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Lymphedema (PDQ®): Supportive care – Health Professional Information [NCI]
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Lymphedema is swelling that occurs when protein-rich lymph fluid accumulates in the interstitial tissue. This lymph fluid may contain plasma proteins, extravascular blood cells, excess water, and parenchymal products.[1] Lymphedema is one of the most poorly understood, relatively underestimated, and least researched complications of cancer or its treatment. The Institute of Medicine of the National Academies published a report in 2006 recommending a "survivorship care plan" for cancer patients that incorporates information about late effects of treatment, health management behaviors, disease management, and recurrence monitoring.[2] The Institute of Medicine also highlighted critical shortfalls in the transition to survivorship, particularly in providing education about late effects of treatment.
Lymphedema is an important consideration for clinicians who care for cancer patients because of its relatively high frequency and significant functional and quality of life implications for patients. Lymphedema is an independent predictor of decreased quality of life, even when other predictive factors such as socioeconomic status, decreased range of motion, age, and obesity are taken into account.[3]
This summary will review issues related to anatomy and pathophysiology of lymphedema related to cancer, its clinical manifestations, diagnosis, and treatment. Primary (congenital) lymphedema and non–cancer-related lymphedema (e.g., recurrent cellulitis, connective tissue disease, and infection) will not be reviewed here.
In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.
Anatomy and Pathophysiology of the Lymphatic System
The human lymphatic system generally includes superficial or primary lymphatic vessels that form a complex dermal network of capillarylike channels that drain into larger, secondary lymphatic vessels located in the subdermal space. These primary and secondary lymphatic vessels parallel the superficial veins and drain into a deeper third layer of lymphatic vessels located in the subcutaneous fat adjacent to the fascia. A muscular wall and numerous valves aid active, unidirectional lymphatic flow in secondary and subcutaneous lymphatic vessels. Primary lymphatic vessels lack a muscular wall and do not have valves. An intramuscular system of lymphatic vessels that parallels the deep arteries and drains the muscular compartment, joints, and synovium also exists. The superficial and deep lymphatic systems probably function independently, except in abnormal states, although there is evidence that they communicate near lymph nodes.[4] Lymph drains from the lower limbs into the lumbar lymphatic trunk, which joins the intestinal lymphatic trunk and cisterna chyli to form the thoracic duct that empties into the left subclavian vein. The lymphatic vessels of the left arm drain into the left subclavian lymphatic trunk and then into the left subclavian vein. Lymph channels of the right arm drain into the right subclavian lymphatic trunk and then into the right subclavian vein.
One function of the lymphatic system is to return excess fluid and protein from interstitial spaces to the blood vascular system. Because lymphatic vessels often lack a basement membrane, they can resorb molecules too large for venous uptake. Mechanisms of clinical edema include increased arteriovenous capillary filtration and reduced interstitial fluid absorption. Causes of increased capillary filtration include increased hydrostatic pressure in capillaries, decreased tissue pressure, and increased membrane permeability. Reduced interstitial fluid resorption can be caused by decreased plasma oncotic pressure, increased oncotic pressure of tissue fluid, and lymphatic obstruction.
Anatomy of the lymph system showing the lymph vessels and lymph organs, including the lymph nodes, tonsils, thymus, spleen, and bone marrow. Lymph (clear fluid) and lymphocytes travel through the lymph vessels and into the lymph nodes where the lymphocytes destroy harmful substances. The lymph enters the blood through a large vein near the heart.
Clinical Manifestations
The onset of secondary lymphedema is often insidious. However, it may be suddenly provoked by local inflammation from causes such as infection or limb injury. Therefore, patients should be evaluated for evidence of cellulitis. Classically, lymphedema is characterized by nonpitting swelling of an extremity, usually with involvement of the digits. Early stages of lymphedema manifest with pitting edema until fibrosis develops. The distribution of the swelling may be restricted only in the proximal or distal portion of the limb. Lymphedema may also predispose to recurrent skin infections.[5]
Lymphedema can and does occur in the trunk, in addition to the limbs. For example, radiation therapy to the chest wall is associated with the development of edema specifically in the irradiated breast.[6,7]
Patients with lymphedema may report a wide variety of complaints, including heaviness or fullness related to the weight of the limb, a tight sensation of the skin, or decreased flexibility of the affected joint. The texture of the skin may become hyperkeratotic, with verrucous and vesicular skin lesions. With upper-extremity involvement, the patient may have difficulty fitting the affected area into clothing or wearing previously well-fitting rings, watches, or bracelets. Similar difficulties with lower-extremity lymphedema include a sensation of tightness or difficulty wearing shoes, itching of the legs or toes, burning sensation in the legs, or sleep disturbance and loss of hair. Ambulation can be affected because of the increased size and weight of the affected limb. Activities of daily living, hobbies, and the ability to perform previous work tasks may also be affected.
Psychological symptoms
Breast cancer survivors with arm lymphedema have been found to be more disabled, experience a poorer quality of life, and have more psychological distress than do survivors without lymphedema.[8,9] In addition, women reporting swelling have reported significantly lower quality of life with multiple functional assessments.[10]
Lymphedema can occur after any cancer or its treatment that affects lymph node drainage. It has been reported to occur within days and up to 30 years after treatment for breast cancer.[11] Eighty percent of patients experience onset within 3 years of surgery; the remainder develop edema at a rate of 1% per year.[12] Upper-extremity lymphedema most often occurs after breast cancer; lower-extremity lymphedema most often occurs with uterine cancer, prostate cancer, lymphoma, or melanoma.[1] A large population-based study supports the evidence that lower-limb lymphedema is experienced by a significant proportion of women after treatment for gynecological cancer, with the highest prevalence (36%) among vulvar cancer survivors and the lowest prevalence (5%) among ovarian cancer survivors.[13]
There is no consistency in the data on the incidence and prevalence of lymphedema after breast cancer, probably because of differences in diagnosis, the different characteristics of the patients studied, and inadequate follow-up to capture delayed development of the disorder. The overall incidence of arm lymphedema can range from 8% to 56% at 2 years postsurgery.[10]
It is important to diagnose and treat lymphedema when it is mild because those with mild lymphedema make up the cohort that gives rise to preventable severe, debilitating lymphedema. Women with mild lymphedema are more than three times as likely to develop severe lymphedema than are women with no lymphedema.[14]
Risk Factors
Patients undergoing axillary surgery and/or axillary radiation therapy for breast cancer are at higher risk for developing lymphedema of the arm. Previous convention suggested that nodal positivity was a predisposing factor for the development of lymphedema in breast cancer patients.[15] Controlling for axillary radiation, one study actually found an inverse relationship between nodal positivity and arm volume.[15]
Axillary node removal
Compared with axillary sampling alone, partial or total mastectomy followed by full axillary lymph node dissection significantly increases a patient's chance of developing arm edema. For example, in one series of 100 women who underwent partial or total mastectomy and then full axillary lymph node dissection or axillary sampling, arm edema developed in more patients who underwent axillary lymph node dissection compared with sampling alone (30% vs. none).[16] In addition, the extent of axillary lymph node dissection increases the risk for developing arm edema. For example, in one series involving 381 women undergoing segmental mastectomy and axillary lymph node dissection, women who had ten or more lymph nodes removed were more likely than women who had few lymph nodes in the specimen to develop arm symptoms within the first year (53% vs. 33%) and within the next 2 years (33% vs. 20%).[17]
Sentinel node biopsy
For patients with breast cancer, sentinel lymph node dissection has gained favor over axillary lymph node dissection for the axillary staging of early disease because of decreased morbidity and because of the questionable survival benefits of axillary lymph node dissection, as shown in a phase III randomized study (ACOSOG-Z0011) of axillary lymph node dissection in women who had stage I or IIA breast cancer and a positive sentinel node.[18][Level of evidence: I] Several studies have shown that lymphedema is more prevalent in breast cancer patients who undergo axillary lymph node dissection than in those who undergo sentinel lymph node biopsy.[19][Level of evidence: II] One study evaluated 30 patients with unilateral invasive breast carcinoma who underwent sentinel lymph node biopsy and 30 patients who underwent axillary lymph node dissection. This study found a 20% rate of developing lymphedema in the axillary lymph node dissection group compared with none in the sentinel lymph node biopsy group.[19] Rates of lymphedema among women who undergo sentinel lymph node biopsy have been reported to be between 5% and 17%, depending on the diagnostic threshold and length of follow-up.[20,21,22] The majority of diagnosed lymphedema is mild.[21][Level of evidence: II]
Among all breast cancer patients, being obese or overweight may predispose women to developing lymphedema after treatment for breast cancer.[11,23][Level of evidence: I] A well-conducted prospective study followed 138 breast cancer patients for 30 months postdiagnosis. Individuals with body mass indices of 30 or higher at the time of diagnosis were 3.6 times more likely to develop lymphedema, but weight gain after diagnosis was not related.[24]
Some studies have correlated the degree of lymphedema with the level of obesity.[11][Level of evidence: I] Similarly, among young breast cancer survivors, persistent swelling was related to having more lymph nodes removed and being obese.[10]
The dose-response relationship between obesity and risk for lymphedema onset is not known. There have also been no studies to determine whether weight loss among patients at risk for developing lymphedema would reduce risk. At this time, it is not possible to advise patients regarding the dose-response relationship of weight loss and risk reduction or the body weight associated with lowest risk of incident lymphedema.
