Lymphoedema: estimating the size of the problem

Moderators: Birdwatcher, Cassie, patoco, Senior Moderators

Lymphoedema: estimating the size of the problem

Postby patoco » Sun Jun 11, 2006 3:01 pm

Lymphoedema: estimating the size of the problem

Lymphedema People


Lymphoedema: estimating the size of the problem

Anne F Williams Centre for Research and Implementation of Clinical Practice, Thames Valley University,
London and University of Glasgow, Glasgow, Peter J Franks Professor of Health Sciences, Centre for Research
and Implementation of Clinical Practice, Thames Valley University, London and Christine J Moffatt Professor of
Nursing, Centre for Research and Implementation of Clinical Practice, Thames Valley University, London

Lymphoedema is a problem frequently encountered by professionals working in palliative care. This article reviews the evidence on the magnitude of the problem of lymphoedema in the general population and provides evidence on specific high risk groups within it.

Prevalence is a good indicator of the burden of disease for chronic problems such as lymphoedema, as it indicates the numbers of patients who require care. Incidence is indicative of changes in the causes of lymphoedema and the success of any prevention programmes. Both are important means of assessing the current level of need and the
potential for the changing needs in managing this condition. Problems exist in all studies in relation to precise definitions of lymphoedema, inconsistent measures to assess differential diagnosis and poorly defined populations. While there is some evidence of high rates in
relation to breast cancer therapy, the total burden of lymphoedema in the general population is largely unknown. Palliative Medicine 2005; 19: 300 /313

Key words: chronic oedema; epidemiology; prevalence; Lymphoedema; incidence


Lymphoedema is a chronic swelling arising from the
accumulation of fluid and other tissue elements that would
otherwise drain via the lymphatic system. It can be a
grossly disfiguring condition, usually affecting a limb,
which causes discomfort and may cause pain, and can be
complicated by recurrent infections often requiring hospital
admission. Untreated, limbs can become huge and the
term elephantiasis illuminates their appearance. Sufferers
report the psychological impact of the condition to be
considerable. Causes include cancer treatment, parasitic
infection and congenital problems in the development of
the lymphatic system.

In addition, lymphoedema frequently
occurs in patients with other chronic diseases
e.g., spina bifida, rheumatoid arthritis and stroke.
While not exclusive to palliative care services, the
association between cancer therapy and lymphoedema
has led to many services being located within the palliative
care system. The emphasis of treatment is on helping the
patient to achieve as much self-sufficiency and independence
as possible, given the chronic nature of their
condition and to reduce the incidence of co-morbidity
and the need for intensive therapy and hospitalisation.

This article will review the epidemiology of lymphoedema,
with particular reference to the prevalence and
incidence of the condition.

Epidemiology definitions

Epidemiology is defined as the study of disease in relation to populations.1 Within this there are a number of key measures that are important in defining the disease burden (prevalence) and the number of new cases that develop over a specified time period (incidence). Both measures are important to services providing care to patients since they will indicate the potential care requirements of a population and examine how the disease profile is likely to change over time as new cases add to this burden. The task of obtaining accurate figures for lymphoedema incidence and prevalence is, however, complex and the literature is limited. This paper will discuss some of the difficulties associated with exploring lymphoedema incidence and prevalence and review relevant literature related to specific types of lymphoedema and lymphoedema-associated conditions.

Defining cases of lymphoedema

In evaluating the prevalence and incidence of a condition
it is essential to describe precisely how the disease is
defined. A repeatable, valid and accepted definition will
allow for comparisons between and within ‘at risk’
populations to evaluate temporal and geographical
differences and give some indication of the nature of
the disease. Whilst definitions are essential to determine
the consistency of measurement, lymphoedema is rarely
defined in precise terms. In a previous review, Logan
highlighted some of the problems inherent in ascertaining
rates in lymphoedema.2 Amongst various studies there
are inconsistencies in methods used to determine the
Address for correspondence: Peter J Franks, CRICP, Thames Valley University, 32 /38 Uxbridge Road, London W5 2BS, UK.


Palliative Medicine 2005; 19: 300 /313

# 2005 Edward Arnold (Publishers) Ltd 10.1191/0269216305pm1020oa presence of swelling, quantify the degree of swelling and assess skin and tissue changes.

In a recent publication we have used a general
definition of chronic oedema/lymphoedema to describe
the overall presence of swelling to health professionals.
Population studies of this nature frequently rely on
clinical classification of a condition, which may be
confirmed at a later date using more objective invasive
and non-invasive tests.

‘Chronic oedema is a broad term used to describe
oedema which has been present for more than 3
months and involves one or more of the following
areas: limb/s, hands/feet, upper body (breast/chest,
shoulder, back), lower body (buttocks, abdomen),
genital (scrotum, penis, vulva), head, neck or face.
Oedema which develops as a result of a failure in the
lymphatic system is referred to as lymphoedema but
chronic oedema may have a more complex underlying
aetiology. At this stage we do not expect to make a
differential diagnosis but need to record the actual
numbers of people with oedema suggestive of chronic
oedema/lymphoedema, even if a medical diagnosis has
not been confirmed.’3

This recent prevalence study used a case ascertainment
method in an urban health authority and identified a
prevalence figure of 1.33 per 1000.3 However, the authors
suggest this may underestimate the actual number as the
ascertainment of patients through health professionals is
limited where not all patients are likely to be receiving
treatment for their condition. Nevertheless, it is similar to
the 1.44 per 1000 prevalence of chronic oedema in
Norway reported by Petlund.4

Differential diagnoses

There are a number of problems in establishing a
differential diagnosis in lymphoedema, particularly in
relation to primary lymphoedema.5 Although lymphoscintigraphy
is an invaluable tool in assisting in the
diagnostic process, investigative methods are not universally
standardized and can be inadequate. In some
instances, several contributory factors, such as obesity
and venous insufficiency, may confuse the clinical picture
and make accurate diagnosis difficult.5

Despite these difficulties, attempts have been made
over several decades to provide a classification for
lymphoedema.6 9 Browse and Stewart suggested that
only those with obvious abnormality of the large vessels
or aplasia/dysplasia of the peripheral channels should be
considered as having primary lymphoedema and describe
these as genetically determined or acquired later in life.8,9

It is clear that identification of primary lymphatic
abnormalities can be problematic due to the varying
presentations and difficulties with investigation and
differential diagnosis.

The classification of secondary lymphoedema is also
highly problematic. These may be post-traumatic, postinflammation/
infection, secondary to lymph node dissection
and irradiation or result from a range of other

The development of swelling, particularly in
those with advanced cancer, may sometimes be due to
failure of more than one system. Lymphatic damage or
insufficiency may be compounded by venous obstruction,
cardiac, renal or hepatic failure. Swelling associated with
chronic venous disease is often not recognised as a
lymphoedema-type problem, despite the knowledge that
ulceration and infection are likely to damage the
lymphatic system.

The term ‘chronic oedema’ has become widely used in describing a range of oedemas, some with a considerable lymphatic component and
many of which have complicated aetiologies. Consideration
of these other types of oedema clearly influences the
data on incidence and prevalence.

