Elsevier

Mayo Clinic Proceedings

Volume 80, Issue 11, November 2005, Pages 1480-1484
Mayo Clinic Proceedings

REVIEW
Breast Cancer-Related Lymphedema

https://doi.org/10.4065/80.11.1480Get rights and content

Every year in the United States, breast cancer is diagnosed in more than 200,000 women. Because of the prevalence of breast cancer, treatment-related sequelae are of importance to many survivors of the disease. One such sequela is upper extremity lymphedema, which occurs when fluid accumulates in the interstitial space and causes enlargement and usually a feeling of heaviness in the limb. Axillary surgery contributes considerably to the incidence of lymphedema, with the incidence and severity of swelling related to the number of lymph nodes removed. Lymph-edema after standard axillary lymph node dissection can occur in up to approximately 50% of patients. However, the risk of lymph-edema is decreased substantially with newer sentinel lymph node sampling procedures. Adjuvant radiotherapy to the breast or lymph nodes increases the risk of lymphedema, which has been reported in 9% to 40% of these patients. Management of lymph-edema requires a multidisciplinary approach to minimize the effect on the patient's quality of life. This review presents an overview of the pathophysiology, diagnosis, prevention, and treatment of breast cancer-related lymphedema.

Section snippets

ANATOMY OF THE LYMPHATIC SYSTEM AND PATHOPHYSIOLOGY OF LYMPHEDEMA

The lymphatic system is composed of superficial and deep lymphatic vessels that collect lymph from the skin, subcutaneous tissue, muscle, bone, and other structures. Lymph fluid consists of water, protein, cellular debris, toxins, and other macromolecules. The lymphatic system is designed to drain this fluid and return it to the intravascular circulation. Lymph fluid enters the interstitium, which increases oncotic pressure, thereby drawing water into the interstitium. When this drainage is

BREAST CANCER AND LYMPHEDEMA

Sentinel lymph node (SLN) mapping studies have confirmed the presence of 3 interconnecting lymphatic systems in the breast8,9—the dermal, subcutaneous, and parenchymal lymphatics, which travel along the routes of the breast's blood supply to the regional lymphatics. The primary drainage is to the axilla, with only a small proportion of the lymph draining to extra-axillary sites (internal mammary, infraclavicular, and supraclavicular lymph nodes). Metastatic spread to the axilla occurs in

SYMPTOMS AND DIAGNOSIS OF LYMPHEDEMA

Patients with breast cancer and lymphedema may report symptoms such as a sensation of arm fullness and mild discomfort, which are seen in the early stages of the condition. Joint immobility, pain, and skin changes are noted frequently in the later stages of lymphedema. Patients also may be predisposed to infections involving the affected extremity.

Diagnosis of lymphedema requires a detailed medical history and physical examination. Changes may include pitting of tissues, increased thickness of

STAGING OF LYMPHEDEMA

A staging system has been developed for lymphedema (Table 1). Many clinicians have defined clinically significant lymphedema as a difference in circumference of greater than 2 cm between the extremities.21,36,48,49 However, most clinical trials have used volume-based rating scales to assess edema. Other parameters that have been used to determine the stage of lymphedema include limb circumference, tissue texture, dermal changes, subjective sensations, and tissue responses to gravity or pressure.

TREATMENT

The treatment of lymphedema associated with breast cancer can include combined modality approaches, compression therapy, therapeutic exercises, and pharmacotherapy.

SUMMARY

Lymphedema is a chronic and debilitating disease that can arise from breast cancer treatment. It generally is under-reported and undertreated. The effects of lymphedema on a patient's quality of life are substantial and can be devastating. Further education and better clinical trials are needed to address the importance of early recognition and treatment of lymphedema after breast cancer.

REFERENCES (60)

  • American Cancer Society

    Estimated new cancer cases for selected cancer sites by state, US, 2005. In: Cancer Facts & Figures 2005

  • American Cancer Society

    Estimated cancer deaths for selected cancer sites by state, US, 2005. In: Cancer Facts & Figures 2005

  • II Pipinos et al.

    The lymphatics

  • World Health Organization

    Lymphatic filariasis

  • P Petropoulos

    Lymphedema

  • KA Kern

    Achieving the lowest false-negative rate in peritumoral breast lymphatic mapping: the oncologic search for the Holy Grail

    Ann Surg Oncol

    (2003)
  • SD Nathanson et al.

    Pathways of lymphatic drainage from the breast

    Ann Surg Oncol

    (2001)
  • JC Chang et al.

    Prognostic and predictive markers

  • WA Woodward et al.

    Changes in the 2003 American Joint Committee on Cancer staging for breast cancer dramatically affect stage-specific survival

    J Clin Oncol

    (2003)
  • PI Pressman

    Surgical treatment and lymphedema

    Cancer

    (1998)
  • L Liberman et al.

    Sentinel lymph node biopsy after percutaneous diagnosis of nonpalpable breast cancer

    Radiology

    (1999)
  • G Querci della Rovere et al.

    An audit of the incidence of arm lymphoedema after prophylactic level I/II axillary dissection without division of the pectoralis minor muscle

    Ann R Coll Surg Engl

    (2003)
  • J Engel et al.

    Axilla surgery severely affects quality of life: results of a 5-year prospective study in breast cancer patients [published correction appears in Breast Cancer Res Treat. 2003;80:233]

    Breast Cancer Res Treat

    (2003)
  • P Schrenk et al.

    Morbidity following sentinel lymph node biopsy versus axillary lymph node dissection for patients with breast carcinoma

    Cancer

    (2000)
  • MW Kissin et al.

    Risk of lymphoedema following the treatment of breast cancer

    Br J Surg

    (1986)
  • A Herd-Smith et al.

    Prognostic factors for lymphedema after primary treatment of breast carcinoma

    Cancer

    (2001)
  • VS Erickson et al.

    Arm edema in breast cancer patients

    J Natl Cancer Inst

    (2001)
  • L Gerber et al.

    Comparison of pain, motion, and edema after modified radical mastectomy vs. local excision with axillary dissection and radiation

    Breast Cancer Res Treat

    (1992)
  • DK Blanchard et al.

    Relapse and morbidity in patients undergoing sentinel lymph node biopsy alone or with axillary dissection for breast cancer

    Arch Surg

    (2003)
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