Lymphedema

LYMPHEDEMA

What is it?

Lymphedema is swelling of a body part due to abnormal lymphatics (the system that fights infection and monitors inflammation in the body). For breast cancer patients, lymphedema can occur in the arm or trunk (chest wall) following axillary (armpit) lymph node surgery. The surgery can disrupt the channels that carry lymph (the fluid responsible for fighting infection and dealing with inflammation) from the hand, arm and trunk into the bloodstream. When those channels cannot do their job, the lymph can leak out into the surrounding tissues. Water then follows the lymph into those tissues, creating swelling.

Lymphedema may start out as a mild ache in the arm. Other people may notice that their arm feels tight or heavy. Sleeves or jewelry may fit more tightly on that affected side. Other people will experience obvious swelling in a finger, the hand or the arm. Lymphedema can also occur on the trunk, just below the armpit.

How is it diagnosed?

Many cases of lymphedema are brought to the doctor’s attention when the patient notices a change herself. Some cases are found by regular measurement of the arm size with a tape measure. Other cases are found by measuring arm tissue changes with specialized devices. When these measurements go higher than a certain value, then the diagnosis of lymphedema is made.

How is it treated?

Lymphedema is treated with the help of a specially trained physical or occupational therapist. Often, a patient’s breast doctor makes the referral. Therapists start out with manual decompression therapy: specific techniques that encourage the tissue fluid to drive back into the bloodstream. Often, this therapy is accompanied by compression garments.

 Compression sleeves or gauntlets (sleeve and glove in one) are worn for several hours a day and provide constant pressure to keep fluid out of the tissues.

Automatic compression devices can also be used. They provide more pressure than manual decompression or compression sleeves, and may be used several times a day.

Lymphedema is treated most successfully when it is found early. It is important to call your doctor if you notice aching, heaviness, swelling or tightness in the arm or hand on the side where you had surgery.

How can it be prevented?

The things that affect lymphedema are things that cannot be controlled: body mass index (BMI) at the time of surgery and the number of lymph nodes removed during the operation. Women with more body fat are more likely to develop lymphedema. Also, lymphedema is more likely to develop with the removal of more lymph nodes. Radiation therapy to the axilla also increases the risk of lymphedema.

If you are going to engage in activities where you could get cuts on your hands or arms, you should wear long sleeves and gloves. If you have a cut or scrape, keep it clean, dry and covered until it heals. You should use antibiotic ointment on any skin break.

If you’re going out in the sun, be sure to wear sunscreen on the affected arm and hand (you should wear sunscreen all over!).

It is important to know that if you have no cuts, scrapes or infections, having your blood pressure checked or having blood drawn in the arm on the side where you had surgery does not cause lymphedema or increase your risk of lymphedema.

If you need your blood drawn or blood pressure checked, you should ask the nurse or technician to access the arm that you feel more comfortable using.

Can I exercise?

 We now know that exercising with arm weights does not cause lymphedema. In fact, it may help treat it. If you want to proceed with an exercise program, consult with your doctor to set a safe regimen.

Does my risk for lymphedema ever go away?

Unfortunately, if you have had axillary node surgery then you will always be at risk for lymphedema. But the risk goes down over time. The greatest risk is in the first five years after surgery.

Impact of Ipsilateral Blood Draws, Injections, Blood Pressure Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer

Bottom line:

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Activities traditionally associated with increasing the risk of lymphedema do not appear to pose a threat. However, body mass index (BMI) greater than or equal to 25 lb/in2, full axillary lymph node dissection (ALND), regional lymph node radiation (RLNR) and cellulitis are significantly associated with the development of lymphedema.

Summary:

There is widespread belief that breast cancer patients who have undergone ALND (full or sentinel) should avoid certain activities that are presumed to increase lymphedema risk. Many care providers advise against blood draws, injections and blood pressure checks in the ipsilateral (operated side) arm. It is also commonly recommended that patients take specific precautions against trauma and wear compression garments on the affected side during air travel.

This group examined the outcomes of lymphedema in 632 female patients who received full or sentinel ALND as part of their breast cancer treatment. During follow up office visits, each participant was questioned about the number of times she had injections, blood pressure checks or blood draws on the ipsilateral side. She was also asked about episodes of cellulitis and air travel. Arm girth was measured preoperatively and at regular postoperative intervals. Patient age, BMI, tumor and treatment details were recorded. The median length of follow up was two years.

Results showed no associations between ipsilateral blood pressure checks, injections, blood draws, air travel or trauma and lymphedema. However, there were increased risks of lymphedema in women with BMI’s of 25 lb/in2 or greater, in women who had a full ALND, women who received RLNR and in women who developed cellulitis.

Source:

Ferguson C. et. al., J Clin Oncol, published online ahead of print on December 7, 2015 as 10.120

Guidelines for the Diagnosis, Detection, Prevention and Treatment of Breast Cancer-Related Lymphedema

Take-home message: Breast cancer-related lymphedema (BCRL) is a potentially devastating side effect of breast cancer treatment. The American Society of Breast Surgeons (ASBrS) has created a set of recommendations, with the goal improving outcomes.

Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema: Recommendations from a Multidisciplnary Expert ASBrS Panel

Part 1: Definitions, Assessments, Education and Future Directions

Part 2: Preventive and Therapeutic Options

McLaughlin, SA et. al. Ann Surg Oncol (2017) 24:2818-2835

BCRL is an ongoing concern for patients undergoing axillary treatment as part of breast cancer therapy. This expert panel reviewed current information about lymphedema- including how it happens, its risk factors, surveillance techniques and treatment.

The risk for the disorder approaches 10% for women undergoing sentinel lymph node biopsy (SLNB), and may rise to about 15% for women undergoing axillary lymph node dissection (ALND). The risk climbs to 25-40% for women receiving axillary surgery and radiation therapy. BCRL can impair quality of life, possibly leading to loss of employment, depression, increased medical costs and inability to perform daily activities. It is understood that early detection offers the greatest chance at successful treatment. There are many methods of detection, and circumferential tape measurement is commonly used. However, newer methods such as bioimpedance spectroscopsy, tissue dielectric constants and infrared perometry may be superior because they are less subjective and have more reproducible results. Regardless of surveillance method, it is recommended that surveillance for BCRL be performed at regular intervals for 3-5 years in the postoperative period. Patients’ own observations of symptoms of lymphedema are also very important in disease detection.

Risk factors for BCRL have been updated. From a surgical standpoint, the risk increases with increasing number of axillary lymph nodes removed. Nodal irradiation after axillary surgery and obesity/elevated body mass index (BMI) are also risk factors for development of the disease. Also, certain chemotherapy regimens have been associated with BCRL. The panel noted that venipuncture (blood draws), injections, blood pressure checks and air travel are commonly suspected to increase the risk of BCRL. However, scientific studies have refuted all of these assumptions.

Weight-resistance exercise was suspected to increase the risk of BCRL. The panel pointed out that such activity has no effect on BCRL risk. In fact, such exercise improves the symptoms of lymphedema and leads to fewer exacerbations of the condition. Moreover, aerobic exercise is also safe – even for women who already have BCRL.

Surgical treatments for risk reduction are being developed and studied. Axillary reverse mapping (ARM) is a technique where, prior to SLNB, the arm lymphatics are injected with a blue dye. This allows the surgeon to avoid harming those channels and nodes that drain the arm. Current data shows that the ARM technique leads to a significant decrease in BCRL. Another technique, called lymphatic microsurgical preventive healing approach (LYMPHA), involved connecting larger lymphatic channels into larger veins at the end of ALND surgery. This technique is also associated with a lower risk of BCRL.

The standard treatment for BCRL is combined decongestive therapy (CDT). This consists of manual drainage with a trained therapist, wearing compression garments, engaging in specific exercises and vigilant skin care. 

Surgical treatment of BCRL is also being developed. Lymphatic-venous anastamosis (LVA) involves creating multiple connections between lymphatic channels and veins in the affected arm, with the observation that the congested lymph system drains into the bloodstream and reduces swelling. Another surgical technique is vascularized lymph node transfer (VLNT), which involves relocating lymph nodes from one part of the body to the extremity affected by BCRL. Liposuction, which removes excess tissue volume, may debulk and alleviate discomfort but does not treat the underlying cause of BCRL. So, patients who receive this treatment must receive continuous postoperative compression and follow up with a therapist.

As a result of its extensive review, the panel made the following 10 recommendations for BCRL:

1. Clinicians should establish a surveillance plan because early diagnosis leads to early treatment and increases the likelihood for limited disease burden.
2. Baseline and follow-up measurements of the ipsilateral (operated side) and contralateral (non-operated side) arms of all breast cancer patients are critical. A comprehensive measurement strategy should include a combination of objective and subjective measures.
3. Clinicians should practice personalized medicine strategies to minimize axillary surgery, question the routine use of postmastectomy or regional nodal irradiation, and should use genomic tests to guide the use of chemotherapy to collectively minimize the additive effects of multimodality therapy. Patients should maintain a healthy BMI.
4. Surgeons should admit and accept that lymphedema risks exist and educate themselves and their patients about these risks at preoperative and follow-up visits. Education should continue into survivorship and be incorporated into survivorship care plans.
5. The origins of BCRL are complex. Association of BCRL only with venipuncture, blood draws and air travel oversimplifies the problem.
6. Use of the ipsilateral arm for IVs or blood pressures is not contraindicated, although most patients prefer to use the contralateral arm. Personalized risk-reduction strategies are more appropriate than blanket application of behaviors.
7. Clinicians should encourage at-risk and affected lymphedema patients to exercise. Resistance and aerobic exercise is safe. Patients with BCRL should work with a trained lymphedema professional to learn to exercise safely.
8. Emerging data on preventive surgical strategies with ARM and LYMPHA are promising and should be explored further with appropriate patients.
9. CDT is the cornerstone of therapy. Patients with symptoms or measured changes should be referred for lymphedema therapy evaluation, formally educated, and provided with graduated intervention according to staging and presentation.
10. LVA and VLNT may be effective for early secondary BCRL. Patients should be assessed by a multidisciplinary team, with an understanding that surgery will be part of a multimodality treatment plan. Lymphatic liposuction with long-term compression is effective for severe late-stage BCRL unresponsive to conservative management.