Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema: Recommendations from a Multidisciplinary Expert ASBrS Panel

 Part 1: Definitions, Assessments, Education and Future Directions

 Part 2: Preventive and Therapeutic Options

Authors: McLaughlin, SA et. al.

Source: Ann Surg Oncol (2017) 24:?2818-2835

Part 1: www.ncbi.nlm.nih.gov/pubmed/28766232

Part 2: www.ncbi.nlm.nih.gov/pubmed/28766218 

BCRL is an ongoing concern for patients undergoing axillary treatment as part of breast cancer therapy. This expert panel reviewed current information about lymphedema—including how it happens, its risk factors, surveillance techniques and treatment.

The risk for the disorder approaches 10% for women undergoing sentinel lymph node biopsy (SLNB), and may rise to about 15% for women undergoing axillary lymph node dissection (ALND). The risk climbs to 25-40% for women receiving axillary surgery and radiation therapy. BCRL can impair quality of life, possibly leading to loss of employment, depression, increased medical costs and inability to perform daily activities. It is understood that early detection offers the greatest chance at successful treatment. There are many methods of detection, and circumferential tape measurement is commonly used. However, newer methods which measure light waves or electricity as they travel through tissue, such as bioimpedance spectroscopy, tissue dielectric constants and infrared perometry may be superior because they are less subjective and have more reproducible results. Regardless of surveillance method, it is recommended that surveillance for BCRL be performed at regular intervals for 3-5 years in the postoperative period. Patients’ own observations of symptoms of lymphedema are also very important in disease detection.

Risk factors for BCRL have been updated. From a surgical standpoint, the risk increases with increasing number of axillary lymph nodes removed. Nodal irradiation (radiation treatment to the axilla/ underarm) after axillary surgery and obesity/elevated body mass index (BMI) are also risk factors for development of the disease.  Also, certain chemotherapy regimens have been associated with BCRL. The panel noted that venipuncture (blood draws), injections, blood pressure checks and air travel are commonly suspected to increase the risk of BCRL. However, scientific studies have refuted all of these assumptions.

Weight-resistance exercise was suspected to increase the risk of BCRL. The panel pointed out that such activity has no effect on BCRL risk. In fact, such exercise improves the symptoms of lymphedema and leads to fewer exacerbations of the condition. Moreover, aerobic exercise is also safe—even for women who already have BCRL.

Surgical treatments for risk reduction are being developed and studied. Axillary reverse mapping (ARM) is a technique where, prior to SLNB, the arm lymphatics are injected with a blue dye. This allows the surgeon to avoid harming those channels and nodes that drain the arm. Current data shows that the ARM technique leads to a significant decrease in BCRL. Another technique, called lymphatic microsurgical preventive healing approach (LYMPHA), involved connecting larger lymphatic channels into larger veins at the end of ALND surgery. This technique is also associated with a lower risk of BCRL.

The standard treatment for BCRL is combined decongestive therapy (CDT). This consists of manual drainage with a trained therapist, wearing compression garments, engaging in specific exercises and vigilant skin care.

Surgical treatment of BCRL is also being developed. Lymphatic-venous anastomosis (LVA) involves creating multiple connections between lymphatic channels and veins in the affected arm, with the observation that the congested lymph system drains into the bloodstream and reduces swelling. Another surgical technique is vascularized lymph node transfer (VLNT), which involves relocating lymph nodes from one part of the body to the extremity affected by BCRL. Liposuction, which removes excess tissue volume, may debulk and alleviate discomfort but does not treat the underlying cause of BCRL. So, patients who receive this treatment must receive continuous postoperative compression and follow up with a therapist.

As a result of its extensive review, the panel made the following 10 recommendations for BCRL:

1. Clinicians should establish a surveillance plan because early diagnosis leads to early treatment and increases the likelihood for limited disease burden.
2. Baseline and follow-up measurements of the ipsilateral (operated side) and contralateral (non-operated side) arms of all breast cancer patients are critical.  A comprehensive measurement strategy should include a combination of objective and subjective measures.
3. Clinicians should practice personalized medicine strategies to minimize axillary surgery, question the routine use of postmastectomy or regional nodal irradiation, and should use genomic tests to guide the use of chemotherapy to collectively minimize the additive effects of multimodality therapy.  Patients should maintain a healthy BMI.
4. Surgeons should admit and accept that lymphedema risks exist and educate themselves and their patients about these risks at preoperative and follow-up visits.  Education should continue into survivorship and be incorporated into survivorship care plans.
5. The origins of BCRL are complex.  Association of BCRL only with venipuncture, blood draws and air travel oversimplifies the problem.
6. Use of the ipsilateral arm for IVs or blood pressures is not contraindicated, although most patients prefer to use the contralateral arm.  Personalized risk-reduction strategies are more appropriate than blanket application of behaviors.
7. Clinicians should encourage at-risk and affected lymphedema patients to exercise.  Resistance and aerobic exercise is safe.  Patients with BCRL should work with a trained lymphedema professional to learn to exercise safely.
8. Emerging data on preventive surgical strategies with ARM and LYMPHA are promising and should be explored further with appropriate patients.
9. CDT is the cornerstone of therapy.  Patients with symptoms or measured changes should be referred for lymphedema therapy evaluation, formally educated, and provided with graduated intervention according to staging and presentation.
10. LVA and VLNT may be effective for early secondary BCRL.  Patients should be assessed by a multidisciplinary team, with an understanding that surgery will be part of a multimodality treatment plan.  Lymphatic liposuction with long-term compression is effective for severe late-stage BCRL unresponsive to conservative management.