Lymphoedema Evidence Library
Lymphoedema Evidence Library › Worked cases

Worked clinical cases

Eight cases for teaching and self-assessment, written for therapists, nurses and doctors. Read the case, answer the questions, then open the answers. Each answer gives the certainty of the evidence and links to the appraised sources.

  1. Case 1: Arm swelling eight months after breast cancer surgery
  2. Case 2: Before axillary dissection
  3. Case 3: Leg swelling after treatment for cervical cancer
  4. Case 4: Recurrent cellulitis
  5. Case 5: Painful legs in a young woman
  6. Case 6: Bilateral leg swelling, obesity and breathlessness
  7. Case 7: Swelling with venous disease
  8. Case 8: Leg swelling with purple nodules

Case 1: Arm swelling eight months after breast cancer surgery

A 52-year-old teacher had a mastectomy with axillary dissection (14 nodes) and regional nodal radiotherapy 8 months ago. She notices her ring is tight and her arm feels heavy by evening. Tape measurement shows a 9% excess volume in the right arm. She has been told never to have blood taken from that arm, to stop gardening and to avoid flying, and asks whether she needs daily lymphatic massage.

Questions

  1. How would you confirm and grade the lymphoedema?
  2. What is the first-line treatment, and how certain is the evidence?
  3. Does she need MLD?
  4. What would you tell her about the arm precautions?
Show answers
  1. Compare both arms with the same method (tape and frustum formula, or perometer) and report excess volume; 9% is mild (5–20%). Record pitting, Stemmer sign and symptoms, and a QoL tool such as Lymph-ICF-UL. Diagnosis and measurement
  2. Compression: a class 1–2 sleeve, with intensive bandaging only if the sleeve does not control it. In early BCRL, garments alone were nearly as effective as intensive CDT (low), and a sleeve at diagnosis of mild BCRL cut 6-month progression from 57% to 16% (low). Add progressive resistance training. Dayes 2013 · Blom 2022
  3. No. In chronic BCRL, MLD added nothing to compression, exercise and skin care against a sham massage (moderate). It may be used for comfort or for breast and trunk swelling. De Vrieze T 2022
  4. Blood draws, injections, blood pressure readings, heat and air travel on the affected side were mostly not associated with onset (observational, low). She can garden with gloves, fly with her sleeve on, and should treat cuts and infection promptly. Hunley 2024

Case 2: Before axillary dissection

A 46-year-old woman with node-positive breast cancer will have an axillary dissection followed by nodal radiotherapy. Her BMI is 32. She asks what she can do to avoid arm swelling.

Questions

  1. What is her risk, and what increases it?
  2. What should happen before surgery?
  3. Which preventive measures have trial support?
Show answers
  1. High: axillary dissection, regional nodal radiotherapy and BMI above 30 are the main risk factors (moderate); chronic BCRL at 3 years is about 26% after ALND v 4% after sentinel biopsy. Koelmeyer 2022 · Boyages 2023
  2. A baseline measurement of both arms, so that later changes can be detected; most early changes would otherwise fall within normal ranges (low). Chen 2025
  3. A compression sleeve for the first year (moderate for first-year swelling, low for lasting benefit); progressive resistance exercise (RR 0.68, moderate); weight reduction; and, where available, immediate lymphatic reconstruction at the time of dissection (9.5% v 32%, low). Paramanandam 2022 · Chen 2026 · Coriddi 2023

Case 3: Leg swelling after treatment for cervical cancer

A 58-year-old woman treated with chemoradiotherapy for cervical cancer two years ago presents with gradually increasing swelling of the left leg. She is HIV positive and on antiretroviral therapy.

Questions

  1. What must be excluded before calling this lymphoedema?
  2. What checks are needed before compression?
  3. How would you manage it?
Show answers
  1. Recurrent pelvic tumour (abrupt onset, pain, proximal swelling, collateral veins are red flags), deep vein thrombosis, and venous outflow obstruction from pelvic disease or radiotherapy. Duplex scanning, and imaging of the pelvis where recurrence is possible. Forner-Cordero 2022 · Lower-limb and primary lymphoedema
  2. Ankle–brachial pressure index or toe pressures: below 0.5 no compression and refer to a vascular surgeon; 0.5–0.8 reduced compression under supervision. About a quarter of lymphoedematous legs have a toe–brachial index below 0.7. Trihan 2024
  3. Skin care, bandaging or wraps to reduce, then a garment; exercise (cycling is safe). In South Africa about 30% of women have a measurable leg-volume difference 1–2 years after pelvic radiotherapy, mostly mild (very low). Khutjwe 2020

Case 4: Recurrent cellulitis

A 34-year-old man with primary lymphoedema of the right leg since his teens has had four admissions for cellulitis in two years. He has tinea between his toes and wears his stocking only occasionally. He has read about lymphatic surgery online.

