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Kidney - Renal Cancer Home page: Lymphedema People http://www.lymphedemapeople.com Special Page Dedication Steve Dunn I would very much like to dedicate this page to Steve Dunn - want to share what someone on one of our groups posted in his honor: A true giant in On-line Advocacy for Cancer patients, Steve Dunn, has passed away after developing Sepis while in the hospital for treatment. Here is the article that was posted on ACOR's manager's list about Steve. We will all miss him dearly. Bill Steve Dunn died on August 19, 2005, after ten months of hospitalization for complications from bacterial meningitis. Steve was well known in the cancer community for his unique website www.cancerguide.org which he established after a near-fatal bout with cancer. Experimental treatment resulted in his complete recovery from Stage IV kidney cancer. He became a tireless advisor and advocate for other cancer patients. Steve was vital to the Association of Cancer Online Resources, where hemanaged a number of mailing lists for cancer patients and their families. He served as a member of advisory committees with the FDA and other organizations. Steve's work will go on through the many people whom he inspired with his dedication and expertise. Steve was the proud father of one daughter, now five years old. He was also an avid mountain climber, backpacker, skier, biker, and runner. Email messages in memory of Steve may be sent to STEVE-MEMORIAL@ACOR.ORG These messages are displayed online at http://listserv.acor.org/archives/steve-memorial.html ((Many of you have asked what you can do in Steve's honor, so here is the information. Steve left his family well taken care of financially, so there is no need for donations to them. They agree the following is what Steve would want:)) Donations in memory of Steve may be made to ACOR, where they will be used to maintain his Cancerguide website. We all want his work to continue. Send a check made out to ACOR with the words "Steve Dunn" in the memo area (at bottom left on the check). The address is: ACOR Donor Services 173 Duane St You can also donate online at: http://tinyurl.com/dgd6q (This will take you to ACOR's own page at NetworkForGood; or you can go to the main webpage at www.networkforgood.org and enter ACOR or Association of Cancer Online Resources to find the right page for your donations.) Dedicate your gift to Steve Dunn. You may forward this information as you see fit. http://www.cancerguide.org/kidney.html Kidney Cancer Primary kidney cancer, also called renal cancer, is a malignant tumor that originates in the kidney. There are two main types of primary kidney tumors -- renal-cortical tumors and transitional cell tumors. Renal-cortical tumors account for nearly 90 percent of all kidney tumors. Transitional cell tumors of the kidneys and ureters are similar to bladder tumors. Kidney cancer rarely strikes children and young adults; the exception is a pediatric kidney cancer called Wilms' tumor. Risk Factors Studies have shown that certain lifestyle factors increase the risk of developing renal tumors. Smoking, high blood pressure, eating a high-fat diet, and obesity all may contribute to an increased risk of kidney tumors. Although we don't know all the causes of kidney cancer, the following factors can also increase the risk of developing this disease: long-term dialysis, a process in which a machine filters the blood of a person without functioning kidneys exposure to asbestos, such as occupational exposure exposure to cadmium, a metal which can increase the cancer-causing effect of smoking a family history of kidney cancer von Hippel-Lindau syndrome, a disease that is caused by a genetic mutation that leads to multiple tumors in the kidney, often at an early age tuberous sclerosis, a disease characterized by several bumps on the skin, seizures, mental retardation, and cysts in the kidneys, liver, and pancreas If you are exposed to asbestos or cadmium at work, be sure to follow occupational safety practices that limit your exposure. Symptoms Kidney cancer usually shows no symptoms in the early stages. It is generally not suspected until the patient begins to experience symptoms; at this point the tumor may have grown fairly large. As the cancer progresses, symptoms may include some of the following: blood in the urine low back pain that cannot be accounted for by something else (such as an injury) a mass or lump in the abdomen fatigue unexplained weight loss, which may be rapid fever that is not due to a cold or flu swelling of the ankles and legs (due to an impaired ability to rid the body of liquid waste) Some of these symptoms may be due to other causes, such as an infection. But you should see your doctor to determine what is causing them and how they should be treated. Diagnosis Kidney cancer is less common in the United States than many other cancers, such as those of the breast and colon. Therefore, there are no widely used screening programs for kidney cancer in this country; that is, apparently healthy people do not usually have regular examinations for this cancer. However, people who are on long-term kidney dialysis and those with von Hippel-Lindau disease or tuberous sclerosis may benefit from periodic evaluation of their kidneys to check for early signs of kidney cancer. Most kidney tumors are found incidentally -- when patients are being evaluated with radiologic imaging studies for other non-specific abdominal complaints (gallbladder pain, for example), or during follow-up for other previously treated malignancies. These "incidental cancers" are often found early, before any symptoms have occurred. Because these cancers are usually detected before they have spread, patients with incidental kidney tumors are often cured of their disease, commonly by surgery alone. Moreover, as many as 25 percent of kidney masses represent a benign condition. Often, Memorial Sloan-Kettering doctors may repeat radiologic imaging with precise studies aimed at the kidney alone to diagnose a benign mass without the need for a biopsy or any surgical intervention. If your doctor suspects you have a kidney tumor, you may undergo computed tomography (CT) scanning or magnetic resonance imaging (MRI). Recently developed imaging techniques -- including 3-D CT, 3-D MRI angiography, and CT urography -- reveal detailed anatomy, allowing the doctor to plan surgery, often using a single imaging test. Radiologists at