History

Fact Explanation
Introduction Lymphoedema is a condition associated with collection of lymphatic fluid due to damage/ obstruction of lymphatic vessels causing inadequate drainage. This leads to localized fluid collection finally leading to tissue swelling. In postmastectomy lymphoedema syndrome, there will be lymphoedema of the surgery side of the upper limb following damage to the lymphatic vessels either during surgery, with fibrous formation in healing[3][4].
Swelling of the arm Patient will complain of gradually increasing swelling of the upper limb at the site of surgery. This may involve the whole hand up to shoulder. they will have experienced gradual tghtening of cloths/ or jeweleries like watches/ rings[3][4].
Fullness/ heaviness of the hand With the lymph oedema patient will feel fullness/ heaviness of the hand[3][4].
Shining and tightening of the skin Patients skin will tighten and stretched causing shine. So patient will feel hardness while touching the hand and with the time skin colour will change[3][5].
Reduction in hand movements/ discomfort during moving the hand With the swelling movements of the upper limb will reduce and there will be some discomfort while trying to move the limb[3][6].
Aching pain/ weakness of the limb With the soft tissue swelling there will be increased pressure over the intra limb structures. So nerves can get compress causing ache/ weakness of the limb[3][7].
Past history or history of recent onset fever, malise, nausea, vomiting and pain, swelling, redness, warmth of the affected limb Patients with lymphoedema are at risk of developing recurrent cellulitis attacks. These patients will usually have a history of recent trauma to the skin[7][8].
Chronic ulcers Patient can develop repeated trauma of the hand with stretched, swollen skin. Also they are at risk of poor healing the previously developed ulcers due to poor blood supply for healing, Also pooling of the lymph will produce a good culture media for organisms to grow[9].
Sudden onset severe pain, swelling, redness of the limb These patients are at risk of developing deep vein thrombosis. They may present with features of pulmonary embolism (sudden onset shortness of breath, chest pain, cough, wheezing, haemoptysis) as well[10][11].
History of loss of weight, loss of appetite, malaise, lethary and abnormal growth/ discoloration of the skin in affected limb. With the long term lympoedema patients can develop carcinomas like lymphangiosarcoma, squamous cell carcinoma, malignant melanoma, basal cell carcinoma and Kaposi's sarcoma[1][2].
history of mastectomy surgery This will include the type of surgery and duration of it and other treatment modalities associated with the surgery. There are various types of surgical approaches which can leads to development of post mastectomy lymphoedema. eg: 1) simple mastectomy with axillary lymph node removal 2) lumpectomy of the breast with axillary lymph node removal 3) modified radical mastectomy with axillary lymph node removal Combination of radiotherapy to lymph nodes with the surgery will increase the incidence of developing lymphoedema, When considering the duration from the surgery with the time of development of lymphoedema, Patient can develop it with in days, months or years after surgery. This will depend on the type of surgery and preventive practices of the patient[12][13].
Social history In this section, patient's occupation (eg; if the patient is engage in fine works like sewing patient will feel difficulty in continuing it with lymphoedema), educational level ( this will helpful in educating the patient regarding the condition, prevention of lympoedema and prevention of complications) , echonomocal status ( with the echonomical level will able to modify the patient's life style. Eg: if the patient is the bread winner of the family and engage in activities with high risk we can only advice regarding protective measures), level of limitations to daily activities ( eg: can Identify the areas which patient can not involve in and help with occupational therapy) need to be considered. These information will help for the individual management plan[3][4].
History suggestive of breast cancer complications 1)Respiratory complications suggestive of pleuritic type chest pain, haemoptysis, dyspnoea. 2) Central nervous system complications suggestive of headache, nausea/ vomiting, seizures, body weakness, paresthesia 3) Bony complications suggestive of intractable severe back pain. 4) liver metastesis suggestive of loss of appetite, yellowish discoloration of eyes, body swelling, abdominal distension[14][15]