While this paper concentrates on lymphatic problems
associated with westernized countries, tropical lymphoedema
is acknowledged as a significant problem in other
parts of the world. Lymphatic filariasis and infestation by
Wuchereria bancrofti is a major cause of lymphoedema in
some areas of Africa and India and has significant
implications for health services in these countries.10

Measuring lymphoedema

Various methods exist for the measurement and calculation
of the degree of swelling.11 Measurement using water
displacement, electric volumetry and skin circumferences
are the most common techniques but are open to
variations in their use. For example, skin circumferences
may be taken at a wide range of sites on the limb. In the
UK the most common technique consists of 4 cm
circumferences extending distally to proximally, which
are used to calculate the total volume of the limb as the
sum of a series of cylinders. A number of studies have
explored the validity and reliability of arm volume
measured by these different methods and most conclude
that while these methods are highly correlated and
reliable, they are not interchangeable and cannot be
mixed or substituted.12 14

In their review Stanton et al . highlight a volume of
/200 ml as measured by water displacement as a
sensitive indicator of arm lymphoedema and this definition
is used in many studies.11 Clearly, reducing this
cut-off figure to /100 ml may appear to increase the
prevalence of lymphoedema,15 but it may also be argued that this also enables identification of mild oedema.

Stanton et al. , however, suggest that percentage differences
are more universally applicable, allowing for
easier comparison and, as such, a difference of 10% in
volume may be an appropriate cut-off point.11 The
potential accuracy of the volumes also requires standar-
Lymphoedema: estimating the size of the problem 301
dization and accuracy in protocols for measurement and

More recently, Bland et al . have suggested the value of
a 5% or /1 cm increase in arm circumference is a reliable detector of probable lymphoedema in the clinical setting.

However, although circumferential measurements
are widely used in the literature, many people with
lymphoedema do not have uniform swelling throughout
the limb and it is common for swelling to be localized to
hand or upper arm.18,19 This indicates that reliance on
the use of one or two circumferential measurements of
the swollen limb is inadequate and also does not take in
account any changes in limb circumference due to
increased fat or muscle mass. Asymmetry in limb circumferences
and volumes, due to arm dominance, should also
be a consideration.20

Ideally, circumferences should be taken along the length of the limb and the total limb volume with possible proximal and distal limb segment
volumes should be calculated. Many studies have used
subjective reporting of swelling alone, though the correlation
with objective measures is often poor.18,21

Time to lymphoedema development

The length of time to lymphoedema development is also
an important consideration. Most patients experience an
acute post-operative oedema and this leads to temporary
limb swelling. Persistent oedema for greater than three
months duration is more likely to be lymphoedema and
oedema prior to this point should be excluded. Additionally,
studies need to be undertaken over an adequate
time period as lymphoedema may develop at any stage
post-treatment. Edwards et al. showed the onset of
lymphoedema to occur in the first 18 months postsurgery,
21 while others report a thirty-nine month median
time interval to lymphoedema development.22 This
suggests that a longer follow up is required to ensure
that a late lymphoedema is recognized.19,23

Literature search methodology

A search was undertaken of PubMed, Medline (from
1966), CINAHL (from 1982), the Cochrane Database of Systematic Reviews up to December 2003 and The International Society of Lymphology Congress Proceedings.

The terms lymphoedema, chronic oedema, prevalence,
incidence and epidemiology were used. Filarial
lymphoedema was omitted from the search as it was felt to be beyond the scope of this review.

Primary lymphoedema

At present there are no published figures to confirm
prevalence and incidence of primary lymphoedema.
However, a small number of audits and reviews in the
UK have provided some evidence on the numbers of
patients with primary lymphoedema of those attending
lymphoedema clinics. A national study by the British
Lymphology Society reported that 8% of 603 patients
newly referred to 27 UK lymphoedema clinics over a
three-month period suffered from primary lymphoedema.

Williams et al. estimated that 12% of the 714
patients attending a lymphoedema clinic over the previous
five years suffered from primary lymphoedema.25
Furthermore, an audit of the 908 patients attending a
clinic over a four-year period, reported 218 (24%) having
non-cancer lymphoedema.26 Of these 218, 62 (28%) were
diagnosed with primary lymphoedema, although only
14 had unequivocal evidence of a primary lymphatic
disorder, the remainder having a history suggestive of a
primary lymphatic cause. However, those already attending
clinics are likely to represent ‘the tip of the iceberg’
and it is likely that patients with primary disease will be
under-represented due to poor diagnosis and services
that often concentrate on patients with cancer related
disease. This is illustrated by the long lead time from
disease onset to referral for treatment.24

Other studies outside the UK have adopted a more
epidemiological approach to investigations of primary
lymphoedema. A retrospective evaluation of primary
lymphoedema in Minnesota (USA) between 1955 and
1974 estimated an annual incidence rate of 1.15/100 000
in the population aged under 20.27

More recently, a national epidemiological study in Spain surveyed 308
centres such as surgical and vascular units.28 From
2743 people with lymphoedema identified by these units, 1009 (36.8%) were reported as having primary lymphoedema.

Of these, 2% were recognised as having congenital
lymphoedema (present from birth), 30% were estimated
to have lymphoedema praecox (swelling developing
around puberty) and 68% were reported as having
lymphoedema tarda (lymphoedema developing in later
life). The apparently high number with lymphoedema
tarda indicates that many of these may in fact have
secondary lymphoedema.


Rudkin and Miller reviewed 250 cases of lower limb
lymphoedema and showed that around 4% exhibited
unique characteristics representative of lipoedema, a
condition distinct from lymphoedema but often diagnosed
as primary lymphoedema.29 Again, there are no
clear figures indicating the numbers affected by this
condition that is frequently associated with, but often
mistaken for, lymphatic insufficiency.
302 AF Williams et al.

Secondary non-cancer-related swelling
There may be a range of factors contributing to the
development of lymphoedema, including chronic venous
disease, trauma, inflammation, infection and conditions
such as arthritis. However, prevalence and incidence data
on these secondary causes are limited. One small study in
the UK explored the prevalence of oedema in leg ulcer
patients in hospital and the community.30 It suggested
that oedema was present in 55% of the 56 patients,
although the prevalence in the community-based patients
was much greater at 77%. Another study of 689 chronic
leg ulcers identified 17 cases of ulceration due to

Blankfield et al. investigated the causes of bilateral
leg oedema in 45 primary care patients in the USA.32
Investigation with ECG and duplex scan of the legs
identified 33% with cardiac cause, 42% with pulmonary hypertension and 22% with venous insufficiency.

Other causes of leg swelling included medication,
nephrotic syndrome and hypoalbuminemia. The researchers
concluded that leg swelling, particularly in
those over 45-years-old, requires investigation as problems
such as congestive cardiac failure and pulmonary
hypertension are poorly recognised, particularly in
their early stages.

Cancer-related lymphoedema

Lymphoedema related to cancer and/or cancer treatment
may be readily identified as patients usually have an
obvious clinical history and have regular follow up after
their cancer treatment. In the audit by Sitzia et al. ,24 80%
of the 603 newly assessed patients were estimated to have
cancer-related lymphoedema, this group suffering from
swelling for a much shorter period than those with
primary lymphoedema.

Lymphoedema is most commonly associated with
surgery and/or irradiation to the lymph nodes. Shaw
and Rumball reviewed the case notes of 208 patients
who underwent cervical, axillary or inguinal lymphadenectomy in order to study the incidence of complications.33

Their classification distinguished between early
(less than one month) and late (more than one month)
onset. They reported an overall incidence of late
lymphoedema as 14.9% and identified lymphoedema as
the most common long-term complication, particularly
in patients who underwent groin dissection. The study
did not identify how lymphoedema was defined or

Breast cancer-related lymphoedema

In 1921, Halstead recognised the problems of arm
swelling following breast surgery and assumed this
‘surgical elephantiasis’ was due to streptococcal infection. 34 A summary of the literature on breast cancer related lymphoedema is given in Table 1.15,18,21 23,42 66 It is clear from Table 1 that there have been a large number of investigations of breast cancer related lymphoedema.

