Breast Cancer – Related Lymphedema

It has been estimated that approximately between 3 and 5 million patients in the United States have lymphedema, with a significant portion developing as a result from cancer or its treatment.  Breast cancer – related lymphedema can effect approximately 1 in 5 patients who are treated for breast cancer. To get a better understanding of this, we have to dig deep to see how this disease can develop and how early treatment is vital.

What is Lymphedema?

Lymphedema is a chronic disease marked by swelling in the body due to an abnormal collection of lymphatic protein-rich fluid. Lymphedema commonly develops when there is an impaired or disrupted flow of lymph fluid from the lymphatic vessels or lymph nodes. If healthy lymphatic vessels are unable to accommodate the increased lymphatic flow, an accumulation of lymph fluid develops in the tissues. Because of the increased fluid in the area, the body experiences an inflammatory reaction resulting in scar tissue called fibrosis leading to tissue and skin changes.  The increased fluid and fibrosis can also prevent the delivery of oxygen to the area which provides a nest for bacteria to grow called cellulitis. In addition, the development of immune cells takes place in the lymphatic system making it one of the most important defense mechanisms in the body.

With specific cancer related surgeries such as breast cancer, surgical resection may require the removal of lymph nodes which can cause secondary lymphedema. To minimize this risk, surgeons may opt for a Sentinel Lymph Node Biopsy (SLNB) when needed. With this procedure, only the front line or the first few lymph nodes sre removed that drain from the wound site.

What is the function of the Lymphatic System?

The lymphatic system is very important in keeping your body healthy and consists of lymph vessels, lymph nodes, lymph tissues, organs, and ducts.

The system transports lymph, a clear fluid that originates in tissue spaces throughout the body. This lymph fluid consists primarily of protein, fatty acids, water, salt, white blood cells, and debris. This fluid gets absorbed from the interstitial spaces into the lymphatic vessels where it travels into the venous system.

The goal of the lymphatic system is to absorb and transport large molecules such as proteins that are too large to be collected from the venous system. Your lymphatic system additionally carries fluid and harmful substances to your lymph nodes to be filtered out with the body’s natural defense of cells called lymphocytes that ultimately fights the bacteria and cleanses the body.

What causes Lymphedema?

Lymphedema can be classified as either primary lymphedema (genetic) or secondary lymphedema (without anatomical malformation).

Primary lymphedema can be passed down genetically and also be present at birth such as Milroy’s Disease, a disorder during infancy that causes lymph nodes to form abnormally.

Lymphedema is most commonly caused by secondary lymphedema which can occur through the removal or damage of lymph nodes as part of cancer and/or radiation treatment. Cancer itself can also block lymphatic vessels. For example, when a tumor is near lymph vessels, it could grow large enough to block the flow of lymph fluid.

With specific cancer related surgeries such as breast cancer, surgical resection may require the removal of lymph nodes. If the cancer has spread, it has been most likely moved into the underarm lymph nodes first because they drain lymph from the breast.

To minimize this risk, surgeons may opt for a Sentinel Lymph Node Biopsy (SLNB).  With this procedure, only the front line or the first few lymph nodes are removed that drain from the site.  However, sometimes many more nodes need to be removed called an axillary lymph node dissection (ALND).  About 20 percent of women who undergo an ALND can develop lymphedema.

Radiation therapy may also be necessary but can damage healthy lymph nodes and vessels causing scarring of the lymphatic vessels leading to fibrosis and decreased flow resulting in a backup of fluid in the body’s tissues.

What are the signs and symptoms of Lymphedema?

  • Swelling of a part or all of the extremity
  • A feeling of heaviness of the limb
  • Decreased range of motion
  • Tightness in the skin or tissue
  • Discomfort or aching of the limb
  • Recurring infections
  • Hardening of thickening of the skin (fibrosis)

How can a lymphedema therapist help?

Without treatment, lymphedema can cause progressive swelling, fibrotic tissue, neurologic changes and infection. Lymphedema therapists can help to manage the condition through Complete Decongestive Therapy (CDT).

Manual Lymph Drainage (MLD):  MLD is a technique designed to increase the movement and reabsorption of lymph fluid back into the lymphatic system.  The light touch and basic hand positions of MLD were created to follow the anatomy of the lymphatic system. The goal of MLD is to re-route the flow around blocked areas of its normal path into healthy lymph vessels which will eventually drain back into the venous circulation.

Compression Bandaging: Can help prevent lymph fluid build up and move lymph to an area that is draining well. It additionally improves the efficiency of the muscles and joint pumps.

Remedial Exercise:  An individualized home exercise program involving both aerobic and low-load resistance can be provided.  These light exercises are aimed to encourage lymph fluid to drain out of the limb. This additionally includes diaphragmatic breathing to increase muscles and joint pumps and, as well as, to increase venous and lymphatic return.

Meticulous Skin and Nail Care:  The education of good skin and nail care can significantly reduce the risk of infections. The smallest injury to an area that has lymphedema can create an entry point for infection.  It is important to avoid insect bites and burns, as well as, to clean all injuries immediately.

Lymphedema is an ongoing condition that has no cure, however, steps can be taken to prevent the progression, minimize symptoms, and improve outcomes. Getting treatment right away can lower the risk of lymphedema as well as its complications.  A trained lymphedema therapist can help to devise a treatment program that will control the swelling and meet your individualized goals for returning to normal daily activity.

In good health,
Christine M. Rodriguez, MS, OTR/L, CHT, CLT-UE

References:

  1. Cihiangir Ozaslan, Bekir Kuru. (2004). “Lymphedema after treatment of breast cancer.” The American Journal of Surgery 187 (1), 69-72.
  1.   Foeldi: Textbook of Lymphology, 2nd Edition, 2006. Chapter 4: Physiology and

pathophysiology of the lymphatic system.

  1.   Lawanda, Brian D, Mondry, Tammy E. Johnstone, Peter A.S. (2009).

“Lymphedema:A Primer on the Identification and Management of a Chronic

Condition in Oncologic Treatment.”  CA Journal for Clinicians. 59; 8-24.

  1.   National Lymphedema Network:  https://lymphnet.org

Image Credits: 

Image 1: L is for Lymphedema: Chemo for Beginners

Image 2: The Lymphatic System: Google sites

Image 3:  https://www.scripps.org; What are the Benefits of Lymphedema Therapy?

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