ReviewLymphedema following axillary lymph node dissection for breast cancer
Introduction
Arm lymphedema is a distinct clinical entity, first described by Halsted, in 1921, as “elephantiasis chirirgica” [1]. During the last decades, many studies have reported a wide range of both subjective and objective prevalence rates for arm lymphedema in breast cancer patients following excision of axillary lymph nodes. Nowadays, lymphedema is considered as a relatively common, potentially serious and unpleased complication after axillary lymph node dissection (ALND) that can cause functional, cosmetic, and psychological problems and can interfere with the quality-of-life (QOL) of breast cancer patients. Moreover, lymphedema can predispose to the development of other, long-term, “epigenic” complications.
The aim of this paper is to present currently available data regarding the definition, pathophysiology, incidence, prevention, and management of this post-ALND complication.
Section snippets
Anatomy—pathophysiology
Lymph fluid is formed as a result of pressure forces at the arterial side of a capillary bed. At the arterial end of a capillary, the hydrostatic pressure of the blood overcomes the colloid osmotic pressure of the plasma protein. At the venous end, the hydrostatic pressure has fallen to below the colloid osmotic pressure and re-absorption occurs by osmosis. About one-tenth of the filtered fluid enters the lymphatics [2], [3]. Under normal conditions, interstitial fluid is in balance with
Definition–classification–diagnosis
Lymphedema is defined as an abnormal, generalized, or regional accumulation of protein-rich interstitial fluid, resulting in edema formation and eventually in chronic inflammation with or without fibrosis. Lymphedema occurs primarily as a consequence of malformation, underdevelopment, or acquired disruption of the lymphatic circulation.
Lymphedema is commonly classified as primary or acquired (secondary) and as acute or chronic. In breast cancer patients, arm lymphedema is always acquired
Incidence
Lymphedema represents one of the most common complications after ALND. It has been estimated that, currently, approximately 400,000 patients in the USA are afflicted with lymphedema of the upper extremity [24]. The variety of methods used to define lymphedema, in association with the great variability of procedures and radiation treatments and different duration of follow-up periods, have resulted in an extremely wide variation of the reported incidences (2–56%) [6], [7], [12], [18], [19], [21]
Clinical manifestations and natural history
At the early stages of lymphedema formation, the involved extremity typically presents a “puffy” swelling, which may be intermittent. Once established, lymphedema should be viewed as a long-term complication, since it has an inexorable tendency to progress and persist for many years following primary treatment for breast cancer [32], [33]. With chronic impairment in lymphatic drainage, in the involved upper limb may appear the characteristic features of induration and fibrosis, which may be
Infectious complications
Lymphedema predispose to the development of infections complications (most commonly cellulites) of the involved upper limb [6], [35]. Accumulated protein-rich lymph fluid in the edematous arm provides an ideal culture medium for bacterial growth. Lymphatic dysfunction also impairs regional immunosurveillance and local immune responses [36], thereby further increasing the risk of infectious complications. The clinical presentation of soft-tissue infection in lymphedema can be variable, from very
Risk factors (Table 1)
Treatment
There is no cure for breast carcinoma-associated lymphedema [20]. A variety of aggressive physiotherapeutic interventions have been proposed for the control of symptoms and to minimize complications, by reducing upper limb swelling. Decongestive lymphatic therapy is the most popular treatment for patients with lymphedema and includes manual centripedal lymphatic massage, compressive garments or bandaging or sleeves (exerting a pressure of 30–40 mm Hg) or the application of intermittent pneumatic
Prevention
Attention to detail and proper surgical techniques, including sharp anatomic dissection, proper hemostasis, closed-suction drainage, and tissue approximation without tension, are the cardinal features to avoid post-ALND lymphedema [61], [88]. The adventitia of the vein should be preserved during ALND to decrease the likelihood of complications from this vein (such as thrombosis and edema formation) [88]. Efforts to diminish wound sepsis, including perioperative antibiotics as wound infection
Comments—future perspectives
Arm swelling remains a common problem following breast cancer treatment, even in the era of breast conservation therapy. Since currently no definitive cure exists, prevention by limiting and/or eliminating risk factors is of prime importance. Early diagnosis of lymphedema is significant because often it does not disappear and can get worse with time. Prompt intervention with appropriate therapeutic measures (as described above) may not only prevent progression, but might return the limb to
References (103)
- et al.
Cellulitis after axillary lymph node dissection for carcinoma of the breast
American Journal of Medicine
(1992) Lymphedema
American Journal of Medicine
(2001)- et al.
Colour Doppler demonstrates venous flow abnormalities in breast cancer patients with chronic arm swelling
European Journal of Cancer
(1994) - et al.
Increased arterial inflow demonstrated by Doppler ultrasound in arm swelling following breast cancer treatment
European Journal of Cancer
(1994) Lymphedema following the surgical treatment of breast cancer; a review of pathophysiology and treatment
Journal of Pain and Symptom Management
(1992)- et al.
