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Management

    continued...

    Pharmacologic therapy

    No chronic pharmacologic therapy is recommended for patients with lymphedema. Diuretics are typically of little benefit and may promote intravascular volume depletion because the lymphedema fluid cannot be easily mobilized into the vascular space. Coumarin is associated with significant hepatotoxicity and has not been found to have any benefit in controlled trials.[14] Antibiotics should be used promptly for patients with evidence of cellulitis; intravenous use may sometimes be required for severe cellulitis, lymphangitis, or septicemia.

    Weight loss

    The results of a small randomized trial have suggested that breast cancer–related lymphedema may improve with weight loss.[15][Level of evidence: I] The mechanism by which obesity may predispose to lymphedema is unclear, but proposed mechanisms include an increased risk of postoperative complications, including infection, reduced muscle pumping efficiency, and separation of lymphatic channels by subcutaneous fat.[15] A larger, longer-term weight-loss intervention in cancer patients with lymphedema (including those with lower-extremity disease) is warranted to further explore weight loss for disease management.

    Low-level laser therapy

    Studies suggest that low-level laser therapy may be effective in reducing lymphedema in a clinically meaningful way for some women.[16][Level of evidence: I] Two cycles of laser treatment were found to be effective in reducing the volume of the affected arm, extracellular fluid, and tissue hardness in approximately one-third of patients with postmastectomy lymphedema at 3 months posttreatment.[16] Suggested rationales for laser therapy include a potential decrease in fibrosis, stimulation of macrophages and the immune system, and a possible role in encouraging lymphangiogenesis.[16]

    Surgery

    Surgery is rarely performed on patients who have cancer-related lymphedema. The primary surgical method for treating lymphedema consists of removing the subcutaneous fat and fibrous tissue with or without creation of a dermal flap within the muscle to encourage superficial-to-deep lymphatic anastomoses. These methods have not been evaluated in prospective trials, with adequate results for only 30% of patients in one retrospective review. In addition, many patients face complications such as skin necrosis, infection, and sensory abnormalities.[17] The oncology patient is usually not a candidate for these procedures. Other surgical options include the following:

    • Microsurgical lymphaticovenous anastomoses, in which the lymph is drained into the venous circulation or the lymphatic collectors above the area of lymphatic obstruction.
    • Liposuction.
    • Superficial lymphangiectomy.
    • Fasciotomy.
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