History of other causes which leads to secondary lumphpoedema Need to ask about the possible aetiological causes for develpment of secondary lymphoedema like trauma to the affected limb/ scarring, past history of burns, history of chronic large wounds, pimary cancers which can cause lymphatic metastases/ Lymphoma, chronic venous insufficiency, intravenous drug use, recurrent infection of cellulitis/erysipelas/ Lymphadenitis, history of tuberculosis[16][17][18].
History of possible trauma to the hand History of accidental cannulation, vaccination, giving injections, blood drawing and blood pressure monitoring from the susceptible hand following mastectomy is important as it can complicated with lymphoedema[3].
References
  1. BARNETT WO, HARDY JD, HENDRIX JH. Lymphangiosarcoma following post-mastectomy lymphedema. Ann Surg [online] 1969 Jun, 169(6):960-968 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1387587
  2. MARSHALL JF. Lymphangiosarcoma of the Arm Following Radical Mastectomy Ann Surg [online] 1955 Nov, 142(5):871-874 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1465017
  3. CEMAL Y, PUSIC A, MEHRARA BJ. Preventative measures for lymphedema: Separating fact from fiction J Am Coll Surg [online] 2011 Oct, 213(4):543-551 [viewed 31 October 2014] Available from: doi:10.1016/j.jamcollsurg.2011.07.001
  4. LOUDON A, BARNETT T, PILLER N, IMMINK MA, VISENTIN D, WILLIAMS AD. The effect of yoga on women with secondary arm lymphoedema from breast cancer treatment BMC Complement Altern Med [online] :66 [viewed 31 October 2014] Available from: doi:10.1186/1472-6882-12-66
  5. FU MR, ROSEDALE M. Breast Cancer Survivors' Experiences of Lymphedema-Related Symptoms J Pain Symptom Manage [online] 2009 Dec, 38(6):849-859 [viewed 31 October 2014] Available from: doi:10.1016/j.jpainsymman.2009.04.030
  6. TILLEY A, THOMAS-MACLEAN R, KWAN W. Lymphatic cording or axillary web syndrome after breast cancer surgery Can J Surg [online] 2009 Aug, 52(4):E105-E106 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724805
  7. SHIN BW, SIM YJ, JEONG HJ, KIM GC. Lipedema, a Rare Disease Ann Rehabil Med [online] 2011 Dec, 35(6):922-927 [viewed 31 October 2014] Available from: doi:10.5535/arm.2011.35.6.922
  8. CONNOR MP, GAMELLI R. Challenges of cellulitis in a lymphedematous extremity: a case report Cases J [online] :9377 [viewed 31 October 2014] Available from: doi:10.1186/1757-1626-2-9377
  9. SPENTZOURIS G, LABROPOULOS N. The Evaluation of Lower-Extremity Ulcers Semin Intervent Radiol [online] 2009 Dec, 26(4):286-295 [viewed 31 October 2014] Available from: doi:10.1055/s-0029-1242204
  10. GORMAN WP, DAVIS KR, DONNELLY R. Swollen lower limb: general assessment and deep vein thrombosis West J Med [online] 2001 Feb, 174(2):132-136 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071280
  11. GORMAN WP, DAVIS KR, DONNELLY R. Swollen lower limb--1: General assessment and deep vein thrombosis BMJ [online] 2000 May 27, 320(7247):1453-1456 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127644
  12. TORRES LACOMBA M, YUSTE SáNCHEZ MJ, ZAPICO GOñI Á, PRIETO MERINO D, MAYORAL DEL MORAL O, CEREZO TéLLEZ E, MINAYO MOGOLLóN E. Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial BMJ [online] 2010:b5396 [viewed 31 October 2014] Available from: doi:10.1136/bmj.b5396
  13. FULFORD D, DALAL S, WINSTANLEY J, HAYTON MJ. Hand surgery after axillary lymph node clearance for breast cancer: contra-indication to surgery? Ann R Coll Surg Engl [online] 2010 Oct, 92(7):573-576 [viewed 31 October 2014] Available from: doi:10.1308/003588410X12699663904475
  14. BOSTWICK J 3RD, PALETTA C, HARTRAMPF CR. Conservative treatment for breast cancer. Complications requiring reconstructive surgery. Ann Surg [online] 1986 May, 203(5):481-490 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1251149
  15. WELTZ CR, GREENGRASS RA, LYERLY HK. Ambulatory surgical management of breast carcinoma using paravertebral block. Ann Surg [online] 1995 Jul, 222(1):19-26 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1234750
  16. SABAGEH D, OGUNTOLA AS, OGUNTOLA AM, BAJOWA OO. Incidental detection of microfilariae in a lymph node aspirate: A case report Niger Med J [online] 2014, 55(5):438-440 [viewed 01 November 2014] Available from: doi:10.4103/0300-1652.140392
  17. CHEIFETZ O, HALEY L, BREAST CANCER ACTION. Management of secondary lymphedema related to breast cancer Can Fam Physician [online] 2010 Dec, 56(12):1277-1284 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001918
  18. BAE H, KIM HJ. Clinical Outcomes of Extracorporeal Shock Wave Therapy in Patients With Secondary Lymphedema: A Pilot Study Ann Rehabil Med [online] 2013 Apr, 37(2):229-234 [viewed 01 November 2014] Available from: doi:10.5535/arm.2013.37.2.229