Memorial Sloan-Kettering are leaders in the use of these studies. Ultrasound may be used to determine if a kidney mass is a fluid-filled cyst or a solid tumor. If you doctor suspects that you have cancer of the renal pelvis, or transitional cell carcinoma, he or she may perform a cytoscopy -- in which small tube with a lens is inserted into the urethra so the bladder and urethra can be seen; a pyelogram; or a ureteroscopy, in which a narrow lighted tube is passed through your urethra, into your bladder, into a ureter, and into the renal pelvis to look for signs of cancer. Your doctor may remove a small piece of tissue to examine (biopsy) for cancer cells. It is now understood that kidney tumors are a family of tumors with varying degrees of aggressiveness. About 90 percent of all kidney tumors are classified as renal-cortical tumors. These tumors are actually a family of different tumor types. About 65 percent of renal-cortical tumors are the conventional, or clear-cell type, which have the most malignant potential. The remaining 35 percent are oncocytomas (which are virtually benign) and two types of indolent (slow-growing) tumors -- papillary carcinoma and chromophobe carcinoma. After surgery to remove a renal-cortical tumor, doctors will examine the tumor cells to determine which of the cell types mentioned above is present. Our doctors can then use this information, along with the size of the tumor, and other aspects of the tumor's growth, to more accurately predict the patient's prognosis and determine whether further treatment is necessary. In addition to these tests, your doctor will take your medical history into account, perform a physical examination, and order laboratory studies such as blood and urine tests. Treatment For those diagnosed with a kidney tumor, Memorial Sloan-Kettering offers the most comprehensive and advanced treatment options to both eradicate the disease and preserve the patient's ability to function normally. Our physicians help to determine the choice of treatment for a kidney tumor depending on the specific tumor size, location, and stage of the disease -- that is, how large the tumor has grown, how deeply it has invaded the kidney, and whether it has spread to nearby organs, lymph nodes, or another part of the body. Treatment may include surgery, chemotherapy, radiation therapy, or immunological therapy, alone or in combination. Our doctors are experts in the management of both localized and advanced kidney tumors. Surgery Surgery is the most common form of treatment for kidney tumors, and it is often the only treatment necessary. Memorial Sloan-Kettering's urologic surgeons have expertise in all surgical approaches to kidney tumors, including kidney-sparing and laparoscopic surgery. If an operation is necessary, our team of specialists will evaluate the patient and, based on the size and location of the tumor, recommend either the removal of the tumor (partial nephrectomy) or removal of the entire tumor-bearing kidney (complete or radical nephrectomy). Partial Nephrectomy: Kidney-Sparing Surgery Kidney-sparing (or nephron-sparing) surgery is the term used for the removal of a kidney tumor, leaving a margin of normal kidney tissue, in order to preserve the function of the remaining kidney. Studies from Memorial Sloan-Kettering and other institutions have demonstrated equal results between partial and complete nephrectomy in patients with small tumors (less than 4 centimeters), while maintaining functioning kidney tissue. Our surgeons are among the most experienced world-wide in these technically demanding operations. In appropriate situations, our team can offer laparoscopic partial nephrectomy. Complete (Radical) Nephrectomy In some situations, the entire kidney needs to be removed. These tend to be larger tumors that have advanced locally, and sometimes they have advanced to another part of the body. Our team can help determine whether patients with such tumors may be best served by laparoscopic or open nephrectomy. Because we are able to offer all possible modes of treatment, we can tailor the approach to each individual patient. For transitional cell carcinoma of the kidneys and ureters, surgical approaches include nephroureterectomy (removal of the kidney and ureter) and segmental resection (partial removal of the ureter). These procedures can also be performed laparoscopically. When transitional cell carcinoma is found on the surface of the renal pelvis or ureter, it may be treated by laser surgery, which uses a narrow beam of light to remove cancer cells. During the surgery, the doctor may remove nearby lymph nodes to examine them for cancer cells. Doctors will examine the cells of the tumor to determine which type of cancer is present. Systemic (Whole-Body) Therapy Chemotherapy -- treatment with anticancer drugs -- is sometimes used in addition to surgery to treat kidney cancer. Conventional, or clear-cell, renal cancer does not respond to chemotherapy, so any drugs that are used are being evaluated as part of a clinical trial, in an effort to find more effective treatments. Transitional cell carcinoma is sensitive to chemotherapy, so it is used to treat patients with advanced cancer of this type. Sometimes it is helpful to apply such chemotherapy directly to the tumor by feeding teh drug into the renal pelvis. This so-called intrapelvic chemotherapy is sometimes done in addition to surgery. For kidney tumors that have spread widely to other parts of the body, Memorial Sloan-Kettering's medical oncologists have access to the latest systemic immunotherapies available. Two such drugs that stimulate the immune system -- interleukin 2 and interferon -- have shown promise in treating renal cancer. Another type of immunotherapy being investigated by our doctors involves the donation of stem cells (blood-forming cells) to the patient from a relative who has compatible stem cells -- this is an allogeneic stem cell transplant. T lymphocytes -- certain white blood cells in the donated stem cells -- frequently see an organ of the patient (host) as foreign, and attack the organ. This is called graft versus host disease (GvHD). The hope is that the cells from the donor will see the tumor as "foreign" and attack it as well. Before the stem cell transplantation, the patient will receive chemotherapy drugs to suppress the immune system and to destroy some of their own bone marrow cells, so the new stem cells from the donor will grow. Radiation Therapy Radiation