Lymphedema
Lymphedema is an abnormal swelling that occurs when there is a blockage in the lymphatic system, which then cannot adequately drain the circulating lymph fluid. This swelling can be caused in the arms and legs by a tumor or cancer cells blocking the lymph vessels, or can occur in the arms as a result of lymph node removal as part of cancer surgery, because of damage from radiation therapy, or because of injury or infection in the lymph node area.
In addition to the discomfort and cosmetic effects, the swollen arm is at greater risk for serious infection from even minor injuries, such as finger cuts.
Question
What is lymphedema?
Lymphedema is swelling caused by a collection of excess lymph fluid, brought about by a blockage in the lymphatic system. This complication may happen after the axillary lymph nodes (under the armpits) are removed during surgery, or are injured during radiation therapy. It may also be caused by a tumor interfering with the normal drainage of fluid. Lymphedema can be permanent after breast surgery and can be very difficult to manage, even with vigorous massage and exercise. The best management is prevention, which is why the sentinel node procedure is one of the most important breast cancer advances in recent years.
There is no cure for lymphedema, but the symptoms can be eased with diligent care of the limb or limbs that are affected. The symptoms may include severe fatigue, a heavy swollen limb, or localized fluid accumulation in the limb. Pain with the uncomfortable weight or fluid retention can also add to lymphedema problems. Treatments focus on minimizing the swelling and controlling the pain. Lymphedema treatments include:
Therapeutic exercise. Light exercise may be recommended by a lymphedema therapist or physical therapist to help with lymph fluid drainage. These exercises are not to cause fatigue but to enhance circulation and promote a gentle contraction of the muscles in the arms to help keep the tissue soft and assist in moving the lymphedema fluid. The exercises should be prescribed in consultation with a physician to promote function and comfort during the patient's treatments.
Manual lymph drainage/decongestive therapy. This is a known tool for lymphedema management that involves manual manipulation of the lymphatic ducts for the purpose of encouraging lymph flow away from the affected arm and back to healthy lymph nodes where the excess fluid can drain. The technique was founded by Emil Vodder in the 1930s for the treatment of immune disorders and sinusitis.
Manual lymph drainage involves gentle, rhythmic massaging of the skin to stimulate flow of the lymphatic system and reduce swelling. A session usually lasts forty to sixty minutes and manipulation of the skin starts with the neck, trunk, and then the affected limb.
Compression wrapping or bandaging. Compression wrapping, in which the entire arm is wrapped, helps with encouraging lymph fluid to drain from the extremity toward the trunk of the body. When bandaging your arm, you need to wrap tighter at the end of your limbs and loosen it as you go up toward the body. This helps to facilitate lymphatic flow by providing a pump-like pressure going from the fingers toward the body. It is advised to use short-stretch bandages as opposed to the long-stretch bandages used to treat sprains, because the short-stretch bandages encourage lymphatic flow and help to soften swollen tissue. This must be first taught by a physical therapist or lymphedema specialist with ongoing follow-up and monitoring. Proper placement of compression wrapping is essential in promoting proper lymph drainage.
Compression garments. These include long sleeves worn by the person with lymphedema following decongestive therapy to reduce and minimize edema. Compression garments are worn to reduce swelling and usually need to be worn every day and must be replaced on a regular basis. Depending on the recommendation of the therapist, the patient may have an over-the-counter standard size or may have to have a custom-fit compression garment. Currently there is controversy about compression sleeves. Some today would argue that decongestive massage techniques and specialized wraps are better than the older style sleeves. It is often difficult to get insurance coverage for lymphedema treatments and compression garments, so you may need to check with your local breast cancer center for available resources in your area.
Pneumatic compression. In this treatement, a compression pump moves the lymph fluid gently with a pneumatic sleeve attached to the pump. This is usually done for ten to fifteen minutes prior to manual lymph drainage. The pump sequentially inflates and deflates the sleeve in order to move lymph fluid away from your fingers and toward your body to help recirculate the excess fluid and reduce swelling.
Skin care. People with lymphedema or whose lymph nodes have been removed are at higher risk for infections in the affected areas. Special care of your skin with gentle cleansing and moisturizing is important to promote circulation of lymph fluid and prevent cuts or other damage to the skin that could result in a skin infection of the affected area.
Lymphedema Prevention and Coping
All women with lymph node dissections or radiation to the axilla or supraclavicular areas are at risk for lymphedema. To reduce your risk of lymphedema you can:
Keep your skin clean, and protect your arm and breast area from injury. Avoid skin tears or cuts that may contribute to the possibility of an infection. Wear a glove when gardening or doing other tasks where skin injury may occur.
Elevate your arm on a pillow at night or whenever possible after your breast surgery.
Avoid tight or constricting clothing that may hinder circulation in the affected arm. Avoid carrying a bag over the shoulder on the side of the node dissection. After a node operation, much of the lymph returns to the body through lymphatics over the shoulder, and a purse or other strapped bag can cut off that circulation.
Find out all you can about lymphedema so that you understand its causes and symptoms. This information will help guide you when you make decisions about your treatment options. The more you know, the better able you will be to facilitate your treatment and speak to your doctor and physical therapist about what you are experiencing. This type of conversation will help them plan your individual treatment strategy.
Take good care of your affected arm by gentle cleansing and taking safety precautions to avoid injury to the affected limb from cuts or scratches. Be hypervigilant in caring for your skin by applying moisturizer daily to prevent dry skin and cracking.
Find other women who have experienced lymphedema in your area for support, or inquire about a lymphedema support group in your area. You can also contact the National Lymphedema Network, which may be able to refer you to others who have been through it and put you in contact with them. It is helpful to talk to others who have had this problem, because they can offer the help and support that only comes from experience.
Essential
Tumors have a biology of their own, and great strides have been made toward understanding cancer biology and how to manipulate it. Once you understand the tumor's biology, then you and your doctor can guide your treatment decisions. Staging breast cancer gives guidelines for comparison, so doctors can standardize diagnosis and treatment and understand outcomes in a way that is universal for patients and clinical centers.
