Health: Lymphoedema

Lord McColl of Dulwich Excerpts

Wednesday 9th September 2015 Lords Chamber

[Lord McColl of Dulwich (Con)]

My Lords, I am grateful to the noble Lord, Lord Hunt, for introducing this debate on the subject of lymphoedema, which arises when the lymphatics fail to regulate the fluid balance in the tissue spaces. That results in oedema, usually of the arms and legs. For example, normally in the legs there are four or five lymph channels each measuring one millimetre in diameter travelling up the inside of the leg to the lymph nodes in the groin, and from there they go up into the chest where the lymph is discharged into the veins in the chest.

Lymphoedema can be due to underdevelopment of the lymphatics, known as primary lymphoedema, which usually manifests itself in a person’s 20s or 30s. But if the lymph channels are completely absent, the symptoms of the condition appear much earlier. That is due to a genetic fault. Secondary lymphoedema is where there is a blockage in or removal or disease of the lymphatics, and is far and away the commoner of the two. The blockage can be due to cancer infiltrating the system or to worms—a condition called filariasis, which is quite common in the Far East. It is transmitted by mosquitoes, but noble Lords can be reassured: one has to be bitten many times by many mosquitoes before one gets the disease. The condition is common in Sri Lanka, but in the old days of the British Empire it was pretty well eliminated by reducing the mosquito population, which also reduced the incidence of malaria.

Lymphoedema occurs when the lymphatics are removed in certain cancer operations such as the old radical mastectomy or operations where the lymph node system is removed or reduced. As I mentioned, primary lymphoedema is due to underdeveloped or—rarely—absent channels. The first symptom is a slight swelling of the front of the foot. But if that is not dealt with, the whole leg can become enormously swollen and the skin grossly thickened—maybe as much as a centimetre in thickness. The legs become huge and very heavy, which makes it difficult for the patient to walk. To reduce the symptoms, an operation was designed by the surgeon Mr Charles, where the skin is resected, all the subcutaneous tissue is removed and then the skin is put back. The cosmetic results are not good, but the procedure does enable the patient to walk. That kind of radical surgery is rarely necessary these days.

As the noble Lord, Lord Hunt, has already emphasised, the important point is to have early diagnosis so that the swelling can readily be reduced by elevation and the use of close-fitting elastic stockings. The treatment has to continue for life and it is important that the patient understands this. The elastic stockings have to be applied before the patient gets out of bed, and this requires a lot of attention to detail. It is also important to avoid infections of the skin because they can make the condition worse by interfering with the underlying lymphatics. Elevation, compression, massage and physiotherapy are extremely important.

It should also be stressed that primary lymphoedema due to the genetic affection of the lymphatics is actually fairly rare. People are critical of doctors if they do not diagnose the condition right away, but it should be pointed out that the initial symptoms of puffiness can be due to a hundred and one different conditions. Primary lymphoedema is not often seen in general practice but, as I say, people are critical if doctors do not spot rare diseases immediately. However, a GP may not see one of these cases in a lifetime.

We have heard a lot of discussion about teaching on this subject in hospitals and medical schools. Of course they teach it. Swelling of the ankles is a very common condition and there are many different reasons for it; they are gone into in some detail. Discussion about a national strategy would be interesting, but what one must really emphasise is that diagnosis has to be made early on. There are computer-assisted ways of helping in diagnosis which alert the doctor as early as possible when someone comes into the surgery with, say, a puffy ankle or front of the foot. Diagnosis can be made early and suitable treatment started right away. Lymphoedema of the arms is usually due to previous cancer surgery and is less common today as radical surgery for cancer of the breast has been replaced by more conservative surgery along with radiotherapy and chemotherapy.

Early diagnosis must be encouraged before the swelling becomes severe, and effective treatment must be initiated in the form of elevation, physiotherapy, compression, exercise and meticulous attention to detail to prevent infection. Also, of course, obesity should be avoided; it is the greatest epidemic affecting this country for 95 years.