Other risks
Other risk factors for developing lymphedema include the following:
- Extent of local surgery.
- Local radiation (axillary, inguinal, pelvic, or supraclavicular regions).
- Delayed wound healing.
- Tumor causing lymphatic obstruction of the anterior cervical, thoracic, axillary, pelvic, or abdominal nodes.
- Scarring of the left or right subclavian lymphatic ducts by either surgery or radiation.
- Intrapelvic or intra-abdominal tumors that involve or directly compress lymphatic vessels and/or the cisterna chyli and thoracic duct.
Roughly one-third of breast cancer patients (and a majority of African Americans with breast cancer) present with regional disease and positive lymph nodes,[22] thus requiring complete axillary lymph node dissection; many undergo further irradiation of their axillary and supraclavicular lymph node beds. Lymphedema is a persistent adverse effect of breast cancer treatment that will continue to occur long into the future, despite increasing use of sentinel lymph node biopsy procedures.
Exercise does not increase risk of lymphedema onset
Historically, those at risk for lymphedema have been advised to avoid using the affected limb. The reasoning for this clinical advice seems to arise from the notion that the removal of lymph nodes altered the response of the affected area to inflammation, infection, injury, and trauma—therefore, it would be wise to avoid stressing the limb. However, exercise has a different effect on the body at lower doses than it does at higher doses; extreme exercise would promote inflammation and injury and should be avoided in patients at risk for lymphedema.[25] By contrast, slowly progressive, carefully controlled increases in physiologic stress on a limb at risk for lymphedema may actually provide protection for real-life situations that require taxing that body part (e.g., carrying grocery bags, doing holiday shopping, or lifting a child).[26] Therefore, physiologic evidence exists to question the historic advice to restrict use of the affected limb.
Furthermore, there is empirical evidence that upper-body exercise does NOT result in increased onset of lymphedema among breast cancer survivors.[27,28];[23,29,30] The largest of these studies (N = 204) [23][Level of evidence: I] measured the arms of women before breast surgery with axillary node dissection and randomly assigned participants to one of two rehabilitation programs:
- No activity restrictions (NAR). The women in this group (N = 104) had no restrictions on physical activities that used the affected limb for 6 months postsurgery. The NAR patients followed a supervised program of moderate, progressive resistance exercise training 2 to 3 times per week. The resistance exercises (total exercise time = 45 minutes) included a minimum of 15 repetitions for each exercise, using low resistance (0.5 kg) during the first 2 weeks. The resistance was increased individually for each patient (no upper limit), with the aim of enhancing muscular strength and endurance but always using 15 repetitions per set for each exercise.
- Activity restrictions (AR). The women in this group (N = 100) were instructed to restrict the activity of the affected limb for 6 months postsurgery. The patients were told to avoid heavy or strenuous physical activities such as aerobic or other types of exercise classes that included heavy upper-limb physical activity or work, and to avoid carrying or lifting groceries or other items weighing more than 3 kg.
At the end of 2 years of postsurgical follow-up, the incidence of new lymphedema was 13% in both groups. Of note, the single most important predictor of lymphedema onset in this large study was obesity.[23]
Another large (N = 134 completers) randomized study compared a 1-year weight-lifting intervention with a no-exercise control group for breast cancer survivors who had unilateral disease and at least two lymph nodes removed. No patients had evidence of lymphedema at baseline. A progressive weight-lifting program did not result in an increased incidence of lymphedema. The study was designed as an equivalence trial but noted a lower incidence of lymphedema in the weight-training group (11% vs. 17%, with a significant difference of 7% vs. 22%, for those with five or more lymph nodes removed).[31]
Patients with and at risk for lymphedema should be evaluated by a certified lymphedema therapist to ensure it is safe to proceed with exercise of the affected body part. (See the Lymphology Association of North America website for referrals to certified lymphedema therapists in locations across the United States.)
Patients who have lymphedema should wear a well-fitting compression garment during all exercise that uses the affected limb or body part. If there are questions regarding whether lymphedema is present, there is no evidence as to whether use of a garment will be helpful or harmful. Garments must be well fitted to be useful, are costly, may not be covered by insurance without a clear diagnosis, and must be replaced every 6 months. Among women with an unclear diagnosis, it is likely that the risk of avoiding upper-body activity outweighs the risk of engaging in slowly progressive upper-body activity without a garment. Patients without lymphedema do NOT need to wear a garment while doing exercise with the at-risk limb.
Evidence from studies with breast cancer survivors suggests that upper-body exercise among women with and at risk for lymphedema should start at a very low intensity and progress slowly and according to symptom response.[26];[29][Level of evidence: I] There should be a certified lymphedema specialist to whom these women can be referred if there is a need for evaluation of possible flare-ups or onsets. If there is a break in exercise of a week or longer, it is strongly recommended that women decrease the intensity of activity with the upper body and then increase it again gradually. Changes in symptoms (increased heaviness, achiness, puffiness, swelling) that last a week or longer should be evaluated for possible onsets or flare-ups. It is likely that starting at low intensity and progressing slowly is better for the affected limb than is avoiding activity.
Diagnosis and Evaluation
Lymphedema is typically evident by clinical findings such as nonpitting edema, usually with involvement of the digits, in a patient with known risk factors such as previous axillary dissection. Other causes of limb swelling, including deep venous thrombosis, malignancy, and infection, should be considered in the differential diagnosis and excluded with appropriate studies, if indicated.
If the diagnosis is not evident on the basis of clinical assessment, imaging of the lymphatic system with lymphoscintigraphy (radionuclide imaging) may be necessary. Lymphangiography is generally no longer a favored diagnostic test and may be contraindicated in patients with malignancy because of concern that it may contribute to metastatic spread of tumor. Additional imaging techniques such as magnetic resonance imaging may complement information obtained via lymphoscintigraphy by providing anatomic and nodal detail.[32]
The wide variety of methods described in the literature for evaluating limb volume and lack of standardization makes it difficult for the clinician to assess the at-risk limb. Options include water displacement, tape measurement, infrared scanning, and bioelectrical impedance measures.[33]
The most widely used method to diagnose upper-extremity lymphedema is circumferential upper-extremity measurement using specific anatomical landmarks.[5] Arm circumference measures are used to estimate volume differences between the affected and unaffected arms. Sequential measurements are taken at four points on both arms: the metacarpal-phalangeal joints, the wrist, 10 cm distal to the lateral epicondyles, and 15 cm proximal to the lateral epicondyles. Differences of 2 cm or more at any point compared with the contralateral arm are considered by some experts to be clinically significant. However, measuring specific differences between arms may have limited clinical relevance because of implications, for example, of a 3-cm difference between the arm of an obese woman and the arm of a thin woman. In addition, there can be inherent anatomic variations in circumference between the dominant and nondominant limb related to differences in muscle mass and variations after breast cancer treatment that may occur with atrophy of the ipsilateral arm or hypertrophy of the contralateral arm.[3] A small study comparing various methods of assessing upper-limb lymphedema did not show any superiority of any one method.[33] Sequential measurements over time, including pretreatment measurements, may prove to be more clinically meaningful.
The water displacement method is another way to evaluate arm edema. A volume difference of 200 mL or more between the affected and opposite arms is typically considered to be a cutoff point to define lymphedema.[34]
One common method of lymphedema classification uses three stages based on severity.[5] Stage I is spontaneously reversible and typically is marked by pitting edema, increase in upper-extremity girth, and heaviness. Stage II is characterized by a spongy consistency of the tissue without signs of pitting edema. Tissue fibrosis can then cause the limbs to harden and increase in size.[5] Stage III, also called lymphostatic elephantiasis, is the most advanced stage, but is rarely seen following breast cancer treatment.[5]
Another commonly used approach to classifying lymphedema is the Common Terminology Criteria for Adverse Events v3.0 (CTCAE), which were developed for grading adverse events in the context of clinical trials.[35] A key advantage of the CTCAE approach is that it includes both objective measures (interlimb discrepancy) and subjective, clinical assessments in diagnosing lymphedema. This allows for the very real possibility that a patient could have clinically meaningful, treatable lymphedema isolated to a segment of his or her limb that would not meet objective interlimb discrepancy criteria, but which could still be graded according to severity by signs and symptoms, as follows:
- Grade 1: 5% to 10% interlimb discrepancy in volume or circumference at point of greatest visible difference; swelling or obscuration of anatomic architecture on close inspection; pitting edema.