Examination

Fact Explanation
General examination General examination for pallor( anemia with breast carcinoma), hydration, nutritional status of the patient, BMI, presence of low mood/ depresssion.
Examination of the limb for the presence of lymphoedema Inspection; inspection for lymphoedema, extension of swelling, skin discoloration/ dryness/ scaling, skin changes like peau d'orange appearance, range of movements. Inspection of the surgical scar need to be done. look for evidence of cannulation & blood drawing, from the affected limb following mastectomy. Palpation: Tenderness with swelling, sensation of the limb. check the ability of pinching the skin( in lymphoedema this is difficut to do). Pulse should be examined [3][4][5][6][7].
Inspection for complications Look for infections: In cellulitis patient will be febrile, limb examination will reveals swelling, warmth, tenderness and presence of skin abrasions/ ulcers. Skin folds and in-between fingers need to be examined for fungal infections[5][9]. Look for chronic ulcers: examined the ulcer (site, edges, base) and surrounding area[10]. Look for the evidence of deep vein thrombosis; examine the limb for swelling, warmth, severe tenderness, limited movements[8][11]. Look for evidence of skin neoplasm: examined for abnormal growth, skin discoloration, in chronic ulcer presence need to examine the edges for evertion[12][13].
Examintion for complications of breast carcinoma Examine systems for distal metastases, 1)contralateral breast for lumps, ulcers, abnormal discharges from nipple 2) respiratory system for blood stained sputum, pleural effusion 3) central nervous system for development of seizures, focal neurological signs 4) abdominal examination for jaundice, hepatomegaly, ascites. 5) examine the back for tenderness and scalp for pulsatile lumps. [1][2]
References
  1. Complications requiring reconstructive surgery. Ann Surg [online] 1986 May, 203(5):481-490 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1251149
  2. WELTZ CR, GREENGRASS RA, LYERLY HK. Ambulatory surgical management of breast carcinoma using paravertebral block. Ann Surg [online] 1995 Jul, 222(1):19-26 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1234750
  3. CEMAL Y, PUSIC A, MEHRARA BJ. Preventative measures for lymphedema: Separating fact from fiction J Am Coll Surg [online] 2011 Oct, 213(4):543-551 [viewed 31 October 2014] Available from: doi:10.1016/j.jamcollsurg.2011.07.001
  4. TILLEY A, THOMAS-MACLEAN R, KWAN W. Lymphatic cording or axillary web syndrome after breast cancer surgery Can J Surg [online] 2009 Aug, 52(4):E105-E106 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724805
  5. SHIN BW, SIM YJ, JEONG HJ, KIM GC. Lipedema, a Rare Disease Ann Rehabil Med [online] 2011 Dec, 35(6):922-927 [viewed 31 October 2014] Available from: doi:10.5535/arm.2011.35.6.922
  6. FU MR, ROSEDALE M. Breast Cancer Survivors' Experiences of Lymphedema-Related Symptoms J Pain Symptom Manage [online] 2009 Dec, 38(6):849-859 [viewed 31 October 2014] Available from: doi:10.1016/j.jpainsymman.2009.04.030
  7. LOUDON A, BARNETT T, PILLER N, IMMINK MA, VISENTIN D, WILLIAMS AD. The effect of yoga on women with secondary arm lymphoedema from breast cancer treatment BMC Complement Altern Med [online] :66 [viewed 31 October 2014] Available from: doi:10.1186/1472-6882-12-66
  8. GORMAN WP, DAVIS KR, DONNELLY R. Swollen lower limb--1: General assessment and deep vein thrombosis BMJ [online] 2000 May 27, 320(7247):1453-1456 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127644
  9. CONNOR MP, GAMELLI R. Challenges of cellulitis in a lymphedematous extremity: a case report Cases J [online] :9377 [viewed 31 October 2014] Available from: doi:10.1186/1757-1626-2-9377
  10. SPENTZOURIS G, LABROPOULOS N. The Evaluation of Lower-Extremity Ulcers Semin Intervent Radiol [online] 2009 Dec, 26(4):286-295 [viewed 31 October 2014] Available from: doi:10.1055/s-0029-1242204
  11. GORMAN WP, DAVIS KR, DONNELLY R. Swollen lower limb: general assessment and deep vein thrombosis West J Med [online] 2001 Feb, 174(2):132-136 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071280
  12. BARNETT WO, HARDY JD, HENDRIX JH. Lymphangiosarcoma following post-mastectomy lymphedema. Ann Surg [online] 1969 Jun, 169(6):960-968 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1387587
  13. MARSHALL JF. Lymphangiosarcoma of the Arm Following Radical Mastectomy Ann Surg [online] 1955 Nov, 142(5):871-874 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1465017

Differential Diagnoses

Fact Explanation
Lymphoedema due to other causes Primary lympoedema usually occur due to an abnormal development of the lymphatic vessels. This is usually occur at early ages of life. No secondary cause can be identified. Secondary lymphoedema can occur due to various reasons like infections (filariasis), carcinoma (following nodal metastases), surgical procedures, trauma. These reasons can be differentiate from Postmastectomy lymphoedema syndrome as this is clearly develop following the surgery for breast carcinoma[1][2].
Limb infections like cellulitis, erysipelas Isolated Infections of the hand will present with limb swelling. But these will associated with the fever, constitutional symptoms, inflammatory changes at the site of infection. Commonly there will be history of breaching the skin which act as an entry point for the infections. Basic investigations like FBC, ESR/CRP will also differentiate the both conditions as infection is associated with high WBC counts and inflammatory markers[3][4].
Isolated Deep vein thrombosis of the upper limb This will be an acute presentation with severe pain, swelling and limitation of the limb. But the development of lympoedema will be gradual and progressive. D dimers and doppler scan will confirm the diagnosis[5][6].
Systemic diseases causing limb swelling Systemic causes like renal failure, liver failure and heart failure will develop generalized body swelling. But all of these conditions patient will not develop isolate single limb swelling and they will have separate symptoms according to the disease. eg: renal failure- anaemia, reduced urine output liver failure- jaundice, ascites, easy bruising heart failure- exercise intolerance, gallop rhythm on auscultation[7][8]
Lipoedema This is a bilateral symmetrical condition commonly occur in women resulting from fatty obliteration of lymphatics and lymph nodes. This will not give skin changes like in lymphoedema and Magnetic resonance imaging will help to differentiate the two conditions[9][10].
References
  1. PEREIRA DE GODOY JM, AZOUBEL LM, DE FáTIMA GUERREIRO DE GODOY M. INTENSIVE TREATMENT OF LEG LYMPHEDEMA Indian J Dermatol [online] 2010, 55(2):144-147 [viewed 31 October 2014] Available from: doi:10.4103/0019-5154.62745
  2. DALE RF. Primary lymphoedema when found with distichiasis is of the type defined as bilateral hyperplasia by lymphography. J Med Genet [online] 1987 Mar, 24(3):170-171 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1049951
  3. U.K DERMATOLOGY CLINICAL TRIALS NETWORK'S PATCH TRIAL TEAM. Prophylactic antibiotics for the prevention of cellulitis (erysipelas) of the leg: results of the U.K. Dermatology Clinical Trials Network's PATCH II trial Br J Dermatol [online] 2012 Jan, 166(1):169-178 [viewed 31 October 2014] Available from: doi:10.1111/j.1365-2133.2011.10586.x
  4. COX NH, COLVER GB, PATERSON WD. Management and morbidity of cellulitis of the leg. J R Soc Med [online] 1998 Dec, 91(12):634-637 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1296982
  5. Prophylaxis of venous thrombosis. Br Med J [online] 1971 Feb 6, 1(5744):305-306 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1794881
  6. BROZOVIć M. Mechanisms of deep vein thrombosis: a review. J R Soc Med [online] 1979 Aug, 72(8):602-605 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1436915
  7. ANAND IS, CHANDRASHEKHAR Y, FERRARI R, POOLE-WILSON PA, HARRIS PC. Pathogenesis of oedema in chronic severe anaemia: studies of body water and sodium, renal function, haemodynamic variables, and plasma hormones. Br Heart J [online] 1993 Oct, 70(4):357-362 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1025332
  8. PASCHOS P, PALETAS K. Non alcoholic fatty liver disease and metabolic syndrome Hippokratia [online] 2009, 13(1):9-19 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2633261
  9. SHIN BW, SIM YJ, JEONG HJ, KIM GC. Lipedema, a Rare Disease Ann Rehabil Med [online] 2011 Dec, 35(6):922-927 [viewed 31 October 2014] Available from: doi:10.5535/arm.2011.35.6.922
  10. DE GODOY JM, BARUFI S, GODOY MD. Lipedema: Is Aesthetic Cellulite an Aggravating Factor for Limb Perimeter? J Cutan Aesthet Surg [online] 2013, 6(3):167-168 [viewed 31 October 2014] Available from: doi:10.4103/0974-2077.118431

