Refractory edema in advanced metastatic cancer is one of the more challenging clinical problems. Diuretic therapy tends not to be particularly effective.

Occasionally, there may be contributing factors that can be fully or partially addressed. There may be inferior or superior vena cava obstruction by clot (for which anticoagulation may be a consideration), or tumour (which might be helped with corticosteroids, radiation, chemotherapy). It is worth reviewing the medications to see if edema is a potential adverse medication effect. There are case reports of opioids causing peripheral edema, which improved with switching opioids, and gabapentin and pregabalin are known to cause edema.

Extensive intrabdominal and pelvic disease may impair venous and lymphatic return from the legs. Hypoproteinemia can result in edema due to fluid shifts into extravascular space.

General measures to reduce edema include:

• Elevation. This is not as helpful in lymphedema caused by tumour, but is often recommended nonetheless.
• Activity/exercise if possible.
• Compression garments. Involves physiotherapy or occupational therapy to assess for this possible intervention. Although not always well tolerated, these devices may be helpful.
• Manual lymph drainage through massage. Massage therapists and physiotherapists who specialize in lymphedema management may be able to help with this intervention.
  

Further care includes:

Meticulous and gentle skin care. This includes keeping the skin clean and moisturized in order to minimize the risk of skin-barrier breakdown and the risk of infections.
Assessment and care to ensure safety and mobility. For example, if lower limbs are heavy, transfers may be very difficult. If lower limbs are “weeping,” the person may be at risk of slipping on wet floors.

There are reports of using subcutaneous drainage for refractory lymphedema.[1,2] Subcutaneous drainage is assessed and considered on a case-by-case basis, and further research is required in this area.

References

1. Faily J, De Kock I, Mirhosseini M, Fainsinger R. The use of subcutaneous drainage for the management of lower extremity edema in cancer patients. J Palliat Care. 2007;23:185-187.

2. Jacobsen J, Blinderman CD. Subcutaneous lymphatic drainage (lymphcentesis) for palliation of severe refractory lymphedema in cancer patients. J Pain Symptom Manage. 2011;41(6):1094-1097.

Other references

CarePartners Palliative Care. Lower extremity lymphedema management toolkit. Author: April 2008.

Kerchner K, Fleischer A, Yosipovitch G. Lower extremity lymphedema. J Am Acad Dermatol. 2008;59(2):324-331.