Lower Extremity Lymphedema in a Patient With Melanoma

ABSTRACT: Surgical resection and lymph node dissection and assessment are essential to staging and treatment of melanoma, but can result in lower-extremity lymphedema that impairs patients’ mobility.

It is estimated that more than 62,000 men and women will be diagnosed with melanoma in 2008, with more than 8,400 deaths, and an estimated lifetime risk predicted to be 1 in 55.[1] Although deadly in its later stages, melanoma carries an excellent prognosis if it is diagnosed early. Fortunately, most melanoma cases (80%) are diagnosed at a localized stage; the 5-year survival rate for this group is 98.5%.

Unfortunately, a minority of patients have metastatic disease at diagnosis (3%), and 5-year survival rates for these patients are dismal, at 15.3%.[2] Treatment options for melanoma are based on the stage of disease at presentation. For patients with AJCC (American Joint Committee on Cancer) Stage I and II melanoma, sentinel lymph node (SLN) biopsy has become a standard staging procedure. SLN biopsy has emerged as a reliable technique for identifying micrometastatic disease in clinically negative regional lymph node basins.

SLN biopsy is based on a theory that lymphatic metastases follow an orderly progression through lymph channels from the primary tumor to a particular lymph node (“sentinel,” simply “guard” node) before spreading into other regional nodes.[3] Simply put, if the sentinel node does not contain evidence of metastatic melanoma, then the remainder of the lymph nodes in the basin are also highly likely free of disease, thus further dissection is spared. The status of the sentinel node evaluation has become the single most important predictive factor for recurrence and survival for melanoma patients[4,5] and should be considered for patients with melanomas ≥ 1 mm, or in patients with lesions < 1 mm if there are additional factors that should be considered, such as ulcerated lesions, Clark’s Level IV lesions (defined as invasion of the reticular dermis) or lesions with a high mitotic rate.

Traditionally, management of Stage II, or in some cases Stage I, cutaneous melanoma involved elective dissection of the draining nodal basin as a means to improve survival. However, improved survival has been difficult to demonstrate in randomized trials, and therapeutic gains have been questioned. Likely reasons include high morbidity associated with the procedure, a high complication rate, and the possibility of incorrectly identifying the proper draining nodal basin, and/or missing a second or aberrant nodal drainage basin.

Therefore, elective nodal dissection is no longer recommended; instead, completion (or therapeutic) nodal dissection is advised when a sentinel node has been identified; it is considered to be definitive treatment, with the goal of surgery being long-term survival. Prognosis for patients with cutaneous melanoma is dependent on the number of involved regional nodes and the thickness of the primary tumor.

Patients with pathologic or clinical evidence of regional nodal metastases as well as those with thick primary lesions (T4) have been demonstrated to be at high risk of disease recurrence.[6] Once palpable nodal disease develops, the ability to provide effective local/regional control and long-term survival is diminished.[7] Because local spread of melanoma commonly occurs in regional lymph nodes, sampling these nodes is necessary to assess the extent of disease and identify appropriate treatment, therefore sentinel lymph node assessment has become the procedure of choice for assessing status of the lymph nodes.

While surgical resection and lymph node assessment offers the most effective treatment for management and staging of melanoma, the long-term effects of LN resection can result in long-term consequences for the patient; for some, effects such as lymphedema can be disabling. Furthermore, SLN biopsy, though minimally invasive and regularly performed with little morbidity, also can be associated with lymphedema.[5]

PATHOPHYSIOLOGY OF LYMPHEDEMA
Lymph fluid comprises protein, water, fats, and cellular waste. It is transported through lymph vessels to lymph nodes and empties into blood vessels. These vessels are thin, allowing the large proteins to filter through easily.

In the case of an obstruction (from surgery, radiation, trauma, infection, tumor, etc), the large proteins filter through the vessels and invade the interstitial tissues, which causes an accumulation of highly concentrated, protein-filled fluid in an area distal to the blockage.[8] Surgery and infection cause scarring that can obstruct blood lymph flow and cause a proximal collection of fluid.

Removal of nodes (in sentinel node biopsy, or more likely, in elective or therapeutic nodal dissection) further damages the system. If the patient subsequently receives radiation therapy, this causes constriction of lymphatic vessels, worsening any pre-existing edema.[3] Congestion of the lymph system leading to edema “results when the amount of fluid that needs to be removed exceeds lymphatic system’s ability to remove it.”[9] Lymphedema arises from an imbalance between the normal amount of protein load and the reduced transport capacity of the lymph vascular system.[10] It can be acute or chronic.

THE PATIENT, “SK”
The patient, SK, is a 47-year-old, overweight Caucasian woman who was diagnosed in 2003 with a melanoma in her right calf. She underwent wide excision followed by SLN biopsy. At that time she had 0/2 positive LN, and had no additional treatment.

