Lymphedema after breast cancer surgery

INTRODUCTION — Lymphedema is one of the most troubling complications after breast cancer surgery (specifically after axillary lymph node surgery). It is caused by interruption of the lymph drainage in the axilla, which produces swelling of the arm, discomfort and an abnormal appearance of the arm. Many women find that lymphedema can worsen the physical and emotional strain of dealing with breast cancer.

The overall incidence of lymphedema after treatment for breast cancer is 25 percent, although this varies depending upon the extent of surgery, the time since surgery, and whether radiation therapy was used. Generally, patients who undergo more extensive surgery, have many lymph nodes removed, or have radiation therapy to the axilla after surgery are more likely to develop lymphedema. Most women who develop lymphedema do so within four years after their operation.

CAUSES — Lymph is a clear fluid that contains mostly white blood cells (the blood cells that fight infection). The lymphatic system drains the body's tissues and organs into a series of tubes or ducts. The fluid is filtered through lymph nodes (also called glands) and eventually drains into the blood stream.

Lymphedema that develops after treatment for breast cancer is called secondary lymphedema. It develops because there is a disruption in the normal lymphatic drainage. This interruption can be caused by: Surgery, particularly removal of the lymph glands in the armpit (also called the axilla) Trauma or injury to the arm Infection caused by insect bites or scratches after breast cancer surgery Tumor-related obstruction of the lymph drainage Radiation treatment to the axilla

As expected, women who require axillary lymph node dissection because of a positive sentinel lymph node have more arm symptoms than those who undergo only sentinel lymph node biopsy. In one trial that compared women who underwent sentinel lymph node biopsy alone versus women who had sentinel lymph node biopsy followed by axillary lymph node dissection, the sentinel lymph node biopsy alone group had lower rates of arm edema (4 versus 19 percent), impaired shoulder range of motion (4 versus 11 percent), shoulder/arm pain (8 versus 21 percent), and numbness (11 versus 38 percent) [1].

Patients who develop lymphedema many years after surgery, or who have lymphedema that is increasing, should be evaluated for a possible recurrence of the breast cancer.

SYMPTOMS — Initially, patients may experience a heavy sensation in the affected limb, accompanied by an aching discomfort. The swelling may be soft and pitting at first. Typically this swelling becomes firm and nonpitting, and the skin becomes dry. Patients may have restricted movement, numbness, or a sense of stiffness in the arm.

Lymphedema has a different appearance than other types of edema. Edema caused by excessive fluid usually develops in the legs, and is caused by conditions such as cirrhosis or congestive heart failure. Edema causes pitting, which leaves an imprint for several seconds when a finger is pressed into the swelling. In contrast, lymphedema is non-pitting. (See "Patient information: Edema").

IMPACT OF LYMPHEDEMA — While lymphedema is not a life-threatening condition, it can have a major impact on a person's lifestyle and quality of life. A change in cosmetic appearance often leads to concerns about body image.

After breast cancer surgery, many women are already self-conscious about their appearance, and the edema can worsen this concern. Psychologic symptoms such as anxiety, depression, social avoidance, and sexual dysfunction can result. A decreased ability to use the affected arm can impact quality of life, particularly if it is the patient's dominant arm. Lymphedema can reduce tissue healing and occasionally causes chronic pain. For these reasons, prevention strategies and early treatment of lymphedema are strongly recommended.

PREVENTION STRATEGIES — A number of recommendations for the prevention of lymphedema have been proposed, although the effectiveness of those recommendations is variable. Early identification and treatment can help to minimize the severity of lymphedema. Patients should report any symptoms of pain or swelling to a healthcare provider as soon as possible; do not wait for symptoms to worsen.