The majority of these studies have attempted
to identify factors in the treatment of the breast cancer
that predispose patients to develop lymphoedema. The
studies indicate that there is a wide range of incidences,
much of which may be explained by differences in case
definition and sampling procedures. There appear to be a
number of themes around the risk factors associated
with lymphoedema development, particularly, the use of
irradiation,15,36,37,39,45,47,49,54 56 the extent of axillary
node dissection,35,36,40,54,56,59 61,63,65,66 combined axillary
surgery and irradiation,22,41,43,46,48,50,51,60,62, obesity,
21,35,36,45,57,61 surgical wound infection,37,40,45,57
tumour stage and extent of surgery.21,48,49,51,56 Despite
improvements in surgical technique it is difficult to see
reductions in the incidence of lymphoedema, with
more recent studies still exhibiting high rates of development
in excess of 30% of women treated.18,63,64
However, this may be a consequence of detecting more
mild cases in isolated parts of the arm, such as the hand
or forearm.18

Lymphoedema secondary to groin dissection
The study by Shaw and Rumball reported a 40%
incidence of lymphoedema following groin dissection
confirming a previous study of 55% of 90 patients who
underwent ilio-inguinal dissection.33,67 When 33 of the
previous 90 patients were followed up at a review clinic,
26 (79%) reported some experience of swelling, often
worse in the first six months after surgery. Twenty-two
(67%) of the 33 patients had persistent lymphoedema at
the time of review, a follow up period ranging from one
to eight years post-treatment.

Lymphoedema secondary to malignant

Commonly the management of malignant melanoma
involves ilio-inguinal lymph node dissection and a study
from 1977 reported a lymphoedema incidence of up to
80% in these patients.68 Other studies have identified
lymphoedema in 23 and 26% of patients, respectively and
Lymphoedema: estimating the size of the problem 303

Table 1 Summary of papers/studies of breast cancer-related lymphoedema and reported risk factors
Author/s and dates Details Reported incidence Measurement method Definition of oedema Risk factors described
Fitts et al. (1954)53 Review of papers and study of
130 women following radical mastectomy 8 /95% (reviewed papers).

49% (study group)
Clinical examination Not defined Obesity; number of axillary nodes
removed; wound margin necrosis
Treves (1957)36 Study of 768 women following

