The management of lymphoedema in 2024

Lymphoedema is a multi-faceted condition best diagnosed within a biopsychosocial model, according to specialist Dr Kirsten van Duinen (Nij Smellinghe Hospital, the Netherlands). She provided an update on the diagnostic techniques and management strategies used in this population.

“Lymphoedema is an accumulation of oedema in the interstitium, caused by a disbalance of filtration to the interstitium and the transfer to the lymphatic system,” explained Dr van Duinen [1]. “Chronic oedema can be caused by an increased capillary filtration, a decreased lymphatic absorption, or a combination of these 2 elements.” Importantly, lymphoedema is a growing problem: 52–69% of the homecare population in the UK has chronic oedema. Of those patients, approximately 75% also have a wound. Both these issues are usually treated with compression therapy [2]. “Oedema is labelled as chronic if it persists for more than 3 months,” continued Dr van Duinen. “Overweight, lack of physical activity, certain pharmaceutical therapies, and ageing are important factors that contribute to the increasing prevalence of oedema.”

Dr van Duinen emphasised that chronic oedema is not a diagnosis but a symptom or a sign. Thus, it is essential to know its underlying cause to treat it successfully. Additionally, the healthcare professional should pay attention to all factors that may impact oedema. “Pathophysiological causes of oedema are an increased venous pressure, such as thrombosis, a decreased lymph transport, an increased tissue pressure, and a decreased capillary osmotic pressure, for example, in the case of albumin deficiency,” said Dr van Duinen.

Dr van Duinen suggests taking into consideration patient information such as weight, mobility, medication, comorbidities, and also social factors, participation in society, and personality traits, such as preferred coping mechanisms. “We must make patients aware of the factors they can influence themselves; weight loss is an important modifiable factor.”

For primary lymphoedema, genetic testing via next-generation sequencing may be performed. “For example, if we find an FLT4 abnormality in a patient, we know how to treat this person,” added Dr van Duinen. “Other forms of primary lymphoedema may be associated with cardiovascular diseases or leukaemia. Therefore, genetic testing is highly relevant.” Dr van Duinen also mentioned that difficult cases are discussed in a monthly meeting of the European Reference Network workgroup for paediatric and primary lymphoedema.

Lymphoscintigraphy, near-infrared fluorescence with indocyanine green, and dynamic intranodal MRI lymphangiography are imaging techniques for the lymphatic system. Lymphoscintigraphy delivers a qualitative and quantitative image. “Although it gives a good image, obesity is a confounding factor to interpret these images,” commented Dr van Duinen. Lympho-fluoroscopy gives a superficial overview of the lymphatic system. “This technique is mostly used for a sentinel node procedure or reconstructive lymphatic surgery,” according to Dr van Duinen. Also, its application is restricted to cases of secondary lymphoedema. Finally, MRI lymphangiography is used to depict thoracal and abdominal parts of the lymphatic system, serving specific diagnostic and therapeutic purposes, such as chyle leakage.

“Although manual lymph drainage is frequently used in patients with lymphoedema, there is practically no evidence for its effectivity,” Dr van Duinen continued [3]. “Only in the neck and head area, it may be applied in the initial treatment phase.”

Finally, Dr van Duinen discussed the so-called health monitor, a tool developed to deliver personalised management of chronic health conditions. The tool measures how the patients experience their health status with respect to ‘acceptance’ and ‘perceived control’ through a short questionnaire. Depending on the outcome, patients can receive various types of guidance, such as additional information to improve a patient’s perceived control or personal coaching to work on one’s acceptance.

1. Van Duinen KF. Update lymfologie. Dermatologendagen 2024, 11–12 April, Amsterdam, the Netherlands.
2. Moffatt CJ, et al. Lymph Res Biol. 2019;17:147-154.
3. De Vrieze T, et al. J Physiother. 2022;68:110-122.

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Posted on 31 May 202431 May 2024