2833 American Cancer Society Lymphedema Workshop Supplement to Cancer The Treatment of Lymphedema Ethel Földi, M.D. Foldiklinik, Fachklinik für Lymphologie, Hinterzarten, Germany. BACKGROUND. Before the treatment of arm lymphedema after breast carcinoma treatment with complex decongestive physiotherapy can be initiated, it is mandatory to differentiate between benign and malignant forms (due to relapse) and to establish the diagnosis of accompanying diseases, if present. METHODS. In benign lymphedemas, the aim of complex decongestive physiotherapy is to restore the symptom free “Stage 0 of latency” and to maintain fitness for work. The palliative treatment of malignant lymphedemas results in the amelioration of the quality of life. RESULTS. The results of treatment depend on the experience of the physician in clinical lymphology, on the training and dedication of the lymphedema therapist, and on the compliance of the patient. CONCLUSIONS. A study concerning gene expression has shown that complex decongestive physiotherapy influences the pathological alterations of the interstitium in lymphedema patients. Cancer 1998;83:2833– 4. © 1998 American Cancer Society. KEYWORDS: lymphedema, complex decongestive physiotherapy, manual lymph drainage, inflammation. L Presented at the American Cancer Society Lymphedema Workshop, New York, New York, February 20 –22, 1998. Address for reprints: Ethel Földi, Prof., M.D., Földiklinik GmbH & Company KG, Fachklinik für Lymphologie, Rosslehofweg 2-6, 79856, Hinterzarten, Germany. Received July 2, 1998; accepted August 20, 1998. © 1998 American Cancer Society ymphedema is not a symptom, as other edemas are, but a disease, arising as a consequence of a low output failure of the lymphatic system. A rational therapy must be based on the knowledge of pathophysiology. Progress achieved in the fields of microcirculation and molecular biology enables us to understand many aspects of those morphologic and functional alterations that take place in the tissues as a consequence of lymphostasis. Due to the increase in the number of patients suffering from lymphedema, the importance of clinical lymphology increases world wide. There are several reasons for this: 1) There are more elderly people. With age, the force of the lymph pumps decreases, and lymphedema risk factors, such as heart failure, diseases of metabolism, and arthropathies, arise. 2) The progress in the treatment of malignancies results in longer remissions and even in more patients cured; however, as a side effect of the therapies, the cases of lymphedema of the head, limbs, and genitalia increase. The method of choice for the treatment of lymphedema is complex decongestive physiotherapy (CDP). CDP must be embedded into comprehensive medical care: the majority of lymphedema patients suffer from one or even several accompanying diseases. In addition, the results of CDP depend to a very high degree on the stage at which the treatment begins. To prevent harmful side effects, the constituents of CDP often have been applied in a modified form. Whether lymphedema is primary or secondary has no relevance concerning CDP. Along with the question of accompanying diseases, 2834 CANCER Supplement December 15, 1998 / Volume 83 / Number 12 the main problem is to distinguish between benign and malignant lymphedema: The malignant forms are caused either by untreated carcinoma or by a relapse after carcinoma treatment. CDP is a tetrade: Its constituents are manual lymph drainage (MLD), skin care, compression, and remedial exercises. MLD applied in an isolated form is absolutely inadequate. In the drainage area bordering the lymphostatic region, mild strokes are applied. The aim is to stimulate lymphangiomotoric activity. Inside the lymphedematous region itself, the strokes are applied with more pressure to limber up indurated tissues. Compression bandages are constructed in the following manner: For skin protection, one pulls on a cotton sleeve. One inserts upholstering materials with either a smooth surface or a rugged surface followed by textile elastic compression bandages. By using remedial exercises, one activates the muscle and the joint pumps. The aim of skin care is to prevent mycotic and bacterial infections. Skin care starts with hygienic measures. If necessary, disinfective agents are applied; eventually, antimycotics and/or antiallergics are used. In addition to CDP, other methods of physiotherapy often are applied to mobilize joints, to improve the function of the muscle and joint pumps, to rebuild muscles, or to alleviate pains. CDP is a two-phase treatment. The aim of phase one is to mobilize edema fluid and to initiate the regression of fibrosclerotic tissue alterations. During phase one, the patients need both mentally and physical rest. Treatment must be applied at least once a day and, eventually, twice a day. Uncomplicated cases can be treated as outpatients, and more severe cases are treated as inpatients. Phase two serves to prevent the reaccumulation of edema fluid and to continue the breakdown of the scar tissue. Phase two is an outpatient treatment. Its main constituent is compression by elastic stockings or sleeves. Self-treatment includes skin care and remedial exercises; if necessary, MLD is applied. The intensity of application of the components of CDP in its two phases depends on the stage of lymphedema at which the treatment starts and on the nature and severity of accompanying the disease. The palliative treatment of malignant lymphedemas consists of the application of phase one of CDP. In contrast to the treatment of benign lymphedema in which diuretics have no place whatsoever, in malignant lymphedema, CDP often must be complemented with diuretics. In contrast to benign lymphedema in which CDP serves to maintain the patient’s fitness to work, the role of CDP in the treatment of malignant lymphedema consists in improving the quality of life. The prerequisites of successful CDP are the following: 1) What concerns the physician, i.e., knowledge of lymphology and of the pathophysiology of those diseases that are linked to disturbances of microcirculation. A thorough check-up and therapy of accompanying diseases are mandatory. 2) Physiotherapists must be trained both by clinical lymphologists and by experienced physiotherapists. They must have a deep insight into anatomy and into the consequences of surgical and irradiation therapy of carcinoma. They must be aware of the contraindications of CDP and its various modifications. 3) The materials for bandaging and compression stockings, i.e., sleeves made to measure, must be available in excellent quality. 4) Full compliance of the patient is mandatory. If the patient is not ready to wear the compression stockings, then relapse will occur. Also, if CDP fails, the possibility of self-mutilation, which is by no means rare, must be taken into consideration. Unfortunately, there is a world wide ignorance concerning the clinical symptomatology of lymphedema. Consequently, false forms of treatments are initiated. This statement can be illustrated by an example. A couple of days ago a 32-year-old man was sent to me. His disease has been initiated by a minor accident involving the right hand while making pizza. Soon, an elephantiastic, very painful lymphedema of the right arm arose. Later on, both lower extremities became lymphedematous as well. The diagnoses of several doctors and hospitals included lymphedema of the right arm, chronic pain syndrome, and generalized reflectory sympathetic dystrophy syndrome. The treatment consisted in the intrahecal application of morphine with a pump. Amputation of the arm had been recommended. It was a case of selfmutilation: The young man constricted his limbs with bands. His motive was to obtain an invalid pension. I would like to stress that benign lymphedema does not cause pain, and generalized reflectory sympathetic dystrophy syndrome does not exist. In this case, CDP will not work; the patient must be entrusted to a psychiatrist. It is generally known that the tissue alterations in lymphedema correspond to a chronic inflammation. In a clinical study not yet published, we have shown that phase one of CDP of a duration of 4 weeks significantly reduces the gene expression of CD14, VLA4, TNFR1, and CD44. This means that CDP reduces or alleviates the chronic inflammatory process. Our findings provide an explanation for the regression of the fibrosclerotic tissue in the course of phase two of CDP.