therapy is sometimes given as the primary form of treatment for patients who are not well enough to undergo surgery. It can also be used to relieve the symptoms of kidney cancer, such as pain. Rehabilitation Therapy For patients with kidney cancer, rehabilitation therapy provides a means to improve function and mobility after surgery or chemotherapy. Memorial Sloan Kettering's physical therapists evaluate patients' functional needs shortly after surgery or hospitalization and design an individualized treatment and exercise plan to increase each patient's strength, endurance, and balance and thereby improve their mobility and function. After chemotherapy, radiation, or abdominal surgery for cancer, a patient may notice changes in his or her range of motion, strength, flexibility, balance, and endurance. Occupational therapists educate patients about these changes and about adaptive equipment and compensatory techniques that can increase their independence during their daily routines. They also evaluate and treat patients' ability to perform basic daily activities such as bathing, dressing, and moving around their environment. http://www.mskcc.org/mskcc/html/362.cfm Information from Memorial Sloan-Kettering Cancer Center http://www.mskcc.org/mskcc/html/44.cfm Arm and Leg Swelling After Cancer With the advent of better and more effective cancer treatments, the survival rate for all cancers has risen dramatically. With this progress, a new and often misunderstood and misdiagnosed complication has arisen. Many cancer survivors , having overcome cancer, find themselves with sudden and often unexplained swelling, usually of the arms or of the legs. This swelling occurs because of one of several factors. First, the swelling begins after lymph nodes have been removed for cancer biopsies. Second, the swelling may start as a result of radiation damage to either the lymph nodes and/or the lymph system. Due to either the removal of lymph nodes or damage to the lymph system, your body is no longer able to rid itself of excess fluids. The fluids collect in the limbs effected and swelling beings. This swelling is called lymphedema. The swelling that occurs is permanent, and while it is not curable it is treatable. Permanent Leg Swelling ****In the situation of any permanent leg swelling whether the cause is known or unknown, the diagnoses of lymphedema must be considered**** There are several groups of people who experience leg swelling from known causes, but it doesn't go away or unknown causes where the swelling can actually get worse as time goes by. Group One This group includes those who have had the injuries, infections, insect bites, trauma to the leg, surgeries or reaction to a medication. When this swelling does not go away, and becomes permanent it is called secondary lymphedema. Group Two Another extremely large group that experiences permanent leg swelling are cancer patients, people who are morbidly obese, or those with the condition called lepedema. What causes the swelling to remain permanent is that the lymph system has been so damaged that it can no longer operate normally in removing the body's waste fluid. In cancer patients this is the result of either removal of the lymph nodes for cancer biopsy, radiation damage to the lymph system, or damage from tumor/cancer surgeries. This is also referred to as secondary lymphedema. Group Three Group three consists of people who have leg swelling from seemingly unknown reasons. There may be no injury, no cancer, no trauma, but for some reason the leg simply is swollen all the time. The swelling may start at birth, it may begin at puberty, or may begin in the 3rd, 4th or even 5th decade of life or sometimes later. This type of leg swelling is called primary lymphedema. It can be caused by a genetic defect, malformation or damage to the lymph system while in the womb or at birth or be part of another birth condition that also effects the lymph system. This is an extremely serious medical condition that must be diagnosed early, and treated quickly so as to avoid painful, debilitating and even life threatening complications. Treatment should NOT include the use of diuretics. What is Lymphedema? Lymphedema is defined simply as an accumulation of excessive protein rich fluid in the tissues of the leg. The accumulation of fluid causes the permanent swelling caused by a defective lymph system. A conservative estimate is that there may be 1-2 million people in the United States with some form of primary lymphedema and two to three million with secondary lymphedema. What are the symptoms of Lymphedema? If you are an at risk person for leg lymphedema there are early warning signs you should be aware of. If you experience any or several of these symptoms, you should immediately make your physician aware of them. Unexplained aching, hurting or pain in the leg. Experiencing "fleeting lymphedema." This is where the limb may swell, even slightly, then return to normal. This may be a precursor to full blown leg lymphedema. Localized swelling of any area. Sometimes lymphedema may start as swelling in one area, for example the foot, or between the ankle and knee. This is an indication of early lymphatic malfunction. Any arm inflammation, redness or infection. You may experience a feeling of tightness, heaviness or weakness of the leg. How is Lymphedema Treated? The preferred treatment today is decongestive therapy. The forms of therapy are complete decongestive therapy (CDT) or manual decongestive therapy (MDT), there are variances, but most involve these two type of treatment. It is a form of massage therapy where the leg is very gently massaged to actually move the fluid out of the leg and into an area where the lymph system still functions normally. With these massage treatments, swelling is reduced and then the patient is fitted with a pre-measured custom pressure garment to keep the swelling down and/or is taught to use compression wraps to maintain the leg size. What are some of the complications of lymphedema? Infections such as cellulitis, lymphangitis, erysipelas. This is due not only to the large accumulation of fluid, but it is well documented that lymphodemous limbs are localized immuno-deficient. Draining wounds that leak lymphorrea which is very caustic to surrounding skin tissue and acts as a port of entry for infections. Increased pain as a result of the compression of nerves usually caused by the development of fibrosis and increased build up of