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Can Breast Reconstruction Cause Lymphedema

Lymphedema is a condition that can affect the arms, legs and even the face after breast cancer treatment. It’s caused by damage to the lymphatic system, which is responsible for draining fluids from the body.

If you have lymphedema, it means your lymph nodes have been removed through surgery or radiation treatments. This can cause swelling in your arms or legs and make them feel heavy and uncomfortable.

In this blog post, we’ll cover: can breast reconstruction cause lymphedema, how to avoid lymphedema after lymph node removal, post mastectomy lymphedema a treatment protocol, and how common is lymphedema after lymph node removal.

can breast reconstruction cause lymphedema

Lymphedema Lymphedema is abnormal swelling that happens when too much lymph collects in any part of the body. Reviewed by 5 medical advisers Sections How lymphedema happens Signs and symptoms of lymphedema Risk factors for lymphedema Reducing risk of lymphedema and flare-ups Finding a lymphedema specialist Lymphedema evaluation: What to expect at your appointment Diagnosing lymphedema Creating your lymphedema treatment plan Treatments for lymphedema Breast reconstruction and other surgeries after a lymphedema diagnosis Lymphedema and your job Lymphedema is abnormal swelling that happens when too much lymph collects in any part of the body.

Lymph is a thin, clear fluid that circulates through the lymphatic system to remove waste, bacteria, and other substances from the body’s tissues. Edema is the buildup of excess fluid. Lymphedema can be a side effect of breast cancer surgery or radiation therapy. This usually develops in the arm or hand, but sometimes it can affect the breast, chest, underarm, trunk, or back. If breast cancer spreads, it tends to move into the underarm lymph nodes because these nodes drain lymph from the breast. That’s why breast cancer surgeons often remove at least two or three lymph nodes from under the arm — called a sentinel lymph node biopsy (SLNB). When surgeons have to remove many or most of the underarm nodes, it’s called an axillary lymph node dissection (ALND). These surgeries can cut off or damage some of the nodes and vessels that make up the pathways that lymph moves through.

Over time, lymph can build up and overwhelm the remaining pathways, resulting in lymphedema — sometimes months or even years after breast cancer treatment ends. Radiation treatments also can affect the lymphatic system. The risk of radiation-related lymphedema is highest in people who receive radiation directly to the underarm because it’s where most of the lymph nodes are located. Because lymphedema tends to develop gradually, you may feel an unusual sensation — such as tingling or numbness — that comes and goes before you notice any visible swelling. But sometimes swelling can happen suddenly, without any warning signs. Other common symptoms of lymphedema include achiness, fullness or heaviness, puffiness or swelling, and decreased flexibility or tightness in the affected areas.

Lymphedema also can lead to infections that spread through the body, so it’s important to tell your doctor if you experience any of these symptoms so you can get treatment as early as possible. There’s no way to know for sure whether you might develop lymphedema after breast cancer treatment, but you can help yourself by: knowing your risk factors taking steps to reduce your risk being aware of early symptoms Left untreated, lymphedema can worsen and cause severe swelling and permanent changes to the tissues under the skin, such as thickening and scarring.

Breast Lymphedema Treatment

Lymphedema is a problem that may occur after cancer surgery when lymph nodes are removed. Lymphedema can occur months or years after treatment. It’s a chronic (ongoing) condition that has no cure. But steps can be taken to help keep it from starting, and to reduce or relieve symptoms. If left untreated, lymphedema can get worse. Getting treatment right away can lower your risk of infections and complications.

What is the lymphatic system?

The lymphatic system is a network of tiny vessels and small, bean-shaped organs called lymph nodes that carry lymph throughout the body. Lymph is a clear, colorless fluid that contains a few blood cells. It starts in many organs and tissues. The lymphatic system is part of your immune system. It helps protect and maintain the fluid balance of your body by filtering and draining lymph and waste products away from each body region. The lymphatic system also helps the body fight infection.

How Lymphedema Happens

During surgery for cancer, nearby lymph nodes are often removed. This disrupts the flow of lymph, which can lead to swelling. This is lymphedema. Lymphedema can affect one or both arm, the head and neck, the belly, the genitals, or the legs. Swelling can worsen and become severe. Skin sores or other problems can develop. Affected areas are also more likely to become infected.