Some possible preventive strategies include: Avoid trauma and injury to the affected arm. Injections should not be done in the affected arm, if at all possible. Blood drawing and placement of intravenous lines may occur but caution is needed to minimize pressue and avoid infection. Avoid constriction in the affected arm. Tight fitting clothing, blood pressure monitoring or any activity that could interfere with lymph flow should be avoided. Try to prevent infection. Practice careful skin and nail hygiene to prevent an entry point for infection. Use skin moisturizes to prevent dry, cracked skin. Use topical antibiotics on small skin breaks or abrasions, such as a paper cut. Avoid heavy exercise and lifting heavy objects with the affected arm immediately after surgery. Moderate to heavy exercise of the limb may increase blood flow, which can increase edema. Check with a healthcare provider before resuming exercise or heavy activities. Gentle stretching and range of motion exercises, provided by the surgeon, may be used immediately after surgery. Avoid extreme temperature changes during bathing or washing dishes. Hot tubs and saunas should be avoided or used with caution. Avoid resting the arm below the heart or sleeping on the arm for prolonged periods Contact a healthcare provider if the affected arm develops a rash, becomes red, blistered, or warm, or if a fever develops (temperature greater than 100.4ºF or 38ºC). These symptoms could signal the beginning or worsening of lymphedema.

MONITORING — In a woman with lymphedema, the size of the arm is often monitored over time to detect changes and measure response to treatment. The standard way to estimate size is by taking measurements of the circumference of the arm at several pre-determined points.

An alternate way to measure is by using the water displacement method. This appears to be more accurate and sensitive to small changes in arm size, and is often used for clinical trials. However, it is not clear if there is any advantage of monitoring arm size at home by this more complicated method, as compared to a simple measurement of arm circumference.

A water displacement arm volumeter device has been developed for home use (show figure 1) [2]. The device can be made at home using widely available polyvinyl chloride (PVC) pipes that are sold in hardware stores. Instructions for building the home volumeter, as well as the appropriate technique for using the device, are provided by the author (show table 1).

TREATMENT — The underlying cause of lymphedema cannot be corrected. The main goals of treatment are optimizing preventive strategies to limit the amount of edema, provide symptom relief and prevent worsening of edema. Because drugs and surgery have shown little benefit and can sometimes be harmful, the main therapeutic approaches are non-surgical and nonpharmacologic (non-drug).

Treatment should encompass the range of symptoms a woman is experiencing. Eliminating discomfort, improving range of motion in the arm, and decreasing psychologic distress are important outcomes of therapy. Patients are often referred to clinicians or programs with expertise in treating lymphedema.

General measures — Careful skin and nail care should be performed to prevent infection, which may result in cellulitis and worsening of lymphedema. Women should avoid cuts, pinpricks, hangnails, insect bites, contact allergens or irritants, pet scratches, and burns to the affected arm. Patients should be encouraged to use skin moisturizers and topical antibiotic ointments after small breaks in the skin that occur as a result of a paper cut or abrasion. Protective gloves for household work and gardening also may be helpful. Use an electric razor rather than a razor blade to remove hair in the axilla.

Whenever possible, patients should avoid medical procedures, such as vaccination, blood pressure monitoring, acupuncture, and venography in the affected arm. (See "Prevention strategies" above).

Lymphedema may be worsened by saunas, steam baths, or hot tubs; spending time in hot climates; or travel. Many patients report worsening of their lymphedema during air flight, suggesting that patients who use compression sleeves should probably wear them in flight.

Patients are encouraged to maintain an ideal body weight. Obesity is a contributory factor for the development of lymphedema, and may limit the effectiveness of compression pumps or sleeves.

Nonpharmacologic therapy — Several nonpharmacologic treatment modalities are effective.

Arm elevation — Although elevation of the arm is not an effective treatment by itself, it may be recommended in conjunction with other therapies [3].

Exercise — After the immediate recovery phase, moderate exercise is recommended. If the arm starts to hurt, a patient should lie down and elevate the arm. Nonfatiguing exercises can enhance muscle contraction, which can improve lymph flow and reduce swelling. Walking, swimming, light aerobics, bike riding, and yoga are all recommended. Avoid repetitive movements against resistance with the affected arm, such as scrubbing or pushing/pulling heavy objects.

Some clinicians recommend avoiding certain forms of exercise, including rowing, tennis, golf, skiing, squash, racquetball, or other vigorous repetitive movements. However, there is no published evidence to suggest that these activities promote or worsen lymphedema.

Compression garments — Applying pressure to the arm can encourage fluid movement and ultimately reduce swelling. Compression can be achieved by using an elastic lymphedema sleeve (show picture 1A-1B), or by wrapping the arm in elastic bandages (if a sleeve does not fit). Some people require a custom-made garment if a standard size sleeve does not fit.

