A 45-year-old woman with a history of breast cancer is admitted to hospital for symptom control of nausea and pain. She had a right mastectomy and lymph node removal 9 years ago. She received chemotherapy post operatively for 5 years. Recent investigations have revealed disease progression in the left breast with bone metastases. On review you notice she has a swollen right arm and hand that is looking very red and is warm to touch.
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1. What indicates this is likely to be lymphoedema as opposed to general oedema?
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Correct answer:
The involvement of lymph nodes in the disease profile and the fact that they have been removed means there has been disruption to the lymph system through disease and surgery. There may also have been damage to the remaining system due to the chemotherapy treatment.
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2. What additional information would you want to find out from her regarding her arm?
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Correct answer:
- How long it has been swollen? It could have been that way since her surgery 9 months ago or it may have. Has it recently developed?
- Has there been an increase in swelling or is this ‘normal’ for her?
- Are there any breaks in the skin or any other skin changes that might indicate infection?
- Has she seen anyone about it and had any clinical input? Whether it is long-standing or recent, she may have had advice regarding the management of her lymphoedema. This may include the provision of hosiery. If she has been given hosiery, you would want to know if she still wears it, whether it is still comfortable and when it was last reviewed.
- Does she have any pain in her arm due to the swelling or tightness?
- Does the swelling affect her carrying out daily activities?
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3. What do the symptoms of redness and warmth in the arm indicate?
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Correct answer:
Possible cellulitis or infection.
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4. What would you do in terms of skincare for this patient?
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Correct answer:
- Ensuring her arm is moisturised with a non-fragrant cream, like diprobase or E45, each day after washing.
- Ensure this limb is not used for taking of blood pressure or blood or used for any other interventions or procedures. Make sure that clothing is loose enough not to cause marking.
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5. What referrals might you make for this patient?
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Correct answer:
A referral to a lymphoedema service or specialist for review.
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6. What type of advice or modes of treatment would you expect a lymphoedema specialist to suggest?
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Correct answer:
- To try and do normal daily activity as much as possible.
- Provision of specific exercises.
- Manual lymph drainage (MLD) and teaching the patient/carer/family simple lymph drainage (SLD) wearing hosiery once the cellulitis (if present) has been treated.