Often during breast cancer treatment, some or all of the lymph nodes under the arm are treated with radiation. The lymph nodes under the arm are also called the axillary lymph nodes. They drain the lymphatic vessels from the upper arms, from most of the breast, and from the chest, neck, and underarm area.

When many lymph nodes under the arm have been removed, a woman is at higher risk of lymphedema for the rest of her life. Radiation treatments to the under arm lymph nodes can cause scarring and blockages that further increase the risk of lymphedema. Lymphedema may occur right after surgery or radiation, or months or even years later.

Types of Lymphedema

There are several types of lymphedema:

  • A mild type of lymphedema can occur within a few days after surgery and usually lasts a short time.
  • Lymphedema can also occur about 4 to 6 weeks after surgery or radiation and then go away over time.
  • The most common type of lymphedema is painless and may slowly develop 18 to 24 months or more after surgery. It does not get better without treatment.

Lymphedema can happen any time after surgery or radiation to the lymph nodes. The risk continues for the rest of the person’s life. Lymphedema can’t be cured, but it can be managed. Any swelling should be checked by a healthcare provider right away.

There’s no way to know who will and won’t get lymphedema, but there are things that can be done to help prevent it.

Can lymphedema be prevented?

Women treated for breast cancer who have good skin care and who exercise after treatment are less likely to develop lymphedema. Newer types of lymph node surgery have also helped decrease lymphedema risk. But there is no sure way to prevent lymphedema.

Symptoms of Lymphedema

The main symptom of lymphedema after breast cancer treatment is swelling of the arm on the side where lymph nodes have been removed. The amount of swelling may vary. Some people may have severe swelling (edema) with the affected arm being several inches larger than the other arm. Others will have a milder form of edema with the affected arm being slightly larger than the other arm.

Other symptoms of lymphedema may include:

  • Feeling of fullness, heaviness, or tightness in the arm, chest, or armpit area
  • Bra, clothing, or jewelry don’t fit as normal
  • Aching or new pain in the arm
  • Trouble bending or moving a joint, such as the fingers, wrist, elbow, or shoulder
  • Swelling in the hand
  • Thickening of or changes in the skin
  • Weakness in the arm

If you notice any of these symptoms, see your healthcare provider right away. Treatment needs to be started right away to keep lymphedema from getting worse.

How is lymphedema diagnosed?

There are no tests for lymphedema. Instead, your healthcare provider will ask about your medical history and give you a physical exam. You’ll be asked about:

  • Past surgeries you’ve had
  • Any problems after your surgeries
  • When the swelling started
  • If you’ve had severe swelling (edema) in the past
  • What medicines you’re taking
  • What other health conditions you have, such as high blood pressure, heart disease, or diabetes

Imaging tests, measures of volume, blood tests, and other tests may be used to diagnose lymphedema.

Treatment for Lymphedema

Treatment depends on how severe the problem is. Treatment includes ways to help prevent and manage the condition, and may include:

  • Exercise. Exercise helps improve lymph drainage. Specific exercises will be advised by your doctor or physical therapist.
  • Bandages. Wearing a compression sleeve or elastic bandage may help to move fluid, and prevent the buildup of fluid.
  • Diet and weight management. Eating a healthy diet and controlling body weight is an important part of treatment.
  • Keeping the arm raised. Raising the arm above the level of the heart when possible lets gravity help drain the fluid.
  • Preventing infection. It’s important to protect the skin in the affected area from drying, cracking, infection and skin breakdown. Your healthcare provider will advise you about how to care for your skin and nails to help prevent problems.
  • Massage therapy. Massage by someone trained in lymphedema treatment can help move fluid out of the swollen area.

how to avoid lymphedema after lymph node removal

Lymphedema is the accumulation of protein rich fluid that occurs when the ability of the lymphatic system to transport interstitial fluid is exceeded. This devastating disorder affects an estimated 3–5 million Americans and a staggering 140–200 million people worldwide 1. In the United States and Western countries, lymphedema occurs most commonly as a complication of lymph node dissection for cancer treatment. It is estimated that as many as 30–50% of patients who undergo lymph node dissection go on to develop lymphedema2, 3. Lymphedema can even occur after less invasive procedures such as sentinel lymph node dissection thereby putting nearly all cancer survivors at risk for this dreaded complication4. Although lymphedema occurs most commonly as a complication of breast cancer management, it is also seen frequently in patients treated for other solid malignancies. In fact, a recent meta-analysis of nearly 8000 patients reported an overall incidence of 16% in patients treated for gynaecological, melanoma, urologic, sarcoma, and head and neck malignancies5.