41% Circumferential measurements ]/3 cm Circumference
increase compared with
contralateral limb
Axillary surgery; obesity;
Britton and Nelson
Review of 19 papers 1908 /1960
and study of 114 lymphoedema
6.7 /62.5% (reviewed papers) Circumferential measurements ]/2 cm Circumference
increase compared with
contralateral limb
Post-op wound complications:
delayed healing; cellulitis,
irradiation damage to skin
Howell-Hughes and
Patel (1966)38
Review of 11 papers 1944 /1960 41 /80% Not discussed Not defined Lymphatic and venous
obstruction due to fibrous tissue
Study of 58 women following
mastectomy; 39% had irradiation
31% Circumferential measurements
at five sites
]/1.5 cm Circumference
increase at two or more sites
compared with contralateral
Irradiation; inadequate nutrition
leading to delayed wound healing
Study of 74 women following
breast conserving surgery and
breast irradiation; 86% had axillary
node dissection (AND) and 24%
had axillary irradiation
14% overall; 7% (those B/60
years) 25% (those /60)
Circumferential measurements
at two sites (forearm and upper
]/2.5 cm Circumference
increase compared with
contralateral limb or pitting
oedema in dorsum of hand
Age /60 years; axillary node
dissection; wound infection;
surgical splitting of pectoralis
minor muscle in /60 years
al. (1988)41 Study of 57 patients following
mastectomy; 23% had irradiation
11% (surgery alone); 46%
(surgery and irradiation)
Circumference 10 cm above
]/2.5 cm Circumference
increase compared with
contralateral limb
Adjuvant irradiation in those with
metastatic axillary nodes
Badr El Din
Review of files of 100 patients
with stage 3 breast cancer treated
1974 /1988; all had neo-adjuvant
irradiation and 74% had neoadjuvant
chemotherapy; 92% had
22% Not discussed / case study
Not defined Not defined
al. (1989)43 Study of 94 patients; 42% had
mastectomy and axillary
clearance; 58% had mastectomy
and axillary sampling and 52% of
these had irradiation
8 /32% Circumference at 15 cm above
and 10 cm below olecranon
Not defined Combined axillary surgery and
al. (1992)44 Study of 118 patients; 51% had
mastectomy and axillary
clearance; 49% had wide local
excision and axillary clearance
then breast irradiation
7.6% Water displacement ]/200 ml Increase compared
with contralateral limb
Similar risk with axillary sampling
and clearance
Study of 136 women following
mastectomy and AND; 63% had
21 /89% (depending on factors
Water displacement ]/150 ml Increase compared
with contralateral limb
Obesity; oblique skin incision;
infection; irradiation
Study of 121 patients following
wide local excision and axillary
surgery; 61% had irradiation
21% (axillary sampling); 30%
(axillary sampling and
irradiation); 29% (axillary
clearance); 54% (axillary
clearance and irradiation)
Water displacement.
Circumferences at 10 cm distal
and 15 cm proximal to
]/200 ml Increase compared
with contralateral arm
Combined axillary surgery and
304 AF Williams et al.
Table 1 ( Continued)
Author/s and dates Details Reported incidence Measurement method Definition of oedema Risk factors described
Study of 683 women following
mastectomy, axillary node
sampling and irradiation
41% Circumference at eight sites on
]/1.5 cm Circumference
increase at two or more
adjacent sites compared with
contralateral limb
Axillary irradiation; delayed
wound healing; thoracic fibrosis
al. (1996)48 Study of 200 patients following
mastectomy (35%) or wide local
excision (WLE) (65%); 44% had
8.3% (axillary irradiation);
9.1% (axillary sampling and
irradiation); 7.4% (axillary
clearance); 38.3% (axillary
radiotherapy and irradiation)
Circumference at 15 cm above
lateral epicondyle and water
]/200 ml Increase compared
with contralateral limb
Combined axillary surgery and
irradiation; breast irradiation;
nodal status; tumour stage
Review of 1077 women following
mastectomy (93%) and WLE (7%)
for unilateral breast cancer
without recurrence; 467 (43%)
had irradiation
28 /38% Self reported questionnaire /
method validated
Self reported Irradiation; mastectomy has
greater risk than WLE
Study of 362 women with breast
cancer comparing those treated in
1983 (94% mastectomy: 6%
WLE) and those treated in 1988
(71% mastectomy: 29% WLE);
irradiation in 48% (1983) and 52%
8 /15% Not discussed Not defined Number of /ve axillary lymph
nodes; combined axillary
dissection and irradiation
Schunemann and
Willich (1997)51
Study of 5868 women treated
1972 /1995; various combinations
of surgery and irradiation
24% (overall); 22.3 /44.4%
(depending on cancer
Circumferential measurements
10 cm above and 10 cm below
]/2 cm Circumference
increase compared with
contralateral limb
Combined surgery and irradiation;
radical breast surgery
Petrek and Heelan
Review of seven papers and study
of 272 women treated 1976 /78
6 /30% (reviewed papers);
28% (study group)
Self reported circumferential
measurements at two sites
below and above the
olecranon / method validated
Circumference increase
compared with contralateral
limb. ]/2 inches / severe.
1 /2 inches / minimal
Not identified
Study of 303 women treated for
early stage breast cancer
4.3% Self reported Not defined Not identified
al. (1999)15 Study of 226 women following
mastectomy in 1979 /1983 (five
year follow up); unknown number
had irradiation
20% Water displacement ]/100 ml Increase compared
with contralateral limb
/ve axillary lymph nodes
requiring irradiation
al. (2000)54 Study of 84 women following
mastectomy and axillary node
dissection for stage 1 and 2 breast
cancer; high risk patients had
adjuvant irradiation and/or
26% (subjective report)
3 /14%
Circumference 15 cm above
and 10 cm below the
olecranon. Also used nine
circumferential measures to
calculate volume
]/200 ml Increase compared
with contralateral limb
Axillary dissection; non-significant
increased risk in irradiated group
Study of 110 women T1, N0
staging following mastectomy and
axillary dissection; 68% had
19% Self reported and water
/10% Increase in arm
volume in relation to
Edwards (2000)21 Study of 201 women treated
1994 /6; 57% had mastectomy
(22% irradiated); 43% WLE (72%
11%; (23.4% subjective) Water displacement and self
reported. Volume adjusted to
address natural asymmetry of
]/10% Increase in arm
volume compared with
contralateral arm
High BMI; axillary surgery;
mastectomy /risk than WLE;
tumour size and grade
Lymphoedema: estimating the size of the problem 305
Table 1 ( Continued)
Author/s and dates Details Reported incidence Measurement method Definition of oedema Risk factors described
Study of 1278 women;
mastectomy (24%); 19% had
WLE and axillary node dissection
without irradiation; 57% had WLE,
axillary node dissection and breast
15.9% Arm circumference six 6 sites
to calculate% difference
/5% Increase in sum of the
differences between the two
Post-operative breast irradiation;
T2 tumour classification; ( /30
lymph nodes removed /
borderline risk)
al. (2001)57 Study of 263 women treated
1976 /8 and followed up over
twenty years
13%; (49% self-reported) Circumferences at four
sites / self measurement
Circumference increase any
one site compared with
contralateral limb; ]/2 inches
defined as severe but noted
50% had mild swelling defined
as increase of B/0.5 inches
Infection; injury; weight gain
al. (2001)23 Study of 100 women with
unilateral breast cancer; 64% had
mastectomy; 36% had WLE and
axillary node clearance
10% Optoelectronic volometer /200 ml Increase compared
with contralateral limb
No association between lymphoedema
and type of surgery or
number of lymph nodes removed
al. (2001)58 Study of 420 women treated with
mastectomy or WLE; 72% had
sentinel lymphadenectomy (SL);
28% had level 1 /2 axillary
clearance due to metastatic
disease in sentinel nodes
3% (SL); 17% (SL and axillary
‘Arm measurements’ taken
pre- and post-operatively but
no detail given
/20% Volume increase
compared to contralateral arm
Extent of axillary staging; tumour
in upper outer quadrant of breast;
post-operative trauma and/or
infection to arm
Study of 655 women following
WLE and axillary dissection or
irradiation; compared to others
treated elsewhere with combined
axillary surgery and irradiation
1% (axillary irradiation); 26%
(axillary dissection)
measurements / not detailed
/1 cm Increase in
circumference compared with
contralateral arm ( /2 cm if
dominant arm)
Axillary dissection in postmenopausal
al. (2002)60 Study of 112 patients treated
1993 /7 with WLE and breast
irradiation or mastectomy; most
had level 1 or 2 axillary dissection;
high risk patients had irradiation to
supraclavicular and axillary nodes
12.5%; 5% (axillary surgery);
30% (axillary surgery and
Self report questionnaire.
Water displacement.
Circumferences at four sites
/200 ml Increase compared
with contralateral limb. Self
Axillary dissection and irradiation
al. (2002)61 Study of 294 patients treated
1990 /92 with WLE; all had breast
irradiation; 88% had axillary
dissection; 44% had irradiation to
axillary and supraclavicular nodes
13.6%; 18% (surgery with
breast and axillary irradiation);
10% (following surgery alone)
Circumferential measurements
10 cm above and 10 cm below
lateral epicondyle. Subjective
Any increase in circumference
compared to contralateral arm.
Self report
Axillary node dissection; high
body weight
al. (2003)62 Study of 106 women treated
1995 /6; 73% had mastectomy;
27% had WLE; 10% had
13% Water displacement.
Circumference 15 cm above
and 10 cm below olecranon.
/200 ml Increase in volume
compared to contralateral arm.
]/2 cm Increase in
circumference at any one
point (identified as less
sensitive than water
Axillary lymph node dissection;
adjuvant axillary irradiation
Querci della Rovere
al. (2003)18
Study of 198 women following
level 1 and 2 axillary dissection;
with oedema for /6 months;
20% had mastectomy and axillary
dissection; 71% had WLE and AD;
10% had only AD
32.8%; (27.8% were mild to
moderate); (5% were severe).
Oedema seen in single sites
but not affecting whole of arm
in most cases e.g., hand,
Circumferences at 15 cm
above and 10 cm below elbow.
Subjective assessment by
patient, nurse and doctor
/5% Increase in
circumference compared to
contralateral arm (mild);
moderate /B/10%; severe /
Nodal status; affected dominant
arm; right sided cancer increases
risk of forearm oedema;
non-consultant surgeon
306 AF Williams et al.
Table 1 ( Continued)
Author/s and dates Details Reported incidence Measurement method Definition of oedema Risk factors described
al. (2003)63 Study of 145 women; 62% had
WLE; 38% had mastectomy; 86%
had AND; 67% had irradiation
38% Self-reported (telephone
Age B/50 years; axillary node
dissection; cytotoxic
chemotherapy; work outside
home; lower risk if treated for
Study of 153 women followed up
at 20 years post adjuvant
chemotherapy; 65% had
mastectomy; unknown number
had irradiation
39% Self-reported (telephone
None described
Study of 714 women (727 arms)
women with stage 1 and 2 breast
cancer and treated with breast
conservation surgery and breast
irradiation; 32% had irradiation to
axilla and supraclavicular nodes;
15% had level 1 /3 axillary
4.1%; 10.7% (axillary surgery
and irradiation)
Circumference of forearm at
10 cm below olecranon
/2 cm Increase in forearm
circumference compared with
contralateral limb. /4 cm /
Combined axillary node surgery
and irradiation
Study of patients with primary
breast cancer diagnosed between
1973 and 2000; excluding those
with uncontrolled axillary
ecurrence. Part 1: 1242 patients.
Part 2: 677 patients
Part 1: 0.4% reporting
problematic symptoms
affecting quality of life (not
numbers with swelling). Part
2: 6.2% reported ‘a lot of’
Part 1: patient self report and
clinical examination by
clinician. Part 2: patient
Suggest circumferential
measurements are of limited
Not specific but identify
unnecessary axillary interventions
as increasing the risk
Study of 125 women (node
negative at time of surgery); 62%
had sentinel lymph node biopsy
and 91% of these had irradiation;
38% had AND; 77% of these had
2.6% (sentinel node biopsy
and axillary sampling); 27%
(axillary node dissection)
Circumferences at 10 cm
above and 10 cm below
]/3 cm Increase in
circumference compared
with contralateral arm
Axillary node dissection has
greater risk than sentinel node

Lymphoedema: estimating the size of the problem 307
a previous review has indicated a 6 /20% incidence of
lymphoedema in patients following combined inguinal
and pelvic lymph node dissection for stage III melanoma.
69 71

Karakousis et al . studied 77 patients following groin
dissection, mainly for malignant melanoma.72 They
identified oedema in 21% of these patients and reported
those who had a primary tumour of the lower leg to be
significantly more likely to develop swelling. They also
showed that those who wore compression garments postoperatively
were less likely to develop swelling. The same
author later studied 205 patients following groin dissection
and suggested that all had some localized oedema of
the anteromedial thigh, with around 40% having swelling
of the lower leg.73 Interestingly, Urist et al. also
suggested lymphoedema to be mostly confined to the

Strobbe et al. studied 71 patients with positive iliac
and/or obturator fossa nodes, reporting mild/moderate
lymphoedema in 19% and severe lymphoedema in 6%
of patients.74 A study by Serpell et al. reviewed
73 lymphadenectomies in 64 patients, showing lymphoedema
to be more common after groin dissection,
occurring in 29% of patients following inguinal surgery
compared to 6% of axillary dissections.75 This study
defined lymphoedema as post-operative swelling persisting
beyond three months and highlighted the use of postoperative
prophylactic measures, such as seven days bed
rest and six months use of below knee compression
hosiery to reduce the risk of lymphoedema.To reduce the
risk of lymphoedema, Wrone et al. suggest that sentinel
node biopsy is associated with a 1.7% incidence of
lymphoedema and Lawton et al . have described the
use of a fascia-preserving technique when complete
lymphadenectomy is indicated.76,77 This study reported permanent oedema in 8% of patients following axillary dissection and 14% of those having groin dissection.