In November 2007, the patient noted a new lump in her right groin. A fine needle aspiration of the mass revealed melanoma. In December 2007 she underwent radical groin dissection. Pathology demonstrated 1/19 positive nodes, with extranodal extension in that node of 3.5 cm. Postoperatively, she did well without complications. Ten days later, she experienced an acute onset of edema, particularly in her thigh. The edema receded somewhat over the next few days, but persisted.

SK then underwent a course of radiation to the right groin owing to the presence of extranodal extension. Upon completion of radiation therapy, her edema became worse, and she reported progressive pain in her right leg that extended to her thigh. It has persisted, and has had a moderate impact on her day-to-day living. Her symptoms include a “heaviness” of the limb, persistent “achiness,” and difficulty fitting into the shoe for her right foot.

She also notes an increase in edema and achiness later in the day. Her occupation requires her to travel often, and she notes increased swelling and tenderness with travel, leading to discomfort for 2 to 3 days after flying.

NURSING MANAGEMENT
At the time of SK’s acute increase in edema post-operatively, the NP arranged an appointment for venous ultrasound to evaluate SK for other pathology related to or contributing to the edema, specifically deep vein thrombosis, and/or chronic obstruction. Results were negative. A physical examination was performed to rule out cellulitis or another source of edema, such as injury.

A full sensory and motor exam was conducted to evaluate function. SK was educated about lymphedema, including contributory and controllable factors of edema such as obesity and lack of aerobic exercise.[7] As she was moderately obese, SK was counseled on proper nutrition as well as gentle exercise.

Key to treatment is prompt referral to physical therapy, specifically a certified lymphedema physical therapist. Indeed, this referral was initiated by the nurse practitioner and was obtained prior to starting radiation as interventions are most effective at an early stage.[7]

As her edema suddenly increased in the postoperative period, before she even began radiation, it was felt that to some degree it was an acute response to surgery. For that reason, she was taught bandaging strategies for compression.

Physical therapy treatment goals for SK included maximizing function, minimizing the impact of her edema, and formal fitting of a compression garment to be used as maintenance therapy for compression during the day, and SK will continue to use a compression bandage during sleep.[7] Interventions were successful at improving the degree of her lymphedema, as well as the associated “heaviness” she felt with ambulation.

SK continued to note increased edema with air travel and was counseled on the importance of using a compression garment to prevent further exacerbation.[11]

DISCUSSION
Lower-extremity edema from impaired lymph drainage after inguinofemoral node dissection negatively impacts a patient’s quality of life, by limiting comfortable mobility, posing a risk of infection (cellulitis), and creating an esthetically unpleasant appearance. Wearing a compression stocking and engaging in physical therapy can help to alleviate the problem. Nursing intervention is necessary when caring for a melanoma patient undergoing lymph node dissection to complete staging.

There are very few data in the medical literature regarding the incidence of lymphedema in melanoma patients, as much of the literature discusses lymphedema immediately following breast cancer surgery and pertains to upper-extremity lymphedema. Lower- extremity lymphedema poses a special challenge to the melanoma patient because it can significantly impact mobility and predisposes the patient to further potential complications such as infection.

These complications have the potential to significantly affect quality of life in patients with melanoma. Risk factors for the development of lymphedema include surgery, particularly lymph node removal whether that includes sentinel node dissection only, and/or completion dissection; it is considered standard of care, and in the case of Stage II melanoma, dissection is considered definitive. Postoperative radiation may also be a risk factor, but other factors need be considered and minimized whenever possible, including obesity, decreased activity, and radiation, all of which are known to increase the risk of lymphedema.

Nursing care can make a tremendous impact on patient outcomes. With a basic knowledge of lymphedema, nurses can be proactive in patient education, monitor for the presence of lymphedema, and quickly intervene to minimize its extent.[6] Effective management begins with identification of symptoms that can signal lymphedema, such as shiny skin, loss of hair, and delayed wound healing. Assessing firmness of the limb, as well as presence or absence of pitting edema, and taking accurate limb measurements are essential. Prompt referral to a certified lymphedema specialist is essential, given that lymphedema is a progressive problem.

If treated early with complete decongestive therapy (CDT) by a qualified certified lymphedema therapist (with a CLT-LANA degree), the progression of lymphedema can be slowed. Four stages of CDT include: manual lymph drainage, involving a gentle manual massage technique; compression bandaging to help keep fluid and protein from flowing in to break down areas of scarring and fibrosis; remedial exercises; and meticulous skin and nail care to minimize risk of acute infection.[8,9]

In some instances, specialized lymphatic drainage pumps are used, such as gradient pneumatic lymphedema pumps or intermittent pneumatic pumps. Diuretics have little use in lymphedema. They pull excess water into the interstitial spaces, but not the excess protein. Thus when the diuretic is discontinued, the concentrated proteins pull more water back into the affected area,[8] often making the edema worse. Patients as well as other medical providers, often trying to help, must be made aware of the limited use of diuretics in addressing this problem.