Patients with lymphedema have chronic, progressive swelling, pain, recurrent infections, and significantly decreased quality of life. The swelling can progress to gigantic proportions causing gross disfigurement with severe detrimental effects. In addition, lymphedema is a significant source of biomedical expenditures with one recent study demonstrating a more than $10,000 increase in the annual treatment costs of cancer survivors with lymphedema as compared with those without lymphedema6.

Treatment for lymphedema remains suboptimal and is, in most cases palliative with a goal of preventing disease progression rather than a cure. Medical and surgical treatments have been reported but in general these therapies have been disappointing and the results sometimes difficult to reproduce. In most instances, patients are treated with life-long physical therapy with manual lymphatic drainage and require tight fitting, uncomfortable elastic garments. Due to the expense, time, and discomfort associated with these treatments, there is a high degree of non-compliance and associated disease progression.

Despite the morbidity and costs of lymphedema, the mechanisms that regulate its development remain largely unknown. It remains unclear for instance why some patients develop lymphedema and others who are identically treated do not. Similarly, it is unknown why certain risk factors such as radiation, obesity, or infection increase the risk of lymphedema. Perhaps the most perplexing aspect of lymphedema is the fact that it develops in a delayed manner usually 1–5 years after surgery. Sometimes lymphedema can develop even decades after surgery after seemingly trivial trauma. This gap in our knowledge has prevented development of targeted treatment options.

Similarly, our lack of understanding of the cellular and molecular mechanisms in the development of lymphedema have complicated effective preventative strategies. In fact, many of the current recommendations for prevention of lymphedema are anecdotal with scant scientific evidence. The current recommendation from the National Cancer Institute 7, The Royal Marsden Hospital (UK) 8 and The National Lymphedema Network (NLN) 9 are presented in table 1. However the NLN state that there is little evidence-based literature with respect to many of these recommendations and the majority of them are based on what is known through decades of clinical experience and comprehension of the pathophysiology by experts in lymphedema.

Table 1

Preventative recommendations for lymphedema (adapted from the NCI, The Royal Marsden Hospital and NLN (2, 3, 4).

The purpose of this systematic review was to evaluate the current recommendations for prevention of lymphedema and present current scientific evidence supporting or disputing these claims.

Methods

Search Strategy

A review of preventative measures for lymphedema was performed by using a search strategy that included the key terms: “lymphedema/lymphoedema, preventative measures, myths, advice, recommendations, air travel, venipuncture/blood drawing/phlebotomy, blood pressure measurement, blood pooling, exercise, burns, extreme temperatures or hot or cold or heat, obesity, leg crossing or venous pressure and lymphedema”.

The search terms were applied to electronic bibliographic databases (Medline, SCOPUS, and Google Scholar) to find all relevant studies. No limits were applied to year of study; however, we did exclude publications that were not in the English language. Only studies describing risk factors for lymphedema or suggestions to prevent lymphedema were included. Relevant articles not found in the electronic bibliographic search were sought by a hand search review of references, tables used and abstracts from each article.

Data Extraction

Data was extracted into a database developed for this systematic review. The database was pilot tested on 5 articles randomly selected that were to be included, and was adjusted as necessary. The data extracted included, author, year of publication, evidence level of study and recommendations made or disputed. Studies were subsequently categorized as levels 1–5 scientific evidence based on the US Agency for Health Care Research and Quality (Table 2) 10.

Table 2

Results

Our literature search identified 763 papers of which 49 met inclusion criteria for review. These studies were grouped into 7 broad categories related to their recommendations: 1) Avoidance of needle sticks, 2) Avoid limb constriction, 3) Elevate the limb, 4) Avoid air travel and wear compression garments when flying, 5) Maintain normal body weight, 6) Avoid extremes of temperature and sunburns and 7) Avoid vigorous exercise.