Lymphedema after treatment of breast cancer
American Journal of Surgery
(2004) - et al.
Quality of life of breast cancer patients with lymphedema
American Journal of Surgery
(1999) - et al.
Cellulitis after axillary lymph node dissection for carcinoma of the breast
American Journal of Medicine
(1992) - et al.
Psychiatric consultation of women undergoing rehabilitation for upper-extremity lymphedema following breast cancer treatment
Journal of Pain and Symptom Management
(1993) - et al.
Soft tissue sarcoma after treatment for breast cancer—a Swedish population based study
European Journal of Cancer
(1998)
Edema of the arm as a function of the extent of axillary surgery in patients with stage I–II carcinoma of the breast treated with primary radiotherapy
International Journal of Radiation Oncology Biology Physics
Arm lymphedema in patients treated conservatively for breast cancer: relationship to patient age and axillary node dissection technique
International Journal of Radiation Oncology Biology Physics
Decongestive lymphatic therapy for patients with cancer-related or primary lymphedema
American Journal of Mediicne
Effectiveness of modified complex physical therapy for lymphedema treatment
Australian Journal of Physiotherapy
Sentinel lymph node biopsy in malignant melanoma: a series of 100 consecutive patients
British Journal of Plastic Surgery
The swelling of the arm after operations for cancer of the breast—elephantiasis chirurgica—its cause and prevention
Bulletin of the John Hopkins Hospital
A lymphatic function test
Surgical Forum
Lymphedema; pathogenesis, prevention, treatment
Cancer Practice
The pathophysiology of lymphedema
Cancer
Lymphedema after complete axillary node dissection for melanoma. Assessment using a new, objective definition
Annals of Surgery
Long-term morbidity following axillary dissection in breast cancer patients-clinical assessment, significance for life quality and the impact of demographic, oncologic and therapeutic factors
Breast Cancer Research and Treatment
Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis
Cancer
An audit of the incidence of arm lymphedema after prophylactic level I/II axillary dissection without division of the pectoralis minor muscle
Annals of the Royal College of Surgeons of England
Measurement of upper limb volumes: a clinical method
ANZ Journal of Surgery
Assessment of morbidity from complete axillary dissection
British Journal of Cancer
Incidence of arm swelling following axillary clearance for breast cancer
British Journal of Surgery
Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema
Cancer
Complications of level I and II axillary dissection in the treatment of carcinoma of the breast
Annals of Surgery
Patient risk factors and surgical morbidity after regional lymphadenectomy in 204 melanoma patients
Cancer
Arm edema in conservatively managed breast cancer
Radiology
Arm edema in breast cancer patients
Journal of the National Cancer Institute
Risk of lymphedema following treatment of breast cancer
British Journal of Surgery
Factors that influence the incidence of brachial edema after treatment of breast cancer
Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery
Arm function after axillary dissection for breast cancer: a pilot study to provide parameter estimates
Journal of Surgical Oncology
Arm morbidity following treatment of breast cancer with total axillary dissection: a multivariate approach
Oncology
Incidence of breast carcinoma-related lymphedema
Cancer
Arm morbidity after breast-conserving therapy for breast cancer
Acta Oncologia
Chronic arm morbidity after curative breast cancer treatment: prevalence and impact on quality of life
Journal of Clinical Oncology
Impact of axillary lymph node dissection on the therapy of breast cancer patients
Journal of Clinical Oncology
Lymphedema 30 years after radical mastectomy
American Journal of Physical Medicine and Rehabilitation
Evidence for altered cell-mediated immunity in postmastectomy lymphedema
British Journal of Dermatology
The role of infection in post-mastectomy lymphedema
Surgical Annuals
The psychological morbidity of breast cancer-related arm swelling
Cancer
Arm problems and psychological distress after surgery for breast cancer
Canadian Journal of Surgery
Psychiatric consultation for women undergoing rehabilitation for upper extremity lymphedema following breast cancer treatment
Psycho-oncology
Long-term compliance with treatment in obstructive arm lymphedema in cancer
Palliative Medicine
Breast cancer survivors: psychosocial concerns and quality of life
Breast Cancer Treatment and Research
Quality of life and breast cancer survivors. Psychosocial and treatment issues
Cancer Practice
Cited by (200)
2023 Year in review: Early breast cancer
2024, BreastThree-dimensional non-contrast magnetic resonance lymphography severity stage for upper extremity lymphedema
2024, Magnetic Resonance ImagingRobotics in Screening, Diagnosis and Treatment of Breast Cancer: A Perspective View
2024, Clinical Breast CancerA Prospective Study of Radiation Therapy After Immediate Lymphatic Reconstruction: Analysis of the Dosimetric Implications
2023, International Journal of Radiation Oncology Biology PhysicsDevelopment and Validation of a Normal Tissue Complication Probability Model for Lymphedema After Radiation Therapy in Breast Cancer
2023, International Journal of Radiation Oncology Biology Physics