best practice for the management of lymphoedema ... - EWMA

MANAGEMENT OF MIDLINE
LYMPHOEDEMA
The management of midline lymphoedema
(Box 16), ie lymphoedema of the head and
neck, trunk, breast or genitalia, can be
particularly challenging, especially because
of the lack of standardised objective
measurement methods to evaluate
treatment effects and to facilitate
measurement for appropriate compression
garments.
Practitioners treating midline
lymphoedema will be trained at specialist
level. Management will require
collaboration with the patient and a
multidisciplinary team. In some
circumstances, care may be managed
jointly with community staff.
Truncal lymphoedema
Lymphoedema can affect the chest, back,
abdomen, buttocks, breast or genitalia in
isolation or in combination with limb
oedema. Lymphoedema of the trunk is often
secondary to a tumour compressing the
lymphatics or to trauma and tissue damage
from cancer treatment. Consequently,
particular attention should be paid to
determining the presence or recurrence of
cancer during initial assessment.
The management strategies described for
breast and genital lymphoedema can be
combined, where necessary, with those for
the management of limb lymphoedema 56 .
Breast lymphoedema
There is little consensus on the best
approach to the management of breast
lymphoedema. However, prevention, early
diagnosis and supportive care have much
to offer. MLD and SLD form an important
part of treatment. Medium compression
(25-30mmHg) may be applied using
suitable bras (including sports bras), Lycra
foundation garments or custom made
garments. Tissue thickening may be
softened by using customised foam pads.
The anatomy of the area may make
bandaging difficult.
Genital lymphoedema
Genital lymphoedema can be highly
incapacitating and extremely difficult to
manage. Careful monitoring for signs of
infection and scrupulous skin care are
crucial. MLD and SLD are important
treatment components.
When genital lymphoedema and lower
limb lymphoedema co-exist, treatment of
the lower limb swelling may exacerbate the
genital oedema. In this situation, clearance of
the core lymphatics through MLD is
particularly important.
Women usually require custom made
compression garments with anatomically
contoured stasis pads to treat thickened and
swollen areas. In men, MLLB may be used
and self-bandaging taught. Depending on
the degree of swelling, supportive close
fitting shorts containing Lycra (eg cycle
shorts) may be a useful alternative to ready
to wear or custom made scrotal supports or
compression garments. In either sex, surgical
management may sometimes be necessary.
Lymphoedema of head and neck
Lymphoedema of the head and neck is often
a complication of cancer or secondary to
tissue damage in this area. MLD and SLD are
key elements of treatment. Low pressure
compression may be applied using
bandaging or custom made garments. Low
density foam pads can be used to apply
localised pressure. Compression should
never be applied to the neck area. Surgical
management of eyelid lymphoedema may be
considered.
TREATMENT
DECISIONS
BOX 16 Principles of
management for midline
lymphoedema
The individually tailored
management plan for
patients with lymphoedema
of the head and neck, trunk,
breast or genitalia, is likely to
include:
■ daily skin care
■ exercise/movement
■ massage – MLD and/or
SLD
■ compression – bandaging,
compression garments and
individualised foam pads
■ self monitoring
NB Compression may not be well
tolerated in midline lymphoedema
and MLD may be the only realistic
option.
BEST PRACTICE FOR THE MANAGEMENT OF LYMPHOEDEMA 23