system. Suitable sports would be, for example, running, walking, cycling (if you have suffered from abdominal cancer do not cycle for hours at a time), swimming and hiking. With all due caution, every type of exercise is better than doing nothing!

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13. My skin has been sensitive since having radiotherapy and hardens easily. What can I do about this?

Give particular care to the area of skin treated with radiotherapy every day. Use a natural oil without chemical additives such as sea buckthorn oil. The area of skin treated with radiotherapy should be massaged twice per day with light circular movements so as to avoid increasing the blood circulation.

Further additional recommendations include:

Integrate 30 minutes of exercise into your daily routine.
Avoid injuring the skin e.g. when gardening or even during skin care routines such as shaving.
Avoid having injections in the quadrant that was operated on. After breast cancer this refers to the affected upper quadrant, front and back. After abdominal cancer this means the affected lower quadrant, also front and back.
Go to the doctor immediately if your arm or leg develops any inflamed reddening and if you develop a fever.
If you require a compression stocking, make sure you replace this after 6-8 months. The stockings are only effective for a limited period of time.
Make sure you pay special attention to the skin care in the affected area.
Your clothing should be comfortable and should not restrict breathing in anyway or be at all constricting.