fluids. Loss of Function due to the swelling and limb changes. Depression - Psychological coping as a result of the disfigurement and debilitating effect of lymphedema. Deep venous thrombosis again as a result of the pressure of the swelling and fibrosis against the vascular system. Also, can happen as a result of cellulitis, lymphangitis and infections. Sepsis, Gangrene are possibilities as a result of the infections. Possible amputation of the limb. Pleural effusions may result if the lymphatics in the abdomen or chest are to overwhelmed to clear the lung cavity of fluids. Skin complications such as splitting, plaques, susceptibility to fungus and bacterial infections. Chronic localized inflammations. Can lymphedema be cured? No, at the present time there is no cure for lymphedema. But it can be treated and managed and most of the complications can be avoided. Life with lymphedema can still be active and full, with proper treatment, patient education, and patient life style adaptation. Information and Resources for Kidney/Renal Cancer National Kidney Cancer Association http://www.nkca.org/ Kidney Cancer - Medline Plus Links and Information Page http://www.nlm.nih.gov/medlineplus/kidneycancer.html Kidney cancer information centre CancerBacup - UK http://www.cancerbacup.org.uk/Cancertype/Kidney Kidney Cancer UK http://www.kcuk.org/ Kidney Cancer Treatment and Research National Cancer Institute http://web.ncifcrf.gov/research/kidney/ What Is Kidney Cancer (Renal Cell Carcinoma)? http://www.cancer.org/docroot/cri/conte ... cer_22.asp Kidney Cancer MedicineNet http://www.medicinenet.com/kidney_cancer/article.htm Kidney Cancer Cancer Information Network http://www.cancerlinksusa.com/kidney/index.asp American Cancer Society http://www.cancer.org/docroot/home/index.asp Cancer Information on the Internet http://www.hackley.org/medical_services ... _links.htm Cancer Resource Center http://patient.cancerconsultants.com/li ... x?id=32333 Cancer Lynx http://www.cancerlynx.com/ Cancer Information & Support International http://www.cancer-info.com/ Lymphedema WHAT IS IT? Lymphedema is a buildup of a fluid called lymph and protein in the tissues under the skin. Lymph accumulates when there is an obstruction to normal flow causing swelling, usually in an arm or leg. The lymph system is similar to the blood system in its network of vessels that carry lymph fluid throughout the body. Trauma to lymphatic tissue by surgery or radiotherapy is the main cause of lymphedema in the context of cancer. It can result from surgery and/or radiation therapy during treatment for cancers of the breast, abdomen, melanoma, connective tissues (sarcomas) and the pelvic area, as well as lymphomas, in both men and women. Lymphedema may also be the result of infection, such as dermatophytosis in the foot. Cancer tumors also can block the lymph vessels, especially in people with prostate cancer or lymphoma. IF I HAVE CANCER WILL I DEVELOP LYMPHEDEMA? Not necessarily. The most frequent cases occur in women with breast cancer; 10% to 25% of breast cancer patients will develop lymphedema. While most cases are mild, approximately 400,000 women cope daily with some degree of disfigurement, discomfort, and sometimes disability because of arm and hand swelling. Because of improvements in radiation and surgical techniques (such as removing smaller samples of lymph nodes), lymphedema is less common today than it use to be. Lymphedema develops in about one in four breast cancer patients who have a mastectomy with lymph-node dissection. The risk doubles for those who also receive radiation treatments to the underarm area. Radical prostatectomy, a procedure that removes the prostate gland, seminal vesicles and sometimes the nearby pelvic lymph nodes, can lead to lymphedema . One type of Kaposi’s sarcoma is called the lymphadenopathic form that can spread throughout the body and may aggressively involve lymph nodes, viscera, and occasionally the GI tract – resulting in a kind of lymphedema. SENTINEL LYMPH NODE BIOPSY If breast cancer spreads, it first goes to the lymph nodes under the arm. That's why women with breast cancer have these nodes examined. Until recently, surgeons would remove as many lymph nodes as possible, but this greatly increased the risk of lymphedema. More recently, a growing number of physicians have begun focusing on finding the sentinel nodes — the first nodes to receive the drainage from breast tumors and therefore the first to show evidence of cancer’s spread. Experts believe that if a sentinel node is removed and found to be healthy, then the chance of finding cancer in any of the remaining nodes is very small and no other nodes need to be removed. This spares as many as 75% of women who have no evidence of tumor spread to the axillary nodes the risk of complications, especially lymphedema. WHEN DOES IT DEVELOP? Lymphedema can appear any time after surgery or radiation treatment including many years later. When the condition develops very soon after surgery, it is usually mild, and goes away within one to two weeks. It can also develop six to eight weeks after surgery or radiation. Again, this type of lymphedema usually goes away in a few weeks. Unfortunately, the more common form of lymphedema in cancer survivors develops slowly over time. It may show up many months or even years after treatment ends and swelling can range from mild to severe. In most cases however, lymphedema appears between six and 12 months after treatment. While people who have many lymph nodes removed and radiation therapy have the highest risk of developing lymphedema, some high-risk patients won’t develop the condition. WHEN TO CALL A PROFESSIONAL Patients should contact a physician if they had a mastectomy, lower abdominal surgery or radiation treatments in the past, and the affected limb becomes red, painful or hot, or if it develops open sores or areas of broken skin. Doctors should be consulted especially if there is a fever in addition to swelling. Diagnostic Tests Usually, no specific testing is necessary to diagnose lymphedema, but tests may be done such as a blood count that can identify signs of infection. Ultrasound may be ordered to look for blood clots, which can cause swelling. Computed tomography (CT) may be used to find a tumor that could be blocking lymph vessels. In addition, there are more specialized tests that can identify lymph flow and lymph vessel abnormalities. Symptoms The first signs of lymphedema can be a change in