Examqo › Examqo library › Vascular surgery › Venous and lymphatic disease · IMLE

Lymphoedema

Lymphoedema is chronic swelling from impaired lymphatic drainage — primary (congenital or appearing at puberty) or secondary (usually after cancer treatment, and worldwide mainly from parasitic infection); a positive Stemmer sign supports the diagnosis, imaging is lymphoscintigraphy, and basic treatment is complete decongestive therapy (manual drainage, compression bandaging, exercise and skin care) followed by lifelong compression garments.

לקריאה בעברית

Why it matters in the exam

In primary lymphoedema there is a congenital form (Milroy, linked to VEGFR3), a form appearing around puberty (praecox — the commonest primary form, mainly in women) and a late form after age 35 (tarda). In secondary lymphoedema the commonest cause in developed countries is cancer treatment — axillary or groin node dissection and radiotherapy (for example after breast cancer) — and worldwide filariasis (Wuchereria bancrofti). The swelling starts as soft pitting oedema, and later becomes hard, fibrotic and non-pitting, with skin thickening. Stemmer sign — inability to pinch the skin at the base of the second toe — is positive in lymphoedema. The differential diagnosis includes venous oedema, heart failure, hypoalbuminaemia, DVT and lipoedema — symmetrical fat deposition in the legs of women, which is painful and spares the feet.

ISL stages: 0 — latent, no visible swelling; I — soft oedema that subsides with limb elevation; II — oedema that does not subside with elevation, with early fibrosis; III — severe skin thickening ("elephantiasis") with skin changes. The core treatment is conservative: in the intensive phase — manual lymphatic drainage, multilayer compression bandaging, exercise and skin care; in the maintenance phase — fitted compression garments for life. Diuretics are not effective in lymphoedema. Recurrent skin infections (cellulitis) are common and worsen the swelling, and in a patient with repeated episodes prophylactic penicillin is given. Surgical options: physiological operations — lymphaticovenous anastomosis (LVA) or vascularised lymph node transfer — in early stages, and liposuction or excision (Charles) in late stages with fatty and fibrotic tissue. A rare and serious complication is lymphangiosarcoma (Stewart–Treves) in a limb with long-standing oedema, for example years after breast cancer treatment.

In new arm swelling after cancer treatment, tumour recurrence in the axilla or venous thrombosis must be excluded before attributing it to the lymphatics alone.

Key points

• Primary or secondary; secondary — mainly after cancer treatment.
• Positive Stemmer sign.
• Lymphoscintigraphy.
• Complete decongestive therapy then compression garments.
• Stewart–Treves — a rare and serious complication.

Summary table

In the full version for subscribers

• A simple algorithm
• Memory aid
• Exam traps
• 5 review cards
• Enough for IMLE

The full version is open to subscribers of: Vascular surgery, Plastic surgery, Oncology, Medical licensing exam (IMLE).

Subscriber? Read the full topic Plans and prices 25 free questions

Sources

• International Society of Lymphology Consensus Document: The diagnosis and treatment of peripheral lymphedema, 2023 — Staging and treatment
• ESVS Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs, 2022 — Differential diagnosis of the swollen limb
• Rutherford's Vascular Surgery and Endovascular Therapy, 10th edition (2022) — Lymphedema: evaluation and treatment

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.