Breast cancer-related lymphedema is abnormal swelling that can develop in the arm, hand, breast, or torso on the side treated for breast cancer.
It is a chronic, progressive, debilitating, disfiguring and painful negative effect of breast cancer and its treatment.
Lymphedema can develop suddenly or gradually. It can happen soon after surgery or can develop months or years later. While there is no way to know for sure if you will develop lymphedema, every breast cancer survivor has a life time risk of developing it and risk goes on increasing as the follow up period increases. Although, the estimates of incidence rates have varied over time especially since the progression to less invasive surgical techniques.
It not only appears in fingers, forearm, arm but also shoulder, breast, chest & back. Truncal lymphedema or the lymphedema affecting breast, chest & back is the part most people are ignorant about and a result of this is that 70% of truncal lymphedema are not reported.
WHAT IS THE LYMPHATIC SYSTEM?
To better understand lymphedema, we must understand the lymphatic system. The lymphatic system functions parallel to the circulatory system and consists of lymphatic vessels, lymph nodes and lymphoid tissue. The most important role of the lymphatic system is to absorb and transport large molecules (including protein and cellular debris) which are too large to be collected by veins and venous capillaries.
SO, WHAT IS LYMPHEDEMA?
Fluid from blood circulation diffuses through the thin walls of the capillaries into the interstitial space from where the oxygen & nutrients are supplied to the cells. 80% of this fluid re-enters the venous system & 20% is transported through lymphatic system as lymph to lymph nodes that act as “filtering stations” and then to the venous trunks into the blood circulation.
Lymph contains proteins, water, cellular component and fat.
When there is any disruption of the lymphatic transport system, lymphedema appears which is the collection of protein rich fluid (lymph) in the interstitial space.
WHAT CAUSES BREAST CANCER RELATED LYMPHEDEMA?
During breast cancer treatment a patient undergoes surgical procedures either modified radical mastectomy or lumpectomy which may be combined with axillary lymph node dissection (ALND) or sentinel lymph node biopsy (SLNB), radiation and chemotherapy.
The surgical procedures cause disruption of lymphatic flow whereas radiation treatment to axillary area, chest & breast causes scarring and blockage of lymph vessels as well as lymph nodes. These changes increase the risk of BCRL. Here I’ve listed all the potential risk factors for developing Lymphedema:
Lumpectomy
Mastectomy
Lymph node removal (sentinel node biopsy or axillary dissection)
Radiation therapy to your chest, armpit and/or neck
An infection or seroma after surgery
Injury to the surgical area or the affected arm
Weight gain after treatment or being overweight.
WHAT ARE THE SYMPTOMS OF LYMPHEDEMA?
Feeling of fullness, heaviness or tightness in arm or armpit area.
Pain / aching in the arm & shoulder region.
Weakness in the arm on the operated side.
Swelling of arm on the side where lymph nodes have been removed.
Trouble bending or moving joints such as the fingers, wrist, elbow or shoulder.
Anterior chest wall swelling that is most commonly located in the affected breast, or chest wall, over the collarbone (area of neck), underarm, along scar lines.
Swelling of the back usually appears as extra rolls of fat along the side of trunk, fullness over the shoulder blades and fullness across the waistline on the affected side of trunk.
If breast reconstruction has been done, the reconstructed breast appears too large, misshapen & uncomfortable during daily activities.
Bra, clothing, jewelry & wrist watches don’t fit as normal.
Bra belt digs in the shoulder.
Dryness or thickening of arm skin on affected side.
RISK REDUCTION PRACTICES
ACTIVITY/ EXERCISE/ LIFESTYLE
Exercise and stretch your muscles on a regular basis. Don’t overwork your body; if you feel discomfort, take a break.
Gradually build up the duration and intensity of any activity or exercise.
Maintain or safely work towards a healthy body weight. Obesity is known to be a major risk factor. Weight management reduces chances for the onset of lymphedema as well as reduces risk of worsening the course of lymphedema.
Post-surgery the range of movement should be limited to 90 degrees for 7-14 days to avoid seroma formation & encourage lymphatic regeneration. There after the range of movements are decided after re-examination.
SKIN CARE - AVOID TRAUMA/ INJURY TO REDUCE INFECTION RISK
Keep the limb clean & dry. Special attention to the areas between the fingers or the skin folds when drying and applying lotion.
Apply low pH moisturizers daily to prevent chapping of skin.
Attention to nail care, do not cut cuticles.
Protect exposed skin with sunscreen with SPF of at least 30. Reapply it often.
Use insect repellent to avoid stings and bug bites.
Be careful if you shave under your at-risk arm; consider using an electric razor. Avoid nicks and irritation.
Wear gloves when washing dishes, gardening, or cleaning with harsh detergent.
Use thimble while sewing
If you get a cut or scratch on your at-risk arm or hand, clean the area with soap and water and apply antibacterial ointment. Cover the area with a bandage.
If you get a burn on your at-risk arm or hand, apply a cold pack or cold water for 15 minutes, clean the area with soap and water, and cover it with a bandage.
Watch for signs of infection, including redness, swelling, increased temperature of limb and limb tenderness.
Do not use saunas, long hot water showers or hot water baths.
No massage to the limb on the affected side.
Be wary of blood draws and injections in your at-risk arm:
If you had a sentinel lymph node biopsy, it’s better to have your blood drawn and shots given on your arm that’s not at risk for lymphedema. However, you can use your at-risk arm if needed. Inform the health provider of your risk to ensure they take necessary precautions.
If you had an axillary lymph node dissection, always use your arm that’s not at risk, unless your doctor tells you it’s okay.
Lymph nodes were removed on both sides of your body, talk with your doctor about which arm would be safest to use or other parts of the body.
AVOID LIMB CONSTRiCTION
Avoid tight fitting or heavy jewelry or watches.
Do not apply BP cuff to the arm on the affected side.
Do not wear shirts with elastic sleeves which leave a mark on your arm.
Use well supportive bras with broad shoulder straps, no underwire support.
EARLY DETECTION
Early diagnosis and treatment are vital in effective management of breast cancer lymphedema.
The steps for early detection of BCRL starts with assessment of relevant baseline measurements before surgery.
Range of movement of upper limb.
Baseline posture.
Arm circumference.
Weight / BMI
Level of activity/ exercise
After surgery the serial measurements of the arm on the affected side are compared to pre-surgery measurements which helps in early diagnosis of lymphedema. 1-2 cm post-operative edema of the arm on side of surgery is expected up to 6 weeks.
Evidence indicates that early detection of latent lymphedema offers an opportunity to identify and treat lymphedema more successfully when lymphedematous components are still in the fluid stage and reversible which helps to avoid progression into an “Irreversible stage”. When lymphedema is diagnosed late, the fibrous tissue formed affects the outcome to the therapy.
Lymphedema cannot be cured but it can be managed, and the condition can be reversed near to normal.
The gold standard management for lymphedema is Complete Decongestive Therapy (CDT) which is multicomponent treatment system carried out by certified lymphedema therapist(CLT).
It includes:
Manual lymphatic drainage
Compression therapy
Decongestive & breathing exercises
Skin and nail care
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