Breast Cancer & Lymphoedema


LYMPHEDEMA OVERVIEW — Lymphedema is swelling caused by a build up of lymph fluid, usually in the arm in women who have been treated for breast cancer. Lymphedema is one of the most troubling complications that can develop after breast cancer surgery; between 9 and 25 percent of women develop lymphedema after surgery for breast cancer. Many women find that lymphedema worsens the physical and emotional strain of dealing with breast cancer.

The risk of developing lymphedema depends upon the extent of surgery, the time since surgery, and if radiation therapy was used. Generally, people who undergo more extensive surgery, have many lymph nodes removed, or have radiation therapy to the axilla (arm pit) after surgery are more likely to develop lymphedema. Most women who develop lymphedema do so within four years after their operation.

WHAT IS LYMPHEDEMA? — Lymph is a clear fluid that contains mostly protein and 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 bloodstream.

Lymphedema can develop if the lymph vessels are interrupted. This interruption can be caused by:

Women who have multiple lymph nodes removed (a full axillary node dissection) are more likely to develop lymphedema than those who have only sentinel lymph node biopsy. Women who have both surgery and radiation treatment are at even higher risk.

Lymph node biopsy and dissection are discussed in detail in a separate topic review.

LYMPHEDEMA SYMPTOMS — The initial symptoms of lymphedema may include

In some cases, these symptoms develop before swelling is noticeable. Let your healthcare provider know as soon as possible if you develop any of these symptoms; recognizing and treating lymphedema in the early stages may prevent or slow its worsening over time.

HOW IS LYMPHEDEMA DIAGNOSED? — Most women will know if they have lymphedema because they have one or more of the symptoms listed above. If you suspect that you have new or worsening lymphedema, consult with your healthcare provider.

PREVENTING PROGRESSION OF LYMPHEDEMA — Women with lymphedema can do several things to prevent the condition from getting worse over time. Expert groups recommend the following:

LYMPHEDEMA TREATMENT — There is no cure for lymphedema. The main goals of treatment are to control swelling, relieve symptoms, and prevent edema from worsening over time. Treatment should begin as soon as possible after lymphedema is diagnosed. Women who are treated in the early stages are more likely to have a positive outcome.

Treatment should address the all of the symptoms of lymphedema, including swelling, discomfort, difficulty moving the arm, and psychological distress. A healthcare provider or program with expertise in treating lymphedema can be especially helpful.

Because drugs are of little benefit and can sometimes be harmful, the most common approaches are nonpharmacologic (ie, they do not involve medications).

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 [2].

Exercise — After the immediate recovery phase, moderate exercise is recommended. If the arm begins to hurt, lie down and elevate the arm. Walking, swimming, light aerobics, bike riding, and yoga are all recommended to improve lymph flow and reduce swelling. 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 evidence that these activities promote or worsen lymphedema.

Compression garments — Applying pressure to the arm can encourage fluid movement and ultimately reduce swelling. Pressure can be applied by using an elastic lymphedema sleeve or by wrapping the arm in elastic bandages. Some people require a custom-made garment if a standard size sleeve does not fit.

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.

Some clinicians recommend the garment be used for up to 24 hours per day, while others recommend use only during waking hours or exercise. Compression garments should be replaced every four to six months, or when they begin to lose their elasticity.

Massage therapy — Massage or manual lymphedema therapy (MLT) may help to mobilize lymph fluid. MLT applies light pressure to the arm and torso to mobilize fluid from the fingers and hand to the upper arm and chest.

Manual lymphedema therapy is usually used in conjunction with compression garments and therapeutic exercise. Whenever possible, patients should see practitioners trained in MLT.

Complex decongestive physiotherapy — Complex decongestive physiotherapy (also called complex physical therapy) uses a combination of massage, skin care, exercise, and compression garments. It is considered an effective treatment for lymphedema that is unresponsive to compression therapy alone. The treatment is performed by a physical therapist until arm swelling is improved (several weeks to months), followed by a maintenance program.