Avoidance of needle sticks

This is perhaps the most common preventative measure for patients at risk for developing lymphedema and is based on the concept that these injures may lead to infection and hence development or exacerbation of lymphedema. Most hospitals recommend this even in patients who have undergone sentinel lymph node biopsy. Patients are often designated with armbands and other measures to avoid accidental or inadvertent blood draws/needle sticks. Patients and clinicians often go to great lengths to adhere to this recommendation by performing blood draws from foot veins or having central venous catheters placed.

The historical source of this recommendation probably dates back to Halstead who in 1921, hypothesised that post-surgical infection or infection was the underlying cause of swelling of the arm following breast cancer surgery 11. Unfortunately, the vast majority of evidence that opposes or supports this recommendation is of poor scientific quality (level 4 or 5). Most reports are small series and anecdotal observations. For example, in a retrospective study of 79 patients treated with breast cancer, Villasor’s level 3 study reported that 3 patients developed lymphedema immediately after venipuncture of the affected arm and based on this finding proposed that venipuncture of the affected arm should be avoided.12. Similarly, Britton and Nelson in 1962 performed a level 4 retrospective study to identify etiological factors for 114 patients who developed lymphedema after radical mastectomy and reported that 53% of these patients had a history of recurrent cellulitis following either an insect bite, cat scratch, needle or thorn prick with a marked increase in swelling or pain in their arm 13. They concluded that any mode of bacterial entry could trigger development of cellulitis and lymphedema leading to the recommendation of avoiding venipuncture and meticulous skin care to avoid development or exacerbation of lymphedema. Interestingly, this is the only reference in the literature that we encountered reporting a potential link between needle sticks and infection and appears to be the only evidence for the underlying rationale of this recommendation. A level 5 study by Smith and colleagues reported that 10 patients referred to the lymphedema service over a 2 year period reported a direct correlation with venipuncture and the onset of new swelling in their arms 14. Similarly, in an unusual level 4 report, Brennan et al described a case of a 78 year old woman who developed lymphedema 30 years after a left radical mastectomy after performing needle sticks for blood monitoring for her newly diagnosed diabetes 15. Other studies have never been published but were rather only reported at scientific conventions. Foldi, et al cite Harlow and colleagues at the 18th convention of the International Society of Lymphology (ISL) 2001, in which they reported a significantly increased rate of lymphedema in a group of 252 patients after venipuncture. No details or other data were provided 1.

Clark, Sitzia and Harlow performed the only level 2 prospective observational study in 2004 examining the incidence and risk factors (including hospital skin puncture) for arm lymphedema in patients with breast cancer 16. They measured limb circumference pre-operatively and at regular time periods post-operatively in 188 women who had undergone treatment for breast cancer. The authors reported that 8/18 (44%) patients who had any needle stick developed lymphedema as compared with 31/170 (18%) patients who did not have venipuncture, concluding that skin puncture statistically significantly increased the risk of lymphedema 16. The authors, however, did not report the timing of lymphedema development in relation to venipuncture and did not evaluate the effect of potential confounding variables that may alter the rate of lymphedema. In addition, although the measurements were made prospectively, the analysis was retrospective and no “randomization” was done.

Other retrospective case series have suggested that venipuncture does not increase the risk of lymphedema development after lymphadenectomy. Cole reported no cases of lymphedema development in a level 4 retrospective audit of 14 patients who had “non-accidental skin puncturing” with a 2 month follow up of the at risk limb 17. Similarly, in their level 4 study, Winge et al analyzed the results of a questionnaire administered to 348 patients treated for breast cancer. Of the 311 respondents, 88 reported a history of intravenous procedures on the affected side but only 4 developed swelling as a complication in relation to venipuncture 18. This finding led the authors to conclude that intravenous procedures on ipsilateral arms pose a very low risk of complications such as lymphedema however they acknowledge that their sample size is small, and the study is retrospective, advocating a need for larger multi-centred studies.