- Grade 2: More than 10% to 30% interlimb discrepancy in volume or circumference at point of greatest visible difference; readily apparent obscuration of anatomic architecture; obliteration of skin folds; readily apparent deviation from normal anatomic contour.
- Grade 3: More than 30% interlimb discrepancy in volume; lymphorrhea; gross deviation from normal anatomic contour; interfering with activities of daily living.
- Grade 4: Progression to malignancy (e.g., lymphangiosarcoma); amputation indicated; disabling lymphedema.
- Meneses KD, McNees MP: Upper extremity lymphedema after treatment for breast cancer: a review of the literature. Ostomy Wound Manage 53 (5): 16-29, 2007.
- Hewitt M, Ganz PA, eds.: From Cancer Patient to Cancer Survivor – Lost in Transition: An American Society of Clinical Oncology and Institute of Medicine Symposium. Washington, DC: The National Academies Press, 2006.
- Petrek JA: Commentary: prospective trial of complete decongestive therapy for upper extremity lymphedema after breast cancer therapy. Cancer J 10 (1): 17-9, 2004.
- Horsley JS, Styblo T: Lymphedema in the postmastectomy patient. In: Bland KI, Copeland EM, eds.: The Breast: Comprehensive Management of Benign and Malignant Diseases. Philadelphia, Pa: Saunders, 1991, pp 701-6.
- Bicego D, Brown K, Ruddick M, et al.: Exercise for women with or at risk for breast cancer-related lymphedema. Phys Ther 86 (10): 1398-405, 2006.
- Meek AG: Breast radiotherapy and lymphedema. Cancer 83 (12 Suppl American): 2788-97, 1998.
- Roberts CC, Levick JR, Stanton AW, et al.: Assessment of truncal edema following breast cancer treatment using modified Harpenden skinfold calipers. Lymphology 28 (2): 78-88, 1995.
- Pyszel A, Malyszczak K, Pyszel K, et al.: Disability, psychological distress and quality of life in breast cancer survivors with arm lymphedema. Lymphology 39 (4): 185-92, 2006.
- Ridner SH: Quality of life and a symptom cluster associated with breast cancer treatment-related lymphedema. Support Care Cancer 13 (11): 904-11, 2005.
- Paskett ED, Naughton MJ, McCoy TP, et al.: The epidemiology of arm and hand swelling in premenopausal breast cancer survivors. Cancer Epidemiol Biomarkers Prev 16 (4): 775-82, 2007.
- Shaw C, Mortimer P, Judd PA: Randomized controlled trial comparing a low-fat diet with a weight-reduction diet in breast cancer-related lymphedema. Cancer 109 (10): 1949-56, 2007.
- Petrek JA, Senie RT, Peters M, et al.: Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer 92 (6): 1368-77, 2001.
- Beesley V, Janda M, Eakin E, et al.: Lymphedema after gynecological cancer treatment : prevalence, correlates, and supportive care needs. Cancer 109 (12): 2607-14, 2007.
- Norman SA, Localio AR, Potashnik SL, et al.: Lymphedema in breast cancer survivors: incidence, degree, time course, treatment, and symptoms. J Clin Oncol 27 (3): 390-7, 2009.
- Purushotham AD, Bennett Britton TM, Klevesath MB, et al.: Lymph node status and breast cancer-related lymphedema. Ann Surg 246 (1): 42-5, 2007.
- Borup Christensen S, Lundgren E: Sequelae of axillary dissection vs. axillary sampling with or without irradiation for breast cancer. A randomized trial. Acta Chir Scand 155 (10): 515-9, 1989.
- Liljegren G, Holmberg L: Arm morbidity after sector resection and axillary dissection with or without postoperative radiotherapy in breast cancer stage I. Results from a randomised trial. Uppsala-Orebro Breast Cancer Study Group. Eur J Cancer 33 (2): 193-9, 1997.
- Lucci A, McCall LM, Beitsch PD, et al.: Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol 25 (24): 3657-63, 2007.
- Celebioglu F, Perbeck L, Frisell J, et al.: Lymph drainage studied by lymphoscintigraphy in the arms after sentinel node biopsy compared with axillary lymph node dissection following conservative breast cancer surgery. Acta Radiol 48 (5): 488-95, 2007.
- Wilke LG, McCall LM, Posther KE, et al.: Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial. Ann Surg Oncol 13 (4): 491-500, 2006.
- Francis WP, Abghari P, Du W, et al.: Improving surgical outcomes: standardizing the reporting of incidence and severity of acute lymphedema after sentinel lymph node biopsy and axillary lymph node dissection. Am J Surg 192 (5): 636-9, 2006.
- Jemal A, Siegel R, Ward E, et al.: Cancer statistics, 2009. CA Cancer J Clin 59 (4): 225-49, 2009 Jul-Aug.
- Sagen A, Kåresen R, Risberg MA: Physical activity for the affected limb and arm lymphedema after breast cancer surgery. A prospective, randomized controlled trial with two years follow-up. Acta Oncol 48 (8): 1102-10, 2009.
- Ridner SH, Dietrich MS, Stewart BR, et al.: Body mass index and breast cancer treatment-related lymphedema. Support Care Cancer 19 (6): 853-7, 2011.
- Radak Z, Chung HY, Koltai E, et al.: Exercise, oxidative stress and hormesis. Ageing Res Rev 7 (1): 34-42, 2008.
- Schmitz KH: Balancing lymphedema risk: exercise versus deconditioning for breast cancer survivors. Exerc Sport Sci Rev 38 (1): 17-24, 2010.
- Cheema B, Gaul CA, Lane K, et al.: Progressive resistance training in breast cancer: a systematic review of clinical trials. Breast Cancer Res Treat 109 (1): 9-26, 2008.
- McKenzie DC, Kalda AL: Effect of upper extremity exercise on secondary lymphedema in breast cancer patients: a pilot study. J Clin Oncol 21 (3): 463-6, 2003.
- Ahmed RL, Thomas W, Yee D, et al.: Randomized controlled trial of weight training and lymphedema in breast cancer survivors. J Clin Oncol 24 (18): 2765-72, 2006.
- Courneya KS, Segal RJ, Mackey JR, et al.: Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J Clin Oncol 25 (28): 4396-404, 2007.
- Schmitz KH, Ahmed RL, Troxel AB, et al.: Weight lifting for women at risk for breast cancer-related lymphedema: a randomized trial. JAMA 304 (24): 2699-705, 2010.
- Rockson SG: Lymphedema. Am J Med 110 (4): 288-95, 2001.
- Ridner SH, Montgomery LD, Hepworth JT, et al.: Comparison of upper limb volume measurement techniques and arm symptoms between healthy volunteers and individuals with known lymphedema. Lymphology 40 (1): 35-46, 2007.
- Mondry TE, Riffenburgh RH, Johnstone PA: Prospective trial of complete decongestive therapy for upper extremity lymphedema after breast cancer therapy. Cancer J 10 (1): 42-8; discussion 17-9, 2004 Jan-Feb.
- Cheville AL, McGarvey CL, Petrek JA, et al.: The grading of lymphedema in oncology clinical trials. Semin Radiat Oncol 13 (3): 214-25, 2003.
Ideally, prevention should begin before treatment, by educating the patient and family in a sensitive fashion about the potential risk of developing lymphedema. Proceeding in this way may diminish a breast cancer survivor's dissatisfaction with the educational information received about lymphedema, and could serve as a foundation for making decisions and coping with lymphedema, should it develop later.[1] Patients should be taught to recognize the early signs of edema because treatment outcomes may be significantly improved if the problem is detected early.[2]
Refer to the Exercise does not increase risk of lymphedema onset subsection in the Risk Factors section of this summary for more information.
Other preventive measures
Generally anecdotal recommendations for taking preventive measures include the following:
Hygiene: Skin and Nail Care
- Maintain meticulous skin hygiene and nail care to prevent a portal of entry for infection which may result in cellulitis.
- Cut toenails straight across; see a podiatrist as needed to prevent ingrown nails and infections.
- Use skin moisturizers and topical antibiotic solutions after small breaks in the skin, such as paper cuts.
- Use sunscreen and suntan gradually.
- Wear cotton socks; keep feet clean and dry.
- Wear gardening and cooking gloves and use thimbles for sewing.
- Avoid going barefoot outdoors.
- Avoid blood draws (including finger sticks), vaccinations, or intravenous lines in the affected arm.
- Use the unaffected extremity to test temperatures (e.g., for bath water or cooking), as sensation may be diminished.
- Be aware of the signs of infection (fever, swelling, redness, pain, and heat) and see a physician for evaluation immediately.
