Ask Dr. Peter Mortimer

Areas of Expertise:
  • Breast cancer related lymphoedema
  • Genetic basis of primary lymphoedema
  • Lymphatic spread of cancer eg melanoma

Professor Peter Mortimer trained in Dermatology in Sheffield and Oxford. He was appointed 'Physician to the Skin Department' at St George's and consultant skin physician to the Royal Marsden Hospital since 1986 and has been Professor of Dermatological Medicine to the University of London since 2000. Interest in lymphatics began in Oxford where he undertook his thesis on 'the measurement of skin lymph flow'. Current research is focused on breast cancer related lymphoedema, the genetic basis of primary lymphoedema and lipoedema as well as melanoma spread by lymphatics. He has over 240 publications cited on PubMed. He has been Chief Investigator on research programme grants from The Wellcome Trust, British Heart Foundation and Cancer Research UK. His clinical practice deals almost entirely with chronic oedema, lymphoedema, lymphatic malformations, lymph-related disorders and lipoedema. He is a founder of both the Lymphoedema Support Network and British Lymphology Society and appointed the first Clinical Training Fellow in Lymphovascular Medicine in the UK.


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  1. Treatment Advice
    Question (Gaynor , ):
    • Hi. I am asking the question on behalf of a family member. As a result of being diagnosed with cancer of the uterus approx 14 years ago they underwent a full hysterectomy, they subsequently had chemotherapy and radiotherapy. The lymph nodes were removed from the left leg area. Over the past 4 years lymphodema has become an increasing problem down the left leg. A large lump has grown on the inner thigh and treatment is having very little impact. They are under the care of the Christie Hospital but due to this condition being extremely under funded there are very few options. They currently wear a compression stocking every day which is bearable however trying to obtain a second stocking has become impossible as the nurses never get the measurements right. Very frustrating!! They have visited a clinic in London to investigate the possiblity of lymph node transplant but apparently this is not an option as it has been stated there is a lot of scar tissue?? Whatever that means. I would like to know if there is anywhere in the UK that specialised in lymphodema and what does your research suggest for long term treatment? Many Thanks

    Answer:
    • May 2017

      As per Dr. Mortimer-

      The large lump that has grown on the inner thigh is presumably a large lymphoedema fold although without imaging such as ultrasound examination one cannot be sure. Treating lymphoedema folds is difficult and needs very skilled bandaging. It is important to ensure there is no (over)weight issues as that makes these folds more likely to develop, and more difficult to treat. If all else fails one might have to consider liposuction but everything depends on the circumstances of this patient. Reconstructive lymphatic surgery is unlikely to be an option.
      The biggest lymphoedema centre in the UK is at St George’s Hospital in London. The lymphoedema Support Network in the UK (http://www.lymphoedema.org/lsn) should be contacted for advice”

  2. Lymphedema with cellulitis
    Question (Carmen, ):
    • Since uterine cancer diagnosis and treatment 5 years ago, I have had recurring infections. For the past two years I have experienced rapid onset of cellulitis and lymphedema. I am concerned because the cellulitis comes on so quickly as does the swelling. My doctor has me on daily antibiotic but I do not feel any better. Do you have any suggestions? I am frustrated. Thank you.

    Answer:
    • Apr 2016

      As per Dr. Mortimer-

      “Recurrent infections are a common occurrence with lymphoedema.  It is also very common for the effects of the infection to develop rapidly.  Patients can feel fine one minute and within 15 minutes feel ill with chills and flu-like symptoms.  This is because of the effect lymphoedema has on immune cell trafficking and function within the swollen region.  Research has shown that it is not helpful to give antibiotics only when infections occur.  The infections need to be prevented and the recommendation is for prophylactic penicillin.  Advice for patients on this subject can be found at
      http://www.lymphoedema.org/Menu3/Cellulitis Consensus.pdf

  3. Keratosis
    Question (Ken, ):
    • My question regards the skin lesions that appear to be a hyperkeratosis that are commonly seen particularly in cases of lower extremity lymphedema. Are these keratoses similar histologically to actinic keratoses which may develop from overexposure to sunlight? Do they simply represent a hyperplasia of the keratinocytes or a metaplasia of the keratinocytes in which their cell structure undergo change.

    Answer:
    • Sep 2015

      The hyperkeratosis seen with lymphoedema reflects an increase in the horny layer (keratin) on the surface of the skin.  It is related to the increased thickening of the skin which is often called elephantiasis because it represents elephant skin.  The hyperkeratosis is different from a keratosis which is a benign tumour on the surface of the skin usually resulting from sun damage. 

      Therefore the hyperkeratosis seen with lymphoedema is simply an excessive production of mature keratin from normal keratinocytes.  A keratosis is related to a hyperplasia or dysplasia of the underlying keratinocytes which are the cells responsible for producing the keratin.

