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Germ Cell Ovarian Cancer - Lymphoedema
Contents:
Lymphoedema is a swelling in one of more parts of the body which occurs when the
lymphatic
system does not work properly. People who have lymphoedema may notice swelling that they cannot explain in an arm or leg. The area may also feel heavy, painful or uncomfortable.
The heart pumps blood throughout the body to supply oxygen and other nutrients to the body's tissues. When the blood passes into tiny vessels called capillaries, an exchange of fluid occurs to nourish the cells and remove waste matter. Most of this fluid is then returned to the heart by the veins, but the remainder of the fluid (approximately 10%) must be removed by another system of vessels called the lymphatic system.
As well as draining away extra fluid from the tissues, the lymphatic system plays an important role in maintaining the body's
immune defences.
Lymph
nodes (or glands) lie along the lymph vessels and filter the lymph fluid to remove
bacteria and dead or abnormal cells. Many people notice areas under their arms or in the
groin become tender when they have an infection. This is because the lymph nodes, which are located in these areas, are working to filter out unwanted cells. Lymph nodes also exist in close chains under the jaw, in the neck and around the internal organs in the
pelvis.
The lymphatic system consists of:
Lymph is the clear, watery fluid inside the lymphatic vessels. It is generally low in
protein concentration in most areas of the body, but the lymph draining from the liver and small intestine has a higher concentration of protein.
The lymph vessels are small capillaries, similar to those found is the body's blood circulatory system, which carry lymph around the body.
These are small bean-shaped structures located along the lymphatic vessels in chains or clusters. The node receives lymph from the lymph vessels. The lymph is then filtered through the node and passes back out into the lymph vessels.
The lymph nodes associated with the female gynaecological system are:
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external iliac nodes - drain vulva, cervix and lower portion of the uterus; |
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internal iliac nodes - received drainage from all internal pelvic organs as well as vulva, clitoris and urethra; |
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common iliac nodes - receives lymph drainage from cervix and upper portion of vagina; |
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inferior gluteal nodes - receives lymph drainage from cervix, the lower portion of the vagina and Bartholin's glands; |
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superior gluteal nodes - receives drainage from cervix and vagina;
- sacral nodes - drain cervix and vagina; |
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subaortic nodes - drain cervix and vagina; |
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aortic nodes - drain cervix, uterus, oviducts and ovaries; |
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rectal nodes - drain cervix and vagina; |
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parauterine nodes - drain vagina, cervix and uterus; |
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superficial femoral nodes - drain external genitalia of the vulvar region, gluteal region, leg and foot; |
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deep femoral nodes - drains the leg. |
There are a number of conditions which place some people at a higher risk for developing
lymphoedema, these include:
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congenital
malformation of the lymphatic system; |
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severe burns and trauma; |
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disease and infection such as cancer which can damage the
lymph nodes or vessels; and |
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surgery to remove nodes or radiotherapy given as part of treatment for cancer. |
Surgery for the treatment of cancer affecting the female gynaecological
tract can involve removal of some or all of the deep lymphatic vessels and nodes in the
pelvic region.
Radiation
therapy can also affect these nodes. If you have had these treatments, you may be at higher risk for developing
lymphoedema.
Not every person who has these conditions will develop
lymphoedema, however, these conditions do increase the risk.
If you have a limb that has developed swelling that you cannot explain, you may have signs of
lymphoedema. Your limb may feel heavy and the flesh may start to feel thick and hard if the swelling has been there for a while. Lymphoedema can appear early after treatment for cancer or years after surgery. However, not all swollen limbs are the result of
lymphoedema. It is very important to get in touch with your surgeon or oncologist if you notice swelling in an arm or leg. This is so they can make sure the swelling is not the cancer returning and can make an accurate diagnosis so the lymphoedema can be treated.
To diagnose the condition, the doctor may need to perform one or more of the following tests:
There are a number of risk factors which have been suggested as increasing the risk of developing lymphoedema for people who have had surgery or disease affecting some part of their lymphatic system. These include:
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Aircraft travel or travelling long distances - when sitting for long periods of time, the
lymphatics in your
groin can become compressed and pooling of fluid can occur in your feet. By wearing a pressure stocking and getting up to exercise your limbs this risk can be reduced. |
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Skin damage - scratches, sunburn, insect bites, cuts, cutting nail cuticles, using a razor, using harsh chemicals. The skin should be well cared for with low allergy moisturisers, sun protection, wearing gloves in the garden and good nail care as it provides protection from infection. This is important because when infection occurs in the body, it sets off a process called inflammation which causes swelling in the injured area. This swelling my be too much for a damaged lymph system to cope with and could increase the risk of
lymphoedema. |
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Infection - if you notice redness, swelling or heat, it is important to see your doctor immediately. |
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Medical procedures - including having blood taken, injections, acupuncture needles. |
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Tight clothing and jewellery - including tight socks, knee-high stockings, pants, sandals and strappy shoes |
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Performing activities which require standing for long periods of time - many activities such as cooking can be broken down so much of the preparation can be done while sitting. Lymph moves as a result of muscle activity so gentle exercise is great. |
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Poor general health and being overweight - have a healthy diet and take good care of yourself |
Whilst all these factors may increase the chance of developing lymphoedema in theory, we still do not have adequate evidence to support it. This means that some people may still develop lymphoedema even if they follow all these 'rules', whereas others may not be so careful and experience no swelling. The best advice is to take care of your limb, but do not let the fear of developing the condition stop you from enjoying activities.