Extremity Positioning
- Keep the arm or leg elevated above the level of the heart when possible.
- Avoid constrictive pressure on the affected arm or leg.
- Do not cross legs while sitting.
- Wear loose jewelry and clothes with no constricting bands.
- Carry a handbag on the opposite arm.
- Do not use elastic bandages and stockings with constrictive bands.
- Do not sit in one position for longer than 30 minutes.
Avoiding the Pooling of Blood in the Involved Extremity
- Avoid rapid circular movements that cause centrifugal pooling of fluid in distal parts of the limb.
- Avoid local application of heat to the limb, which may increase blood flow.
- Do not maintain the limb in a gravity-dependent position for long periods of time.
- Avoid tight-fitting clothing or blood pressure monitoring in the affected arm, which could cause a tourniquet effect and obstruct lymph flow.
The goal of lymphedema treatment centers on controlling limb swelling and minimizing complications; the underlying lymphatic vessel interruption cannot be corrected. Because clinical trials evaluating pharmacologic measures are generally not found to be effective, nonpharmacologic measures are the mainstay of treatment, with the goal of maximizing the activities of daily living, decreasing pain, increasing range of motion, and improving function.
Nonfatiguing exercises may induce sufficient muscle contraction to move lymph into terminal lymphangioles and reduce swelling. Aerobic exercise may also increase the tone of the sympathetic nervous system, which causes the lymph collector vessels to pump more vigorously.[3] Multiple studies indicate that exercise, including upper-body exercise, is safe for women with breast cancer–related lymphedema.[4]
There is also evidence that slowly progressive weight lifting among women with previously diagnosed breast cancer–related lymphedema leads to a reduction by half of the likelihood of a clinically meaningful exacerbation of lymphedema (a flare-up) that requires treatment by a physical therapist.[5][Level of evidence: I] A group of 141 breast cancer survivors with lymphedema were randomly assigned to a twice-weekly, year-long weight-lifting intervention (N = 71) or to a wait-list comparison group (N = 70). The intervention started with 13 weeks of supervised training with little to no resistance; the amount of weight lifted was increased very gradually and only if there was no change in lymphedema symptoms or swelling. The participants all wore well-fitting, custom-made compression garments that were replaced 6 months into the intervention period. Women with breast cancer–related lymphedema should be guided to work with a certified fitness professional or physical therapist to learn the proper biomechanical form for upper-body weight-lifting exercises before undertaking this program on their own. (The specifics of the intervention are available to certified fitness professionals and physical therapists through the National Lymphedema Network.) Further research is needed to develop a version of this intervention that can be broadly disseminated.
One small pilot study has examined the safety of an intervention similar to that described above in cancer survivors with lower-extremity lymphedema secondary to melanoma or gynecologic or urological cancers. In this uncontrolled pilot study, 20% of participants developed a cellulitic infection within the first 2 months after starting a slowly progressive weight-lifting regimen.[6] Further research is needed to determine whether weight-lifting is a safe exercise modality for cancer survivors with lower-extremity lymphedema.
Gradient pressure garments
Gradient pressure garments (also known as lymphedema sleeves or stockings) generate greater pressures distally than proximally, which enhances mobilization of edema fluid. Some patients may require custom-made sleeves to achieve an appropriate fit. The use of these garments may be especially important at high altitudes, such as during air travel, because the ambient atmospheric pressure is less than the outlet transcapillary pressure within the superficial tissues, which can lead to worsening edema.
Bandaging involves the use of inelastic material to discourage reaccumulation of lymph by reducing capillary ultrafiltration and optimizing the efficacy of the intrinsic muscle pump. Bandaging may change an initially resistant limb to one with less edema, resulting in decreased limb volume and allowing a garment to be applied successfully.[7][Level of evidence: I]
Skin care
The goal of skin care is to minimize dermal colonization by bacteria and fungus, especially in the crevices, and hydrate the skin to control dryness and cracking.
Complex decongestive therapy
Complex decongestive therapy is a multimodality program that consists of manual lymphedema drainage therapy, low-stretch bandaging, exercises, and skin care.[8] This approach has been recommended as a primary treatment by consensus panels and as an effective therapy for lymphedema unresponsive to standard elastic compression therapy.[9,10]
Complex decongestive therapy is divided into two successive phases. The first phase consists of intensive treatment to allow substantive reduction of lymphedema volume. The second phase consists of maintenance treatment at home. Compliance with the use of the elastic sleeve and low-stretch bandage has been found to be an important determinant of success with maintenance therapy at home.[8] Complex decongestive therapy has also been shown to improve lymphedema following groin dissection.[11] Patients should be referred to a properly trained therapist for optimal results.
Intermittent external pneumatic compression
Intermittent external pneumatic compression may also provide additional improvement with lymphedema management when used adjunctively with decongestive lymphatic therapy. One small randomized trial of 23 women with new breast cancer–associated lymphedema found an additional significant volume reduction when compared with manual lymphatic drainage alone (45% vs. 26%).[12][Level of evidence: I] Similarly, improvements were also found in the maintenance phase of therapy. Concerns regarding the use of intermittent pneumatic compression include the optimum amount of pressure and treatment schedule and whether maintenance therapy is needed after the initial reduction in edema.[13][Level of evidence: I] There is a theoretical concern that pressures higher than 60 mmHg and long-term use may actually injure lymphatic vessels.
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][17,18] 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 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.[19] 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.
Integrative Modalities
Manual lymphedema therapy
Manual lymphedema therapy, a type of massage technique, involves the use of a very light superficial massage with gentle, rhythmic skin distention, ideally limited to pressures of approximately 30 mmHg to 45 mmHg.[3] In comparison to many other massage techniques, manual lymphedema therapy is very light to the touch. The strokes often feel like a "brushing" technique. Manual lymphedema therapy decreases congested lymph nodes by directing it to the circulatory and lymphatic system.[3] Manual lymphedema therapy begins on unaffected areas to direct the lymph away from the affected extremity.
A limited number of trials have been conducted among women with breast cancer who are experiencing lymphedema. These trials have reported significant reductions in limb volume when manual lymphedema therapy is administered as the sole intervention or as an adjunct to standard of care.[20,21,22][Level of evidence: I] However, large randomized controlled trials are needed to confirm these preliminary findings.
Manual lymphedema therapy should be introduced in a closely supervised medical setting, by a clinician specifically trained in manual lymphedema therapy.[23] No adverse events have been reported in the pilot studies that administered manual lymphedema therapy to women with breast cancer. The reported adverse events are associated with the general discipline of massage therapy and are largely related to treatments delivered by unlicensed massage therapists or treatments that include deep and rigorous massage techniques. Manual lymphatic therapy, also known as manual lymphatic drainage, can be taught to patients for self-care.
Despite the safety profile, the following special precautions should be considered when massage therapy is delivered to individuals with cancer:
- Avoid directly massaging any open wounds, hematomas, or areas with skin breakdown.
- Avoid directly massaging tumors that are apparent on the skin surface.
- Avoid massaging areas with acute deep venous thrombosis.
- Avoid directly massaging radiated soft tissue when the skin is sensitive.[24]
Additional integrative modalities have been under investigation for their role in the treatment of secondary lymphedema. Selenium has been studied in clinical trial NCT00188604, and acupuncture and moxibustion have been studied in clinical trial LJMC-AMWELL-SL as treatments for lymphedema.
Refractory Lymphedema and Complications
If lymphedema is massive and refractory to treatment, or has an onset several years after the primary surgery without obvious trauma, a search for other etiologies should be undertaken. Of particular importance is exclusion of the recurrence of tumor or the development of lymphangiosarcoma, which should be excluded with computed tomography or magnetic resonance imaging. The complication of lymphangiosarcoma is classically seen in the postmastectomy lymphedematous arm (Stewart-Treves syndrome). The mean time between mastectomy and lymphangiosarcoma is 10.2 years, with a median survival of 1.3 years. Clinically, the lesions of lymphangiosarcoma may initially appear as blue-red or purple with a macular or papular shape in the skin. Multiple lesions are common; subcutaneous nodules may appear and should be carefully evaluated in the patient who has chronic lymphedema.[25]
- Ridner SH: Pretreatment lymphedema education and identified educational resources in breast cancer patients. Patient Educ Couns 61 (1): 72-9, 2006.
- Markowski J, Wilcox JP, Helm PA: Lymphedema incidence after specific postmastectomy therapy. Arch Phys Med Rehabil 62 (9): 449-52, 1981.
- Petrek JA: Commentary: prospective trial of complete decongestive therapy for upper extremity lymphedema after breast cancer therapy. Cancer J 10 (1): 17-9, 2004.
- Schmitz KH: Balancing lymphedema risk: exercise versus deconditioning for breast cancer survivors. Exerc Sport Sci Rev 38 (1): 17-24, 2010.