A transient oedema was also present in 48% of the groin
dissection group, resolving over a median of twelve
months. Factors including obesity, post-operative seroma
and occult metastases have been described as contributing
to the risk of lymphoedema in this group.75,76

Lymphoedema secondary to genitourinary

There is limited literature on this subject and Okeke et al.
suggest that lymphoedema is uncommon from cancers of
pelvic genitourinary organs, such as kidney and testes.78
However, in patients with advanced disease and complications,
such as recurrence or pelvic tumour mass
obstructing venous and lymphatic return, gross oedema
of the legs and genitalia will often occur. Worldwide, the
problem of genital lymphoedema is most common
secondary to filariasis and is also associated with primary
cancer-related lymphoedema and traumatic injury.79 87
Soto et al . reported lymphoedema in 100% of men
following inguinal dissection for penile carcinoma.82
Martin Martinez et al . have also shown lymphoedema
in 28.5% of these patients following inguinal lymphadenectomy
and Ornellas et al. have reported a figure of
16% in this same group.84,85 Male circumcision has also
been shown to be associated with lymphoedema.88

Henningsohn et al. have recently described the development
of swelling or heaviness in the legs or lower
abdomen in 20% of those following radical radiotherapy
compared to 10% of those who had radical cystectomy
and urostomy for carcinoma of the bladder.89 They
indicated that lymphoedema is a minor problem in this

Lymphoedema secondary to gynaecological

Nesvold et al . cited a lack of information after gynaecological
surgery causing a delay in diagnosis and treatment
of lymphoedema.90 In this study, 83 patients reported a
20% incidence of swelling following treatment for cervical
and vulval cancers, similar to findings reported in other
studies of these patients.91,92

In vulval cancer treatment, Leminen et al. established lymphoedema to be more common in women suffering a wound infection following
radical vulvectomy including groin dissection, occurring
in 48% of patients.93 Gould et al . also showed a 29.5%
incidence in patients undergoing inguinal lymphadenectomy
in the treatment of vulvar carcinoma similar to the
28% incidence reported by other authors.94,95 Preservation
of the saphenous vein during inguinal lymphadectomy
has been advocated as decreasing morbidity in
relation to chronic oedema in this patient group in one

Lymphoedema has also been shown to occur in
three of 80 patients receiving palliative radiotherapy for
ovarian cancer, although research is limited.97
More substantial literature is available in relation to
cervical cancer. One study reported lymphoedema leading
to distress in 14% of patients, regardless of whether
surgery or surgery combined with radiotherapy was
used.98 Relatively low rates (1%) of ‘severe’ lymphoedema
have also been reported, although how severity was
established is not specified.99 Martimbeau et al . studied
402 patients following treatment for Stage IB cervical
cancer showing that 23.4% developed some degree of
lymphoedema.100 A similar result was reported in a study
by Gerdin et al. (21%) following hysterectomy and
radiotherapy, where the risk of lymphoedema was also
associated with external pelvic irradiation.101 Fiorica
et al. also studied patients following treatment for Stage
IB cervical cancer, with a median follow-up time of
308 AF Williams et al.twenty-eight months.102

No indication is given as to how lymphoedema was measured and only one out of 50 patients was identified as having swelling. Similarly
low incidence figures are reported by Bo¨sze et al. who
assessed perioperative complications in 116 women
having cervical cancer treatment.103 They reported none
with lymphoedema but three with a lymphocyst, who
might be at subsequent risk of swelling. As the authors
surmise, the relatively short follow up period (not
specified) does not allow for evaluation of late sequelae, such as chronic lymphoedema.

A comprehensive study undertaken in Sweden followed
up 54 women post hysterectomy (and radiotherapy
in some cases).104 Of these 54 women, 41% had an excess
limb volume of more than 5% larger than the unaffected
limb and in interviews, eight (15%) described the problem
as serious. Lymphoedema was also observed as more
severe in those who had undergone more than two intracavity
radiotherapy implants.

Interestingly, the authors observed that only women with unilateral lymphoedema were detected using this method, those with mild
symmetrical swelling not necessarily being identified.
Similar results were obtained in a study of 179 women
undergoing radical hysterectomy and post operative
irradiation for cervical cancer in Taiwan.105 This study
showed 42% to develop lymphoedema with 16% going on to develop severe cellulitis warranting antibiotic therapy. A further paper reported lymphoedema of the foot in 49% of women ten years post-cervical cancer treatment.

106 The role of omentoplasty in preventing complications,
such as lymphoedema and lymphocoele, in these
patients has also been described.107,108
Lymphoedema secondary to sarcoma

Two studies of lymphoedema following sarcoma treatment
have been reviewed. Lampert et al. observed
40 patients who had received wide local excision and
radiotherapy, at least two years previously.109 They
measured oedema using finger pressures to identify skin
pitting and subjectively estimated that approximately
50% had some degree of oedema. Robinson et al . studied
54 patients at least two years post-treatment of soft tissue
sarcoma of the lower limb or pelvis.110 Lymphoedema
was assessed by pinch test and Stemmer’s sign and
categorized according to its extent up the limb. Lymphoedema was identified in 16 (30%) of the patients, although 21 (39%) had experienced swelling at some time. Interestingly, the authors discuss their rationale for avoiding limb circumferential measures suggesting these may be skewed by previous surgery.


This review highlights limitations in the current literature,
both in terms of quality of studies and lack of sound
incidence and prevalence data. Critical reviews of methods
used raises awareness and insight into how subsequent
research might be conducted and where the
possible pitfalls may lie. There are still a number of areas
to be addressed, namely the accurate identification of
lymphoedema and the diagnostic criteria for making
differential diagnoses between different types of lymphoedema
and chronic oedemas.

There is also a need to consider other problems not highlighted in previous
studies, such as breast oedema. There is clearly a need
to produce sound incidence data on particular ‘high risk’
groups, as these will contribute to the pool of new

This prevention and early detection strategy
may help to prevent patients developing morbidities
associated with the more chronic and severe conditions
of some lymphoedema types. These data will also
contribute to our understanding of the long-term impact
of this progressive condition and provide direction for
future service development.