a patient’s arms or legs or other affected area such as the groin. Initially, skin will remain soft, but if the problem continues, the limb may become hot and red and the skin hard and stiff. The lymph fluid that collects in the tissues can be very uncomfortable, but pain is not always present. Early symptoms of lymphedema may include: A feeling of tightness around the arm on the area that was treated for cancer, Decreased flexibility in a hand, elbow, wrist, fingers, or leg, Difficulty fitting into clothing, Tight fit of a ring, wristwatch, bracelet, or shoe, Weakness, pain, aching or heaviness in the arm, legs, or feet, Skin that looks shiny, has fewer folds, and feels stiff or taut, A dull ache in the affected limb, A feeling of tightness in the skin of the affected limb, Difficulty moving a limb or bending at a joint because of swelling and skin tightness, Pitting (small indentations left on the skin after pressing on the swollen area) In most cases, only one arm or leg is affected. If the leg is involved, swelling usually begins at the foot, then progresses upward toward the ankle, calf and knee. Severity The severity is directly related to the extent of surgery and radiation treatment to the lymph nodes. Severity and general risk of developing lymphedema seems to increase with obesity, weight gain and infection in the affected area. TREATMENTS Lymphedema has no cure so treatment focuses on reducing the symptoms. Treatment has varied from virtually no treatment to surgery, but there are various practical methods to deal with the condition, including elevation of the limb (in the first year only), compression garments (no greater than 20-30 mm Hg), certain types of massage and exercises, pneumatic compression devices (controversial), and other types of physical therapy. Experts also recommend keeping the affected limb clean, dry and lubricated. The National Lymphedema Network (www. Lymphnet.org) encourages massage by an specially certified expert in lymphedema massage.. In many cases, patients can also be trained to massage themselves to improve the flow of lymph fluids. Medications There are no medications to treat lymphedema. Diuretics have been found to be ineffective and may actually exacerbate the condition. Other medicines have been tried, but there is no clear evidence of significant effectiveness with any particular drug. MILD LYMPHEDEMA: Elevating the arm or leg above the level of the heart(during the first year) and flexing it frequently are basic methods to manage the condition. Since elevation is impractical except for short periods, patients should be fitted with an elastic sleeve, covering the arm or leg. A significant reduction in edema (swelling) has been reported after wearing elastic sleeves for 6 consecutive hours per day. Using these garments during exercise, physical activity, and especially air travel is recommended, since air travel seems to exacerbate the condition. If the legs are affected, avoid periods of prolonged standing. If working or standing a lot, a doctor may prescribe special graduated compression stockings to wear throughout the day. A doctor may also suggest a protein-rich, low-salt diet for those who are over-weight or obese. MODERATE TO SEVERE: For people with moderate to severe lymphedema in the legs, doctors prescribe pneumatic compression devices to be used at home to help reduce limb swelling. The “pneumatic stockings” are worn every day for an hour or two to reduce the swelling. Once the swelling has been reduced, a person may still need to wear elastic stockings up to the knee every day from the moment of rising until bedtime. For lymphedema in the arm, pneumatic sleeves--like pneumatic stockings--can be used every day to reduce the swelling; elastic sleeves may also be needed. Others recommend a special type of massage therapy called manual lymph drainage. Antibiotics also may be prescribed to prevent or treat infection in the affected limb. Since skin infections can be more serious in people with lymphedema, a person may need to have antibiotics administered intravenously in the hospital during an infection. Complex Decongestive Therapy More serious cases of lymphedema can be treated with Complex Decongestive Therapy by a physical therapist or other health care professional, who has special training. Complex Decongestive Therapy consists of skin care, massage, special bandaging, exercise, and fitting for a compression sleeve. Seeking and getting treatment early should lead to a shorter course of treatment to get the lymphedema under control. While most insurance companies will pay for this treatment, some do not. Someone certified in the procedure should perform Manual Lymph Drainage (MLD). In the case of lymphedema of the arm, the procedure involves a type of massage that moves built up fluid around the blocked vessels and across the chest to the other side of the body where the lymphatic system is still in tact. Usually the healthy area will be “worked” first. After each treatment, the effected area is carefully bandaged with a special layered wrap that looks like an ace bandage but is made of a different fabric. The wrap is important for keeping the effected limb de-congested. An average course is 15 daily treatments of 60 to 90 minutes each. After a MLD course of treatments, the patients will wear a compression garment every day. The patient should be measured for a new compression sleeve every six months or so. Sometimes a yearly MLD treatment course is recommended as a kind of “tune up.” PREVENTING COMPLICATIONS Because lymphedema development may occur even after several decades, patients should monitor themselves for signs of lymphedema and report any changes to their physicians. Prevention is important and can require daily attention to manage the symptoms of swelling in particular. Arm and hand precautions are based on two key ideas: (1) Do not increase lymph production, which is directly proportional to blood flow, and (2) do not increase blockage to lymph system. Therefore, patients should avoid excessive heat, infections, and overly-strenuous arm exercises which would increase blood flow in the arm and thereby increase lymph production. MANAGING LYMPHEDEMA Patients should follow these suggestions to manage their lymphedema: Avoid puncturing or injuring the skin in any way. Use first aid care if there is a break in the skin. Avoid vaccinations, injections, blood pressure monitoring, blood drawing, and intravenous administration