- Schmitz KH, Ahmed RL, Troxel A, et al.: Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med 361 (7): 664-73, 2009.
- Katz E, Dugan NL, Cohn JC, et al.: Weight lifting in patients with lower-extremity lymphedema secondary to cancer: a pilot and feasibility study. Arch Phys Med Rehabil 91 (7): 1070-6, 2010.
- Badger CM, Peacock JL, Mortimer PS: A randomized, controlled, parallel-group clinical trial comparing multilayer bandaging followed by hosiery versus hosiery alone in the treatment of patients with lymphedema of the limb. Cancer 88 (12): 2832-7, 2000.
- Vignes S, Porcher R, Champagne A, et al.: Predictive factors of response to intensive decongestive physiotherapy in upper limb lymphedema after breast cancer treatment: a cohort study. Breast Cancer Res Treat 98 (1): 1-6, 2006.
- Didem K, Ufuk YS, Serdar S, et al.: The comparison of two different physiotherapy methods in treatment of lymphedema after breast surgery. Breast Cancer Res Treat 93 (1): 49-54, 2005.
- Koul R, Dufan T, Russell C, et al.: Efficacy of complete decongestive therapy and manual lymphatic drainage on treatment-related lymphedema in breast cancer. Int J Radiat Oncol Biol Phys 67 (3): 841-6, 2007.
- Hinrichs CS, Gibbs JF, Driscoll D, et al.: The effectiveness of complete decongestive physiotherapy for the treatment of lymphedema following groin dissection for melanoma. J Surg Oncol 85 (4): 187-92, 2004.
- Szuba A, Achalu R, Rockson SG: Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema. A randomized, prospective study of a role for adjunctive intermittent pneumatic compression. Cancer 95 (11): 2260-7, 2002.
- Dini D, Del Mastro L, Gozza A, et al.: The role of pneumatic compression in the treatment of postmastectomy lymphedema. A randomized phase III study. Ann Oncol 9 (2): 187-90, 1998.
- Loprinzi CL, Barton DL, Jatoi A, et al.: Symptom control trials: a 20-year experience. J Support Oncol 5 (3): 119-25, 128, 2007.
- Shaw C, Mortimer P, Judd PA: Randomized controlled trial comparing a low-fat diet with a weight-reduction diet in breast cancer-related lymphedema. Cancer 109 (10): 1949-56, 2007.
- Carati CJ, Anderson SN, Gannon BJ, et al.: Treatment of postmastectomy lymphedema with low-level laser therapy: a double blind, placebo-controlled trial. Cancer 98 (6): 1114-22, 2003.
- Kozanoglu E, Basaran S, Paydas S, et al.: Efficacy of pneumatic compression and low-level laser therapy in the treatment of postmastectomy lymphoedema: a randomized controlled trial. Clin Rehabil 23 (2): 117-24, 2009.
- Ahmed Omar MT, Abd-El-Gayed Ebid A, El Morsy AM: Treatment of post-mastectomy lymphedema with laser therapy: double blind placebo control randomized study. J Surg Res 165 (1): 82-90, 2011.
- Chilvers AS, Kinmonth JB: Operations for lymphoedema of the lower limbs. A study of the results in 108 operations utilizing vascularized dermal flaps. J Cardiovasc Surg (Torino) 16 (2): 115-9, 1975 Mar-Apr.
- McNeely ML, Magee DJ, Lees AW, et al.: The addition of manual lymph drainage to compression therapy for breast cancer related lymphedema: a randomized controlled trial. Breast Cancer Res Treat 86 (2): 95-106, 2004.
- Williams AF, Vadgama A, Franks PJ, et al.: A randomized controlled crossover study of manual lymphatic drainage therapy in women with breast cancer-related lymphoedema. Eur J Cancer Care (Engl) 11 (4): 254-61, 2002.
- Andersen L, Højris I, Erlandsen M, et al.: Treatment of breast-cancer-related lymphedema with or without manual lymphatic drainage–a randomized study. Acta Oncol 39 (3): 399-405, 2000.
- Ernst E: Massage therapy for cancer palliation and supportive care: a systematic review of randomised clinical trials. Support Care Cancer 17 (4): 333-7, 2009.
- Gecsedi RA: Massage therapy for patients with cancer. Clin J Oncol Nurs 6 (1): 52-4, 2002 Jan-Feb.
- Tomita K, Yokogawa A, Oda Y, et al.: Lymphangiosarcoma in postmastectomy lymphedema (Stewart-Treves syndrome): ultrastructural and immunohistologic characteristics. J Surg Oncol 38 (4): 275-82, 1988.
Current Clinical Trials
Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.
Changes to This Summary (07 / 17 / 2015)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
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This summary is written and maintained by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® – NCI's Comprehensive Cancer Database pages.
About This PDQ Summary
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the pathophysiology and treatment of lymphedema. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
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- be discussed at a meeting,
- be cited with text, or
- replace or update an existing article that is already cited.
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Lymphedema are:
- Andrea Barsevick, PhD (Thomas Jefferson University)
- Larry D. Cripe, MD (Indiana University School of Medicine)
Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
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The preferred citation for this PDQ summary is:
PDQ® Supportive and Palliative Care Editorial Board. PDQ Lymphedema. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/treatment/side-effects/lymphedema/lymphedema-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389244]
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text:
Does that title make sense? I doubt it. Let's see if I can explain.
OK, so you know those people who complain about how busy they are - but it's not with work or anything really "important"? It's more like, "Oh gawd, I'm sooooo busy, because Eustace and Duncan and Dorset have Tae Kwon Do on Mondays, baseball practice on Tuesdays, violin and cello on Mondays, Wednesdays and Fridays, soccer all day on Saturdays, baseball for the OTHER team they play for Wednesdays, and Kumon on Fridays." My head wants to explode just reading that.
A few years ago, before I had any kids, I was showing a house to my client and on the wall of the kitchen the home owners had a schedule with different colors for each kid. They had four kids and from what I could gather each child participated in 2-3 activities per week and didn't get home from their activities before 9 PM on most nights. These were elementary and middle school aged kids. When did they eat dinner? When did they do their homework? What time did they finally get to bed? When did they have time to play with their Ponies and Legos or ride their bikes?
Right then and there I decided 2 kids max and only one activity per child at a time. Forget them, I couldn't take that kind of schedule!
I get that you want to have a well-rounded kid. I do too. I want my kids to try a lot of things and figure out what really interests them. And, let's face it, there are SO MANY things they could try:
Baseball (many kids we know play on multiple teams - why is that?)
Ice Skating
Dance (Ballet, Jazz and/or Tap, Interpretive, Water Ballet, Competitive Jazz Aerobics)
Tae Kwon Do
Art Classes (Painting, sculpture, drawing, pottery, etc.)
Computer Classes (Animation, robotics, programming, etc.)
Instrument lessons (Violin and piano seem to be the dominant ones right now)
Math Monkey
Foreign Languages (Spanish, French, Chinese)
Just to name a few. And I know I'm missing a bunch.
As the parent, though, I feel I have to draw the line and make the kids choose just one - MAYBE two - things at a time. Eustace can't be a violin prodigy, a soccer star, a math whiz and an Eagle Scout - can he? Especially when he's got two other siblings who want to do that much too? When does it become a bunch of shit you're just running your kid around to just so you don't have to entertain them?
I actually overhead a mother the other day complaining that school was taking away from her children's activities. Her direct quote was: "I don't know how the school expects Elmer to get all his homework done when he's playing on 3 baseball teams right now. It's ridiculous how much work they send home for him. What do they do at school all day if he has this much to bring home? We just don't have time for it all. We're far too busy!"
Ummm....Isn't school kind of like a job? Shouldn't school be the first on the list and then if there's time they can do the rest? I asked her, "Why is he on 3 teams? Isn't it more important for Elmer to study so that he can go to college or get a job someday?"
She looked at me like I was speaking Japanese. "Elmer needs to stick with baseball, because that will be his job someday. Elmer is well on his way to being a professional baseball player."
I did not know this woman, she was a friend of a friend. Our mutual friend gave me the look that said, "Jennn....don't start with this lady. I would like to keep her as my friend so keep your big opinionated mouth shut."
I obediently clamped my mouth shut and excused myself from the conversation before I literally slapped this idiotic woman upside her head.
This is not unusual. You go to a party in this town and you hear stupid shit like:
"We have Eloise in Girl Scouts, Kumon, advanced hairbraiding, piano and she has real potential to be a professional racquetball player. We can barely get her reading done every night. The teacher wants her to read 2 chapters a night on top of all the homework!"
It's not just the kids' activities that everyone's complaining about. I also hear a lot about busy schedules that the moms are keeping these days. Friday night I was at a school event I had a hand in planning and this is what I heard from one of the moms:
"I just don't know when you found the time to do this, Jen! You work full time and you take care of the kids. How did you get this done?"