  4. Air travel
    Question (Dorthy, ):
    • Well I am planning a trip and it takes 24hours to get there. I had the lymph node taken out of one arm pit and bc and I have a compression sleeve and I can wear it just incase but what else should I do. Is there a big risk of my arm swelling. Is there something I should worry about in Thailand, should I take shots.

    Answer:
    • Jul 2015

      Patients with existing lymphoedema do find that it temporarily deteriorates during a flight.  However it should return to its former condition within 24 to 48 hours of arrival providing there are no complications eg infection.  For patients with existing lymphoedema the recommendations are to wear the compression garment, perform regular exercises during the flight, elevate the swollen area as much as is feasible and ensure no dehydration.  The problem with air travel is inactivity and the cabin pressure.  On arrival it is worth undertaking exercise to stimulate lymph drainage.

  5. psorisis & lymphodema
    Question (Anna, ):
    • Having psoriasis flare-ups on my elbow of my bad arm is challenging. The meds for it don't work for long. What advise do you have to keep the flaking & rawness at bay?

    Answer:
    • Mar 2015

      In general lymphoedema does not affect psoriasis and therefore one would treat the psoriasis in the normal way with ultraviolet light therapy as creams are not that effective. Psoriasis could be,in theory, worse on a limb affected by lymphedema because of the alteration to immune cell trafficking from the compromised lymph drainage. Therefore it makes sense to treat the swelling as well as one can and ensure no infection (as infection can exacerbate psoriasis)

  6. Lymphedema with Angioedema
    Question (Joseph, ):
    • 20 years ago was the first time the back of my head swelled up. It would get really swollen, hot and skin was very tight. It would spread all over the back and into the temple region between 4-12 seconds. After a week or two, it would drain down my neck and out my shoulders. This continued a couple times a year, every single year. Last June, the swelling got worse and reached my face, swelling one eye shut. It no longer drains, as the back of my head and both sides of my neck down by the collarbone have big squishy lumps. In August and continuing, both my armpits and down both sides of my body have swollen up and have stayed that way. My arms, fingers, legs, knees, ankles and toes also are a bit swollen. From what I was told by a doctor was that I have Primary Lymphedema with Angioedema. However, other doctors aren't sure because I don't fit in the "norm" of Lymphedema patients since it's affecting my entire body, literally from head to toe. I've seen so many doctors (ENT, Immunologist, Neurologist, Vascular Surgeon, Internalist) and have every single one of them stumped. Do you have any idea or opinion or thought as to what these conditions are that are happening to me? For some reason, the doctors are not coming to any kind of conclusion to my situation. I look forward to hearing your thoughts. Much Thanks, Joe

    Answer:
    • Feb 2015

      I am not convinced from your history that you do have lymphoedema with angioedema.  Angioedema manifests with bouts of swelling which settle within minutes or over a few hours.  It is thought to be allergic but no cause is usually found.  It is certainly inflammatory and will respond to oral steroids.  There are reports in the literature of recurrent angioedema giving rise to lymphoedema.  However under those circumstances the lymphoedema swelling is persistent and usually affects sites such as the skin around the eyes, mouth or ears.  I would agree that your circumstances do not fit in with the norm either for angioedema or lymphoedema and therefore it is difficult through an online response to advise.  My suggestion would be to see a lymphoedema physician if possible.

  7. Surgery on a breast cancer treated arm
    Question (Elizabeth, ):
    • I am a left breast cancer survivor of 9 years. I had a lumpectomy and 3 sentinel nodes removed. I have also had a parathyroid removed ( benign) and have Hashimoto Thyroiditis. I want to undergo a trigger finger surgery on my left hand and am concerned about Lymphedema. The procedure involves a wound and a tourniquet on the arm/hand I have always been advised to protect from such things. Can you comment on the risk and any possible options to lessen the risk? Say if a tourniquet was somehow not used. Is the wound made and the tourniquet used the same level of risk? I don't want to trade a painful trigger finger for Lymphedema and I just don't know how to calculate the risk?

    Answer:
    • Jun 2014

      Thank you for this interesting question.  You are right in saying that guidelines recommend avoidance of needle puncture/surgery/tourniquets in/on the at-risk arm following breast cancer treatment.  The concern is that swelling could be precipitated.  Furthermore there is always the risk of infection (cellulitis) which could also precipitate long-term swelling.

      Therefore in an ideal world one would advise against trigger finger surgery but one has to do a risk/benefit analysis.  If there is no alternative to your trigger finger then you should undergo surgery.  However I would ask your surgeon if it can be done without tourniquet (assuming the tourniquet is around the upper arm or forearm).  It may also be worthwhile covering the period around the surgery with antibiotics although there is no evidence that this is necessary.

      I am afraid I don’t know the risk analysis of inducing lymphoedema but I would expect it to be very low with surgery alone and higher if the tourniquet is added.