in the arm affected. Avoid tight-fitting clothing or jewelry. Avoid heat, such as with sunburns or tanning, baths, and saunas. Avoid strenuous exertion, but do exercise while wearing compression garments. Exercise, But Avoid Muscle Strain It is important to use your affected limb for normal everyday activities, yet overuse can cause lymphedema to occur in some people. Follow these suggestions whenever possible: Use affected arm or leg as normally as possible until fully healed, about 4 to 6 weeks after surgery or radiation treatment. Exercise regularly but do not strain the arm or leg. Before any strenuous exercise, such as weightlifting or tennis, talk with a doctor, nurse, or physical therapist about specific goals and limitations to decide what level of activity is right. Ask if a fitted sleeve or stocking should be worn during strenuous activities or while flying. If an arm or leg starts to ache, lie down and elevate it. Avoid vigorous, repeated activities, heavy lifting, or pulling. Watch for early signs of infection: rash, red blotches, swelling, increased heat, tenderness, or fever. Call a doctor right away if there are signs of infection. Experts also recommend that those with lymphedema avoid any trauma to the area affected. Trauma includes extreme temperature changes, repetitive movements against resistance (pushing or pulling), heavy lifting, and excessive exercise. For More Information American Cancer Society The American Cancer Society held an international conference on lymphedema in 1998 in New York City. It involved 60 of the world’s leading experts and included a forum of more than 250 breast cancer survivors, leaders of breast cancer advocacy groups, and others. The conference report plus a lymphedema resource guide are available as a book from the ACS at cancer.org. (See below for title.) National Lymphedema Network The National Lymphedema Network is a charitable organization with an international scope. Founded in 1988, the Network’s mission is to provide education and guidance to patients and health care professionals. The Network promotes standardizing quality treatment for lymphedema patients. In addition, the organization supports research into the causes and possible alternative treatments for this “often incapacitating, often-neglected condition.” Sources: Current Trends in Lymphedema Management, Esther Muscari Lin, RN, MSN, CS, ACNP, AOCN, November 7, 2002. American Cancer Society, Cancer (Vol. http://www.cancer.org/ Cancer Principles and Practices of Oncology, Lippincott Williams & Wilkins, 6th Edition, 2001. http://www.lww.com/productdetailresults ... 60,00.html Harvard Medical School, Intelihealth.com, http://www.intelihealth.com/IH/ihtIH?t= ... Lymphatic Research Foundation, http://www.lymphaticresearch.org/ Lymphedema Online Support Group, http://www.acor.org/ Lymphology Association of North America, offers professional certification. http://www.clt-lana.org/main.html Merck Manual, 17th Edition, 1999. http://www.merck.com/pubs/mmanual_home/contents.htm National Lymphedema Network, http://www.lymphnet.org/ https://www.cancerpage.com/centers/Side ... hedema.asp
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Kako dijagnosticirati Limfedem Dijagnosticiranje Limfedem Važna pitanja za pitajte svog Out Patient njihovih obitelji Povijest Razumjeti pacijente osobne medicinske povijesti KADA LIMFEDEM I SPREMIŠTE CONNIE M. SARVIS, RN, BN, MN, CON (C) CONNIE SARVIS je rana konzultant na Seven Oaks General Hospital in Winnipeg, Manitoba, Kanada. Ključne riječi: limfedem, lymphangitis, tromboza dubokih vena, filariasis, lymphoscintigraphy, Kaposi-Stemmer je znak, decongestive limfedem terapija, manualna limfna drenaža Ova disfiguring i ponekad bolno stanje utječe na mnogim pacijentima raka, i svibanj pojaviti mjeseci nakon operacije ili druge štete na limfni sustav. Prevencija i edukacija pacijenta posebno su važne za pacijente na rizik. Limfedem je uvjet da odražava disheartening realnost za mnoge pacijentima raka i drugih pacijenata, kao i. Simptomi uključuju oticanje, udovi i do dva puta na normal size, kože da uvlake i ostaje na taj način kada se pritisne (pitting), a thickening, hladna i Zamračivanje od kože (brawniness) .1 Visokim sadržajem proteina i limfna koji uzrokuje oticanje je idealno okruženje za dermatitis. The otekline i infekcije mogu postati i onemogućavanje disfiguring, izazivanje značajne fizičke i psihosocijalne oštećenje. Teško je precizno označavanje i učestalost limfedem zbog varijacije u svojoj definiciji i measurement.1 Jedna nedavna pregled izvijestili da limfedem, ruka pojavljuje u 26% pacijenata koji karcinom dojke therapy.2 To ne začuđuje, s obzirom da je limfna sustav je glavni put za metastaziranje. Limfedem, međutim, nije ograničena na karcinom dojke. Tretiraju pojedince za melanomas ili raka, jajnici, testisi, stidnica, ili mjehura može razviti sve limfedem.3 Limfedem također može pojaviti zbog venous bolest, nepokretnost, infekcija i drugih trauma, uključujući i sve veći broj joint replacement venous žetvu i postupci .3 Kao medicinska sestra, vaše vještine u upravljanju lymphedema može učiniti mnogo kako bi sačuvali kvalitetu života tih bolesnika. Zašto je kritična sustav break down Normalno, limfna sustav prikuplja višak tekućine i proteina iz tkiva i tijelo im se seli nazad u bloodstream po stopi od oko tri litre po day.4 Lymph je tjera-moving protiv gravitacije-kroz limfna žila po disanja i pokreta skeletni mišić kontrakcija u kojima se stvara gradijent tlaka. Niz ventili zadržati limfna teče u jednom smjeru. Kada se limfna sustav pati od neke vrsta trauma, ovu mogućnost da biste uklonili višak tekućine je ugrožena, limfna akumulira u interstitial prostore, najčešće u potkožnim masnim tkivima i time uzrokuje oticanje u ruku i nogu, i, manje često, u prtljažniku ili genitals.5 ustajao, protein-bogate limfne kanale tkiva uzrokuje povećanje u veličini i broju, što smanjuje raspoloživost kisika, umiješati se sa zacjeljivanje rana, i stvara optimalno okruženje za bakterijske infekcije (lymphangitis). Limfedem svibanj biti primarni ili sekundarni. Primarni limfedem je rijetka, naslijedila stanje u kojem se limfni čvorovi su ili odsutne ili nenormalan. Sekundarni limfedem rezultate iz oštećenja na limfna sustav-obično iz kirurško uklanjanje limfni čvorovi (koja je često potrebno u pacijentima raka) ili blockages u limfna sustava uzrokovana infekcija, raka, koji je putovao na limfni čvorovi, ili ožiljak tkiva (npr. , Od zračenja