1 Rose G, Barker DJP. Epidemiology for the uninitiated, second edition. London: BMJ, 1987.
2 Logan V. Incidence and prevalence of lymphoedema: a literature review. J Clin Nurs 1995; 4: 213 /19.
3 Moffatt CJ, Franks PJ, Doherty DC, Williams AF, Badger C, Jeffs E, Bosanquet N, Mortimer PS. Lymphoedema:
an underestimated health problem. Q J
Med 2003; 96(10): 731 /38.
4 Petlund CF. Prevalence and incidence of chronic
lymphoedema in a western European country. In Nishi
M, Uchina S, Yabuki S eds. Progress in lymphology
X11. Elsevier Science Publishers B.V. (Biomedical
Division), 1990: 391 /94.
5 ISL. The diagnosis and treatment of peripheral lymphoedema.
Consensus document of the International
Society of Lymphology Executive Committee.Lymphology 2002; 28: 113 /17.
6 Allen EV. Lymphoedema of the extremities: classification,
etiology and differential diagnosis: a study of three
hundred cases. Arch Intern Med 1934; 54: 606 /24.
7 Kinmonth JB. Primary lymphoedema; clinical and
lymphangiographic studies of a series of 107 patients
in which the lower limbs were affected. Br J Surg 1957;
45: 1 /10.
8 Browse NL, Stewart G, Cavezzi A. Lymphoedema:
pathophysiology and classification. J Cardiovasc Surg
1985; 26: 91 /103.
9 Browse N. Aetiology and classification of lymphoedema.
In Browse N, Burnand KG, Mortimer PS eds.
Lymphoedema: estimating the size of the problem 309
Diseases of the lymphatics, chapter 7. London: Arnold,
2003: 151 /56.
10 Campisi C. Global incidence of tropical and nontropical lymphoedema. Int Angiol 1999; 18(1): 3 /5.
11 Stanton AWB, Badger C, Sitzia J. Non-invasive assessment of the lymphedematous limb. Lymphology 2000;
33: 122 /35.
12 Megens AM, Harris SR, Kim-Sing C, McKenzie DC.
Measurement of upper extremity volume in women
after axillary dissection for breast cancer. Arch Phys
Med Rehabil. 2001; 82: 1639 /44.
13 Sander AP, Hajer NM, Hemenway K, Miller AC.
Upper-extremity volume measurements in women
with lymphedema: a comparison of measurements
obtained via water displacement with geometrically
determined volume. Phys Ther 2002; 82: 1201 /12.
14 Karges JR, Mark BE, Stikeleather SJ, Worrell TW.
Concurrent validity of upper-extremity volume estimates:
comparison of calculated volume derived from
girth measurements and water displacement volume.
Phys Ther 2003; 83: 134 /45.
15 Berlin E, Gjores JE, Ivarsson C, Palmqvist I, Thagg G,
Thulesius O. Postmastectomy lymphoedema. Treatment
and a five-year follow-up study. Int Angiol 1999; 18:
294 /98.
16 Sitzia J. Volume measurement in lymphoedema treatment:
examination of formulae. Eur J Cancer Care
1995; 4: 11 /16.
17 Bland KL, Perczyk R, Du W, Rymal C, Koppolu P,
McCrary R, Carolin KA, Kosir MA. Can a practising
surgeon detect early lymphoedema reliably? Am J Surg
2003; 186: 509 /13.
18 Querci della Rovere G, Ahmad I, Singh P, Ashley S,
Daniels IR, Mortimer P. An audit of the incidence of
arm lymphoedema after prophylactic level I/II axillary
dissection without division of the pectoralis minor
muscle. Ann R Coll Surg Engl 2003; 85: 158 /61.
19 Temple LK, Baron R, Cody HS III, Fey JV, Thaler HT,
Borgen PI. Sensory morbidity after sentinel lymph node
biopsy and axillary dissection: a prospective study of
233 women. Ann Surg Oncol 2002; 9: 654 /62.
20 Godal R, Swedoborg I. A correction for the natural
asymmetry of the arms in the determination of the
volume of oedema. Scand J Rehab Med 1982; 14: 193 / 95.
21 Edwards TL. Prevalence and aetiology of lymphoedema after breast cancer treatment in southern Tasmania.
Aust NZ J Surg 2000; 70: 412 /18.
22 Powell SN, Taghian AG, Kachnic LA, Assaad SI, Coen
JJ. Risk of lymphedema after regional nodal irradiation
with breast conservation therapy. Int J Radiat Oncol
Biol Phys 2003; 55: 1209 /15.
23 Duff M, Hill AD, McGreal G, Walsh S, McDermott
EW, O’Higgins NJ. Prospective evaluation of the
morbidity of axillary clearance for breast cancer. Br J
Surg 2001; 88: 114 /17.
24 Sitzia J, Woods M, Hine P, Williams A, Eaton K, Green
G. Characteristics of new referrals to twenty-seven
lymphoedema treatment units. Eur J Cancer Care
1998; 7: 255 /62.
25 Williams AE, Bergel S, Twycross RG. A 5-year review of a lymphoedema service. Eur J Cancer Care 1996; 5:
56 /59.
26 Hardy D, Taylor J. An audit of non-cancer-related
lymphoedema in a hospice setting. Int J Palliat Nurs
1998; 5(1): 18 /27.
27 Smeltzer DM, Stickler GB, Schirger A. Primary
lymphoedema in children and adolescents: a follow up
study and review. Pediatrics 1985; 76(2): 206 /18.
28 Michelini S, Campisi C, Cavezzi A. Studio epidemiologico
nazionale sui linfedemi. Minerva Cardioangiol
1998; 46: 393 /94.
29 Rudkin GH, Miller TA. Lipedema: a clinical entity
distinct from lymphoedema. Plast Reconstruct Surg
1994; 94(6): 841 /47.
30 Prasad A, Ali-Khan A, Mortimer PS. Leg ulcers and
oedema: a study exploring the prevalence, aetiology and possible significance of oedema in leg ulcers, Phlebology 1990; 5: 181 /87.
31 Adam DJ, Maik J, Hartshorne T, Bello M, London NJ.
The diagnosis and management of 689 chronic leg
ulcers in a single-visit assessment clinic. Eur J Vasc
Endovasc Surg 2003; 25: 462 /68.
32 Blankfield RP, Finkelhor RS, Alexander JJ, Flocke SA,
Maiocco J, Goodwin M, Zyzanski SJ. Etiology and
diagnosis of bilateral leg edema in primary care. Am J
Med. 1998; 105: 192 /97.
33 Shaw JHF, Rumball EM. Complications and local
recurrence following lymphadenectomy. Br J Surg
1990; 77: 760 /64.
34 Halstead WS. The swelling of the arm after operation
for cancer of the breast, elephantiasis chirurgica, its
causes and prevention. Bull J Hopkin Hosp 1921; 32:
309 /13.
35 Fitts WT, Keuhnelian JG, Ravdin IS, Schor S. Swelling of the arm after radical mastectomy. Surgery 1954; 35:
460 /64.
36 Treves N. An evaluation of the etiological factors of lymphoedema following radical mastectomy: an analysis of 1007 cases. Cancer 1957; 10: 444 /59.
37 Britton RC, Nelson PA. Causes and treatment of
postmastectomy lymphoedema of arm: report of 114
cases. JAMA 1962; 180: 95 /102.
38 Howell Hughes J, Patel AR. Swelling of the arm
following radical mastectomy. Br J Surg 1966; 53(1):
4 /14.
39 Markowski J, Wilcox JP, Helm PA. Lymphedema
incidence after specific postmastectomy therapy. Arch
Phys Med Rehabil 1981; 62: 449 /52.
40 Pezner RD, Patterson MP, Hill LR, Lipsett J, Desai K,
Vora N, Wong J, Luk K. Arm lymphoedema in patients
treated conservatively for breast cancer: relationship to
age and axillary node dissection technique. J Radiat
Oncol Biol Phys 1986; 12: 2079 /83.
41 Ryttov N, Holm NV, Qvist N, Blichert-Toff M.
Influence of adjuvent irradiation on the development
of late arm oedema and impaired shoulder mobility
after mastectomy for cancer of the breast. Acta Oncol
1988; 27: 667 /70.
310 AF Williams et al.
42 Badr-el-Din A, Coibion M, Guenier C, Nogaret JM,
Lorent I, Van-Houtte P, Tueni E, Mattheiem W. Local
post-operative morbidity following pre-operative irradiation
in locally advanced breast cancer. Eur J Surg
Oncol 1989; 15 6: 486 /89.
43 Aitken RJ, Gaze MN, Rodger A, Chetty U, Forrest
APM. Arm morbidity within a trial of mastectomy and
either nodal sampling with selective radiotherapy or
axillary clearance. Br J Surg 1989; 76: 568 /71.
44 Hoe AL, Iven D, Royal GT, Taylor I. Incidence of arm swelling following axillary clearance for breast cancer.
Br J Surg 1992; 79: 261 /62.
45 Segerstro¨m K, Bjerle P, Graffman S, Nystro¨m A.
Factors that influence the incidence of brachial oedema
after treatment of breast cancer. Scand J Plast Reconstr
Hand Surg 1992; 26: 223 /27.
46 Thomson AM, Air M, Jack WJL, Kerr GR, Rodger A,
Chetty U. Arm morbidity after breast conservation and
axillary therapy. Breast 1995; 4: 273 /76.
47 Ferrandez JC, Serin D, Bouges S. [Frequency of
lymphedema of the upper limb after treatment of breast
cancer. Risk factors. Apropos of 683 cases]. Bull Cancer 1996; 83: 989 /95.
48 Kissen MW, Querci della Rovere G, Easton D, Westbury
G. Risk of lymphoedema following the treatment
of breast cancer. Br J Surg 1986; 73: 580 /84.
49 Mortimer PA, Bates DO, Brassington HD, Stanton
AWB, Strachan DP, Levick JR. The prevalence of arm
oedema following treatment for breast cancer. QJM