"Eh. I had a lot of help. It was a big committee. I'm tired, no doubt, and I'm glad it's over. I need to start learning how to say 'No' more."
"Oh I know! I'm always being hit up to help with this kind of stuff. They think because I'm home and I don't work I have time to put in on this kind of stuff, but I really don't! I do morning carpool, so we're out the door by 7:50. I pick everyone up and drop them off by 8:15. I head to the gym for my 8:30 Hot Yoga class, do that for an hour, cool off with a swim and then meet the girls in the cafe for an organic smoothie. We usually wrap up around 11 so I can hit Target and Whole Foods - can't get out of either of those places for under fifty bucks, am I right, Jen? I check my voicemail and email about this time and realize I have about 30 messages I need to return, so I pull over and do that. Once I'm done with messages, I grab Seamus' dry cleaning and head to Michael's to get all the supplies I'll need for whatever class project Eugene seems to have due every week - don't we just live at Michael's, Jen? Then it's about time for me to run to the courts for my 1:30 tennis lesson with Alejandro - who, by the way, is ah-may-zing. After an hour of staring at Alejandro's butt, teeheehee, I mean learning new technique from Alejandro, I head home to shower and get some dinner ready for the kids. After all, we've only got about 35 minutes to eat as soon as they walk in the door before the first activity of the evening starts. Most nights Seamus and I are running in different directions with kids. Weekends are even worse with each kid having 2 or 3 games every day."
I stood there with my fake smile plastered on my face thinking to myself: What is Alejandro so amazing at and when do you update your Pinterest account? Because making time for Pinterest is way more important than shopping, I haven't been to the grocery store in a week, but my Pinterest account is ah-may-zing.
Listening to her I realized, I spend my time being busy with far more important things. I work several hours a day on my real job and then several more hours on my writing, but it's all from home so I tend to wander off my work and onto Facebook and Pinterest a lot. The Hubs and I haven't sent anything out to be dry cleaned in 5 years so I can take off my list. I try to do laundry every day, but it's a real chore and it never gets fully done. I do go to Target a lot. Mostly to return stuff I should not have bought when I was there yesterday. I barely cook. I volunteer a lot for many different things - it's a good outlet for my bossiness. I watch TV most every day. Our kids are currently doing soccer and gymnastics so I take them to those activities. Most nights I work with my kid on spelling words, reading (he reads to me and I read to both of them), math homework, and whatever the project of the week is. I don't work out. I should. But I don't have time (teeheehee). Maybe I could cram more stupid stuff in like she does if I knew her secret.
So I finally had to interrupt her and ask, "What kind of drugs are you on?"
"Excuse me?"
"Drugs. Are you one of those moms who pops the kids' Ritalin to keep going? Are you guzzling Red Bull, 5 Hour Energy drinks or is it just straight up cocaine?"
"Oh my God, Jen. You are hysterical!" she laughed and walked off.
I don't think those bitches will ever let me in on the secret.
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subset: commoncrawl


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Forsyth County Parks and Recreation is pleased to announce the launch of our new online Reservations System! This system will allow clients to book facilities online, view photos of facilities, and look at diagram layouts of facilities. There are new and up-to-date photos of each facility placed within the Reservations System.
The Reservations System serves as a place for clients to book weddings, family reunions, birthday parties, corporate events, or any function in which a client wants to utilize a Forsyth County Parks and Recreation facility.
The Parks and Recreation Department offers a variety of indoor and outdoor facilities for your event needs. Each of our parks has something unique to offer. Whether you are planning a family picnic, an extravagant wedding, or an annual conference—we can accommodate your event needs!
Click here to make your next reservation! If you need assistance, we can guide you through your first reservation.
Please call (336) 703-2500 if you would like assistance on booking your next non-Tanglewood event.
For assistance booking events at Tanglewood, please call (336) 703-6480.
For Tanglewood Park information, click here.


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Yes, I know. It's nothing but a gigantic ambulatory commercial for toy companies and for the corporate behemoth that sponsors it. However, when I was kid it was a chance to see New York City (where I dreamed of living some day) and one of my two chances to see numbers from whatever was running on Broadway. I was a mild-mannered little boy, but you did not get between me and the television set on Thanksgiving morning or Tony Awards night.
I still watch it, half from nostalgia and half out of genuine interest. Because between the crappy pop music acts and commericals you get local high school bands, and those Azalea women from down South who dress as toilet tissue covers, and the kids who for one reason or another get to ride on the floats. I like to think of families all over the country sitting and waiting for a loved one to pop onto the screen for two seconds, so they can scream "There she is! There she is!" and dine out on the taste of celebrity for an entire year.
One thing lacking, though, is knitting content. This thing is supposed to kick off the holiday season, and what group is more hypersensitive to the approach of the holidays than knitters? This morning you could hear the collective gasp reverberate across the time zones as knitters awoke and suddenly realized what's facing them in the coming weeks.
Not all of us celebrate Chrismahannukwanzawalisolstice, of course, but enough of us do that we should be represented. Our yarn and needles represent the season far more strongly than Hall and Oates, for heaven's sake, and Macy's gave them a slot in the line-up.
While assembling the relish trays I've been brainstorming. Here are a few things I think would make a fine start toward redressing the imbalance. Feel free to add your own ideas, and maybe we can build up enough mass to shake things up next year.
- Five hundred synchronized knitters in spangly costumes, marching and working fair isle in unison.
- An animated float, sponsored by Schacht, featuring fifty lucky knitters (one from each state) riding round and round on a giant Matchless while Raven Symone lip-synchs to "Carol of the Bells."
- The cast of Sesame Street dancing down Broadway on a float celebrating the release of the new movie Elmo in Unfinishedobjectland.
- A 100-foot-tall Elizabeth Zimmermann helium balloon.
Of course, if we're going to make this happen we need star power either at Macy's or NBC. Does anybody know if that nice Meredith Viera knits?
Happy Thanksgiving, y'all, wherever you happen to be.


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In Kentucky yesterday, there was another sign of Tea Party clout. Mitch McConnell - minority leader in the U.S. Senate, and Kentucky's most powerful politician - turned up at his first-ever Tea Party rally. [POST-BROADCAST CORRECTION: This was not McConnell's first Tea Party rally. He participated in a Tea Party event in 2010.] This year, Tea Party candidates have scored upsets in Republican primaries in Missouri, Texas and Indiana. That's where longtime Senator Richard Lugar lost.
In Kentucky, some believe Mitch McConnell fears his own Tea Party primary challenge, in coming years. Phillip Bailey, of member station WFPL, has the report.
PHILLIP BAILEY, BYLINE: Even before Mitch McConnell got a chance to speak at the Kentucky Capitol, about a dozen protesters were out in force.
UNIDENTIFIED GROUP: Hey, hey, ho, ho, Mitch McConnell's got to go.
BAILEY: McConnell is as powerful in Kentucky, as he is in Washington. But he's had to make nice with the new junior senator, Rand Paul, who was elected with strong Tea Party support two years ago - a candidate McConnell didn't back.
SEN. MITCH MCCONNELL: Thank you very much. Thank you very much. And thank you for sending Rand Paul to the Senate.
BAILEY: Despite Tea Party critics, McConnell joined with Paul at the rally, to denounce President Obama's health-care law, while praising his colleague's climb up the political ladder.
MCCONNELL: I'm so grateful that you all helped get him elected in 2010. He's a national leader, making a difference for Kentucky and America. And thank you for your service, Rand Paul.
BAILEY: Kentucky does have a Democratic governor. But the state is solidly Republican. So this rally may be more about McConnell's re-election bid in 2014, than the presidential race. Some Tea Party activists see McConnell for what he's worth: a lawmaker who has accrued three decades of political power. That faction wants to influence the Senate's ranking Republican. Others want McConnell ousted from office, to clean up Washington and cut government spending.
Frank Harris was among those in the crowd. He says he's a former Republican who is now a Libertarian. He recalls McConnell's initial opposition to Paul's candidacy, and believes McConnell's appearance at the rally is a sign the Tea Party movement is being co-opted.
FRANK HARRIS: As far as I'm concerned, bringing Mitch in just shows that Mitch is afraid. He finally has to acknowledge the power, and the strength, of the Tea Party Movement.
BAILEY: Still, McConnell received a warm reception, and polite applause, from the Tea Party crowd. Louisville resident Jim Coyle MC'd the event. He admits he doesn't agree with McConnell on much but will back him, anyway.
JIM COYLE: We have put out invitations to Senator McConnell before. And he hasn't responded - and he hasn't replied. But he did decide to come work with us on this one, so I'll take him at his word. And we'll work on Obamacare, one step at a time.