Investigations - for Diagnosis

Fact Explanation
Lymphangiography With this investigation lumphatic vessels and lymph nodes can be identify with a contrast imaging. This is the gold standered method of diagnosis and it will help to identify abnormalities of the vascular tree[1][2].
Isotope lymphoscintigraphy This test give an idea about the quality of lymphatic drainage. In this test serial images are taken after injecting a radioactive technetium-labelled protein or colloid particles to the lumphatic system[3][4].
Computerised tomography/ Magnetic resonance imaging These imaging tests are useful in diagnosing as well as excluding other possible causes such as venous conditions, soft tissue/ muscle lesions and lipoedema[5][6].
blood smear for microfilariae and urine for Chyluria This is to diagnosed filariasis and useful in excluding the other secondary causes of lympoedema[7][8].
References
  1. BENSON PF, GOUGH MH, POLANI PE. Lymphangiography and Chromosome Studies in Females with Lymphoedema and Possible Ovarian Dysgenesis Arch Dis Child [online] 1965 Feb, 40(209):27-32 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2019268
  2. KINMONTH JB. Lymphangiography in Clinical Surgery and Particularly in the Treatment of Lymphoedema: Hunterian Lecture delivered at the Royal College of Surgeons of England on 25th March 1954 Ann R Coll Surg Engl [online] 1954 Nov, 15(5):300-315 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2377819
  3. BECKER C, ASSOUAD J, RIQUET M, HIDDEN G. Postmastectomy Lymphedema: Long-term Results Following Microsurgical Lymph Node Transplantation Ann Surg [online] 2006 Mar, 243(3):313-315 [viewed 31 October 2014] Available from: doi:10.1097/01.sla.0000201258.10304.16
  4. KAARTHIGEYAN K, RAMPRAKASH M, KALPANA G. Distichiasis-lymphedema syndrome with optic disc pit Indian J Ophthalmol [online] 2011, 59(1):71-72 [viewed 31 October 2014] Available from: doi:10.4103/0301-4738.73703
  5. MIHARA M, HARA H, ARAKI J, KIKUCHI K, NARUSHIMA M, YAMAMOTO T, IIDA T, YOSHIMATSU H, MURAI N, MITSUI K, OKITSU T, KOSHIMA I. Indocyanine Green (ICG) Lymphography Is Superior to Lymphoscintigraphy for Diagnostic Imaging of Early Lymphedema of the Upper Limbs PLoS One [online] , 7(6):e38182 [viewed 31 October 2014] Available from: doi:10.1371/journal.pone.0038182
  6. LEE BB, LAREDO J, NEVILLE R. Current Status of Lymphatic Reconstructive Surgery for Chronic Lymphedema: It Is Still an Uphill Battle! Int J Angiol [online] 2011 Jun, 20(2):73-80 [viewed 31 October 2014] Available from: doi:10.1055/s-0031-1279685
  7. PANTOLA C, KALA S, AGARWAL A, KHAN L. Microfilaria in cytological smears at rare sites coexisting with unusual pathology: A series of seven cases Trop Parasitol [online] 2012, 2(1):61-63 [viewed 01 November 2014] Available from: doi:10.4103/2229-5070.97244
  8. SABAGEH D, OGUNTOLA AS, OGUNTOLA AM, BAJOWA OO. Incidental detection of microfilariae in a lymph node aspirate: A case report Niger Med J [online] 2014, 55(5):438-440 [viewed 01 November 2014] Available from: doi:10.4103/0300-1652.140392

