A 53-year-old woman comes to the office due to progressive distension and tightness in her right lower extremity for the past year. She has had no shortness of breath, fever, or skin rash. The patient was diagnosed with melanoma of the right thigh approximately 2 years ago and underwent surgical resection. Two of her inguinal lymph nodes tested positive for metastasis, and she subsequently underwent inguinal lymphadenectomy and received adjuvant therapy. Recent imaging revealed no evidence of recurrent malignancy. The patient's medical history also includes hypertension and hyperlipidemia. Vital signs are within normal limits. Physical examination shows clear lungs and normal heart sounds without murmurs or gallops. No jugular venous distension is present. The right lower extremity is significantly larger in diameter than the left. Edema is present up to the thigh, with mild skin indentation after application of pressure. The skin overlying the involved area is thickened and dry. Laboratory testing, including complete blood count, serum metabolic panel, and urinalysis, is within normal limits. Treatment of this patient's symptoms should include which of the following strategies?

Question

A 53-year-old woman comes to the office due to progressive distension and tightness in her right lower extremity for the past year.  She has had no shortness of breath, fever, or skin rash.  The patient was diagnosed with melanoma of the right thigh approximately 2 years ago and underwent surgical resection.  Two of her inguinal lymph nodes tested positive for metastasis, and she subsequently underwent inguinal lymphadenectomy and received adjuvant therapy.  Recent imaging revealed no evidence of recurrent malignancy.  The patient's medical history also includes hypertension and hyperlipidemia.  Vital signs are within normal limits.  Physical examination shows clear lungs and normal heart sounds without murmurs or gallops.  No jugular venous distension is present.  The right lower extremity is significantly larger in diameter than the left.  Edema is present up to the thigh, with mild skin indentation after application of pressure.  The skin overlying the involved area is thickened and dry.  Laboratory testing, including complete blood count, serum metabolic panel, and urinalysis, is within normal limits.  Treatment of this patient's symptoms should include which of the following strategies?

Quizplus · Accepted Answer

11ec160b_38d6_b842_9249_29cf2ca53223_MD0001_00 This patient with chronic swelling and thickened skin of the right leg most likely has chronic lymphedema. Lymphedema can be congenital, but it most commonly results from an acquired disruption of lymphatic drainage that allows for accumulation of lymphatic fluid in the interstitial tissue. Malignancy and its treatment (eg, radiation, lymphadenectomy) are frequent underlying causes; other causes include chronic inflammation (eg, recurrent cellulitis, connective tissue disease) and parasitic infection (ie, filariasis due to Wuchereria bancrofti). Obesity is often a strong contributing factor. Lymphedema usually presents with swelling, heaviness, and discomfort in one or more extremities. In early disease, the edema is pitting and the skin remains soft. However, over time there is progressive deposition of subcutaneous collagen and adipose tissue, which leads to firm, dry, and thickened skin and nonpitting edema. Treatment is difficult and typically involves conservative management to increase lymphatic drainage via compression bandages or physiotherapy (ie, manual lymphatic drainage). (Choice A) Selective estrogen receptor modulators (eg, tamoxifen) block estrogen receptors in breast tissue and can be useful in treating breast cancer. Breast cancer may present with upper extremity lymphedema, but lower extremity lymphedema would be extremely unusual. (Choice C) Anticoagulants (eg, heparin) facilitate dissolution of acute deep venous thrombosis (DVT); however, acute DVT is less likely without active malignancy and would not explain this patient's year-long duration of symptoms. (Choice D) Inhibition of vascular endothelial growth factor is useful in the treatment of lymphangiosarcoma, which is a rare complication of lymphedema. Lymphangiosarcoma typically presents as purple maculopapular skin lesions, which are not present in this patient. (Choice E) Diuretics reduce intravascular volume and are useful in treating lower extremity edema that results from elevated venous hydrostatic pressure in true volume overloaded states (eg, heart failure, cirrhosis). However, they are ineffective and contraindicated for lymphedema because lymphedematous fluid cannot be easily mobilized from the interstitial space into the vasculature. When used for lymphedema, diuretics are likely to cause intravascular volume depletion and consequent acute kidney injury. Educational objective: Chronic lymphedema is most commonly caused by an acquired disruption of lymphatic drainage (eg, due to malignancy or lymphadenectomy), and typically presents with swelling and thickened skin in one or more extremities. Treatment is usually conservative and involves compression bandages and physiotherapy; diuretics are ineffective and contraindicated. __________ References: Lymphedema: a primer on the identification and management of a chronic condition in oncologic treatment. (http://www.ncbi.nlm.nih.gov/pubmed/19147865)

A 53-Year-Old Woman Comes to the Office Due to Progressive