BAILEY: Tea Party activists who remain opposed to McConnell cite his inability to block the health-care law. Others highlight his votes backing the bank bailout, the Patriot Act; as well as bringing home hundreds of millions of dollars of federal spending. Jasmine Farrier teaches political science at the University of Louisville. She says that's been McConnell's chief argument for re-election, for decades.
JASMINE FERRIER: At his last re-election, he touted his experience. And he implied that no matter what happened for the White House race, he was going to be the most important Republican in the U.S. Congress. In other words, McConnell's theme in 2008 - his last re-election - was that being powerful serves the interests of the citizens of the commonwealth.
BAILEY: It's those years of experience that make some Tea Party advocates wary. For activists like Frank Harris, he believes McConnell needs a primary challenger.
HARRIS: They'll have to have some money. You know, Mitch has $6 million. I think we could beat Mitch with $2 million.
BAILEY: But Mitch McConnell's re-election is in 2014. There's a bigger, more important presidential election this November that ultimately, will help shape that race.
For NPR News, I'm Phillip Bailey in Louisville. Transcript provided by NPR, Copyright NPR.


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Daucus carota
Cupar F1 Carrot
Days to Maturity: 95 days
Out of stock
Get notified when this product is back in stock
notify meHigh yielding, vigorous roots with disease resistant foliage.
Tapered deep orange roots with broad shoulders and very little greening. Maintains its attractive, uniform appearance and sweet flavor improves in storage; ideal for CSA growers looking for a reliable and long-storing carrot for bunching or season extension. From our partners at Bejo Seeds.
- Storage
- 8" Chantenay-type
- Hybrid
Disease Resistance Details
Intermediate Resistance: Alternaria Leaf Blight, Black Rot, Cercospora Leaf Blight, Cavity Spot
11,000-37,500 seeds/oz (24,250 avg), 175-500M seeds/lb (288M avg) M=1,000
Seeding Rate
- Early bunching carrot plant approximately 45 seeds/ft,
- Full sized carrots plant approximately 30 seeds/ft, and for
- Storage varieties plant 15 seeds/ft.
- Early small bunching – 45M seeds/1000'(~ 1.9 oz), 1.4MM seeds/acre,(~ 5 lb), using ~45 seeds/ft, 18" row spacing;
- Full size – 30M seeds/1000',(~ 1.3 oz), 1MM seeds/acre,(~ 3.3 lb), using ~30 seeds/ft, 18" row spacing;
- Storage – 15M seeds/1000', (0.65 oz), 500M seeds/acre,(~ 1.7 lb), using ~15 seeds/ft, 18" row spacing. M=1,000, MM=1,000,000.
Cultural Info
Carrots are often classified by their root shape:
- Nantes – Blunt tips; straight, cylindrical roots 5 to 7 inches long; sweeter than most other types; good raw eating. Prefers loose soil.
- Chantenay – Shorter than other types, stocky, taper to a rounded tip; rich, sweet flavor and good storage potential. Coarser texture than others.
- Imperator – Long, tapered roots with stocky shoulders and strong tops; slightly fibrous texture. Stores well.Most common type found in groceries. Prefers deep, sandy soil.
- Danvers – Shorter than Imperator varieties, thick-rooted cylindrical shape, widely used in processing, good for juicing. Stores well. Performs well in heavy, clayey soil.
Soil Nutrients and Requirements
Do best in fertile sandy loam, but will perform well under most conditions if appropriate varieties are chosen. For compact soils choose tapered carrots that can wedge their way into soils like Chantenays or Danvers types. Optimal soil temperature for germination is 55-75°F.
Best quality arises from raised beds, free of stones and debris. Imperator types should only be grown on raised beds that have 10-12" tilled zones.
Seeding Depth
Plant Spacing
Thin to 1-2" depending on desired size
Row Spacing
When to Sow
Direct seed as soon as soil can be worked in the spring through mid-summer.
Other Considerations
Weeding shortly after germination allows slow-growing carrots to get a head start against fast-growing weeds.
Harvest when carrots have appropriate coloring and flavor has developed. Carrots hold well in the field for up to 3 weeks in the summer and longer in cool conditions. Some varieties, like Napoli, may be over wintered outdoors or in the high tunnel for an early spring harvest. For storage carrots dig roots after frost but before ground freezes.
Store topped carrots in near freezing temperatures with high humidity. Unwashed carrots store just as well as washed but may stain during storage.
Pest Info
Carrot Weevil and carrot rust fly are common pests. Floating row cover can be an effective control for the Carrot Weevil and Carrot Rust Fly. Other tips include delay sowing seeds until June to avoid the first wave of flies, as well as sowing carrots seeds thinly, as the carrot rust flies are attracted to the smell of bruised carrot foliage.
Disease Info
Fungal leaf blights caused by either Alternaria dauci or Cercospora carotae can cause severe defoliation and greatly reduce yields. White mold (Sclerotinia sclerotiorum) manifests as a cottony white mycelium around roots and lower plant parts, usually late in the season. See Cornell University's Vegetable MD Online for more information.


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As they banged away on a stack of overturned buckets in the sweltering heat of a Saturday afternoon, Brandon Miller and Christian Simmons took shelter under the shadow of the Torpedo Factory with a sign at their feet: Drumming for Tuition.
Jobless even after applying to more than 10 positions, they decided to give street performing a shot, making the 45-minute commute from Stafford to the waterfront every weekend to drum up money.
The young duo expects to earn $2,000 each by summers end, which will go toward their first year of college. Its a sum that has surprised their friends and drawn envy, Miller said. He plans to major in music for percussion and hopes the extra money will cover the cost of books and living expenses.
From the waterfront, up King Street, in alleyways and on corners, buskers, or street musicians, dot the Old Town scene. Beto Guzman, a Peruvian immigrant who speaks little English, makes a career out of letting his guitar and Andean flute a sampoa do all the talking.
Harry Miller, an unshaven, retired school bus driver, plucks his banjo a few blocks away. Sitting on a sack, he says people often mistake him for a homeless man.
Curtis Blues blows frantically on his harmonica while strumming a guitar and tapping a kick-drum with his foot.
Come on, baby, dont you think that pictures worth a dollar? he called out to a woman snapping a photo of the one-man blues band at work. Im in the asking business.
Busking is a trade first documented in ancient Greece where the government punished slanderous lyricists with death. Alexandria doesnt go to such extremes, but there are regulations: performers cannot amplify sound or block the normal flow of traffic, and must move if asked by a vendor.
They are light requirements compared to those overseas, according to Hubert Pynenburg, a Dutchman in town visiting relatives. He stops and drops change into a yawning guitar case at the citys marina.
[Back home] you have to get a permit and you have to be good. You have to perform in front of someone to prove you are good enough, he said.
The guitar case belonged to Kuku Adebola, a burly, bald and bearded Alexandria singer by way of Nigeria. The mellow tune to which he swayed matched his gentle demeanor, and that of his self-titled album, Soldier of Peace. While many musicians are just trying to make ends meet, Adebolas motivation adds diversity to what draws these performers out onto the street.
A lot of people come out here for the money. I love money but not as much as I love music I dont have a social life. This is my social life, he said, greeting familiar faces hes met from years of performing in the same spot.
Adebola plays an eclectic set strongly influenced by traditional African music. Playing to crowds is his way of testing out new ideas without having to deal with the music industry, which he likes to avoid.
Two recent graduates of Edison High School share Adebolas belief in putting the music before the money. David Chung and Trey Douglass move about the spot theyve staked out in front of Market Square their stage. For a year, they have harmonized their voices with an acoustic guitar and an electric ukulele to alternative originals and covers of classics for the busloads of tourists passing by.
Weve made maybe $90 for playing three or four hours, Chung said. But we just like to make people smile.


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If that's the mood you're in today, you might want to skip this entry. Not that I generally corner the market on Blog Bitchery, but this report is going to be obnoxiously sunny. Allow me to get it out of my system. Tune in tomorrow, and things will be back to normal.
On Saturday, Stephanie Pearl-McPhee (she is who is known as Yarn Harlot) made her first visit to Chicago. While I'm not one to get weak-kneed and slobbery over famous knitters in general (okay, Nancy Bush is an exception), I find Stephanie's work to be rock-solid and deeply funny, and I wear my Harlot Fan Club Secret Decoder Ring with pride.
She was scheduled to appear at Arcadia Knitting, which is one of my two favorite yarn shops in the city. (From my very first visit, they've never given me attitude. Quite the contrary. I recommend them to all knitters in Chicago, particularly men who are tired of second-class treatment.)
I stopped by early and, in addition to accidentally buying Gladys Thompson's Patterns for Jerseys, Guernseys and Arans and a skein of Lorna's Laces (oops), I also asked whether they had a photographer hired for the event. They didn't. I offered to be It. They accepted.
[Insert little shout of joy here.]
