THE 7TH SYMPTOMLYMPHEDEMA IN ADVANCED CANCER

Madeleine Fiddes

Rural CNS and Lymphedema Therapist

Hospice Waikato

Hospice NZ Palliative Conference

29-31st October 2014

Overview

• Definition of lymphedema• Types of lymphedema• Stages of lymphedema• Lymphedema and Palliative Care• Treatment options• Collaboratively in the community• Case Studies• Conclusion

Lymphatic system is part of circulatory system. Network of vessels and nodes throughout the body transporting lymph fluid from tissues back to bloodstream.

Functions: Assist immune system

Remove waste products (ALA, 2014)

Lymphatic system

Lymphedema

“Lymphedema is a progressive chronic condition. It leads to excessive accumulation of protein rich lymph fluid in the tissues as a result of lymphatic failure due to either congenital abnormality or damage to the lymphatic system.” (British Lymphology Society, 2010)

Types of Lymphedema

• Primary Lymphedema• Secondary Lymphedema

Primary Lymphedema

Mechanical insufficiency due to unknown cause

Congenital defect of lymphatic system• Milroy’s disease• Lymphedema Praecox – up to age 35 (at puberty)• Lymphedema Tardis –

after age 35 (milder condition)

• Filariasis• Malignancy• Surgical complications• Radiation• Trauma• Infection –acute, chronic

Secondary Lymphedema

Lymphedema and Palliative Care

“Lymphedema is known to affect the physical, psychological and social well-being of the patient” (Tobin et al, 1995).

“Lymphedema in palliative care is associated with worsening levels of function and dependence as well as feelings of hopelessness, disgust and social isolation” (Hewitt et al, 2010).

• Oedema:• Excess low-viscosity, protein-poor interstitial fluid

that exceeds lymphatic capacity to reabsorb

• Lymphedema:• Excess protein-rich interstitial fluid within skin and

sub-cutaneous tissue resulting from lymphatic dysfunction

Oedema

Differential diagnosis: Oedema/lymphedema - Advanced Cancer

• Obstruction - DVT, compression by tumour• Hypoalbuminemia• Renal/hepatic failure• Cardiac failure • Dependant limb, immobility, neurological deficit• Effects of drugs or cytotoxic chemotherapy • Infection – e.g. Cellulitis • Malignant involvement or infiltration of lymphatic

structures – e.g. SVCO (Towers et al. 2010)

Principles of Palliative management

• Reverse the reversible• Patient’s priorities and goals• Benefit versus burden• Patient general condition and prognosis• Psychosocial issues Vaugn Keeley ALA conference, 2014

Explanation - Compassion - Education

Key concepts: Palliative Care and Lymphedema

• Uniqueness of each patient• Interdisciplinary (team) work• Communication• Ingenuity and creativity• Good control of pain and other symptoms• Maintenance of independence• Fears and expectations• Self-care (Towers et al 2010)

We need to continually ask: Is the primary goal life prolongation or is it

comfort and quality of life?

Treatment

Key components of care

• Skin care• Remedial exercise• Lymphatic drainage therapy• Compression – bandaging/garments• Kinesio® Taping

“The Power of Touch”

Differences Standard and Palliative CDT

Standard CDT

• Goal – reduce swelling, transition to garment, life-long maintenance

• Four elements CDT • Two distinct phases in

treatment• Definitive contra-indicators to

treatment

Palliative CDT

• Goal – comfort, support, relief of symptoms, maintain function

• CDT elements modified or omitted

• Less distinction between phases

• Contra-indicators relative(Towers et al, 2010)

Standard and Palliative Bandaging

Standard

• Full standard pressure• Multi-layer bandaging

• 24-hour bandaging during the intense phase

• Foam padding used• Transition to compression

garments

Palliative• Reduced pressure• Fewer layers required• Intensive treatment for

lymphorrhea require frequent re-application

• Bandaging lower leg/s• Soft padding better

tolerated• May transition to lighter

compression garment• (Towers et al, 2010)

Management of LE in the communityGreen (2010); Warilow & Jones (2012); Morgan P (n.d.)

