What is Lymphedema?

Lymphedema is swelling that occurs due to a buildup of fluid.  Lymphatic fluid can build up in an extremity due to damage to the normal drainage of the lymphatic system that can occur due to lymph node removal as part of your cancer surgery.

What can you do to minimize your risk of developing lymphedema?

Before surgery

The risk of lymphedema can be decreased with less aggressive lymph node surgery.  To evaluate whether there has been spread of cancer to your lymph nodes, your surgeon will need to remove some or most of the lymph nodes under the underarm area. Lymph nodes can be removed with either an axillary lymph node dissection or a sentinel lymph node biopsy.  Historically, an axillary lymph node dissection, an operation which removes most of the lymph nodes in the underarm area to check for cancer spread, was performed. In some situations, an axillary lymph node dissection may still need to be performed. Most patients will be candidates for a sentinel lymph node biopsy in which the first few lymph nodes in the underarm area that drain the breast first are removed. If there is no cancer in those sentinel lymph nodes then the rest can be left alone.  The risk of lymphedema after an axillary lymph node dissection can be higher than 30% and with a sentinel lymph node biopsy it is less than 5%. [1] If you are not offered a sentinel lymph node biopsy ask your surgeon if you are a candidate.

If you need to have an axillary lymph node dissection many surgeons will perform Axillary Reverse Mapping (ARM) at the time of your surgery.  With this technique blue dye is injected into her upper arm in hopes identify the lymphatic vessels that are draining the arm so that they can be avoided at the time of your lymph node surgery. Studies have shown that the rate of lymphedema after an axillary lymph node dissection with the addition of ARM is less than 10%. [2] Ask your surgeon if this is a procedure she/he performs.

After surgery

The risk of lymphedema is increased if you have a BMI of greater than 25 at the time of surgery.  It is difficult to lose weight right before your breast cancer surgery, but there are studies showing that people who lose weight after surgery have a decrease in lymphedema symptoms. [3] [4]  Since being overweight can increase your risk of the breast cancer coming back, losing weight will help decrease both your risk of breast cancer coming back and risk of lymphedema occurring.

There are many recommendations regarding lymphedema prevention that you can do at home.  These are the current recommendations from the National Cancer Institute [5]:

Hygiene

• Use moisturizer to keep the skin from drying and cracking
• Treat small cuts in the skin with antibacterial ointment
• Avoid shaving underneath your arm with a razor if you have residual numbness after surgery
• Wear sunscreen
• Wear gloves when cooking and gardening
• Avoid testing the temperature of water with the affected arm
• Avoid saunas, or other heat extremes
• If you have any signs of infection please call your doctor for an evaluation

Positioning/blood pooling

• Avoid tight clothing that could obstruct blood flow
• Avoid tight jewelry on the affected arm
• Avoid applying heat to the affected arm

It should be noted that these many of these recommendations are based on expert opinion without studies to support them.  There is good scientific evidence to support the recommendations to maintain a normal weight and avoid weight gain. There is also good evidence to support a supervised exercise program by a physical therapist if you are at risk of developing lymphedema.  If you have concerns about developing lymphedema discuss this with your doctor as you may be eligible for a referral to a physical therapist.

References

[1]  M.-S. M. F. M. P. A. E. F. Belmonte R, “Prospective study of shoulder strength, shoulder range of motion, and lymphedema in breast cancer patients from pre-surgery to 5 years after ALND or SLNB.,” Supportive Care in Cancer, 2018.

[2]  O. D. K. S. e. a. Tummel E, “Does Axillary Reverse Mapping Prevent Lymphedema After Lymphadenectomy?,” Annals of Surgery, pp. 987-992., 2017.

[3] S. K. P. A. F. A. Ahmed RL, “Risk factors for lymphedema in breast cancer survivors, the Iowa Women’s Health Study,” Breast Cancer Research and Treatment, pp. 981-991, 2011.

[4] F. M, “Breast cancer-related lymphedema: Symptoms, diagnosis, risk reduction, and management,” World Journal of Clinical Oncology, pp. 241-247, 2014.

[5] N. C. Institute, “www.cancer.gov,” 1 June 2018. [Online]. Available: https://www.cancer.gov/about-cancer/treatment/side-effects/lymphedema/lymphedema-hp-pdq#link/_41_toc.

[6] P. A. M. B. Cemal Y, “Preventative measures for lymphedema: separating fact from fiction,” Journal of the American College of Surgeons, pp. 543-551, 2011.