Lymphology Clinic of Brussels

The Lymphedema

A lymphedema is a persistant and chronical swelling of a part of the body, affecting mostly the limbs.
The edema results from a constitutional anomaly, a surgery, for example linked to cancer, or an accidental destruction of a part of the lymphatic system.

 

One of the roles of the lymphatic system consists in the evacuation of the surplus liquids, proteins and other excedent molecules out of the interstitial. If the drainage is not working well, tissues will clog up causing first tensions, then a swelling called edema. The edema gradually densifies and may develop into a chronic, disabling and disheartening pathology if it is not correctly managed.

There are various kinds of lymphedema, having in common their chronicity and their considerable impact on the patient’s quality of life. They are not painful; the swelling can be significant ; they can affect one or more limbs, genital organs or the face.
The treatment has to be continuous and involves various approaches adapted to a clinical situation. There are primary and secondary lymphedema, but they can also coexist.

Primary lymphedema

Lymphedema exists from birth or occurs during lifetime. They generally affect the limbs, or unilaterally or bilaterally or even all limbs. Lymphedema are often syndromic (associated to another pathology). Genetic mutation and a locally breeding ground must be associated in order to enable the emergence of a possible edema in an anatomical area. To date, more than 27 mutatons have been identified. Thus, we are not talking about a primary lymphedema, but about different types of lymphedema.

Primary lymphedema can also be the consequence of a congenital malformation, due to the mother’s exposure to mutagenic agents.

Primary lymphedema is not always signaled in Belgium which makes studies and planification of reimbursement for healthcare difficult. The few epidemiological studies report an incidence of 9 per 1000 births among the European population.These numbers are very approximate for several reasons, the main one being that primary lymphedema does not necessarily appear from birth on, but - while the insufficiency is « sleeping » - can arise throughout life . Therefore it is difficult to identify such patients over a short term. Primary lymphedema occurs mainly in young women, but also later in life and in men as well.

Secondary lymphedema

In Western countries secondary lymphedema are mostly related to cancer treatments.

How does it occur ?

The lymphatic system is the seat of a part of the maturation and the activity of the immune system. It transports not only immune cells, but constitutes also an important hydraulic draining and filtrating network which assures fluid balance in the interstitial by eliminating surplus fluid, molecules or other type of cells. Le système lymphatique est le siège d’une partie de la maturation et de l’activité du système immunitaire, il en véhicule des cellules, mais il représente aussi un important réseau hydraulique de drainage et de filtration qui assure l’équilibre des fluides dans les espaces intercellulaires, en emportant les excès de fluide et de molécules ou cellules de toutes sortes. The lymphatic system can be compared to the « sewage system » of our body. It is made of a very dense entanglement of totally transparent canalisations which are collecting and transporting fluid and « waste » to the lymph nodes (formerly called lymphatic gagnglions).

When the « loaded » fluid reaches the lymph nodes, it undergoes a sorting, partially separating a mixture of small molecules such as water, from bigger molecules such as proteins or larger structures like bacterias or metastasis coming from tumorous sites. Most of the small elements turn back to circulation through the microcirculation of the lymph node and its vein. Only large elements are temporarily retained inside of the lymph node, then follow the lymph path crossing a cascade of several lymphnodes and ending in the venous system at the base of the neck.

Chaque groupe de lymphonoeuds draine, est tributaire, de plusieurs territoires adjacents de notre corps, c’est ainsi que le bras se draine, pour partie, dans les mêmes lymphonoeuds que le sein. La jambe se draine pour partie dans les mêmes lymphonoueuds que les organes génitaux externes.

When metastases leave the primary tumor, they are momentarily sequestered in the first lymphnodes which receive lymph coming from the tumoral territory. That’s why it is essential for surgeons to remove lymphnodes, for both diagnostic and therapeutical reasons.