Avoid Limb Constriction

Similar to the edict on avoidance of venipuncture, the general recommendation to avoid pressure on the affected limb also appears to be based on limited scientific data. The root of this recommendation can probably be traced back to Drury and Jones who hypothesized that increased venous pressure resulted in edema 19. More recently, Petrek et al, and Louden and Petrek hypothesized that blood pressure monitoring, tight bands or clothing, or other interventions increased blood pressure in the at risk limb and that this effect would lead to increased lymph production 20,21. They also hypothesized that tight garments could lead to fibrosis and stenosis of lymphatic vessels thereby resulting in obstruction of lymphatic flow. Other authors have echoed these sentiments hypothesizing that tight, constrictive clothing (especially bra straps, waistbands, or socks) constrict collateral circulation hence are risk factors for lymphedema but also this statement is made with no explanation 22. However, there is little scientific evidence for these statements and the precise relationship between blood flow and lymphatic fluid production remains unknown.

Some groups have challenged the concept that pressure on the affected extremity should be avoided. For example, Greene et al suggested that the use of blood pressure cuffs in patients with established lymphedema should not be contraindicated as the management strategy for these patients relies primarily on compression 23. Patients routinely use compression garments and pneumatic pumps with pressures between 40–200 mm Hg for hours at a time over many months. Similarly, in a retrospective report of 47 patients with a history of breast cancer associated lymphedema, Assmus and Staub reported that short applications (10 minutes) of pneumatic tourniquets for treatment of flexor retinaculum release resulted in no adverse effects 24. Fulford et al conducted a level 4 online survey of hand surgeons, breast surgeons, and breast care nurses to determine if they felt that previous axillary lymph node dissection was a contra-indication to hand surgery. Interestingly, 58% of hand surgeons responded that lymphadenectomy was not a contraindication to elective hand surgery using a tourniquet. In contrast, 70% of breast surgeons and 90% of breast care-nurses felt that elective hand surgery in these patients was contraindicated. Similarly, when asked about the use of compression tourniquets, 79% of hand surgeons reported that this usage was not contraindicated while only 57% of breast surgeons and 68% of breast care nurses advised against this use 25. Similar findings were reported in another level 4 survey of Hand surgeons in the American Society of the Hand. Of the 617 responders (1200 questionnaires were mailed) the majority stated that they would operate on patients with a history of axillary dissection. Nearly all surgeons (98.7%) would operate on patients with axillary surgery who do not currently have lymphedema, while the majority (85.4%) would do so even in patients with established lymphedema. Similarly, the majority (74.1%) felt there was no contraindication to the use of a pneumatic tourniquet in patients with lymphedema 26. These studies highlight that the fact that professional opinions differ significantly, this is likely related to paucity of reliable scientific studies.

In an effort to better address this question, Dawson et al retrospectively reviewed 317 patients who had undergone elective carpal tunnel release in their level 4 study. With a follow-up of 16 months, the authors reported no new cases of lymphedema, worsening lymphedema symptoms, or infections among the 15 patients in the cohort who had a history of breast or axillary surgery. This finding led the authors to conclude that patients with previous breast or axillary surgery should not be denied elective hand surgical procedures based on the idea that this puts them at increased risk of complications such as infection or lymphedema 27. This concept was supported in a level 4 study by Hershko and Stahl who reported no new cases of lymphedema and no cases of long-term worsening of lymphedema symptoms after elective hand surgery in 25 patients with a history of axillary lymph node dissection 28. These findings support the concept that compression is not a significant risk factor for development of lymphedema in at risk patients. In addition, given that hand surgery is an invasive procedure with skin incisions and subsequent wound healing, these findings can also be interpreted to suggest that loss of skin integrity in a controlled and sterile manner does not increase the risk of lymphedema.

Elevate the Limb

Recommendations concerning limb position are based on blood pooling and resultant increased venous pressure in the affected extremity. Similar to other commonly accepted preventative measures, there is little scientific evidence to support this recommendation. For example, keeping the extremity elevated above the level of the heart is useful for edema in general but probably less helpful in the setting of lymphedema due to the high oncotic pressure of lymphatic fluid. Similarly, crossing the legs is thought to hinder venous return and increase venous pressure in the affected extremity 29,30,31. It has been postulated that decreased activity of the calf-muscle pump or prolonged standing or sitting will result in pooling of blood in the lower extremity resulting in increased venous pressure and interstitial fluid leakage. Chronically increased lymphatic fluid stasis resulting from these postural changes are then thought to promote tissue fibrosis and worsen lymphedema 29. Although these hypotheses seem putatively possible, the exact relationship between venous pressures and lymphatic fluid accumulation remains unknown.