Questions

  1. What reduces recurrence most reliably?
  2. What else must be addressed?
  3. Should he be referred for surgery?
Show answers
  1. Penicillin V prophylaxis, 250 mg twice daily for 12 months, halved recurrence while taken (22% v 37%; high certainty for recurrent cellulitis, moderate in lymphoedema); the effect ends when it is stopped, and leg lymphoedema predicts a poorer response. Thomas 2013
  2. Treat the tinea, daily skin care, and consistent compression; reducing the oedema reduces attacks. Wounds, skin and cellulitis
  3. Only after a period of compliant conservative care. LVA reduced cellulitis in before–after series, and the one randomised trial is very low certainty; in primary lymphoedema, surgery near the groin can damage functioning lymphatics. Mihara 2024 · Gaxiola-García 2024

Case 5: Painful legs in a young woman

A 29-year-old woman has painful, symmetrical enlargement of both legs from the hips to the ankles, sparing the feet, with easy bruising. It began at puberty and worsened after pregnancy. Stemmer sign is negative and there is no pitting. She has lost weight through dieting, but her legs have not changed.

Questions

  1. What is the likely diagnosis?
  2. What conservative treatment would you offer?
  3. What does the evidence say about liposuction?
Show answers
  1. Lipoedema: symmetrical painful fat sparing the feet, bruising, onset at hormonal change, negative Stemmer sign. Pitting or a positive Stemmer sign would suggest added lymphoedema. Lipoedema
  2. Compression for symptoms, movement and exercise, weight management for any co-existing obesity, and psychological support. Explain that diet does not remove lipoedema fat. Kruppa 2020
  3. The LIPLEG trial found pain fell by ≥2 points in 68% after liposuction v 8% with CDT at 12 months, with more adverse events (low certainty, unblinded); NICE advises use within research. Bertsch 2025

Case 6: Bilateral leg swelling, obesity and breathlessness

A 67-year-old man with a BMI of 52 has swollen, weeping legs and gets breathless walking to the bathroom. He was told he is "too big" for lymphoedema treatment.

Questions

  1. What should be checked before compression?
  2. Can he be compressed?
  3. What else should be offered?
Show answers
  1. Heart failure (BNP, echocardiography), arterial status, and drugs that cause oedema. Todd 2011
  2. Yes, once heart failure is compensated: start at about 20 mmHg on both legs and step up one leg at a time over about 2 weeks. Wounds 2023
  3. Treatment should not be withheld because of BMI; adjustable wraps help with fit and donning; refer for weight management or bariatric assessment. Above a BMI of about 50, obesity alone can cause lymphatic failure. Fletcher 2025 · Greene 2015

Case 7: Swelling with venous disease

A 71-year-old woman has a swollen left leg with varicose veins, skin pigmentation and a healed ulcer. Duplex scanning shows great saphenous reflux and a previous iliofemoral thrombosis.

Questions

  1. Is this venous oedema or lymphoedema?
  2. What role does venous intervention have?
  3. What does compression need to achieve?
Show answers
  1. Both are likely (phlebolymphoedema): severe venous disease damages dermal lymphatics, and venous failure underlies 20–30% of limb lymphoedema. A normal lymphoscintigram does not exclude a lymphatic component. Bollinger 1982 · Neligan 2016
  2. Treat reflux, and look for iliac outflow obstruction (intravascular ultrasound finds stenoses missed by venography); stenting can relieve the oedema. Varicose vein surgery alone rarely resolves established lymphoedema. Földi 2000
  3. Inelastic, stiff compression (static stiffness index ≥10) after checking arterial status. Partsch 2007

Case 8: Leg swelling with purple nodules

A 38-year-old man in Durban, recently diagnosed with HIV, has a swollen left leg with purple nodules on the foot and shin. A clinic has been treating "cellulitis" for a month.

Questions

  1. What is the likely diagnosis, and what test is needed?
  2. Does compression help?
  3. What other malignancy should be remembered in long-standing lymphoedema?
Show answers
  1. Kaposi sarcoma lymphoedema; biopsy the nodules and refer to oncology for antiretroviral and systemic therapy. Gangrene with popliteal thrombosis has been reported in a Durban patient. Ebrahim 2009
  2. Compression is reasonable for comfort once the diagnosis is clear, but locally made zinc-paste bandages added to chemotherapy did not improve the swelling in a Kenyan pilot (very low). Chang 2022
  3. Stewart–Treves angiosarcoma: biopsy new purple papules or atypical "cellulitis" in long-standing lymphoedema. da Costa Vieira RA 2019