LymphLink Question Corner - Archived from April-June 2002
Catherine M. Tuppo, PT
Q: I am a 42-year-old woman who was diagnosed with cervical cancer two years ago. My treatment consisted of radiation to the pelvis with seed implants. I did not have any surgery. A few months ago I began to notice swelling in my left leg, with pain. I had tests for my circulation (two Dopplers, venogram and MRI) and was told that I had a deep vein thrombosis. I have been on coumadin for about 13 weeks. I still have pain and swelling in my leg. I have 2 pairs of compression pantyhose; one pair has a compression of 20-30 mm/Hg, the other has more compression. I prefer to wear the lighter one as it is more comfortable (the other causes my leg to tingle). I wear the stockings all day, but by evening my leg is more swollen. My doctor told me that I have lymphedema, but I thought you could only get lymphedema if you have surgery. Is there a treatment that could help me?
A: Lymphedema can occur without surgery if there has been radiation to the pelvic area. Radiation, while needed to treat the cancer, does have an effect on the lymph nodes in the area. Lymphedema can develop in the area/s that are drained by the regional lymph nodes. Leg swelling can occur due to a limitation in lymph flow if the pelvic and groin lymph nodes are involved. A deep vein thrombosis can also cause leg swelling due to a limitation in blood flow. The swelling in your leg may be due to lymphedema and compounded by the deep vein thrombosis. It is difficult to determine this without more information.
Treatment is available for lymphedema, however you would need to be cleared by your doctor prior to starting this therapy in order to make sure that the deep vein thrombosis is no longer an active concern. If it is, then lymphedema therapy would not be recommended at this time. If your doctor clears you for therapy, the recommended treatment would be CDT (Complete Decongestive Therapy). This type of treatment consists of manual lymph drainage, a type of hands-on technique (like massage) which stimulates the lymph system to uptake more lymphatic fluid and re-route it to other regional lymph nodes; compression bandaging using low stretch bandages to help prevent the re-accumulation of fluid in the leg, and to further assist with lymph flow; and compression garments. Compression garments are usually obtained at the end of the active treatment program, once the swelling is controlled. Garments will help maintain the reduction of swelling, but generally will not help to reduce it. It is crucial that you be properly measured and fitted in order to assure the best results.
My suggestion would be for you to contact your physician to determine if you would be a candidate for CDT. If you are medically cleared to receive CDT, you can find a therapist through the NLN's website listing for treatment centers and providers. CDT should only be provided by a therapist or nurse who is trained and certified in the treatment.
Q: I had a radical hysterectomy and lymph node dissection in July of 1998, followed by radiation and chemotherapy treatment. Everything has been fine since then. I have flown a few times since my surgery and noticed in January 2000 I had swelling in my right leg (my doctors never said anything about lymphedema and flying). It is now about one inch larger than my left. I also have a sort of throbbing pain in my groin and hip. They have recommended a thigh-high stocking for my leg to see if this helps, as they think it is lymphedema. I am 28 years old, work 4 days a week and love to run. I fly to trade shows four times a year. What should I do?
A: It sounds as if you do have lymphedema secondary to your surgery and radiation (though you need to be seen by a trained lymphedema therapist to confirm your diagnosis). Lymphedema is common after these types of procedures and sometimes the trigger can be the change in cabin pressure experienced with flying. When there is a blockage to the lymph flow from surgery or radiation, swelling can occur weeks or years after the original surgery. Sometimes we can point to a triggering event, sometimes not. CDT is an effective treatment for lymphedema (see above). Exercise also is good for lymphedema, but it has to be graduated and progressed properly and should be guided by a therapist skilled in lymphedema treatment.
The pain in your groin area most likely is due to "congestion" of lymph fluid in this area. The stocking that you are wearing ends at the top of your leg and may be pushing fluid toward your groin which might be the cause of your discomfort. Often longer, pantyhose-style garments are needed in order to prevent the accumulation of fluid above the thigh. Your lymphedema therapist would be able to provide you with recommendations for an appropriate compression garment and provide instructions for flying in the future. Using compression during the flight by wearing the pantyhose, or using compression bandages, should help to reduce the chance of increased swelling during air travel. Also, stay active during the flight (get up and walk the aisle every hour), increase your water intake while traveling as the air is dry on the plane, and wear loose-fitting clothing to avoid further constriction. Doing deep abdominal breathing while traveling can also assist with lymph flow. A lymphedema therapist will be able to show you this technique.
Q: I have lymphedema in both legs (the left is more swollen than the right), my abdomen, and my genital area (more on the left side). I have been instructed in self-manual lymph drainage and wear Class I pantyhose during the day. I have had cellulitis in my left leg three times and have been hospitalized for five days because of it. I do the massage every day, but I feel my swelling is getting worse. For the past few years it was only in my left leg; in the past few months my right thigh is also swelling. I work as a schoolteacher and stand a lot during the day. My lymphedema is due to pelvic surgery and lymph node dissection for cervical cancer (I also had radiation therapy). I am concerned about the frequent episodes of cellulitis and that my right leg now is swelling. How can I stop my right leg from worsening?
A: Sometimes lymphedema can progress over time and your frequent bouts of cellulitis may have further influenced your lymphedema. I commend you for performing your own MLD everyday, but at this time it appears that more aggressive treatment may be needed.
This would involve seeing a therapist or nurse trained and certified in CDT, receiving daily MLD and compression bandaging for both legs. In addition, the use of compression shorts (such as those worn for bicycling) over the compression bandages can help with your abdominal and genital swelling. You did not mention if you have been doing any self-applied abdominal techniques, or MLD for the genital edema. Your therapist should be able to show you how to utilize these techniques. Sometimes the addition of a sanitary napkin in your panties under the compression shorts can give provide some added compression to aid in the genital swelling. At this point in you care, a Class I stocking may not be enough compression to help control the edema. Once you have completed the intensive treatment, new pantyhose should be obtained, and most likely this would be at a higher compression.
Before seeking CDT treatment, please talk your doctor about the swelling you are now experiencing in the right leg as there are other medical conditions that can cause leg swelling. Your doctor should be able to determine if it is due to your lymphedema. If it is, then successful treatment with CDT would be appropriate.
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