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

Intermittent pneumatic compression is recommended only for patients who have not improved with other therapies (massage, compression garments, exercise). It is not useful as a sole form of therapy, but is usually combined with complex physical therapy.

Drug treatment — Drug therapy is usually ineffective and in some cases, can be harmful.

Surgery — Surgery is rarely performed to treat lymphedema following breast cancer therapy. When surgery is necessary, the preferred approach includes removal of 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 after surgery.

Some specialized centers have performed lymphatic microsurgery, which involves draining lymph fluid into blood vessels. A newer technique, microsurgical lymph node transplantation, is currently being studied.

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 the appearance of the arm often leads to concerns about body image.

Lymphedema of the arm is an accumulation of lymph fluid in the soft tissues of the arm, with accompanying swelling (also called edema). To understand how it happens, you have to know a little bit about how blood and lymphatic fluid move around your body.

To keep from getting backed up, fluid has to keep moving within networks of vessels and channels. Blood travels from your heart to your arm in arteries and capillaries (the small blood vessels that connect arteries to veins). As the blood moves through the capillaries, it drops off important supplies to the cells in your arm: oxygen, nutrients, and a clear, colorless fluid called lymphatic fluid. The used blood keeps moving and travels back to the heart and lungs, where it gets refreshed. With every beat of your heart, fresh blood returns to your arm with fresh supplies.

Lymph fluid also has to keep moving through the tissues of the arm back into the bloodstream. This fluid flows in another type of vessel, called lymphatics.

Axillary lymph nodesAxillary lymph nodes

The muscles in your arm and contractions in the walls of the lymphatic channels push lymphatic fluid up your arm. Valves in the lymph vessels keep fluid moving forward. The lymphatic channels pass through bean-shaped structures called lymph nodes, which are located under the arm, and in the neck, groin, and other areas. Lymph nodes filter out bacteria, waste products, and toxic substances from the lymphatic fluid. The trapped material is broken down and excreted from the body. Eventually, the used lymphatic fluid leaves the arm, joins the used blood within the veins, gets refreshed in the lungs, and is then pumped back to the tissues by the heart.

Lymphatic fluid contains lots of nutrients. It's an easy target for bacteria that may find their way past the protection of the skin. Bacteria can get in even through something as seemingly innocent as a torn cuticle or a splinter. If bacteria do get in, they can cause infection. Infection, in turn, results in increased blood flow to fight the bacteria—and more lymphatic fluid accumulating and needing to be drained away.

You can think of lymphedema as a plumbing problem: Veins and lymphatic channels are like pipes and drains that can handle the normal load of lymphatic fluid. If lymph nodes and channels are removed, there might not be enough pipes and drains to handle all the fluid.

This can become a real problem when blood flow to your arm increases because of an infection, a burn, overusing the muscles of the arm, or even a bug bite. In these situations, the increased amount of lymphatic fluid flowing in can sometimes be too much for the arm's lymphatic vessels. If the fluid channels can't keep up with all that extra fluid, the fluid begins to back up and gather in the spaces between the cells of your arm's soft tissues. These tissues include the skin, fat, muscle, nerves, blood and lymphatic vessels, and connective tissue. The swelling resulting from this buildup of lymphatic fluid is called arm lymphedema.

Lymphedema can affect the whole arm or only a limited portion, such as the hand, the wrist area, the area below the elbow, or, much less often, only the area above the elbow. Lymphedema can also affect the breast area, because the fluid from that area also needs to drain through the underarm to get back into circulation.

Some women have mild lymphedema, which is hardly noticeable. Some develop moderate lymphedema that may be noticeable, tends to persist, and gets worse when aggravated. Others have severe lymphedema that is very uncomfortable and even disabling. For all of these cases, there are treatments that can help ease the discomfort and lower the swelling.