Greater Manchester Cancer Lymphoedema in Prehab 4 Cancer

Greater Manchester Cancer Lymphoedema in Prehab 4 Cancer Karen Livingstone Macmillan Clinical lead Macmillan GMC Lymphoedema Programme

Greater Manchester Cancer What is Lymphoedema? Lymphoedema is the build up of excess protein-rich fluid in body tissues due to lymphatic insufficiency or obstruction of lymphatic drainage back into the blood stream(1) Lymphoedema may affect 1 or more limbs and corresponding quadrants of the trunk, face, breast and genitals. Lymphoedema of more than 3 months and is essentially incurable. Affects 6. 4 in every 1000(2) population Primary from birth or congenital Secondary which occurs as a result of an external event or trauma to the lymphatic system

Greater Manchester Cancer Anatomy of the lymphatics Made up of superficial primary vessels with no muscular wall or valves and deeper secondary valved lymph vessels which aid unidirectional lymph flow Feed into lymph nodes (glands) Situated throughout the body. Lymph is a clear to white liquid Lymph transported through arterial system across the interstitial tissues and most transported away via the lymphatics and into the venous system

Greater Manchester Cancer Role of the lymphatic system • Integral to the immune system • Defence mechanism against bacteria and mutant cells • Drains and transports ‘waste materials’ from interstitial tissues to the blood stream, including cell products such as protein water and fat

Greater Manchester Cancer Incidence of Lymphoedema in Cancer 25% Breast - 80% in first 3 years 30% Gynaecology 40% Urology 75% Head and Neck 31% Melanoma (3)

Greater Manchester Cancer Causes of Cancer-related Lymphoedema Cancer treatment Site and stage of tumour Surgery – lymph node removal complex scarring, seroma, infection Chemotherapy Radiotherapy ? Genetic component

Greater Manchester Cancer Comorbitities • • • Obesity Venous disease Age Previous cellulitis Immobility http: //wales. gov. uk

Greater Manchester Cancer Development of lymphoedema • Initially slight • Feeling of tension, heaviness, tightness • Observable swelling • Tissues soft and pitting • Uneven distribution • Limb or root of limb, face and trunk • Inflammation • Worse as day progresses or after activity unless H&N Courtesy MFT

Greater Manchester Cancer Treatments Supported self management Specialist intervention Skin Care Exercise Assessment Education Support Simple Lymph Drainage Compression Courtesy MFT

Greater Manchester Cancer Infection - cellulitis • More common following trauma to lymphatics • Important to catch it early to prevent further damage to drainage routes Signs and Symptoms Area becomes red, hot, increased swelling, increased tenderness. May be accompanied by flu-like symptoms, fever, headache or vomiting Same day antibiotics are required

Greater Manchester Cancer Safe to Exercise? Yes Evidence shows physical exercise and resistance training do not increase the risk of developing lymphedema (4) BUT -Think lymphatics ! Recurrent seroma? Wounds? Start low level exercise as advised Slow progressive increase after treatment

Greater Manchester Cancer Safe to Exercise? • Ideally working proximately to distally, combination of stretches, aerobic and strengthening exs • Progressive time/intensity • Slowly introduce prolonged isometric exercise • No maximum weight limit as long as patient is free of symptoms • Compression garments should be worn when exercising if prescribed • Feed back from the limb – ‘what exercise it likes and what it doesn’t’(5) • Pts with compression garments must wear them to exercise in.

Greater Manchester Cancer Could there be symptoms of lymphoedema? Rule out DVT or infection If lymphoedema suspected refer to CNS, Oncology team, GP Early intervention is key Encourage skin care, and encourage pt to elevate Adapt exercises regime

Greater Manchester Cancer Finally ‘Its just a bit of swelling…………’ Please don’t ignore it. Remember early intervention is vital.

References 1. International Society of Lymphology. The diagnosis and treatment of peripheral lymphoedema: 2013 Consensus Document of the International Society of Lymphology. 2013: 46(1): 1 -11 2. Welsh Assembly Government (2009) Strategy for Lymphoedema in Wales: Designed for Lymphoedema. Available at http: //gov. wales/docs/dhss/publications/091208/lymphoedemastrategyforwales. pdf 3 Commissioning Guidance for Lymphoedema Services for Adults in the United Kingdom. The National Lymphoedema Partnership March 2019 4. Rehabilitation of Cancer Survivors with Long-Term Toxicities Oncol Res Treat. 2017; 40(12): 764 -771. doi: 10. 1159/000485187. Epub 2017 Nov 29. 5. Lets Talk Lymphoedema. Mortimer and Lavine 2017. ISBN: 978 -1 -78396 -285 -3. Elliott and Thompson Ltd. Wwweandtbooks. com