Clinical evaluation of patients affected by secondary post-surgical upper limb lymph-oedema provides the research of malignancy signs that induce us to leave patients untreated and to contact the oncologist for further diagnostic investigation.

Secondary post-surgical upper limb lymph-oedema is a chronic, not easily controllable disease, with evolutionary progressive tendency, present in 15-20% of patients who have undergone axillary lymphadenectomy, with an increase of up to 30-35% after radiotherapy, which requires careful clinical-instrumental evaluation for proper staging and subsequent planning of personalised rehabilitative project.
Clinical evaluation consists of the analysis of the overall aspect of the patient and the execution of careful objective examination through which we can evaluate eventual presence of malignancy signs, with subsequent abandonment of the rehabilitative project and referral to the oncologist for specific clinical evaluation.
We consider malignancy signs (isolated or combined):

• skin lesions in the anterior thoracic wall without resolution tendency, or the presence of widespread skin ulcer;
• axillary neoformations;
• presence of visible or palpable nodes;
• fullness in the supraclavicular fossa and shortness of the  acromion-neck distance;
• pronounced and ingravescent proximal oedema, above all with other malignancy signs such as the appearance of collateral veins, expression of deep vein thrombosis or expansive process in the subfascial compartment, and associated neurological symptoms;
• changes in skin colour in the surgical area associated with local oedema or the appearance of cyanotic colour of the arm due to venous involvement (compression in deeper veins or presence of an abnormal mass occupying space). Furthermore, a red-blue haematoma-like skin colour in the lymph-oedematous area highlights the presence of angiosarcoma, a very malignant tumour which originates from endothelial cells of blood vessels, promoted by local immunodeficiency;
• carcinomatous lymphangitis due to the congestion of skin lymphatic vessels secondary to penetration of neoplastic cells in their lumen; though it apparently looks like lymphangitis (warm and red skin), it is different due to its typical general symptoms, and for a slow gradual outbreak of redness which progressively extends over the skin over a period of weeks;
• the fast development of ingravescent oedema, with prevalent tissular fluid component, associated with translucent skin, blisters, lymphorrhoea and ulcers are frequently evident. The oedema is subsequent to or accompanied by pain and neurological symptoms;
• the presence of neurological symptoms: the plexophaty due to compression or tumour infiltration of brachial plexus by adenopathies or axillary or supraclavicular neoplastic masses, which must be distinguished from radiation-induced plexophaty. Intense and oppressive pain, frequently onset in the shoulder with distal irradiation, is always evident. The pain is praecox and often previous to neurological symptoms remaining the only symptom for months;
• no progression or limited progress during correct intensive personalized rehabilitative therapy, in the presence of good patient compliance, is a possible sign of malignancy.

Obviously, in the case of malignancy signs, it is always necessary to send the patient to their own oncologist for further clinical evaluation; subsequent palliative treatment could possibly give the patient a better quality of life.

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