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ICD-9-CM Codes

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  • 457.0 Postmastectomy lymphedema syndrome

  • 457.1 Other lymphedema

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ICD-10-CM Codes

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  • I89.0 Lymphedema, not elsewhere classified

  • I97.2 Postmastectomy lymphedema syndrome

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Preferred Practice Patterns

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Key Features

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Description

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  • Occurs when lymph system is damaged or blocked and buildup of lymph fluid occurs in soft tissues, causing swelling

  • Obstruction of lymphatic vessels or lymph nodes

  • Increased water and protein in the interstitial space3

  • Lymphedema can occur as a result of surgery, chemotherapy, or radiation causing interruption of the lymphatic system

  • Post-mastectomy, axillary, or sentinel lymph node dissection affects upper extremities

  • Considered secondary lymphedema

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Essentials of Diagnosis

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  • Detailed medical history (e.g., surgical procedures, chemotherapy, radiation)

  • Presence of non-pitting edema

  • MRI or CT

  • Circumferential upper-extremity measurement

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General Considerations

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  • Commonly occurs following breast cancer surgery

  • Axillary or sentinel node dissections and radiation therapy increase risk of occurrence

  • Classification for lymphedema 3

    • Mild: less than 3 cm difference between the affected and unaffected limb3

    • Moderate: Between 3 and 5 cm difference between the unaffected and affected limb3

    • Severe: 5+ cm difference between the unaffected and affected limb

  • Graded 1 (least severe) to 4 (most severe) 3

  • Pitting only present in stages 1 and 23

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Demographics

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  • Parallels those of breast cancer

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Clinical Findings

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Signs and Symptoms

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  • Pitting/non-pitting lymphedema of extremity

    • Pitting only present in stages 1 and 23

  • Skin feeling tight or shiny

  • Decreased flexibility/ROM in the hand or wrist

  • Difficulty fitting into clothing in one specific area

  • Ring, wristwatch, bracelet tightness

  • Usually unilateral

  • Asymmetrical appearance

  • Localized presentation

  • Warmth, tenderness

  • Redness

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Functional Implications

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  • Stiffness, limited ROM

  • Sensory disturbances

  • Decreased resistance to infection

  • Susceptibility to skin breakdown

  • Decreased self-care, ADLs

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Possible Contributing Causes

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  • Lymphadenectomy

  • Limb constriction

  • Overuse

  • Obesity

  • Radiation fibrosis

  • Delayed wound healing

  • Scarring of left or right subclavian lymphatic ducts

  • Breast cancer surgery

  • Diagnostic dissection

  • Mastectomy

  • Radiation

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Differential Diagnosis

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  • Edema 3

  • Cellulitis

  • Dermatologic manifestations of cardiac or renal disease

  • Erysipelas

  • Filariasis

  • Lymphangioma

  • Thrombophlebitis

  • Venous insufficiency

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Means of Confirmation or Diagnosis

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Imaging

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  • Indirect lymphangiography

  • Direct lymphography

  • Fluorescent microlymphography

  • MRI

  • Lymphoscintigram

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Diagnostic Procedures

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  • Doppler study

  • Surgical history (axillary lymph node dissection [ALND], modified radical mastectomy)

  • Visual inspection

  • Circumferential measurements

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Findings and Interpretation

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  • Common clinical findings include

    • Increased circumferential limb girth

    • Postural changes

    • Neuromuscular deficits

    • Integumentary complications (atrophic skin ...

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