Use of a lymphedema sleeve is preferred to bandaging because it provides increased pressure at the wrist, which gradually lessens towards the axilla; this helps to move fluid better than bandages, which have equal pressure at all points along the arm. Whichever method is used, proper fit is important to avoid worsening edema in any one area of the arm. People who have lymphedema should wear a compression sleeve when flying.

Massage therapy — Another method to mobilize lymph fluid is massage or manual lymphedema therapy (MLT). MLT applies light pressure to the arm and torso to mobilize edema fluid from the fingers and hand to the upper arm and chest. It is thought that MLT of the skin and subcutaneous tissue may help open gaps or collateral channels between lymphatic ducts, enhancing the flow of fluid through the lymphatic system.

Massage is usually used in conjunction with compression garments and therapeutic exercise. Whenever possible, patients should be referred to practitioners trained in MLT. Patients and family members can also be trained in massage techniques, allowing the patient to continue therapy after finishing formal treatment with a therapist. Mild lymphedema may resolve in two to three weeks, but more severe cases will require a longer time. Patients with active infection or inflammation (redness) of the affected limb, a blood clot, active cancer, or congestive heart failure may not be good candidates for massage therapy.

Complex physical therapy — This is a multimodality approach that uses massage, skin care, exercise and compression garments. It is considered an effective treatment for lymphedema that is unresponsive to compression therapy alone.

External pneumatic compression — When patients do not respond to massage or pressure garments, external pneumatic compression may be used. This treatment uses a sleeve that is intermittently inflated, beginning at the lower end of the arm and working up towards the shoulder.

Currently, pneumatic compression is recommended only for patients treated in a formal lymphedema treatment program who have not improved with other therapies (massage, compression garments, exercise).

Drug treatment — Drug therapy is usually ineffective and, in some cases, can be harmful. Diuretics — Diuretics eliminate excess fluid from the body. Although they are often used to treat edema that develops in individuals with heart failure, they are not effective for lymphedema. Antibiotics — Antibiotics are used to treat infection. Antibiotic treatment should be discontinued after an infection has resolved; continued or preventive antibiotic therapy does not improve lymphedema. However, oral antibiotics may rarely be recommended for extended periods of time (ie, preventively) in patients who have chronic or recurrent infections.

Surgery — Surgery is rarely performed for the treatment of lymphedema following mastectomy. If indicated, the primary surgical approach is to remove subcutaneous fat and fibrous tissue with liposuction. The effectiveness of this approach has not been studied, and there is concern that lymphedema will eventually return following surgery.

Some specialized centers have performed lymphatic microsurgery that involves draining lymph fluid into the venous circulation. A newer technique, microsurgical lymph node transplantation, is under study.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Cancer Institute

1-800-4-CANCER
(www.nci.nih.gov)
People Living With Cancer: The official patient information

website of the American Society of Clinical Oncology
(www.plwc.org/portal/site/PLWC)
National Comprehensive Cancer Network

(www.nccn.org/patients/patient_gls.asp)
American Cancer Society

1-800-ACS-2345
(www.cancer.org)
National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
Susan G. Komen Breast Cancer Foundation

(www.komen.org)
National Lymphedema Network

(www.lymphnet.org)


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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Langer, I, Guller, U, Berclaz, G, et al. Morbidity of Sentinel Lymph Node Biopsy (SLN) Alone Versus SLN and Completion Axillary Lymph Node Dissection After Breast Cancer Surgery: A Prospective Swiss Multicenter Study on 659 Patients. Ann Surg 2007; 245:452.
2. Lette, J. A simple and innovative device to measure arm volume at home for patients with lymphedema after breast cancer. J Clin Oncol 2006; 24:5434.
3. Brennan, MJ, Miller, LT. Overview of treatment options and review of the current role and use of compression garments, intermittent pumps, and exercise in the management of lymphedema. Cancer 1998; 83:2821.
4. Bertelli, G, Venturini, M, Forno, G, et al. An analysis of prognostic factors in response to conservative treatment of postmastectomy lymphedema. Surg Gynecol Obstet 1992; 175:455.
5. Rockson, SIG, Miller, LT, Senie, R, et al. American Cancer Society Lymphedema Workshop. Workgroup III: Diagnosis and management of lymphedema. Cancer 1998; 83:2882.