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006: Demystifying the Lymphatic System and Lymphedema

Updated: Jun 22, 2021

with Special Guest - The Lymphedema Guru

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Episode Summary:

Our lymphatic system is a critical portion of the body's immune system and yet, sadly, it's barely covered in medical school. Tammey spoke with Joachim (Joe) Zuther who wrote the literal textbook on lymphedema. Joe, also known as the Lymphedema Guru, founded the Department of Lymphology at the School for Physical Therapy in Ulm, Germany in 1990. Having found his passion, he formed The Academy of Lymphatic Studies which provides Lymphedema Therapy Certification courses across the United States. His book, “The Textbook for Comprehensive Lymphedema Management” is now in its fourth edition and continues to be an invaluable resource to medical professionals. Joe and Tammey discuss the lymphatic system, lymphedema staging, risks from breast cancer treatment, risk reduction, and the gold standard of treatment, Complete Decongestive Therapy, or CDT.

“It's kind of a neglected system in the body even these days. Medical students only hear a couple of hours about lymphatic system through their studies, it's a shame.” -Joachim Zuther, Lymphedema Guru Click to tweet

Topics in this Episode:

  • Lymph – The Neglected System

  • Breast Cancer Surgical Interventions and the Lymphatic System

  • Lymphedema and Risk Avoidance

  • Talking with Health Professionals about Your Lymphedema Risk

  • Knowing your Treatment Options

  • Free Lymphedema Resources

Guest Contact Information and Social Links:

Contact Information and Social Links:


A special thank you to our sponsor, Riverdance Soapworks. Handcrafted products we personally use. Visit and let them know you heard about them from Tammey.


Tammey Grable-Woodford: Hello and welcome to your killer life. I am so excited today. I have an amazing guest with us who is going to be talking with us about really demystifying some of the, oh goodness, I would say overall mystery about the lymphatic system. Joe, you began your studies into lymphedema management in 1984 and you went on, you founded the department of lymphology at the school for physical therapy in Ulm Germany, and that was in 1990. You are a certified instructor for manual lymph drainage. In 1994 you formed The Academy of Lymphatic Studies, and you also have published a book, The Textbook for Comprehensive Lymphedema Management, which is now in its fourth edition. Is that correct?

Joachim (Joe) Zuther: That's correct, Tammey. That's correct.

Tammey Grable-Woodford: Wow. Well, I only...

Joachim (Joe) Zuther: and it's available in five different languages if I may add so.

Tammey Grable-Woodford: Oh my goodness. Please do, well, and add anything else that I might've missed. I mean, you have such a great history and, and I'm looking forward to diving into this topic with you, but tell us a little bit about you and really how you got started, and why this became such a passion for you.

Joachim (Joe) Zuther: Well, thanks for having me, Tammy. Like you said already, my name is Joachim Zuther, but let's stick with Joe. It makes life easier for all of us. So, my name is Joe Zuther. I am the founder and education director of the Academy of Lymphatic Studies, which is the school that provides continuing education in treatment and management for lymphedema.

And we train healthcare professionals in this therapy since 1994 as you already correct said. I am also the author of The Textbook for Lymphedema Management currently in its fourth edition, but more important, I guess to your listeners, I'm also the author of Lymphedema Blog, which is a website completely dedicated to, provide patients affected by lymphedema and related conditions with all things lymphedema related, it's available on and there are a great number of articles geared towards patients with lymphedema. There are more than a hundred articles now, which are written so patients can easily understand the issue. You find articles explaining primary and secondary lymphedema.

There are questions answered when it comes to quality of life issues, treatment issues, risk reduction issues, and so on and so forth.

Lymph – The Neglected System

Tammey Grable-Woodford: Oh my goodness. And a lot of those we're going to just barely touch on today. You know, when I was diagnosed with breast cancer and found out it was stage three, we, we did all the scans and they said, my lymph looked clear. But they still have that standard practice of removing the Sentinel nodes. And I'll be honest, you know, I remember in school, we're all taught about the nervous system. We are all taught about our circulatory system. I had no idea really the importance of the lymphatic system and how different it is from the other systems in the body. And so would you talk to us a little bit about what is that lymphatic system and why is it so important.

Joachim (Joe) Zuther: It is important and as you rightly pointed out, it's, it's kind of a neglected system in the body even these days. Medical students only hear a couple of hours about lymphatic system through their studies, it's a shame.

Tammey Grable-Woodford: Wow.

