A 59 year old woman presented with an 8 year history of edema of the left arm. Initially, the edema appeared in the upper arm. The patient was treated with combined decongestive physiotherapy (manual and mechanical lymphatic drainage), bandaging and exercises three to four times over a 12 month period. Despite these measures, the edema later extended to the forearm and hand (Fig. 54.1). In the months preceding her admission she developed several episodes of erysipeloid lymphangitis and pain. There were no warts or wounds on the skin. Her past medical history included lumpectomy with axillary lymphadenectomy and radiotherapy for left breast cancer. There was no suggestion of local recurrence on routine follow-up. Initially, the edema had a rhizomelic distribution. It was hard to the touch and did not pit. There were no dystrophic or dyschromic skin lesions, except for signs of acute reticular erysipeloid lymphangitic attacks caused by Gram-positive Staphylococci. A lymphangioscintigram was performed, which showed features compatible with lymphatic impairment in the left arm (Fig. 54.2). This was followed by lymphangio-magnetic resonance imaging (MRI) of the arm and hemithorax which showed no signs of loco-regional recurrence but confirmed lymph stasis, predominantly in the epifascial compartment. Dilated medial arm lymphatic collectors, interrupted at the proximal third of the arm, were also demonstrated. A Duplex of the left subclavian and axillary veins was normal. A diagnosis of chronic secondary lymphoedema was made.
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