Lymphedema After Cancer Surgery

Cellulitis is a bacterial infection of the skin. It is a common complication of lymphedema, and left untreated it can become life-threatening.

• Call 911 or go to an emergency department if redness on the limb is spreading while you watch it, or if a skin infection comes with shaking chills, confusion or drowsiness, a racing heart, fast breathing, dizziness on standing, or passing very little urine. Those are the signs of sepsis, and cellulitis in a swollen limb is one of the ways it starts. Do not wait for a call back.
• Call your care team the same day if the swollen limb becomes painful, tender, red, or hot to the touch, or if you run a temperature of 100.4°F (38°C) or higher and are otherwise well. That combination is how cellulitis usually starts, and it needs antibiotics rather than a wait-and-see approach. If you are also having chemotherapy, treat any fever as an emergency instead.
• Call your care team the same day if the swelling worsens sharply over a few hours, or if any break in the skin on that side starts to look angry or ooze. Skin on a lymphedema limb clears infection slowly.
• Call your care team within a day or two if you notice any other new skin change on the affected side, however minor it seems.

Lymphedema is swelling caused by a buildup of lymph fluid between your skin and muscle. The lymph system carries that fluid through your body and helps fight infection and disease. When the flow is interrupted, fluid collects in the tissue and the area swells.

The National Cancer Institute describes three ways cancer and its treatment disrupt lymph flow.

• A tumor blocks the flow of lymph fluid.
• Surgery for cancer disrupts the flow of lymph fluid.
• Radiation therapy causes scar tissue that blocks the flow of lymph fluid.

That is why lymphedema so often follows an operation involving lymph nodes. Breast cancer surgery, for example, often removes one or more lymph nodes in the underarm area. This raises the risk of lymphedema.

Other things raise the risk too: having an infection, healing slowly after surgery, having lymph nodes removed, past surgeries or radiation, having advanced cancer, and being overweight or having obesity.

This is the part people are rarely told clearly. Lymphedema may arise soon after cancer treatment, or years after treatment has ended. Most often, it develops slowly over months or years. A normal arm at your six-week check does not mean the risk has passed.

Watch the side where you had surgery or radiation for:

• A heavy, full, or tight feeling in the area.
• Swelling. Pressing on it may leave a dent in the skin.
• Numbness or tingling in the affected area.
• Swelling in an arm or leg that makes it look larger than the other side.
• Difficulty moving your arm or leg, or new weakness in it.

In long-term, untreated lymphedema, the skin can become discolored and hardened. Rings, sleeves, or shoes that suddenly feel tight are worth mentioning too.

Contact your doctor as soon as you notice heaviness, swelling, or other signs of lymphedema. Small changes are easier to control than large ones.

A doctor examines the area and compares the size of your swollen arm or leg with the other limb. Tests may include ultrasound, MRI, CT, lymphoscintigraphy, perometry, or bioimpedance spectroscopy.

Lymphedema is described in stages.

• Stage 0. Flow is disrupted, but symptoms may be absent.
• Stage I. The limb feels swollen and heavy. Pressing on it leaves a pit, or dent, in the skin.
• Stage II. The limb is more swollen and firmer. Pressing does not leave a pit.
• Stage III. The limb is extremely swollen. The skin feels hard and thick, and movement may be reduced.

Compression does most of the work. Short-stretch bandaging, compression wraps, leggings, or stockings help move fluid in your arms and legs and prevent buildup. Manual lymphatic drainage, also called lymphatic drainage massage, is gentle massage that helps move lymph fluid. It is used as part of complete decongestive therapy, which the American Cancer Society describes as combining manual drainage, compression, skin care, exercises, and elevation.

A compression pump applies pressure at intervals to the arm or leg. For some people, surgery is an option, including lymphovenous bypass, lymphovenous transplant, liposuction, and laser therapy.

Day to day, exercise works as a natural pump for the lymph system. Elevating the limb, keeping a healthy weight, protecting the skin, wearing compression garments as directed, drinking fluids, and cutting back on salt all help. Garments should be fitted properly, not bought by guess. The American Cancer Society also advises avoiding tight clothing and extreme heat.

• National Cancer Institute, Lymphedema (PDQ) - Patient Version: https://www.cancer.gov/about-cancer/treatment/side-effects/lymphedema/lymphedema-pdq.
• American Cancer Society, Lymphedema: https://www.cancer.org/cancer/side-effects/swelling/lymphedema.html.