Avoid air travel and wear compressive garments on flights

Patients with a history of lymph node dissection are often told to avoid air travel or wear compressive garments (even if they do not have lymphedema) when flying. Unfortunately, as with many other recommended preventative measures, this guideline appears to have little scientific evidence supporting it. Ward and colleagues presented case reports (level 5) of lymphedema development after air travel and cited anecdotal rates of lymphedema development in 5–30% of at risk patients by The National Breast Cancer Centre of Australia 32. Casley-Smith (1996) reported a questionnaire based retrospective study (level 4) in an effort to determine the triggers that led to lymphedema development (infection/insect bite/plane flight/burn/other/unknown) 33. 531 patients responded (1020 surveys were sent) and of these 27 reported that their symptoms started after an aircraft flight. In addition, 67 patients reported worsening of existing lymphedema after flying. These findings led the authors to conclude that lymphedema can be triggered by travelling on aircrafts and may be due to reduced activity or lower cabin pressure for long periods of time resulting in pooling of blood in the limbs. However, the authors acknowledge that this is merely a speculation with no direct evidence.

Other retrospective studies have suggested that air travel has little effect on the development of lymphedema. For example, Graham and colleagues surveyed 293 breast cancer survivors about changes in arm circumference and airplane travel (level 3) and found no cases of permanent new onset lymphedema in this cohort 34. In fact, patients who had taken precautions when flying, such as using compression garments, were actually more likely to develop lymphedema or have progression of their existing lymphedema than those who had not. Similarly, Kilbreath et al prospectively assessed the impact of flying on at risk limbs in breast cancer patients (level 2) by evaluating patients who had flown from Canada to Australia to attend a dragon boat regatta. They found no adverse changes in impedance ratios comparing the normal limb to the at risk limb in 95% of patients when comparing pre and post flight measurements. The authors acknowledged that the subjects in this study had trained for dragon racing and that this exercise may have had a protective effect 35.

Maintain a normal body weight

The clinical evidence supporting this recommendation is strong and derived from multiple studies including level 1 evidence. Early case reports and retrospective studies demonstrated a significant increase in the rate of lymphedema development in obese patients 36–39. In one of the largest early studies aiming to identify risk factors for development of lymphedema, Treves et al evaluated 768 patients following mastectomy and axillary lymph node surgery over a 5 year period (level 3). The overall rate of lymphedema in the entire cohort was 41%. The rate of lymphedema in obese patients (they defined by patients over 150lbs) was nearly double that of non-obese patients (49% vs. 28%) and highly statistically significant. Furthermore, the severity of lymphedema also correlated with obesity leading the authors to conclude that obesity is a significant predisposing risk factor 40.

In a more recent study, Werner and colleagues set out to identify risk factors contributing to the development of arm edema after conservative management of breast cancer. Their prospective level 3 study found that the only significantly associated variable in the development of arm edema was increased BMI; furthermore, increased BMI was associated with increased frequency and severity of lymphedema 41. These findings were supported by Helyer et al in their prospective level 3 study following 137 patients after diagnosis with early stage breast cancer and arm circumference measurements at 6 month intervals for a median of 20 months (range 6–36 months). Similar to Werner et al, this study demonstrated a significant increase in arm volume in patients with a BMI as a continuous variable; patients with a BMI greater than 30 had a more than two-fold increased risk of lymphedema 42. Ridner found an even higher risk of lymphedema (3.6 fold) in obese patients in a prospective longitudinal study (level 2) of 138 breast cancer patients followed for 30 months with arm volume and weight measurements at 3-month intervals 43. Long-term studies have also demonstrated significant increases in the risk of lymphedema development in obese patients. In another level 3 study of 263 breast cancer survivors followed for 20 years after initial treatment, Petrek and colleagues found an astounding overall lymphedema rate of 49% with a 13% rate of severe lymphedema 3. They demonstrated that obesity at the time of diagnosis or weight gain after diagnosis were significant risk factors for development of lymphedema. Similar results were demonstrated more recently by McLaughlin and colleagues in a level 2, 5-year prospective study of nearly 1000 patients, treated with axillary lymph node dissection or sentinel lymph node biopsy4. Even mild increases in body weight appear to increase the risk of lymphedema as evidenced by higher rates of lymphedema in patients with a BMI greater than 25 in a prospective follow-up study of 240 patients treated with breast cancer 44.