Joachim (Joe) Zuther: It's amazing. Ah, well the lymphatic system. What is it? The lymphatic system consists of a network of lymph vessels and lymph nodes that work parallel to, or in conjunction with the circulatory system, the blood system.

The lymphatic system is not a closed circulatory system, like the blood system. As you know, the blood system consists of arterial part and venous part but works on a one-way principle, which means that the lymphatic network starts with small vessels in the interstitial tissues in body tissues where they collect fluids and particles and carries the dead lymph fluid from the tissues back into the venous system.

Now, once that interstitial fluid enters the lymphatic system is called, it's called lymph fluids. This is when it's lymph fluid, so there is interstitial fluid, and once it enters the lymphatic system, it's called lymph. Lymph fluid is a clear and transparent semi-fluid medium that contains water, protein, cellular components, unfortunately in some cases, also malignant cells, which is important to understand the function of metastasis, and also fat.

So the lymph components are all a protein, cell components, and particles of fat. Now the two main components that are of interest to us, and to your listeners, are the lymphatic loads of water and protein.

So where does the water come from? You have to imagine that a large amount of fluid, approximately 24 liters or six gallons leaves the blood capillaries via filtration throughout the day. Now that fluid that leaves those blood capillaries supplies the cells with nutrients like sugars and salts and enzymes and so on and so forth.

Now, once the fluid that leaves the cap… blood capillaries is in the tissues, it cannot be returned indirectly into the blood circulatory system but has to be removed by the lymphatic system. So the lymphatics, the tissue fluid enters or blood fluid enters the tissues, and it provides the cells, the body cells with nutrients, sugars, salts, and in turn picks up metabolic waste and cell particles and transports those lymphatic loads back into the blood system.

So it's, it's… like I said before, it's like a complimentary system to the blood system.

Now, those small lymph vessels that I mentioned before are called lymph capillary. So those lymph capillaries collect the lymphatic load of water and proteins and moves that fluids through ever-larger lymph vessels from the lymph capillaries into the pre-collectors, and from there into the collectors and the lymph collectors move or transport the lymph fluid into the lymph nodes where harmful substances and toxins are filtered out.

And from there the lymph continues with ever-larger lymph vessels or ducts or collecting vessels back to the heart. And, throughout the day, approximately two to three liters of lymph are returned via the lymphatic system into the blood system. So, you can see that just with lymphatic water, the lymph system plays a very, very important role in the body's fluid management.

So, water is one of those lymphatic loads. The other important lymphatic loads are proteins, those also come from the blood, in the course of 24 hours, at least half of the proteins that circulate in the blood will leave the capillaries and travel to the interstitial spaces. Now, those proteins are needed for growth, for metabolism, they maintain proper pH levels. They transport nutrients, provide energy, and so on, so forth.

But as with the water, once the proteins leak out of the blood circulatory system, they cannot directly return back into the blood circulatory system, but also have to be moved by the lymph system. So those two main lymphatic loads, water and protein, are important to understand to understand lymphedema itself.

Lymphedema, the definition of lymphedema is an accumulation of proteins and water in the tissues, and that's a very important difference to other swellings like regular edemas. Lymphedema and edema are not the same. Lymphedema has a high protein content, where regular swellings, like if you sit too long or if you stand too long and you accumulate fluid and you're ankles, for example, this is not lymphedema.

This is regular swelling, like an excess of water in the tissues, but it does not have a higher protein content. So that's important to understand.

Tammey Grable-Woodford: Wow.

Joachim (Joe) Zuther: Now another important factor I need to mention, the lymphatic system does not only play an important part in fluid management and the removal of toxins and cellular waste, but it also plays a very, very important part in the body’s immune defense.

Now, in addition. To the lymph vessels and the lymph nodes I already mentioned, there are lymphatic organs. Like we have primary lymphatic organs like the bone marrow and the thymus where lymphocytes are produced and those lymphocytes then are circulated into the secondary organs, like the lymph nodes and the spleen, for example, where they provide a very, very important role in the body’s immune defense.

So that's in short, the lymphatic system, the components, and the function of the lymphatic system.

Tammey Grable-Woodford: I don't know how you would cover all of that in a few hours of med school. That is a very complex system.

Joachim (Joe) Zuther: Well, I mean, you know, we just covered it in like five minutes. So, you know, cause it's just a basic overview. And I tell you, you know, I don't want to talk down and talk down on doctors and the medical professionals, but you know, many, many doctors, and I know a lot of doctors, they have a hard time understanding the lymphatic system.