terapija, povrede, operacije ili da se ukloniti tumor) ,1 Lymphedema svibanj isto tako biti nuspojava od karcinoma dojke droga citrate tamoksifen (Nolvadex), jer to može uzrokovati krv clots i kasniji tromboza dubokih vena (DVT) da napredak na lymphedema.5 U nekim zemljama trećeg svijeta, najčešći uzrok lymphedema je filariasis, bolesti uzrokovane parazitski crvi Wucheria bancrofti, Brugia malayi i Brugia timori, koji je prenošen putem mosquitoes.6, 7 Lymphedema: Transient ili kronični Secondary lymphedema svibanj biti prelazni ili chronic.1 Transient lymphedema traje manje od šest mjeseci. Kože uvlake kada prešanih i razvedene ostaje bez brawniness.8 čimbenika koji pridobiti bolesnike na prelazni limfedem uključuju kirurški izlučivanje da leak proteina u kirurški site; upala sljedeće ozljede, zračenja, ili infekcija koja vodi do povećanog permeabilnost kapilara; limb nepokretnost da rezultate u smanjen compression od limfna sustav po musculature; privremenog gubitka limfne žile funkcija zbog operacije; i blokada u vein od loptica ili inflammation.1 Kronični limfedem je teško preokrenuti. Ona nastaje kao posljedica tumora ili povratak migracija u limfni čvorovi, infekcija ili ozljeda limfne žile, duga razdoblja nepokretnost, ili terapija zračenja ili operacije koje štete limfnog sustava. Radijacijska terapija može oštetiti inače zdrave limfni čvorovi i posuđe, što uzrokuje scar tissue to form, blokiranje normalna toka limfne tijekom limfna sustav. Kronični limfedem svibanj isto tako pojaviti nakon prethodno neuspješne upravljanje ranim lymphedema ili kada se vene je blokirana od strane krv grušati. Zoom in tih točaka u povijesti-uzimanje Zbog određenih kriterija za dijagnosticiranje limfedem još ne postoje, je temeljita medicinska povijest i fizički ispita neophodni su za diferencirane diagnosis.1 Age of napad će razlikovati primarni od sekundarni limfedem jer rano napad je više vjerojatno da će biti zbog jednog alteration u gena za vaskularne endotelne rast factor.3, Za 7 definitivnog dijagnoza primarnog lymphedema, uzroke sekundarne lymphedema prvo mora biti vladali van. Od sekundarni limfedem sklon rezultat od uzročan događaj kao što je kirurgija ili radijacijske terapije, morat ćete zamoliti detaljnijih pitanja u vezi bilo kakve prošlosti ambulantom i poslijeoperacijske komplikacije, posebno da li je za operacije raka i da li bilo koje limfni čvorovi su uklonjene. Rapid napad of lymphedema svibanj ukazuju na tumor infiltration ili blokiranje od glavnih limfna staza. Povijest bi trebala dokument bilo koje ograničenje pokretljivosti, kao što su korištenje invalidskih kolica; traume (osobito na noge, abdomen, ili genitalija regiji); i boravka u ili posjeta trećim zemljama svijeta (zbog rizika od filariasis). Zamolite bolesnika da li su kronični venous nedostatnost, disfunkcija štitnjače, artritis, ili hipertenzija, jer svaki od tih uvjeta može uzrokovati venous edem. Važno je razlikovati lymphedema iz edem povezane s venous insufficiency.5 Lymphoscintigraphy je test koji može pomoći da razlika s. U ovom postupku, malu količinu radioaktivnog protein dye je injected u web prostor između prvog i drugog broja je zahvaćena limb, limb je tada snimljeno s gama kamera promatrati na obojeni kao što se miče kroz limfna system.9 Slike prikazuju dye izvan limfna strukture predlažemo edem, limfna podrijetla. Kompjutorska tomografija (CT) i magnetska rezonancija (MRI), također se mogu koristiti za dijagnozu limfedem.9 Međutim, ove oblike imaging, kao i lymphoscintigraphy, mogu biti skupi. Fizikalni nalaz da sugeriše limfedem U vaše fizičko procjeni, ispitati koži zahvaćeni ekstremitet (s). Dryness, povećana debljina, hyperkeratosis (skaliranje), lymphangiomas (blisters sadrže limfna tekućina), abnormally topla ili vruća temperatura, neobično tamne kože, i prisustvo bilo koje nodules su svi pokazatelji limfedem.3 Papillomatosis-a cobblestone izgleda kože-svibanj isto tako biti prisutna, ona rezultate iz dilatirane i distended limfna žila u enveloped da su fibrotic tissue.9 Pogledajte, također, za Kaposi-Stemmer's registracije nemogućnosti patiti fold jedan od kože na osnovni je drugi nožni prst jer koža je tako obložen-koji pokazuje na jedan dijagnoza limfedem.9 Pobrinite se da primjetite bilo kakve rane na koži. Pacijenti s limfedem svibanj imati lymphorrhea, plačući i limfna tekućina, koja svibanj biti dovoljno bogat da zapravo pokrenuti ili kapanje niz nogu. Ovaj simptom predisposes pacijenata cellulitis. Limfedem može uzrokovati senzacija limb of heaviness i stezanje kože, topline ili požara, ili "igle i igle." Neki pacijenti imaju iskustvo umjerena do teškog bola zbog nerve compression iz okolnih edematous tissue.10 živaca compression svibanj i smanjiti odgovor na poticanje i pridobiti bolesnike na ozljede i infekcije. Vaša procjena fizičke potrebe uključiti detalje o stupnju oteklina, i oblika i veličina, u limb (s) zahvaćene, bolesnik je visina i težina (i body mass index, ako je dostupno); funkcionalnosti u limb, a arterijska ovlasti . Ako limfedem je jednostrana, quantifying opseg oteklina se usporedbom veličine jedan pogođeni limb za zdrav može biti korisna za qualifying i težini bolesti. Budite svjesni, ipak, da normalni anatomski varijacije mogu otežavati stvari, i da je usporedba neće biti moguće ako oba su zahvaćeni udovi. Ako je zahvaćena limb je   20% veća od nepromijenjen one.11 Mehanička tehnike su temeljne terapija Za bolesnika s umjerenim do teškim lymphedema, decongestive lymphedema terapija (DLT) 11 je standardni tretman. Njezina je svrha pomoći mobilizirati limfna i trošiti fibrosclerotic tkiva. U početno liječenje faza, DLT se sastoji od ručne limfne drenaže (MLD), compression, savjestan higijenu kože kako bi spriječio infekcije, i exercise.12-14 To je obično nakon koje je uslijedilo održavanja program se sastoji od kompresije, njegu kože, i vježbe. Ako lymphedema je blaga do umjerena, DLT svibanj biti bypassed u korist održavanja terapija. Imajte na umu da iako je nadmorska visina je temeljni tretman za edem of venous podrijetla, ne pojavljuju se kao učinkovit za liječenje lymphedema.15 Međutim, nadmorska visina svibanj biti korisni kao dodatak na komponente DLT, opisanog dolje. Drug terapiju i operacije su također raspravlja, ali su ograničene use.16 • ručna limfna drenaža je svjetlo-masažna terapija pritisak dizajnirana za poticanje limfe potičući otvaranje i zatvaranje ventila, u limfne kapilare i posuđe. Smjeru masaža je protiv gravitacije, od distalni na proksimalni dio u