1996; 89: 377 /80.
50 Suneson BL, Lindholm C, Hamrin E. Clinical incidence of lymphoedema in breast cancer patients in Jo¨nko¨ping County, Sweden. Eur J Cancer Care 1996; 5: 7 /12.
51 Schunemann H, Willich N. Lymphedema after breast carcinoma. A study of 5868 cases. Deutsche Medizinische Wochenscrift 1997; 122(17): 536 /41.
52 Petrek JA, Heelan MC. Incidence of breast cancerrelated lymphedema. Presented at: American Cancer Society Workshop, New York, February 20 /22, 1998.
53 Kissane DW, Clarke DM, Ikin J, Bloch S, Smith GC,
Vitetta L. Psychological morbidity and quality of life in
Australian women with early-stage breast cancer: a
cross-sectional survey. Med J Aust 1998; 169: 192 /96. 54 Hojris I, Andersen J, Overgaard M, Overgaard J. Late treatment-related morbidity in breast cancer patients randomized to postmastectomy radiotherapy and systemic treatment versus systemic treatment alone. Acta Oncol 2000; 39: 355 /72.
55 Tengrup I, Tennvall-Nittby L, Christiansson I, Laurin M. Arm morbidity after breast-conserving therapy for breast cancer. Acta Oncol 2000; 39: 393 /97.
56 Herd-Smith A, Russo A, Muraca MG, Del Turco MR,
Cardona G. Prognostic factors for lymphedema after
primary treatment of breast carcinoma. Cancer 2001;
92: 1783 /87.
57 Petrek JA, Senie RT, Peters M, Rosen PP. Lymphedema
in a cohort of breast carcinoma survivors 20 years after
diagnosis. Cancer 2001; 92: 1368 /77.
58 Sener SF, Winchester DJ, Martz CH, Feldman JL,
Cavanaugh JA, Winchester DP. Lymphedema after
sentinel lymphadenectomy for breast carcinoma. Cancer 2001; 92: 748 /52.
59 Albrecht MR, Zink K, Busch W, Ruhl U. Dissection or
irradiation of the axilla in postmenopausal patients
with breast cancer? Long-term results and long-term
effects in 655 patients. Strahlenther Onkol 2002; 178:
510 /16.
60 Kwan W, Jackson J, Weir LM, Dingee C, McGregor G,
Olivotto IA. Chronic arm morbidity after curative
breast cancer treatment: prevalence and impact on
quality of life. J Clin Oncol 2002; 20: 4242 /48.
61 Meric F, Buchholz TA, Mirza NQ, Vlastos G, Ames
FC, Ross MI. Long-term complications associated with
breast-conservation surgery and radiotherapy. Ann Surg
Oncol 2002; 9: 543 /49.
62 Nagel PH, Bruggink ED, Wobbes T, Strobbe LJ. Arm morbidity after complete axillary lymph node dissection for breast cancer. Acta Chir Belg 2003; 103: 212 / 16.
63 Geller BM, Vacek PM, O’Brien P, Secker-Walker RH.
Factors associated with arm swelling after breast
cancer surgery. J Womens Health (Larchmt) 2003; 12:
921 /30.
64 Kornblith AB, Herndon JE, Weiss RB, Zhang C,
Zuckerman EL, Rosenberg S. Long-term adjustment
of survivors of early-stage breast carcinoma, 20 years
after adjuvant chemotherapy. Cancer 2003; 98: 679 /
65 Rampaul RS, Mullinger K, Macmillan RD, Cid J,
Holmes S, Morgan DA. Incidence of clinically signifi-
cant lymphoedema as a complication following surgery
for primary operable breast cancer. Eur J Cancer 2003;
39: 2165 /67.
66 Golshan M, Martin WJ, Dowlatshahi K. Sentinel
lymph node biopsy lowers the rate of lymphedema
when compared with standard axillary lymph node
dissection. Am Surg 2003; 69: 209 /11.
67 James JH. Lymphoedema following ilio-inguinal lymph node dissection. Scand J Plast Reconst Surg 1982; 16:
167 /71.
68 Papachristou D, Fortner JG. Comparison of lymphedema following incontinuity and discontinuity groin dissection. Ann Surg 1977; 185: 13 /16.
69 Ingvar C, Erichsen C, Jonsson PE. Morbidity following prophylactic and therapeutic lymph node dissection for melanoma / a comparison. Tumori 1984; 70: 529 / 33.
70 Urist MM, Maddox WA, Kennedy JE, Balch CM.
Patient risk factors and surgical morbidity after regional
lymphadenectomy in 204 melanoma patients. Cancer
1983; 51: 2152 /56.
71 Hughes TM, Thomas JM. Combined inguinal and
pelvic lymph node dissection for stage III melanoma.
Br J Surg 1999; 86: 1493 /98.
72 Karakousis CP, Heisler MA, Moore RH. Lymphoedema
after groin dissection. Am J Surg 1983; 145: 205 /
73 Karakousis CP, Driscoll DI. Groin dissection in
malignant melanoma. Br J Surg 1994; 81: 1771 /74.
Lymphoedema: estimating the size of the problem 311
74 Strobbe LJ, Jonk A, Hart AA, Nieweg OE, Kroon BB.
Positive iliac and obturator nodes in melanoma:
survival and prognostic factors. Ann Surg Oncol 1999;
6: 255 /62.
75 Serpell JW, Carne PW, Bailey M. Radical lymph node dissection for melanoma. ANZ J Surg 2003; 73: 294 / 99.
76 Wrone DA, Tanabe KK, Cosimi AB, Gadd MA, Souba WW, Sober AJ. Lymphedema after sentinel lymph node biopsy for cutaneous melanoma: a report of 5 cases.
Arch Dermatol 2000; 136: 511 /14.
77 Lawton G, Rasque H, Ariyan S. Preservation of muscle fascia to decrease lymphedema after complete axillary and ilioinguinofemoral lymphadenectomy for melanoma. J Am Coll Surg 2002; 195: 339 /51.
78 Okeke AA, Bates DO, Gillatt DA. Lymphoedema in
urological cancer. Eur Urol 2004; 45: 18 /25.
79 Sauer PF, Bueschen AJ, Vasconez LO. Lymphedema of
the penis and scrotum. Clin Plast Surg 1988; 15: 507 /
80 Gueglio G, Quijada E, Salas H, Daels P, Tejerizo J,
Chernobilsky V, Giudice C, Damia O. [Giant scrotal
lymphedema caused by Milroy’s disease]. Arch Esp Urol 2003; 56: 949 /52.
81 Bolt RJ, Peelen W, Nikkels PG, de Jong TP. Congenital lymphoedema of the genitalia. Eur J Pediatr 1998; 157:
943 /46.
82 Soto DM, Arredondo MF, Pedrero MG, Basquero GB, Zurera CA, Linares AR. [Penile cancer. Review of 18 cases]. Acta Urol Esp 2003; 27: 797 /802.
83 Jacobellis U. Modified radical inguinal lymphadenectomy for carcinoma of the penis: technique and results.
J Urol 2003; 169: 1349 /52.
84 Martin Martinez JC, Herranz AF, Jara R, Subira CC,
Gonzalez CF, Hernandez FC. [Complications of inguinal
lymphadenectomy for penile carcinoma. Origin,
management, and prevention]. Acta Urol Esp 1995; 19:
759 /71.
85 Ornellas AA, Seixas AL, de Moraes JR. Analyses of
200 lymphadenectomies in patients with penile carcinoma.
J Urol 1991; 146: 330 /32.
86 Sowery RD, Beiko DT, Heaton JP. Long-term penile
incarceration by a metal ring resulting in urethral
erosion and chronic lymphedema. Can J Urol 2004;
11: 2167 /68.
87 Tanabe N, Muya M, Isonokami M, Kozuka T, Honda
T, Ohtani H. Lymphedema due to chronic penile
strangulation: a case report. J Dermatol 1996; 23:
648 /51.
88 Sylla C, Diao B, Diallo AB, Fall PA, Sankale AA, Ba M. Complications of circumcision. [Report of 63 cases]. Prog Urol 2003; 13: 266 /72.
89 Henningsohn L,Wijkstrom H, Dickman PW, Bergmark
K, Steineck G. Distressful symptoms after radical
radiotherapy for urinary bladder cancer. Radiother
Oncol 2002; 62: 215 /25.
90 Nesvold IL, Fossa SD. [Lymphedema after surgical
treatment of cervical and vulvar cancer]. Tidsskr nor
Laegeforen 2002; 122: 2531 /33.
91 Finan MA, Hoffman MS, Fiorica JV, Roberts WS,
Gleeson N, Barton DP, Cavanagh D. Surgical management
of groin node metastases from non-vulvar
gynecologic malignancies. Gynecol Oncol 1993; 51:
230 /35.
92 Ryan M, Stainton MC, Slaytor EK, Jaconelli C, Watts S, Mackenzie P. Aetiology and prevalence of lower limb lymphoedema following treatment for gynaecological cancer. Aust NZ J Obstet Gynaecol 2003; 43: 148 / 51.
93 Leminen A, Forss M, Paavonen J. Wound complications
in patients with carcinoma of the vulva. Comparison
between radical and modified vulvectomies. Eur J
Obstet Gynecol Reprod Biol 2000; 93: 193 /97.
94 Gould N, Kamelle S, Tillmanns T, Scribener D, Gold
M, Walker J, Mannel R. Predicators of complication
after inguinal lymphadenectomy. Gynecol Oncol 2001;
82: 329 /32.
95 Gaarenstroom KN, Kenter GG, Trimbos JB, Agous I, Amant F, Peters AA, Vergote I. Postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate groin incisions. Int J Gynecol Cancer 2003; 13: 522 /27.
96 Zhang SH, Sood AK, Sorosky JI, Anderson B, Buller
RE. Preservation of the saphenous vein during inguinal
lymphadenectomy decreases morbidity in patients with
carcinoma of the vulva. Cancer 2000; 89: 1520 /25.
97 Tinger A, Waldron T, Peluso N, Katin MJ, Dosoretz
DE, Blitzer PH, Rubenstein JH, Garton GR, Nakfoor
BA, Patrice SJ, Chuang L, Orr JW Jr. Effective
palliative radiation therapy in advanced and recurrent
ovarian carcinoma. Int J Radiat Oncol Biol Phys 2001;
51: 1256 /63.