Tammey Grable-Woodford: Well, and you know, yes, we did an overview, but then you tie it into everything else within the body and, and it gets far, far more complicated than that overview.

Joachim (Joe) Zuther: Exactly. So what, know what if the lymphatic system works properly, there is no issue, but you know what? They are instances where you can have a disruption of lymphatic system, of disruption of the lymph flow, and then you end up with issues.

Tammey Grable-Woodford: Yes. So in my case, I had my sentinel nodes removed and they, unfortunately, both did have a metastasis, micro-mets in them and my general surgeon at the time, we had the conversation about going back and removing more nodes and he actually, he left the choice up to me saying that they are starting to find more long term side effects with removing all of the nodes rather than just removing the sentinel nodes.

But the other interesting thing he said to me was that once you re… identify and remove the sentinel nodes, it's not like you can go back, they're not like in a chain. So, it's not like you can go back and remove the next couple. You kind of have to remove them all.

But that also kind of leads me to the, to the other question of, you know, what impacts with mastectomy, bilateral mastectomy, lumpectomies, the subsequent radiation, and then of course, the Sentinel node removals. And I know that is a lot, but what are the impacts to the lymph system when it comes to those.

Breast Cancer Surgical Interventions and the Lymphatic System

Joachim (Joe) Zuther: Yeah. Well, mastectomies and lumpectomies are procedures that are performed to treat breast cancer, and I'm sure, as you know, and as most of your listeners know, breast cancer is the most common cancer in women in the Western hemisphere. Generally, it can be said that one out of eight women in the U.S. will develop breast cancer throughout their lives.

And just before our interview here, I checked the national cancer Institute website for the current numbers. And I can tell you from the NCI website that, over 276,000 new cases of invasive breast cancer and over 48,000 cases of noninvasive breast cancers in females and 2,600 breast cancer in males, will be diagnosed in the United States in 2020.

So that's a large number.

Tammey Grable-Woodford: Wow. Yeah…

Joachim (Joe) Zuther: Now again, lumpectomies and mastectomies are procedures that are both performed to remove the breast cancer, and obviously to save the patient's life. So those are very important and necessary procedures. And while both procedures are effective, they have different benefits and risks.

Now a lumpectomy. What is the difference between lumpectomies and a mastectomy? A lumpectomy is a surgery that removes the breast cancer itself while preserving the mammary glands. Those lumpectomies are used for less invasive forms of cancer. However, many patients need additional radiation to destroy any remaining cancer cells and prevent the reoccurrence of cancer as opposed to a lumpectomy.

A mastectomy treats the breast cancer by removing the entire breast, including lymph nodes. There are different types of mastectomy procedures. There are simple mastectomies. With simple mastectomies, mammary glands are removed and no lymph nodes are removed, so it's just a removal of mammary glands. It's for those cases where women looking to prevent breast cancer from ever recurring.

I'm sure many of you have heard of some well-known people, actors, and actresses recently that had the procedure done. So that would be a simple mastectomy. Then there are the radical mastectomies or radical mastectomy, removes the entire breast including the cancer, it removes the lymph nodes and the auxiliary lymph nodes and also the chest musculature, in particular, the pectoral muscle type would be a radical. Very seldom they performed, and only in those cases where the breast cancer is very invasive and spreads into the muscles of the chest.

Now, and then there's the modified radical mastectomy. With this procedure, the mastectomy removes the entire breast, and some of the lymph nodes however, the muscles are not removed would be still lumpectomies and mastectomies.

Now. As I said before, one is absolutely necessary to remove those lymph nodes that contain cancer cells. It is important to consider that any removal of lymph nodes, which is the case with lumpectomies and mastectomies, and the subsequent damage of lymphatic vessels. Remember I told you before that lymph collectors. Connects to the lymph node.

So if you remove lymph nodes, you have to sever those collectors and obviously that would have an impact on the efficacy or the sufficiency of the lymphatics. Now, again, with the removal of lymph nodes, there are also different procedures. There are Sentinel lymph node biopsy these, and they are the axillary lymph node biopsies, complete axillary lymph node removal or ALNB

Now. the Sentinel lymph node biopsy is the most common and least invasive way to remove the lymph nodes are the first nodes, the first lymph nodes into which a tumor drains. So what happens during the surgery, a surgeon checks a radioactive tracer or non-toxic dye around that tumor, which then enables the surgeon to identify.