Investigations - Fitness for Management

Fact Explanation
FBC This will be useful in looking for platelet count, haemoglobin level and WBC count when preparing the patient for invasive procedures and surgeries. Also haemoglobin level will give evidence of any ongoing anaemia which need to be correct to heal ulcers if any. As chemotherapy can cause pancytopenia FBC will help to look for the chemotherapy complications[1][2][15][16].
ESR/ CRP These inflammatory markers will give evidence regarding any ongoing inflammation[3][4].
Renal function tests like serum electrolylres, serum creatinine, blood urea Assessment of the renal function of the patient is useful during invasive investigations and treatments. Also this is useful in excluding associated underlying renal disease as it can cause limb oedema [5].
Liver function tests including AST, ALT, total protein level This also useful in assessing the live function of the patient[6].
ECG/ echocardiogram These will be helpful in pre-operative fitness assessment specially in elderly population[7].
Chest X ray This will give an idea about lung status and this use before surgical procedures to assess the fitness[1][8][9].
Clotting profile with PT/ INR, APTT These test also useful to assess the clotting status of the patient[8][10].
thyroid function test including free T4 and TSH These will assess the thyroid status of the patient and it will exclude any associated hypothyroidism which causes myxoedema[11][12].
Fasting blood sugar This will assess the blood sugar levels of the patient as in diabetes patients are at risk of getting fungal infections and recurrent cellulitis[13][14].
FSH, LH levels As chemotherapy (for breast cancer) can cause ovarian failure in these patients these hormonal test will be useful in assessing the ovarian function[15][16].
Nerve conduction studies Chemotherapy (eg; paclitaxel and cisplatin) can cause neurological complications such as peripheral neuropathy[15][16].
References
  1. SIDDIQ I, HUGHES D. Yellow nails, lymphedema and chronic cough: Yellow nail syndrome in an eight-year-old girl Can Respir J [online] 2012, 19(1):35-36 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299040
  2. CEBECI F, CELEBI M, ONSUN N. Nonclassical yellow nail syndrome in six-year-old girl: a case report Cases J [online] :165 [viewed 31 October 2014] Available from: doi:10.1186/1757-1626-2-165
  3. HANSSON E, SVENSSON H, BRORSON H. Review of Dercum's disease and proposal of diagnostic criteria, diagnostic methods, classification and management Orphanet J Rare Dis [online] :23 [viewed 31 October 2014] Available from: doi:10.1186/1750-1172-7-23
  4. PARK JY, KANG HY, KIM YC. Neutrophilic Dermatosis Confined to the Lymphedematous Area Ann Dermatol [online] 2014 Jun, 26(3):411-413 [viewed 31 October 2014] Available from: doi:10.5021/ad.2014.26.3.411
  5. SPENTZOURIS G, LABROPOULOS N. The Evaluation of Lower-Extremity Ulcers Semin Intervent Radiol [online] 2009 Dec, 26(4):286-295 [viewed 31 October 2014] Available from: doi:10.1055/s-0029-1242204
  6. CHOI I, LEE S, HONG YK. The New Era of the Lymphatic System: No Longer Secondary to the Blood Vascular System Cold Spring Harb Perspect Med [online] 2012 Apr, 2(4):a006445 [viewed 31 October 2014] Available from: doi:10.1101/cshperspect.a006445
  7. FELCHT M, DIKOW N, GOEBELER M, STROEBEL P, BOOKEN N, VOßMERBäUMER U, MERX K, HENZLER T, MARX A, MOOG U, GOERDT S, KLEMKE CD. Warty skin changes, chronic scrotal lymphoedema, and facial dysmorphism BMJ Case Rep [online] :bcr08.2009.2214 [viewed 31 October 2014] Available from: doi:10.1136/bcr.08.2009.2214
  8. ABDELGADIR EI, BASHIER AM, AL HAMEEDI IA, ABDULAZIZ A, ABUELKHEIR S, ALAWADI F. Peri-portal lymphedema in association with an acute adrenal insufficiency: case report J Med Case Rep [online] :98 [viewed 31 October 2014] Available from: doi:10.1186/1752-1947-8-98
  9. SUZUKI M, YOSHIZAWA A, SUGIYAMA H, ICHIMURA Y, MORITA A, TAKASAKI J, NAKA G, HIRANO S, IZUMI S, TAKEDA Y, HOJI M, KOBAYASHI N, KUDO K. A Case of Yellow Nail Syndrome with Dramatically Improved Nail Discoloration by Oral Clarithromycin Case Rep Dermatol [online] , 3(3):251-258 [viewed 31 October 2014] Available from: doi:10.1159/000334734
  10. MORRIS RJ, WOODCOCK JP. Evidence-Based Compression: Prevention of Stasis and Deep Vein Thrombosis Ann Surg [online] 2004 Feb, 239(2):162-171 [viewed 31 October 2014] Available from: doi:10.1097/01.sla.0000109149.77194.6c
  11. HEINRICH TW, GRAHM G. Hypothyroidism Presenting as Psychosis: Myxedema Madness Revisited Prim Care Companion J Clin Psychiatry [online] 2003, 5(6):260-266 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419396
  12. EVANS RJ, SCILLEY C. Massive localized lymphedema: A case series and literature review Can J Plast Surg [online] 2011, 19(3):e30-e31 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3269338
  13. LIN CT, OU KW, CHANG SC. Diabetic Foot Ulcers Combination with Lower Limb Lymphedema Treated by Staged Charles Procedure: Case Report and Literature Review Pak J Med Sci [online] 2013, 29(4):1062-1064 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3817756
  14. KESER I, BASAR S, DUZGUN I, GUZEL NA. Malpractice Leading to Secondary Lymphedema after Radical Mastectomy: Case Report Breast Care (Basel) [online] 2013 Oct, 8(5):371-373 [viewed 31 October 2014] Available from: doi:10.1159/000354578
  15. PALMER BV, WALSH GA, MCKINNA JA, GREENING WP. Adjuvant chemotherapy for breast cancer: side effects and quality of life. Br Med J [online] 1980 Dec 13, 281(6255):1594-1597 [viewed 02 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1715090
  16. MACQUART-MOULIN G, VIENS P, BOUSCARY ML, GENRE D, RESBEUT M, GRAVIS G, CAMERLO J, MARANINCHI D, MOATTI JP. Discordance between physicians' estimations and breast cancer patients' self-assessment of side-effects of chemotherapy: an issue for quality of care. Br J Cancer [online] 1997, 76(12):1640-1645 [viewed 02 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2228193