In an interesting, though small, level 1 randomised clinical trial of 21 patients, Shaw and colleagues found that interventions designed to promote weight loss was associated with a significant decrease in excess arm volume (9% decrease overall) 45. These findings led the authors to conclude that interventions designed to maintain or decrease body weight after surgery can be an effective means of decreasing arm volumes and by inference lymphedema.

While it is clear that obesity is a significant risk factor for the development of lymphedema, the cellular and molecular mechanisms that are responsible for this effect remain unknown. It has been hypothesized that obese patients undergo more extensive surgery resulting in more injury to the lymphatic system. Alternatively, it has been suggested that the heavier limb in obese patients may act as a reservoir for lymphatic fluid. It is also possible that obesity is associated with increased inflammation either with or without overt infection and that this effect may increase tissue fibrosis and lymphatic dysfunction. These are important clinical questions that warrant further study.

Avoid extremes of temperature and sunburns

The NLN and the Lymphedema Framework in the UK advise patients at risk for developing lymphedema to avoid exposure to extreme cold, which can be associated with rebound swelling, to avoid prolonged (greater than 15 minutes) exposure to heat, particularly hot tubs and saunas and avoid placing limbs in water temperatures above 102°Fahrenheit (38.9°Celsius). 9, 46 In addition, patients are advised to apply sunscreen to the affected limb and avoid excessive sun exposure. These precautions are based on the concept that heat or rebound increase circulation from cold exposure may increase blood flow and as a consequence increase lymphatic load 22.

Interestingly, the few studies that have been done to study the effect of heat on lymphedema appear to show positive rather than negative results from heat exposure. Heat therapy is strongly advocated by traditional Chinese medical literature for the treatment of lower extremity elephantiasis47. For example, Zhang Ti-Sheng reported positive results in over 1000 patients treated with heat therapy for lower extremity lymphedema 47. Similarly, Chang reported that microwave heat therapy resulted in significant reductions in limb edema in 85 out of 98 patients (level 2) 48. More than three quarters of patients had reductions of at least 50%. The authors confirmed their findings in a level 1 double blind randomized study 49. Similar positive findings were reported in a level 2 study of 45 patients with upper extremity lymphedema secondary to breast cancer treatment 50. Liu and Olszewski used microwave and hot water immersion hyperthermia therapies on 12 patients with leg lymphedema (level 2) and reported that heating was associated with reduced girth and volume of affected legs, with near resolution of lymph lakes 51. They hypothesised that regional heating resulted in an altered immune response, changes in extracellular matrix protein composition, and greater pliability of tissues leading to decreased edema.


post mastectomy lymphedema a treatment protocol

Lymphedema is swelling in the arm or hand and sometimes in the breast or chest wall that can be very uncomfortable.

It can occur when some or all of the axillary (underarm) lymph nodes are removed as part of treatment for breast cancer. It can also happen after the axillary lymph nodes have received radiation. In both instances, the lymphatic fluid that’s normally filtered from the tissue collects and causes swelling.

Signs of lymphedema include:

If you’re experiencing lymphedema after breast cancer surgery or radiation therapy, the experts at Memorial Sloan Kettering recommend prompt treatment. For many women, lymphedema therapy can be extremely helpful. It’s important to note that there is no known cure for lymphedema at this time. However, the approaches described here may help ease symptoms. MSK’s researchers are actively seeking out ways to both prevent and cure this painful condition.

What Is Lymphedema Therapy?

The first step to getting help is making an appointment with an expert trained in lymphedema therapy. Also known as complete decongestive therapy (CDT), it brings together three major therapies — massage, compression, and exercise. It also involves self-care related to skin health, eating well, and other recommendations you can practice at home.