Patient education should also include a review of the general care of lymphedema. The National Lymphedema Network highlights the following interventions as important in patient education about risk reduction[12]:

• Skin care-Avoid trauma, and reduce infection. Use moisturizers and sunscreen to protect the skin and prevent chapping and chafing; in nail care, do not trim cuticles; use care with razors; if possible, avoid punctures (eg, injections, blood draws); if redness, itching, pain and fever occur, contact the physician to evaluate the patient for possible infection.
• Activity-Gradually increase activity, exercise, alternate rest periods with activity to allow the affected limb to recover, maintain optimal weight, avoid prolonged periods of standing or sitting, avoid crossing legs, and use well-fitting footwear.
• Avoid limb constriction-Wear loose-fitting, comfortable clothing.
• Compression garments-These assist in lymph fluid redistribution: Use during long periods of standing and during air travel.
• Avoid extreme temperatures-Exposure to extreme cold can lead to rebound swelling. Prolonged exposure to heat (>15 minutes, eg, in a hot tub or sauna) should be avoided, as well as placing limb in water temperatures exceeding 102 degrees Fahrenheit.

OUTCOME
As a result of continued follow-up with her lymphedema physical therapy, SK did attain increased function of her affected extremity. She was empowered by partnering in the care and management of her lymphedema by learning manual compression bandaging for use during her frequent air travel, and by learning some gentle aerobic exercises to help increase blood flow. She also sought out a referral to a registered dietician to discuss better nutrition.

SK learned how to assess her extremity to look for early infection. She knew what to do in the case of a sudden increasing edema related to temperature extremes, travel, etc. She had her husband learn the basics of manual massage so that it could be conducted at home in addition to her formal physical therapy sessions at the hospital. Overall, SK learned to live with the morbidity of her lymphedema, and was able to minimize the degree of edema with learned management strategies.

References:

1. National Cancer Institute. Cancer Stat Fact Sheets: Melanoma of the Skin. Available at: http://seer.cancer.gov/statfacts/html/melan.html. Accessed on May 25, 2008.
2. Ries LAG, Melbert D, Krapcho M, et al (eds): Contents of the SEER Cancer Statistics Review, 1975-2004. National Cancer Institute, Bethesda, MD. Available at: http://seer.cancer.gov/csr/1975_2004/results_merged/topic_survival.pdf. Based on November 2006 SEER data submission, posted to the SEER Web site, 2007. Accessed on June 9, 2008.
3. Cormier J, Davidson L, Evans W, et al: Lymphedema in Melanoma Patients. National Lymphedema Network Publication. 17(1), 2005.4. Guggenheim M, Merline M, Hug U, et al: Morbidity and recurrence after completion lymph node dissection following sentinel lymph node biopsy in cutaneous melanoma. Ann Surg 247(4):687–693, 2008.
5. Wrone D, Tanabe K, Cosimi A, et al: Lymphedema after sentinel lymph node biopsy for cutaneous melanoma: A report of 5 cases. Arch Dermatol 136(4):511–514, 2000.
6. Marrs J: Lymphedema and implications for oncology nursing practice. Clin J Oncol Nursing 11(1):19–21, 2007.
7. Dell D, Doll C: Caring for a patient with lymphedema. Nursing 36(6):49–51, 2006.
8. Holcomb S: Identification and treatment of different types of lymphedema. Adv Skin Wound Care 19(2):103-108, 2006. Available at http://ovidsp.tx.ovid.com/spb/ovidweb.cgi. Accessed on May 12, 2008.
9. Holtgrefe KM: Twice-weekly complete decongestive physical therapy in the management of secondary lymphedema of the lower extremities. Phys Ther 86(8):1128–1136, 2006.
10. Zuther J: Treatment of lymphedema with complete decongestive physiotherapy. National Lymphedema Newsletter 11(2), 1999. 11. National Lymphedema Network. Position Statement of the National Lymphedema Network. Topic: Air Travel. May 2008. Available at: http://www.lymphnet.org/pdfDocs/nlnairtravel.pdf. Accessed on June 9, 2008.
12. National Lymphedema Network. Position Statement of the National Lymphedema Network. Topic: Lymphedema Risk Reduction Practices. March 2008. Available at: http://www.lymphnet.org/pdfDocs/nlnriskreduction.pdf. Accessed on June 9, 2008.