Investigations - Followup

Fact Explanation
Fasting blood sugar This useful in assessing the blood sugar levels/ blood sugar control as uncontrolled diabetes patients are at risk of getting recurrent cellulitis attacks and fungal infections[1][2].
D dimer level This also importamt in assessing the presence of deep vein thrombosis and risk of developing pulmonary embolism[3][4].
Doppler studies/ Ultrsound scan These imaging studies will assess the presence of possible complications such as deep vein thrombosis and also exclude any co existing venous insufficiency which can lead to lymphoedema[5][6].
CT pulmonary angiography This is the diagnostic test in pulmonary embolism. This will be useful during follow up as these patient are at risk[7][8].
Swab from ulcers for culture and ABST If chronic ulcers are present with signs of infection, this test will be useful to diagnose the causative agent[9][10].
Regular breat scans ( in contralateral side), bone scans, CT brain, Ultrasound scan of the abdomen These various types of investigations will useful in a patient with history of breast carcinoma to assess the presence of secondary metastases[11][12].
Biopsy from suspected growths/ ulcer edges Histological diagnosis will confirm the associated malignancies (eg; melanoma, basal cell carcinoma, squamous cell carcinoma).
References
  1. LIN CT, OU KW, CHANG SC. Diabetic Foot Ulcers Combination with Lower Limb Lymphedema Treated by Staged Charles Procedure: Case Report and Literature Review Pak J Med Sci [online] 2013, 29(4):1062-1064 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3817756
  2. DUPUY A, BENCHIKHI H, ROUJEAU JC, BERNARD P, VAILLANT L, CHOSIDOW O, SASSOLAS B, GUILLAUME JC, GROB JJ, BASTUJI-GARIN S. Risk factors for erysipelas of the leg (cellulitis): case-control study BMJ [online] 1999 Jun 12, 318(7198):1591-1594 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC28138
  3. AY C, DUNKLER D, PIRKER R, THALER J, QUEHENBERGER P, WAGNER O, ZIELINSKI C, PABINGER I. High D-dimer levels are associated with poor prognosis in cancer patients Haematologica [online] 2012 Aug, 97(8):1158-1164 [viewed 31 October 2014] Available from: doi:10.3324/haematol.2011.054718
  4. DIRIX LY, SALGADO R, WEYTJENS R, COLPAERT C, BENOY I, HUGET P, VAN DAM P, PROVé A, LEMMENS J, VERMEULEN P. Plasma fibrin D-dimer levels correlate with tumour volume, progression rate and survival in patients with metastatic breast cancer Br J Cancer [online] 2002 Feb 1, 86(3):389-395 [viewed 31 October 2014] Available from: doi:10.1038/sj.bjc.6600069
  5. MANDAVA A, RAVURI PR, KONATHAN R. High-resolution ultrasound imaging of cutaneous lesions Indian J Radiol Imaging [online] 2013, 23(3):269-277 [viewed 31 October 2014] Available from: doi:10.4103/0971-3026.120272
  6. MONTGOMERY LD, DIETRICH MS, ARMER JM, STEWART BR, RIDNER SH. Segmental Blood Flow and Hemodynamic State of Lymphedematous and Nonlymphedematous Arms Lymphat Res Biol [online] 2011 Mar, 9(1):31-42 [viewed 31 October 2014] Available from: doi:10.1089/lrb.2010.0012
  7. SOYE JA, LOUGHREY CB, HANLEY PD. Computed Tomography Pulmonary Angiography: A Sample of Experience at a District General Hospital Ulster Med J [online] 2008 Sep, 77(3):175-180 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2604474
  8. HOGG K, BROWN G, DUNNING J, WRIGHT J, CARLEY S, FOEX B, MACKWAY‐JONES K. Diagnosis of pulmonary embolism with CT pulmonary angiography: a systematic review Emerg Med J [online] 2006 Mar, 23(3):172-178 [viewed 31 October 2014] Available from: doi:10.1136/emj.2005.029397
  9. LIN CT, OU KW, CHANG SC. Diabetic Foot Ulcers Combination with Lower Limb Lymphedema Treated by Staged Charles Procedure: Case Report and Literature Review Pak J Med Sci [online] 2013, 29(4):1062-1064 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3817756
  10. KARNASULA VM. Management of ulcers in lymphoedematous limbs Indian J Plast Surg [online] 2012, 45(2):261-265 [viewed 31 October 2014] Available from: doi:10.4103/0970-0358.101291
  11. COLEMAN RE, RUBENS RD. The clinical course of bone metastases from breast cancer. Br J Cancer [online] 1987 Jan, 55(1):61-66 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2001575
  12. ANDERS CK, CAREY LA. Biology, Metastatic Patterns, and Treatment of Patients with Triple-Negative Breast Cancer Clin Breast Cancer [online] 2009 Jun, 9(Suppl 2):S73-S81 [viewed 31 October 2014] Available from: doi:10.3816/CBC.2009.s.008

Investigations - Screening/Staging

Fact Explanation
Types of Post Surgical Lymphedema • Mild :- Occurs within a few days of surgery and resolves in short period of time. • Acute :- Appears after 4 to 6 weeks post surgery and is usually the more painful • Chronic (most common) :- Usually appears after 18 to 24 months post surgery and it is painless.[1][2]
Staging of lymphoedema according to The International Society of Lymphology Stage 0; A latent or subclinical state where swelling is not evident despite impaired lymph transport. Stage I; This represents early onset of the condition where there is an accumulation of tissue fluid with higher protein content, which subsides with limb elevation. The oedema may be pitting at this stage. Stage II; Limb elevation alone rarely reduces swelling and pitting is manifest. In later Stage II the limb may or may not pit as fat and fibrosis supervenes. Stage III; The tissue is hard (fibrotic) and pitting is absent. Skin changes such as thickening, hyperpigmentation, increased skin folds, fat deposits and warty overgrowth develop. Stage III encompasses lymphostatic elephantiasis. At this stage, the swelling is spontaneously irreversible and usually the limb(s) is very large.[3][4]
References
  1. PEREIRA DE GODOY JM, AZOUBEL LM, DE FáTIMA GUERREIRO DE GODOY M. INTENSIVE TREATMENT OF LEG LYMPHEDEMA Indian J Dermatol [online] 2010, 55(2):144-147 [viewed 01 November 2014] Available from: doi:10.4103/0019-5154.62745
  2. MILLER CL, SPECHT MC, SKOLNY MN, JAMMALLO LS, HORICK N, O’TOOLE J, COOPEY SB, HUGHES K, GADD M, SMITH BL, TAGHIAN AG. Sentinel lymph node biopsy at the time of mastectomy does not increase the risk of lymphedema: implications for prophylactic surgery Breast Cancer Res Treat [online] 2012 Oct, 135(3):781-789 [viewed 01 November 2014] Available from: doi:10.1007/s10549-012-2231-1
  3. LOUDON A, BARNETT T, PILLER N, IMMINK MA, WILLIAMS AD. Yoga management of breast cancer-related lymphoedema: a randomised controlled pilot-trial BMC Complement Altern Med [online] :214 [viewed 01 November 2014] Available from: doi:10.1186/1472-6882-14-214
  4. POP TB, KARCZMAREK-BOROWSKA B, TYMCZAK M, HAłAS I, BANAś J. The influence of Kinesiology Taping on the reduction of lymphoedema among women after mastectomy - preliminary study Contemp Oncol (Pozn) [online] 2014, 18(2):124-129 [viewed 01 November 2014] Available from: doi:10.5114/wo.2014.40644