MSK physicians, nurses and other healthcare professionals are experts in breast cancer surgery, reconstruction, radiation oncology and more.

If CDT is not effective, there are other options you may want to consider. Some women choose to have a new, innovative surgery called lymph node transplant designed to improve lymphatic circulation and decrease symptoms. Others may wish to consider pain management approaches.

Here you can find in-depth information on the individual therapies used to help women with lymphedema related to breast cancer.

A compression sleeve is a tight-fitting elastic garment that can be worn on the arm or hand to help drain the lymphatic fluid from your arm. It is one of the garments your lymphedema therapist may recommend as part of complete decongestive therapy. Other types of compression garments include:

Some women may also wear special compression bandages.

It’s important to wear compression garments when you are participating in sports or going on an airplane. Your lymphedema therapist can help you choose the type of compression garment that’s right for you. Certain types of garments may require a custom fitting.

Lymphedema exercises are another key component of complete decongestive therapy. The purpose of exercises for lymphedema is to reduce the volume of lymphatic fluid in the arm or other affected area. Generally, these are light exercises that can help you with your daily activities, such as dressing, carrying packages, or doing household chores.

Most women start out with a series of simple stretches designed to mobilize muscles, joints, and scar tissue. Your lymphedema therapist can show you which exercises would most benefit you. It’s important to increase the intensity of the exercise slowly so that your arm muscles have time to adjust.

Manual lymph drainage is a specialized type of massage. Gentle massage techniques help direct excess lymph fluid away from affected body areas toward regions that can support drainage.

Women at risk of lymphedema or with early symptoms of heaviness or discomfort experience benefits such as reduced pain and discomfort, relaxation, and stimulation of the lymphatic system.

There are many other types of massage, including myofascial release and lympho-fascial release, that can help ease the symptoms of lymphedema. We recommend speaking with your lymphedema therapist to find out which approaches might be best for you.

Cancer-related lymphedema may be prevented or treated through specialized surgical techniques. If lymph nodes are being removed as part of the surgery to treat your cancer, these procedures can be done at the same time to reduce your risk of lymphedema. They can also be performed in patients who already have lymphedema to reduce symptoms.

One technique, called lymphovenous bypass, involves redirecting lymphatic vessels of the arm or leg into nearby veins. Another procedure is lymph node transplantation, which involves taking healthy lymph nodes from one part of the body (called the donor site) and moving them to the area under the arm. Our surgeons may also use liposuction to remove fatty tissue that is deposited by lymphedema.

Neurostimulation involves stimulating the nervous system or giving medications that directly affect the nervous system to relieve pain.

MSK’s experts offer several of these pain management approaches, including stellate ganglion block and thoracic sympathetic block. These are types of nerve blocks. In these procedures, an anesthesiologist gives injections with local anesthetic and occasionally steroids to the nerves that provide feeling to a certain part of the body.

Which type of nerve block may help you depends on where you’re experiencing the pain. A stellate ganglion block affects nerves that go to the arms, whereas a thoracic block affects nerves that go into the chest wall, breast area, and armpit. Usually more than one injection is required.

For shoulder pain brought on by lymphedema, we can offer a nerve block as well as transcutaneous electrical nerve stimulation.

For longer-term pain control, intrathecal drug delivery or spinal cord stimulation may be good options.

Sometimes an injury, infection, burn, or other trauma to the arm triggers lymphedema. Studies have also shown that gaining weight after breast cancer treatment can strain the lymphatic system. Many studies indicate that the risk for developing lymphedema varies based on how the lymph nodes are taken out.

It’s difficult to determine the risk of developing lymphedema because there’s no standard test for diagnosing it. Disruption of lymph flow affects people differently, and lymphedema can develop soon after surgery or years later.

how common is lymphedema after lymph node removal

Lymphedema is a problem that may occur after cancer surgery when lymph nodes are removed. Lymphedema can occur months or years after treatment. It’s a chronic (ongoing) condition that has no cure. But steps can be taken to help keep it from starting, and to reduce or relieve symptoms. If left untreated, lymphedema can get worse. Getting treatment right away can lower your risk of infections and complications.

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