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Lymphedema

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of lymphedema are prepared by our editorial team based on guidelines from the European Association of Urology (EAU/ASCO 2023), the European Society of Gynaecological Oncology (ESGO 2023), the American Academy of Family Physicians (AAFP 2022,2013), the American Vein and Lymphatic Society (AVLS/SVM/AVF 2022), the Public Health Agency of Northern Ireland (PHA/HSE/LNNI ...
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Screening and diagnosis

Diagnosis
As per AVF/AVLS/SVM 2022 guidelines:
Perform clinical examination for the diagnosis of lymphedema.
E
Regard all patients with chronic venous insufficiency (C3-C6) as having lymphedema.
E
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Classification and risk stratification

Staging: as per HSE/LNNI/PHA 2022 guidelines, use the International Society of Lymphology classification system for staging lymphedema.
B
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Diagnostic investigations

Evaluation of limb swelling
As per AAFP 2022 guidelines:
Stratify patients with lower extremity edema based on the location (unilateral versus bilateral) and time course (acute/subacute versus chronic) of the condition.
B
Obtain BNP, TSH, LFTs, basic metabolic panel, and urine protein-to-creatinine ratio in the initial laboratory evaluation of patients with lower extremity edema.
B
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  • Evaluation of head and neck swelling

  • Radionuclide lymphoscintigraphy

  • Genetic testing

Medical management

Pharmacotherapy: as per HSE/LNNI/PHA 2022 guidelines, do not offer routine pharmacological treatment for lymphedema.
D
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Nonpharmacologic interventions

Physical activity
As per HSE/LNNI/PHA 2022 guidelines:
Advise increasing physical activity levels gradually in patients at risk of lymphedema.
B
Encourage exercising with gradual, progressive resistance and aerobic exercise in at-risk patients.
A
Advise patients that they are not required to limit their physical activity or limit the use of their at-risk limb.
B
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  • Compression therapy

  • Manual lymphatic drainage

  • Complex decongestive therapy

Surgical interventions

Indications for surgery: as per AVF/AVLS/SVM 2022 guidelines, consider performing surgery after failing conservative treatment in patients with stage > 2 lymphedema.
E
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Specific circumstances

Patients with breast cancer: as per SIO 2017 guidelines, consider offering low-level laser therapy, manual lymphatic drainage, and compression bandaging to improve lymphedema in breast cancer survivors.
C
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  • Patients with head and neck cancer

  • Patients with vulvar cancer

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Preventative measures

Prophylactic compression therapy: as per HSE/LNNI/PHA 2022 guidelines, do not offer compression garments prophylactically for air travel in patients at risk of developing lymphedema. Offer prophylactic compression garments only if there is a diagnosis of subclinical lymphedema.
D
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