On the way back to the shop around 3 pm (with Harlot due to arrive at 4) I was delighted to step into the subway car and see somebody knitting a (really cute) sock. As a rule, I won't approach a knitter on the subway (or anywhere else) as it's best in the city to leave people alone if you have no compelling reason to bug them. But happily, as we sat on the Lawrence bus heading to the shop she introduced herself - it was Melissa, who you probably know better as The Stitchin' Seminarian.
The shop was already buzzing and I swung into action. Being the photographer at an event like this is marvelous for a shy person because you cannot sit in a dim corner and pretend you're invisible. I started photographing groups of knitters and asking where they'd come from. As expected Harlot's appearance had drawn in not only knitters from the suburbs, but also folks from Minnesota, Michigan, and Indiana.
My first big surprise was how many people recognized me from this blog and introduced themselves. I will not pretend it wasn't gratifying. When I started writing this thing, I did it as a way to motivate myself to keep projects moving and record daily minutiae. At Stitches, I met in person two people (one of them Jon) who read it, and that felt wonderful. On Saturday, at least 20 people had a kind comment to share, and I nearly hit the ceiling.
I was already floating around on a cloud when Harlot showed up. It's difficult to write about her and say anything new, as the 12,493 other bloggers who met her first have it pretty much covered. My summary:
- Yes, she really is that funny. By the time she wrapped up her Q & A and began signing books, I'd laughed so hard and so much that my face hurt.
- She has no pretense about her at all. She took Chicago public transit to the shop, for heaven's sake. I know people who live here who wouldn't have done that.
- She has the patience of a saint. There had to be 80-100 people who lined up for autographs. I was standing there for much of the time taking photographs, and she gave every person her undivided attention.
Here's Emily, who wouldn't you know turns out to be the sister of Tres and a heck of a fun person?
Harlot with Melody, who has one of the most infectious laughs you've ever heard:
And this is Melissa (my fellow public transit rider), who (how meta is this) having her picture taken for her own blog.
And this is Jen (also seen above taking Melissa's picture), the dear woman who designed the bunny hat, and was very nice to me even though I made my version in acrylic.
If the day had ended with the signing, I would have gone home to C bubbling with stuff to tell him. But it did not end there.
Because as things were wrapping up, Bonne Marie (my dear, you are stunning, how did you manage to avoid getting into any of my photographs? hmmm?) asked me if I would like to join Stephanie, the owners of Arcadia, and a few other people for dinner.
Oh, gee. Let me think about that for a little while.
It was heady company for a guy who only got down to knitting in earnest in January. But everybody else was drinking, so I may have given the impression that I held up my end of the conversation.
Before you start thinking it was all very serious, I should also mention that after dinner Stephanie took off her shoes and I took off my boots and we stood back-to-back to see which of us is the shorter person. (She is. But not by much. And I would kill for her waistline.)
In the absolute final picture of the day, proof I didn't make all this up just to piss you off.
Stephanie's the one in the middle. The pretty lady in black is Kathy, one of the owners of Arcadia. I'm the one with no hair and the Cinderella-at-the-Friggin-Ball grin on my face.
(Dear God: Remember that awful eighth-grade Halloween dance when I was 13 and had acne and my haircut sucked and none of the girls would dance with me and I spent most of the evening stuck in the corner listening to a classmate I didn't even like talk about his Star Wars action figures, and then went home, realized my zipper had been open the whole time and cried myself to sleep? Well, you finally made up for it. Thank you.)
*Late addition. I can't believe I forgot to give shout-outs to two people. Marcy, who brought you the Lil' Devil baby pants in from the Stitch 'n' Bitch series; and Stephanie's publicist, Sarah, who also braved the Chicago El without losing her hair and who remembered the little review of the first Harlot book that I wrote way back when. Saturday was a gathering of right-on women. I was fortunate to be there.


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Have you ever wanted to try making your own flavours of pop or soda? Armed with a fruity simple syrup and some club soda you can mix one up in no time! That was exactly my plan for the rhubarb syrup and I was pulling it out of the fridge again just as soon as it had fully chilled. I have to say, as I sit here enjoying a glass of cool and refreshing rhubarb soda, that the rhubarb flavour along the sweetness and tartness, makes an amazing soda and what a wonderful colour! Now I am thinking that a rhubarb mojito with the addition of lime and rum might be up next.
Rhubarb Soda
Making your own gourmet soda/pop at home is super easy and this rhubarb soda just screams spring with its amazing pink colour along with its sweet and tart rhubarb flavour.
- 1 part rhubarb syrup, chilled
- 3 parts club soda or sparkling water, chilled
- ice to taste
- Mix and enjoy.


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Jay Wilburn interviewed me on wide-ranging subjects on his Matters of Faith podcast.
Jay's blurb: The Matters of Faith Podcast with your host Jay Wilburn on Project Entertainment Network explores individual stories of faith and personal struggle. The show does not have an agenda, but seeks to detail the personal experiences of people within various faith communities and people with experiences outside those communities – within organized religion and with spiritual views outside of those traditions. Every person has a story. It may not be your story, but their experiences may help you, may lift you up, or may inspire you as you live out your own story. Listening to the stories of others helps us all to understand each other better as we live out our lives in the world we share. We are all trying to figure out life. This show is meant to help us discuss topics about our journey through life that do not get discussed openly, honestly, and positively often enough.
I enjoyed it and recommend his show to others, both listening and being interviewed. He's talented, disarming, and entertaining. Nice combo when you can get it.
Thanks, Jay!


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Just don't get your cutie-patootie any of these:
Sure, it looks like an internal organ: just not the right one.
These could lead to a lot of fun "what's that supposed to mean?" conversations:
Here's a great one to give your SO in mixed company:
I don't know about you guys, but when I refer to myself in the third person in conversations with John (which is especially fun at parties), I usually prefer the designations "baby" and "your lover".
"Baby, your lover would like you to take the trash out."
"Baby, your lover is going to the store."
"Baby, your lover gets the not-so-subtle hint from your Valentine's present..."
"...but your lover has a headache." (cue "Broken Arrow" by Rod Stewart)
Now, these cake/cookie things may suffer from the whole bum-crack affliction:
...but they still look way more appetizing than these:
Gabrielle H., Maya C., Anne M., Kandace H., Michael H., & Ben O., John's lover thanks you.


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When calling mention you found us on "ComputerMend"
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We have affordable, rapid desktop PC, laptop, tablet and Apple Mac repair services near you.
With ComputerMend repair centres available across the whole of the UK, our locally-based teams can be trusted to either repair (or buy back) your computer at a suitable price. Contact a local technician for rapid, cost-effective desktop PC, laptop, tablet or Mac repairs.
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3 Killed, 4 Injured in Shooting at Spa in Milwaukee Suburb
Three people are dead and four others injured today after a mass shooting at a spa in Brookfield, Wis., a suburb of Milwaukee. The man police suspect in the shooting has also been found dead, according to a county dispatcher in Wisconsin.
According to police, a lone gunman broke into the Azana Spa this morning at 11 a.m. local time and opened fire. Police told the Associated Press they also found an undetonated explosive device inside the spa building.
Police identified the suspected shooter as Radcliffe Franklin Haughton, 45, whose black 2003 Mazda was found by authorities earlier this afternoon. Haughton's father told CBS News earlier today that Haughton's wife, Zina, is an employee at the spa.
Christine Bannister, a dispatch supervisor for Waukesha County communications center, said Haughton was found dead after 5 p.m. (ET).
The FBI and Bureau of Alcohol, Tobacco, and Firearms are also investigating the shooting. The spa building remains surrounded by authorities this afternoon, according to witnesses.
The AP reported that a restraining order had been filed against Haughton by his wife earlier this month.
The four injured spa-goers are said to be in non-life-threatening condition this afternoon.
A separate shooting in the Milwaukee suburbs occurred on Aug. 8 at a Sikh Temple in Oak Creek, Wis. Oak Creek and Brookfield are separated by about 20 miles.


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Presented by John Ruskin to the Ruskin Drawing School (University of Oxford), 1875; transferred from the Ruskin Drawing School to the Ashmolean Museum, c.1949.
Taylor, Gerald, 'John Ruskin: A Catalogue of Drawings by John Ruskin in the Ashmolean Museum, Oxford', 7 fascicles, 1998, Oxford, Ashmolean Museum, no. 152
Ruskin, John, Catalogue of the Educational Series (London: Smith, Elder, 1871), cat. Educational no. 39
Ruskin, John, Catalogue of the Educational Series (London: Spottiswoode, 1874), cat. Educational no. 89
Ruskin, John, 'The Ruskin Art Collection at Oxford: Catalogues, Notes and Instructions', Edward T. Cook and Alexander Wedderburn, eds, The Works of John Ruskin: Library Edition, 39 (London: George Allen, 1903-1912), 21, cat. Educational no. 89