Management - General Measures

Fact Explanation
Health education The patient should be thoroughly educated regarding the condition following the surgery. this should be included aetiology, prevention, complications associated with, early identification of complications, investigation and treatment options available[1][2].
Prevention of development of lymphoedema after mastectomy 1) Prevent infections As these patients are at high risk of getting infections( eg; following surgery, following chemo/radiotherapy) arm infections need to be identify and treat early. Arm should be inspect early, nails need to be cut but not too shortly. If early signs of infection is present oral antibiotics( penicillin) need to be given[6][7]. 2) Protect the limb from trauma The susceptible limb should be given more attention during works to prevent from trauma. high risk works/ work with sharp objects should be avoided. Giving Injections, blood drawing and cannula insertion need to be avoided. Tight clothing, jeweleries also need to be avoided. The susceptible limb should not use to measure blood pressure as well. Try to avoid hanging bags over the shoulder of the affected side[4]. 3) The limb should be keep clean and it should be prevent from drying and scaling. Moisturizing lotions can be use for this and this is very important in preventing limb from getting damage[8]. 4) regular physical exercise Arm should be keep elevated as much as possible as it will promote lymph drain alone the gravity. Heavy weight lifting should be avoided and can involved in regular light works[5]. 5) Maintain ideal body weight Patient should be advised to take balanced nutritious diet and need to maintain ideal body weight[4].
Prevention of development of complications with postmastectomy lymphoedema 1) Regular physical exercise Patient should advice to engage in regular, light physical exercise. This will improve lymph drain with active muscle pumping. Physiotherapist and occupational therapist can supervise the patient and teach about the effective exercises(eg; walking, swimming and cycling)[9]. 2) Maintain body weight this can be done with healthy dietary practices and regular physical exercise[4]. 3) Raising arm and manual drainage raising arm as much as possible, avid sleeping to the affected side for a long time and manual drainage of the lymph with other hand/ with the help of someone else will help to drain and prevent blocking the lymph. Using an arm pump will also help to improve the lymph drain[4][9]. 4) prevent and early identification of the infections These patients are at risk of getting recurrent cellulite attacks. So skin damage should be prevented and if damaged care need to be given to prevent it from contamination. Patients should be educated about symptoms of cellulitis (fever, malaise, vomiting, arm pain, swelling, warmth and redness). patients should be advised to take oral penicillin when getting the alarm of a infection and if the patient already developed cellulitis IV penicillin need to be given[10]. With long term lymphoedema, patient also at risk of developing fungal infections in bending sites, skin folds and in between fingers. So these places need to be examined regularly, keep dry and need to treat with tropical anti-fungals if infections are present. 5) Compression Bandage/ intermittent pneumatic compression therapy/ multilayer lymphedema bandaging/ elastic compression garments This also will useful in prevention of lymph congestion inside lymphatic vessels and promote draining. pressure grading bandages need to be use with maximum pressure at the tip of the fingers and gradually reducing tightness towards upward[11].
Prevent development of deep vein thrombosis. As these patients are at risk of developing deep vein thrombosis prophylactic measures need to be taken like early mobilization, pressure graded stockings/ pneumatic compression and low molecular weight heparin. Close monitoring should be done to identify early[3].
Pain management As patient can get continuous pain due to nerve compression following lymphoedema, pain management is important. So best way to manage the pain is reduce swelling and preventing the occurrence of complications. Analgesics should be added according to the analgesics ladder (eg: Paracetamol, NSAIDs, opioids)[4].
References
  1. AIRD I, WEINBREN K, WALTER L. Angiosarcoma in a Limb the Seat of Spontaneous Lymphoedema Br J Cancer [online] 1956 Sep, 10(3):424-430 [viewed 30 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2073821
  2. MCSWAIN B, STEPHENSON S. Lymphangiosarcoma of the Edematous Extremity Ann Surg [online] 1960 May, 151(5):649-656 [viewed 30 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1613712
  3. MORRIS RJ, WOODCOCK JP. Evidence-Based Compression: Prevention of Stasis and Deep Vein Thrombosis Ann Surg [online] 2004 Feb, 239(2):162-171 [viewed 30 October 2014] Available from: doi:10.1097/01.sla.0000109149.77194.6c
  4. CEMAL Y, PUSIC A, MEHRARA BJ. Preventative measures for lymphedema: Separating fact from fiction J Am Coll Surg [online] 2011 Oct, 213(4):543-551 [viewed 30 October 2014] Available from: doi:10.1016/j.jamcollsurg.2011.07.001
  5. TORRES LACOMBA M, YUSTE SáNCHEZ MJ, ZAPICO GOñI Á, PRIETO MERINO D, MAYORAL DEL MORAL O, CEREZO TéLLEZ E, MINAYO MOGOLLóN E. Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial BMJ [online] 2010:b5396 [viewed 30 October 2014] Available from: doi:10.1136/bmj.b5396
  6. FULFORD D, DALAL S, WINSTANLEY J, HAYTON MJ. Hand surgery after axillary lymph node clearance for breast cancer: contra-indication to surgery? Ann R Coll Surg Engl [online] 2010 Oct, 92(7):573-576 [viewed 30 October 2014] Available from: doi:10.1308/003588410X12699663904475
  7. CONNOR MP, GAMELLI R. Challenges of cellulitis in a lymphedematous extremity: a case report Cases J [online] :9377 [viewed 30 October 2014] Available from: doi:10.1186/1757-1626-2-9377
  8. VAQAS B, RYAN TJ. Lymphoedema: Pathophysiology and management in resource-poor settings - relevance for lymphatic filariasis control programmes Filaria J [online] :4 [viewed 30 October 2014] Available from: doi:10.1186/1475-2883-2-4
  9. MARTíN ML, HERNáNDEZ MA, AVENDAñO C, RODRíGUEZ F, MARTíNEZ H. Manual lymphatic drainage therapy in patients with breast cancer related lymphoedema BMC Cancer [online] :94 [viewed 30 October 2014] Available from: doi:10.1186/1471-2407-11-94
  10. PARK JY, KANG HY, KIM YC. Neutrophilic Dermatosis Confined to the Lymphedematous Area Ann Dermatol [online] 2014 Jun, 26(3):411-413 [viewed 30 October 2014] Available from: doi:10.5021/ad.2014.26.3.411
  11. MOATTARI M, JAAFARI B, TALEI A, PIROOZI S, TAHMASEBI S, ZAKERI Z. The Effect of Combined Decongestive Therapy and Pneumatic Compression Pump on Lymphedema Indicators in Patients with Breast Cancer Related Lymphedema Iran Red Crescent Med J [online] 2012 Apr, 14(4):210-217 [viewed 30 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3385799
  12. QIU SS, CHEN HY, CHENG MH. Vascularized Lymph Node Flap Transfer and Lymphovenous Anastomosis for Klippel-Trenaunay Syndrome with Congenital Lymphedema Plast Reconstr Surg Glob Open [online] , 2(6):e167 [viewed 30 October 2014] Available from: doi:10.1097/GOX.0000000000000099