This obligatory surgical removal partly interrupts drainage of the lymphatic network in all territories dependent on the excised lymphnodes. Fortunately this network is so dense and interconnected that quickly, deviations appear and permit a partial or total compensation of the loss of drainage. In case compensations were not sufficient, fluid and cellular waste accumulate in the tissues building up an edema progressively in the insufficiently drained territories.

Radio- and chemotherapy also influence the decrease of the lympatic draining capacity. In addition to surgery, they can unbalance the already fragilized lymphatic system and lead to decompensation. In that case the edema appears later, after these treatments.

Ageing reduces efficiency of all our body systems, also the lymphatic network. It may remain balanced for years and then decompensates by itself or after injury, wound or infection. The decompensation becomes visible by an edema, sometimes only 30 years after cancer treatment.

Nowadays, scientists also study genetics of lymphedema, because there seems to be predispositions or fragilities linked to the apparition of secondary lymphedema.

Occurrence of secondary lymphedema

Contrary to general perception, lymphedema does not occur suddenly, but develops gradually, discretely until the skin does not resist anymore to the increasing pressure. Only at that moment does the patient begin being aware of the emerging swelling - he feels discomfort because of increasing tensions thus revealing the edema. A single event such as an insect bite, a sunburn, sustained effort, a minor injury, exposure to high temperatures..is sufficient to allow the edema to emerge from the shadows. These events are not responsible for the edema, but can anticipate inside of a few weeks or months, the occurrence of the « sleeping » edema. Thus the goal is not to look for the epiphenomenon as a cause for the onset of edema, but rather try to avoid them.

Risks of developing a secondary lymphedema after cancer surgery

Surgery is more and more selective and less aggressive in relation to the lymphatic system. Also, radiotherapy is more and more focused thus significantly reducing damage of the lymphatic system. Consequently, the risk of developing a secondary lymphedema over time has decreased and is no more an inevitability after cancer surgery.

Nevertheless, there still remains a substantial number of patients who develop lymphedema a few months and even years after cancer treatment.

Many different causes are to blame, but chemotherapy, hormone therapy, sedentariness, obesity and ageing are clearly identified as factors increasing the risk of developing secondary lymphedema.

Paradoxically, we are concerned that the number of secondary lymphedema could stagnate or even increase in the years to come because :

  • ● Cancer is an illness on the rise

    If all cancers are taken together, 15% of patients develop secondary lymphedema on average 27 months after surgery comprising adenectomy.
    The number and incidence of cancer rates are increasing : in Belgium, there are approximately 60.000 new cases annually, namely 15% of 60.000=9000 new secondary lymphedema annually linked to cancer treatment.
    Cancer becomes more and more a long-term pathology leaving time for lymphedema to emerge. The Belgian and the European population is both, growing and aging at the same time. Indeed, 60% of cancers are diagnosed after 60 years.

  • ● Patients are increasingly surviving cancer for a long time

    Cancer treatments improve, they permit patients to survive the illness much longer. Progressively, cancer becomes a chronical disease bringing us to deal with its comorbidities, such as lymphedema.
    So we will have to care for more and more lymphedema.

  • ● There is no medication treating lymphedema

    To this day no medication yet exists to relieve lymphedema. International consensus determines that physical treatment based on the application of multicomponent bandages, manual lymphatic drainage, skin care, elastic garments and other adjuvant treatment are the spearhead of therapy reducing edema and keeping them at their lowest volume.

Early detection of secondary lymphedema after cancer surgery

The Lymphology Clinic of Brussels and its scientific department are currently working in collaboration with ULB’s Lymphology Research Unit, with breast surgeons of the St. Peter’s University Hospital Isala Clinic (Breast Clinic) for the early detection of secondary lymphedema. Researchers are looking for means of investigation permitting the early detection of lymphedema before they become visible to the human’s eye.

Thanks to lymphofluoroscopy, a simple inexpensive imaging technique of lymphatic vessels, researchers analyse the lymphatic system before and after cancer surgery in order to compare its evolution over time. Specific criteria have been established to determine whether an edema might fester without being visible to the naked eye. Therapeutic strategies can be implemented on time before edema arises.