limb. Tijekom masaže-a session obično traje 30 - 60 minuta-pacijenta obično nosi svjetlo compression odijelu ili visoka da zadrži pritisak na tkivo i spriječiti protok limfna natrag u interstitial spaces.16 Idealno, ovaj terapija bi trebao biti pod upravom je certificirani terapeut limfedem. MLD treba izbjegavati u bolesnika s određenim uvjetima, kao što je pacijente koji su iskusni kardiovaskularne kvara ili u kojima DVT je sumnjiva, jer će sila više tekućine prema srcu i svibanj protjerati krv clots.16 MLD, međutim, neće predstavljati rizika u bolesnika s arterijska kompromis (dakle, nema impulsa u noge, slabije prokrvljeni, dijabetes, itd.). • kompresija služi dvojno svrhu optimiziranja akcije na mišiće kao limfna pumpe i spriječava daljnje oteklina. Bez obzira da li su bolesnici primaju početno liječenje faza DLT ili održavanje terapija, arterijska nadležnosti treba da se procijeni s Doppler ultrazvuk prije pomoću kompresije. Prije nego što odluči da oblog zahvaćeni ekstremitet, nekoliko drugih faktora treba da se smatra, kako je dobro. Kompresija može pogoršati stanje siromaha kože, DVT, srce uvjetima, upala, a cellulitis, svibanj je također povećati rizik od infection.16 Istovremeno, limfedem sama stvara teren za uzgoj infekcije-koji je uvjerljiv razlog za korištenje kompresije . Studije su pokazala da višeslojni sustavi smanjuju lymphedema učinkovitije od jednoslojan compression haljine ako se koristi za početno faza treatment.17 višeznačnom compression sustavi sastoje se od tri ili četiri razine bandaging i koriste se u prva dva do tri tjedna od početnih faza treatment.3 povez višeslojni sustavi mogu biti ostavljena na sedam dana u isto vrijeme prije mijenjanja ili su promijenila dva do tri puta tjedno, ako je rana skrb required.18 Pneumatska kompresije pumpe se sastoje od jednostavnih, multichamber rukavu koja odgovara preko zahvaćeni ekstremitet. The komore naizmjence napuhati i umanjiti u skladu s vremenski ciklus, izaziva peristaltic gibanje na swollen tkiva. Njihovo korištenje za kontrolu lymphedema, međutim, je controversial.15 Compression-haljine, kao što su stockings, rukavima, i rukavice-trebali bi se koristiti samo u održavanje therapy.3 su dostupni s polica u malim, srednjim i velikim veličinama, ili mogu biti prilagođeni-made za pacijenta. Haljine su ocijenjeno da dostavi 30 - 60 mm Hg, pressure.19 Pacijenti trošenje odijela za većinu dana i ukloniti ih noću provjeriti, čisto, i moisturize kože. Provjerite je li vaš pacijent ima alergiju na odijelu komponente, kao što je latex. • gadljiv njegu kože je kritična komponenta lymphedema tretman. Visokim sadržajem proteina i limfna tekućina predisposes pacijenata infekcije u lymphedematous limb.20 A dnevnu rutinu bi trebao biti uspostavljen u kojima je zahvaćena limb je obavila očevid za rane, čiste, i moisturized. Rutinske svibanj mijenjati se da svaka dva ili tri dana, tjedno ili u pacijenata koji bi mogao imati koristi od kontinuiranog višeslojni kompresije i čija koža je u relativno dobrom stanju. Oprezno inspekcija je posebno važno ako ima senzorska neuropatija. Nakon čišćenja kože s blagim hypoallergenic sapun i voda, pacijenta treba primjenjivati jedan ublažavajući, po mogućnosti u večernjim satima, za rehydration noćenje. Losione koji sadrže lanolin ili mirisa treba izbjegavati jer one mogu uzrokovati aktivacija s rezultiralo dermatitis. Osim toga, izbjeći petrolatum-based losione, jer oni svibanj oštećenja compression haljine. Prsti i stopala također treba pregledati redovito za gljivične infekcije, što je vrlo čest u pacijenata koji imaju lymphedema. • Tjelovježba može pomoći promovirati limfe i povećati protein reapsorpcija kao rezultat mišića contraction.9, 21, vježbe, međutim, treba biti nježan i odgovara na individualnoj sposobnosti i fitness razini. Snažan sportski se ne preporuča zbog mogućnost trauma.17 • Drug-terapije, osim antibiotika prema infekcija uzrokovanih limfedem-nije bio vrlo koristan u liječenju limfedem direktno. Diuretics pomoći da purge vaskularne fluid, ali oni su u nedjelotvornim kliring iz viška proteina i mogu uzrokovati vezivno tkivo fibrosis.22 Stoga, diuretics ne smije se koristiti, osim ako postoje dokazi od prekomjerne venous fluid.22 Do limfedem može biti riješen, bol može se upravljati s non-opioidni analgetici, tehnike relaksacije, blage do jake opioidni analgetici, lijekovi i pomoćno-npr., amitriptyline HCL (Elavil, Endep, dr.), ili kroskožna električni nervni stimulation.1 • Kirurgija je rezervirana za grubog edematous udovi na de-skupno neke od tkiva. Rezultati su raznolika, međutim, i konzervativne tretman je još uvijek potrebna za upravljanje preostalih limfedem.22 Nadalje, kirurški zahvati na bilo koji lymphedematous limb mogu predstaviti i teškim kroničnim zacjeljivanje rana problema. Edukacija i pomoć su odlučujuće U limfedem, dvije dodatne dimenzije Njega ne treba previdjeti: Edukacija i psihosocijalnog zdravlja. Edukacija je kritično i za prevenciju i upravljanje lymphedema-posebno za rak patients.23 Klinicara je potrebno educirati pacijente o rizik od razviti limfedem nakon operacije ili zračenja terapija, kako prepoznati simptome limfedem rano, i kako upravljati uređajem. Trebat će vam savjetovati bolesnika, na primjer, da nose loose-uklapanje odjeće, a ne na križ njihove noge dok sjedi, i da bi se izbjegla sjediti u jednom položaju za više od 30 minuta. Također je izuzetno važno kako bi se ocijenilo i psihosocijalne učinke limfedem. Stanje može uzrokovati smetnje i glavni unakaženje-prepreka da pacijentima raka, ili preživjeli su često bolestan-opremljeni da prevlada. Pacijenti koji doživljaj boli od stanja izvješće higher levels of body image poremećaj i smanjen spolni drive.24 The dodano teret težačkog, dugo trajati tretmani za limfedem mogu dalje nasrnuti pacijenta, već krhke psihe. Psihosocijalna pitanja svibanj biti upućeno od strane pojedinca ili grupe savjetovanje, zajedno s praktičnim informacijama o prehrani i vježbe, te savjete za branje flattering odjeća i udobna. Vaša nastojanja da se skrb za pacijente koji imaju ili su rizične za-limfedem može učiniti mnogo dobra. To je istinita ne samo kada je riječ o pacijentima 'fizički oporavak, ali kada je riječ o njihovu psihološku dobrobit, kako je dobro. Sada možete prevesti bilo koju stranicu na našoj web stranici pomoću Google translator na našu početnu stranicu: Lymphedema People http://www.lymphedemapeople.com Pat O'Connor Osnivač i Izvršnog Administrator Statistics: Posted by patoco — Mon Jul 14, 2008 10:55 pm