Management - Specific Treatments

Fact Explanation
Multidisciplinary team management Multidisciplinary team management will improve the patients quality of life. Eg; Surgeon will give pre/ post mastectomy care. Oncologst will continue the treatments and will follow up the patient. physician will manage the lymphoedema and associated complications. Dermatologist will look for skin conditions associated with. Psychiatist will help the patient to cope with the disease, relief anxiety and trat for any associated depression Physiotherapist will improve the mobility of the patient Occupational therapist will help to improve the quality by helping patients physical activities Social worker will help in economically and socially.[1][2]
medical treatment 1) Diuretics Diuretics are proven to be minimally effective as it reduced the blood volume. So the capillary filtration will reduce and this causes reduction of the limb swelling.[3][4] 2)benzpyrones This group of drugs are proven to be effective in reducing the progression of the disease. The mechanism are by reduce capillary permeability( which reduces the fluid leakage), improve microcirculatory perfusion , stimulating anti inflammatory effect and decreasing erythrocyte and platelet aggregation.[5]
Surgical treatment There are various surgical options are available such as vascularized lymph node transfer, lymphaticovenous anastomosis, suction Assisted Lipectomy for advanced lymphedema and lymphatic vessel grafting. the decision of going for a surgery and type of surgery will depend on several factors like patient's ftness, prognosis, complications, stage of the lympoedems and patients concern.[6][7]
References
  1. LEE BB, LAREDO J, NEVILLE R. Current Status of Lymphatic Reconstructive Surgery for Chronic Lymphedema: It Is Still an Uphill Battle! Int J Angiol [online] 2011 Jun, 20(2):73-80 [viewed 01 November 2014] Available from: doi:10.1055/s-0031-1279685
  2. DE GODOY JM, DE GODOY MD. Godoy & Godoy technique in the treatment of lymphedema for under-privileged populations Int J Med Sci [online] , 7(2):68-71 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860639
  3. CASSILETH BR, VAN ZEE KJ, CHAN Y, COLETON MI, HUDIS CA, COHEN S, LOZADA J, VICKERS AJ. A safety and efficacy pilot study of acupuncture for the treatment of chronic lymphoedema Acupunct Med [online] , 29(3):170-172 [viewed 01 November 2014] Available from: doi:10.1136/aim.2011.004069
  4. OGAWA Y. Recent Advances in Medical Treatment for Lymphedema Ann Vasc Dis [online] 2012, 5(2):139-144 [viewed 01 November 2014] Available from: doi:10.3400/avd.ra.12.00006
  5. PILLER NB, CASLEY-SMITH JR. The effect of coumarin on protein and PVP clearance from rat legs with various high protein oedemas. Br J Exp Pathol [online] 1975 Oct, 56(5):439-443 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2072776
  6. THOMPSON N. Surgical Treatment of Chronic Lymphoedema of the Lower Limb Br Med J [online] 1962 Dec 15, 2(5319):1566-1573 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1926791
  7. THOMPSON N. Surgical Treatment of Primary and Secondary Lymphoedema of the Extremities by Lymphatic Transposition Proc R Soc Med [online] 1965 Dec, 58(12):1026-1032 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1899075