• Patient• GP• Lymphedema Therapist• Community Nurse• Interdisciplinary approach

Developing: Integrated LE patient pathway

• Referral process• Central point of entry• Multidisciplinary focus• Development of study days

“It is important that practitioners use standard assessment tools and documentation (Hopkins, 2010).

Case Studies

“Sally”

• 66 yr. old female• Clear cell carcinoma of urethra Stage 4• Radical Cystourethrectomy, Hysterectomy, bilateral oophorectomy, vaginectomy, vulvectomy, pelvic lymph node dissection and formation of an ileal conduit

• Radiotherapy• Chemotherapy

Measurement - Leg

Date 29/5/13 17/6/13 28/7/13 15/7/13

Right Left Left Left Left

10cm 20cm 25cm 25cm 23 22

20cm 28 32 28.8 29 27

30cm 35 43 40.5 38.5 38

40cm 33 40 40 37.5 37

50cm 42.5 51.3 50 48 47.5

60cm 52 62 58 57 57

70cm 58

Wendy

• 56 yr. old female• R Breast Ca. – IDC Grade 2• Extensive skin/breast changes – fungating lesion• Lymphadenopathy lower cervical, supraclavicular, axillary regions with brachial plexus involvement

• Radiotherapy• Chemotherapy

Measurement – R arm

Date 1 July 17 July 21 Aug

Wrist 15.5 cm 16.5 cm 15 cm

10 cm 21 23.3 22

20 26.5 29 28

30 31 33 30.5

40 31 32 29

Wendy the Warrior’s supporter

“Mary”

• 53 yr. old woman• Stage 4 Leiomyosarcoma – uterus• Hysterectomy, Bilateral Oophorectomy• Pleomorphic Sarcoma R arm and extensive bony metastasis

Conclusion

“Although lymphedema can be challenging to manage in palliative populations, it is possible to modify existing modalities to effectively reduce

oedema and improve quality of living” (Hewit et el, 2010)

2015 National Hui NZ Lymphedema Therapists

Date: 16 – 17th May 10 - 5pm

Venue: Hamilton Airport Hotel

201, Airport Road, RD2, Hamilton

Palliative care today is much more than end-of-life care

(Saunders, 2005).

Useful web-sites• Lymphoedema Support Network www.lymphoedema.org• Australia Lymphology Association• International Lymphoedema Framework www.lympho.org• Lymphoedema DermNet NZ• National Lymphoedema Network• Lymph notes www.lymphnotes.com• British Lymphology Society www.thebls.com• Lymphoedema Support Network www.lymphoedema.org/lsn• LymphCare

References• Towers, A. et al. (2010). Care of palliative patients with

cancer related lymphedema. J. of Lymphoedema. 5(1).• Morgan. P. Health Professionals ideal roles in

lymphoedema management. BJ of Community Nursing.• Green, T. (2010). Key-worker clinics: the maintenance

phase of LE therapy. Chronic Oedema, October.• Hopkins, A. 2010). Mapping an integrated LE patient

pathway. 5(2).

References• Todd, M. (2009). Understanding lymphoedema in advanced

disease in palliative setting. IJPN. 15(10).• Hewitt, B., et el. (2010). Lymphoedema in Palliative Care.

Cancer Forum, 34(2).• Cooper, G. (2012). Lymphoedema treatment in palliative care:

a case study. British Journal of Nursing. 21(15).• Board, J., & Anderson, J. (2013). Treatment of lymphorrhea.

British Journal of Healthcare Assistants. 7(1).• Todd, M (2010). Managing lymphoedema in palliative care

patients. BJN. 18(8).• Linnitt, N. (2005). Lymphoedema: recognition, assessment and

management. Woundcare. March.• Fenton, S. (2001). The power of touch in last week of life. IJPN.

17(2)

My Role

• Rural CNS• Lymphedema Therapist –

Casey-Smith Method• Registered ALA - member