Once you have been diagnosed as having lymphoedema, you can receive treatment from specialist occupational therapists, physiotherapists and nurses who have the required training. Initial treatment can be intensive - taking up to 6 weeks - however it is effective in reducing the size of the limb. This can help improve how well you walk and reduce strain on joints.
Trained professionals can provide or advise on any of the following:
This approach involves a combination of manual lymphatic drainage, skin care, exercises and compression bandaging followed by the use of low stretch compression garments and maintenance of good skin condition and self-massage.
This is a specialised form of massage that relies on the use of the
superficial lymphatics to redirect lymph fluid. Because it uses the superficial lymphatics as a channel, the massage is very light and there are a number of different massage techniques.
Maintenance of good skin care is important in avoiding infection, as this could cause further swelling due to the body's inflammatory response. It is essential to avoid trauma to the limb , and the use of low allergenic soaps and moisturisers is recommended.
The contraction of muscles and deep breathing that occur during exercise enhance the movement of fluid into the lymphatics. Exercise should be carefully planned and monitored, and should be conducted when bandages or compression garments are applied.
Compression helps to reduce the lymphatic vessels, thereby improving their function. The treating specialist may use compression in the form of bandaging and/or garments
Low stretch bandages are applied in combination with special padding to distribute the pressure over body prominences. Low stretch bandages are chosen in preference to high stretch because they maintain a low resting pressure for comfort and a high working pressure to improve flow in deeper lymph vessels. Low stretch bandaging, when expertly applied, is an important component of treatment, however it can be ineffective or dangerous if it is not carried out by trained therapists.
Low stretch garments with graduated compression maintain the reduction achieved by treatment. Patients should be measured for garments when their limb size has plateaued (evened out) during treatment. Patients will receive either ready-made or custom-made garments, depending on their condition, degree of compression required, age, independence and lifestyle. There are several suppliers of both ready-made and custom garments.
This is another method of compression therapy, which uses pneumatic compression devices called "sleeves". Whilst effective in reducing the size of the swelling, this form of therapy has limited effect on
protein reabsorption. As such, manual lymphatic stimulation and drainage must be used prior to pneumatic compression.
In the early stages of lymphoedema, elevation of the affected limb is useful in reducing swelling. However, it has limited usage for more advanced cases and must be used in combination with the other therapeutic techniques.
Experimental treatment using Helium Neon and Gallium Arsonide lasers has been shown to stimulate lymph vessel regrowth and activity. Further research into this form of therapy is necessary.
There are several components to the pharmacological management of lymphoedema. They are:
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diuretics |
| benzopyrones |
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antibiotics |
Although useful during the early stages of lymphoedema treatment, long term use of diuretics is discouraged.
These operate by stimulating the lymphatic system into breaking down excess protein. Although effective in combination with other therapies, there are a number of serious potential side-effects. These side-effects include severe liver injury, mild nausea and diarrhoea. Accordingly, benzopyrones should be used cautiously.
Antibiotics can be administered for the treatment of cellulitis and other complications of lymphoedema.
Issues relating to disease progression, body
image, self-esteem and depression often arise in cases of lymphoedema.
Counselling and psychological support are important in your treatment and there are support groups run by the Lymphoedema Association of Queensland if you wish to speak to others with the condition.
Your specialist should be able to give you the name of a qualified therapist or the lymphoedema association in your state will have a list of therapists.
There are several operative techniques designed to improve lymphoedema, however, surgery should only be considered if complex lymphatic therapy (CLT) fails to achieve satisfactory results. In addition, surgery damages the superficial lymphatic vessels which reduces the efficiency and worth of later CLT. Examples of operative techniques include:
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Debulking surgery, which involves the removal of excess skin and tissue |
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Liposuction, although it is generally discouraged as not only does it damage the superficial lymphatic vessels but must be periodically repeated as results are typically temporary. |
There are also certain physiologic procedures that promote the return of lymph to the blood circulation by a variety of microsurgical techniques.
Some of the information provided in the above text has been reproduced, with permission, from a booklet titled "A Swollen Limb - What is Lymphoedema?" produced by Jobst Biersdorf and written by Sandra King, Occupational Therapist, Jobst Education Co-ordinator, Biersdorf Australia and Anne Fletcher, RN, State Co-ordiantor (Qld), Breast Cancer Support Service, Qld Cancer Fund.
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