98 Bergmark K, Avall-Lundqvist E, Dickman PW, Henningsohn L, Steineck G. Patient-rating of distressful symptoms after treatment for early cervical cancer. Acta Obstet Gynecol Scand 2002; 81: 443 /50.
99 Sivanesaratnam V, Sen DK, Jayalakshmi P, Ong G.
Radical hysterectomy and pelvic lymphadenectomy for early invasive cancer of the cervix / 14-year experience. Int J Gynecol Cancer 1993; 3: 231 /38.

100 Martimbeau PW, Kjorstad KE, Kolstad P. Stage 1B
carcinoma of the cervix. The Norwegian Radium
Hospital, 1968 /70. Results of treatment and major
complications. Am J Obstet Gynecol 1978; 131: 381 /94. 101 Gerdin E, Cnattingius S, Johnson P. Complications after radiotherapy and radical hysterectomy in earlystage cervical carcinoma. Acta Obstet Gynecol Scand 1995; 74: 554 /61.

102 Fiorica JV, Roberts WS, Greenberg H, Hoffman MS,
LaPolla JP, Cavanagh D. Morbidity and survival
patterns in patients after radical hysterectomy and
postoperative adjuvant pelvic radiotherapy. Gynecol
Oncol 1990; 36: 343 /47.
103 Bosze P, Meszaros I, Pal
falvi L, Ungar L. Perioperative complications of 116 radical hysterectomies and pelvic node dissections. Eur J Surg Oncol 1993; 19, 605 /8.

104 Werngren-Elgstrom M, Lidman D. Lymphoedema of
the lower extremities after surgery and radiotherapy for
312 AF Williams et al.
cancer of the cervix. Scand J Plast Reconstr Surg Hand
Surg 1994; 28: 289 /93.

105 Yeh SA, Leung SW, Wang CJ, Chen HC. Postoperative radiotherapy in early stage carcinoma of the uterine cervix: treatment results and prognostic factors. Gynecol Oncol 1998; 72: 10 /15.
106 Chatani M, Nose T, Masaki N, Inoue T. Adjuvant
radiotherapy after radical hysterectomy of the cervical
cancer. Prognostic factors and complications. Strahlenther Oncol 1998; 174: 504 /9.

107 Logmans A, Kruyt RH, de Bruin HG, Cox PH, Pillay M, Trimbos JB. Lymphedema and lymphocysts following lymphadectomy may be prevented by omentoplasty: a pilot study. Gynecol Oncol 1999; 75: 323 /27.

108 Fujiwara K, Kigawa J, Hasegawa K, Nishimura R,
Umezaki N, Ando M, Itamochi H, Yamaguchi S, Oda
T, Terakawa N, Kohshima I, Kohno I. Effect of simple
omentoplasty and omentopexy in the prevention of
complications after pelvic lymphadenectomy. Int J
Gynecol Cancer 2003; 13: 61 /66.

109 Lampert MH, Gerber LH, Glatstein E, Rosenberg SA,
Danoff JV. Soft tissue sarcoma: functional outcome
after wide local excision and radiation therapy. Arch
Phys Med Rehabil 1984; 65: 477 /80.

110 Robinson MH, Spruce L, Eeles R, Fryatt I, Harmer C,
Thomas M, Westbury G. Limb function following
conservation treatment of adult soft tissue sarcoma.
Eur J Cancer 1991; 27: 1567 /74.

Lymphoedema: estimating the size of the problem 313
User avatar
Site Admin
Posts: 2175
Joined: Thu Jun 08, 2006 9:07 pm

Return to Lymphoedema

Who is online

Users browsing this forum: No registered users and 2 guests