Breast Cancer Related Lymphedema

Original Editor - Lucinda hampton

Top Contributors - Lucinda hampton, Claire Knott and Temitope Olowoyeye  

Introduction

Breast cancer–related lymphedema (BCRL) is a potentially debilitating and often irreversible complication of breast cancer treatment. Risk of BCRL is proportional to the extent of axillary surgery and radiation. Other risk factors include obesity and infections. Minimizing axillary surgery and radiation has been proven to reduce the risk of BCRL.

Comprehensive multidisciplinary assessment at the time of initial diagnosis; early referral to physical therapy after surgery; and patient education regarding weight loss, skin, and nail care are cornerstones of the management of early-stage lymphedema.

End-stage lymphedema may benefit from referral to a plastic surgeon specializing in lymphedema surgery.

Lymphatic Involvement

The inherent characteristics of the lymphatic physiology serve as the primary route for tumor cell metastasis. Image illustrating sentinel lymph nodes. The axillary lymph nodes drain 75% of the lymph from the breasts and so may swell in cancer.

• The increasing size of the tumor triggers a rise in the intratumoral interstitial fluid pressure, and interstitial fluid is released as the system attempts to achieve homeostasis.
• Unlike the vascular vessels, the lymphatic vessels are highly permeable; the flow rate is approximately 100–500x slower, and coupled with lesser shearing stresses due to vasodilation.
• The lymphatic route is superior in facilitating tumor cell dissemination.
• Breast tumors, in particular, preferentially utilize the lymphatic system for tumor cell dissemination.
• Lymph nodes act as a reservoir for tumor cells to take root and form metastatic tumors. The extent of lymph node involvement and regional lymph node status is considered to be crucial in patient prognosis.

The Impact of Surgery, Radiation and Chemotherapy Therapy on Lymphedema Risk

1. 
   Surgery implications: All of the lymph fluid from one side of the upper body (the chest, the ribcage, the arm and hand) drain to the axillary lymph nodes. The more lymph nodes and vessels removed, the greater the likelihood that this flow is going to be disrupted and potentially cause Lymphoedma.The dissection and assessment of the axillary lymph nodes is an essential and routine component in the process of staging and determination of adjuvant therapy modalities. Axillary lymph node dissection (ALND) may result in significant postoperative morbidity (60%) and severe complications, including lymphedema of the arm, seroma, sensory numbness, paresthesia, pain and infection.

• Lymphedema is of particular concern, as it occurs in 6–30% of patients, and no curative therapy is available.
• With the advent of improved screening modalities, breast cancer is now being diagnosed and treated at an early stage, prior to lymph node metastasis.
• Now, when possible, surgeon favour sentinel lymph node biopsy (SLNB). This surgery removes just the first few lymph nodes, the “sentinel nodes”, that drain fluid away from the breast. Identification of the sentinel nodes is done by mapping the flow of lymph with a radioactive substance or blue dye. If the sentinel nodes are free of cancer cells, then no additional nodes need to be removed (lowering risk of Lymphoedema).

2. Radiation treatments also can affect the lymphatic system.

• Radiation therapy can cause the formation of scar tissue that presses on or narrows the remaining lymph vessels and nodes. This interferes even further with the flow of lymph out of the arm and upper body.
• Radiation directly to the underarm carries the most risk for radiation-related lymphedema, since this is where most of the nodes are, but radiation to the breast or chest areas also increases risk.

3. Adjuvant chemotherapy, especially docetaxel, is a risk factors for breast cancer-related lymphedema. Docetaxel use results in the hyperstabilization of microtubule assembly. Treatment of cells with docetaxel causes the inhibition of major cellular events, such as mitotic cell division, endosomal uptake, secretion, and transport.

Physiotherapy

More than one in five patients who undergo treatment for breast cancer will develop breast cancer-related lymphedema (BCRL). Lymphedema can develop at any stage following cancer treatment with most diagnoses being made between three months and 20 years. Identifying and treating lymphedema early leads to best outcomes.

The physical therapist works closely with the client and other members of the health care team to optimise function, enhance participation and manage the symptoms, namely swelling, caused by lymphedema. Therapy generally consists of:

• Quality patient education that begins early in the post-operative period and is followed by evidence-based physiotherapy can be effective in reducing the risk of lymphedema in women who undergo breast cancer surgery with ALND.
• Manual lymphatic drainage (MLD), a type of hands-on therapy, is frequently used for BCRL and often as part of complex decongestive therapy (CDT).
• CDT is a fourfold conservative treatment which includes MLD, compression therapy (consisting of compression bandages, compression sleeves, or other types of compression garments), skin care, and lymph-reducing exercises (LREs).

Physiotherapists should encourage clients to keep doing all of the activities that they enjoy. Research has shown that no activity level, occupation, or hobby is related to developing lymphedema. Resistance training has been shown to be safe and may assist in preventing lymphedema.

Image: Lymphoedma compression sleeve

For further physiotherapy specific information, see Lymphoedema and/or Breast Cancer