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Introduction

Lymphedema is a chronic, progressive condition characterized by the accumulation of protein‑rich interstitial fluid due to impaired lymphatic drainage. It most commonly affects the upper limbs following breast cancer surgery with axillary lymph node dissection or radiation therapy. The condition causes progressive swelling, discomfort, reduced range of motion, recurrent cellulitis, and significant psychological distress.

Standard treatments include complex decongestive therapy (CDT)—manual lymphatic drainage, compression bandaging, exercise, and skin care. However, many patients experience incomplete resolution or struggle with lifelong maintenance. This article presents a clinical case in which hirudotherapy (medical leech therapy) was used as an adjunctive treatment for refractory post‑mastectomy lymphedema, resulting in sustained limb volume reduction and symptom improvement.

Clinical Case Presentation

A 54‑year‑old female presented with a three‑year history of right upper extremity lymphedema following a modified radical mastectomy for breast cancer, which included axillary lymph node dissection and adjuvant radiation therapy. Her symptoms included progressive arm swelling, a heavy sensation, reduced grip strength, and recurrent episodes of cellulitis (two episodes in the past year). She had undergone complex decongestive therapy with moderate initial improvement, but the swelling recurred whenever she reduced compression garment use.

Physical examination revealed a visibly enlarged right arm compared to the left. Circumferential measurements at the mid‑forearm showed a 4.5 cm excess (30.5 cm vs. 26.0 cm). The skin exhibited mild pitting edema, hyperkeratosis, and early fibrotic changes (Stemmer’s sign positive). The patient reported that the lymphedema interfered with her daily activities, including dressing, cooking, and computer work.

Treatment Approach

After informed consent and discussion of risks and benefits, the patient opted to trial adjunctive hirudotherapy alongside her ongoing self‑management (compression garment use and elevation). The treatment protocol involved application of four to six medical‑grade leeches (Hirudo verbana) to the affected arm, focusing on areas of maximal swelling and fibrotic change—specifically the medial upper arm, the cubital fossa, and the dorsal forearm. The patient received six sessions at two‑week intervals.

Standard infection control measures were employed, including skin cleansing, prophylactic oral antibiotics (cephalexin 500 mg twice daily for three days following each session), and post‑application wound care. The patient was instructed to continue compression garment use and daily elevation.

Clinical Outcome

The patient reported noticeable improvement after the second session, with reduced heaviness and improved mobility. By the completion of the sixth session, the following outcomes were documented:

• Limb volume reduction: Mid‑forearm circumference decreased from 30.5 cm to 27.8 cm (2.7 cm reduction), representing approximately 60% of the excess volume

• Symptom relief: Heavy sensation reduced from 7/10 to 2/10; no episodes of cellulitis occurred during the three‑month follow‑up period

• Functional improvement: Patient regained full range of motion and reported being able to perform all daily activities without limitation

• Skin changes: Perceived softening of fibrotic areas and reduction in hyperkeratosis

Improvements were maintained at the three‑month follow‑up, with the patient reporting continued benefit despite occasional lapses in compression garment use. No infectious complications or significant bleeding occurred.

Detailed Mechanism of Action

The therapeutic effects observed in this case can be attributed to the synergistic action of bioactive substances in medicinal leech saliva, which directly address the key pathological features of lymphedema:

Mechanical Decongestion

• Direct fluid removal: Each leech removes approximately 5–15 mL of blood and interstitial fluid during feeding, providing immediate reduction in limb volume and tissue pressure

• Prolonged drainage: Anticoagulants in leech saliva maintain capillary oozing for several hours post‑application, extending the decongestive effect

Anti‑inflammatory Effects

• Eglin and anti‑stasin: These protease inhibitors neutralize inflammatory mediators (elastase, cathepsin G) that perpetuate chronic inflammation and fibrosis in lymphedematous tissues

• Reduction in recurrent infections: By improving local immunity and reducing edema, leech therapy may decrease the frequency of cellulitis episodes

Improving Tissue Permeability and Anti‑fibrosis

• Hyaluronidase and collagenase: These enzymes break down excess extracellular matrix components, softening fibrotic tissue and improving interstitial fluid mobility

• Enhanced lymphatic drainage: By reducing tissue viscosity and pressure, leech therapy may facilitate residual lymphatic function

Promoting Local Microcirculation

• Hirudin and vasodilators: Increased blood flow velocity and capillary perfusion may support tissue oxygenation and waste removal, counteracting the stagnant environment of lymphedema

These combined actions address the three main components of chronic lymphedema: fluid overload, inflammation, and fibrosis.

Safety Considerations and Limitations

Hirudotherapy in patients with post‑cancer lymphedema requires specific precautions:

• Infection risk: Lymphedematous limbs have impaired immune surveillance; prophylactic antibiotics are strongly recommended

• Bleeding: Patients on anticoagulants or with thrombocytopenia require careful assessment

• Skin integrity: Fibrotic, fragile skin may be prone to delayed healing; meticulous wound care is essential

• Not a substitute for comprehensive therapy: Hirudotherapy should complement, not replace, standard complex decongestive therapy

• Contraindications: Active infection, malignancy (in the affected limb), or severe arterial insufficiency

In this case, the patient’s stable post‑cancer status, absence of coagulopathy, and adherence to infection control contributed to the favorable outcome.

Discussion

This case illustrates that hirudotherapy, when integrated into a comprehensive lymphedema management program, can provide meaningful volume reduction and symptom relief for patients with refractory post‑mastectomy lymphedema. The multi‑targeted mechanisms—mechanical decongestion, anti‑inflammation, anti‑fibrosis, and microcirculatory enhancement—directly address the pathological triad of lymphedema: fluid stasis, chronic inflammation, and tissue fibrosis.

While randomized controlled trials are lacking, this case adds to the historical and emerging clinical observations supporting hirudotherapy in lymphedema. Future research should focus on standardized protocols, optimal treatment intervals, and long‑term safety.

Conclusion

Hirudotherapy may serve as a valuable adjunctive option for carefully selected patients with chronic post‑surgical lymphedema who have incomplete responses to standard complex decongestive therapy. When performed under medical supervision with appropriate infection control and patient selection, it can contribute to limb volume reduction, improved function, and reduced risk of infectious complications. Self‑application outside a clinical setting is not appropriate and carries significant risks.

Keywords: hirudotherapy, lymphedema, post‑mastectomy lymphedema, complex decongestive therapy, anti‑fibrosis, microcirculation

Reference (for professional context):
This case report is informed by the established mechanisms of hirudotherapy and the clinical literature on adjunctive treatments for lymphedema. For broader clinical context, see: Rockson SG. Lymphedema after breast cancer treatment. N Engl J Med. 2018.