Elsevier

Surgical Oncology

Volume 15, Issue 3, November 2006, Pages 153-165
Surgical Oncology

Review
Lymphedema following axillary lymph node dissection for breast cancer

https://doi.org/10.1016/j.suronc.2006.11.003Get rights and content

Summary

Lymphedema is a relatively common, potentially serious and unpleased complication after axillary lymph node dissection (ALND) for breast cancer. It may be associated with functional, esthetic, and psychological problems, thereby affecting the quality-of-life (QOL) of breast cancer survivors. Objective measurements (preferentially by measuring arm volumes or arm circumferences at predetermined sites) are required to identify lymphedema, but also subjective assessment can help to determine the clinical significance of any volume/circumference differences. Lymphedema per se predisposes to the development of other secondary complications, such as infections of the upper limb, psychological sequelae, development of malignant tumors, alterations of the QOL, etc. The risk of lymphedema is associated with the extent of ALND and the addition of axillary radiation therapy. Treatment involves the application of therapeutic measures of the so-called decongestive lymphatic therapy. Prevention is of key importance to avoid lymphedema formation. The application of the sentinel lymph node biopsy in the management of breast cancer has been associated with a reduced incidence of lymphedema formation.

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

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