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Breast cancer associated lymphedema

Authors
Emile R Mohler III, MD
Babak Mehrara, MD
Section Editors
Daniel F Hayes, MD
Larissa Nekhlyudov, MD, MPH
Eduardo Bruera, MD
Patricia A Ganz, MD
Deputy Editors
Kathryn A Collins, MD, PhD, FACS
Sadhna R Vora, MD

INTRODUCTION

Lymphedema is defined as the interstitial collection of protein-rich fluid due to disruption of lymphatic flow. Treatment of breast cancer (eg, surgery, radiation therapy) can lead to lymphedema, and is one of the most common causes of secondary peripheral lymphedema. Upper extremity lymphedema occurring in breast cancer patients, including risk factors, monitoring, prevention, and efficacy of lymphedema treatments will be reviewed here. General considerations for the diagnosis and management of lymphedema that includes other etiologies, and surgical treatment of lymphedema, are reviewed elsewhere. (See "Clinical features and diagnosis of peripheral lymphedema" and "Clinical staging and conservative management of peripheral lymphedema" and "Surgical treatment of primary and secondary lymphedema".)

GENERAL PRINCIPLES

Lymphedema occurs when the lymphatic load exceeds the transport capacity of the lymphatic system, which causes filtered fluid to accumulate in the interstitium [1]. Lymphedema that occurs as the result of other conditions or treatments is called secondary lymphedema. Breast cancer associated lymphedema (BCAL) occurs due to obstruction of the lymphatic channels or lymph nodes, or infiltration with tumor cells (lymphangitic carcinomatosis). More commonly, surgical removal of lymph nodes (lymphadenectomy) and radiation therapy lead to development of lymphedema in patients with breast cancer. (See 'Risk factors' below.)

Lymphatic drainage — For the upper extremity and chest wall, the superficial lymphatic system (lymphatic capillaries and precollectors) drains interstitial fluid from the skin and subcutaneous tissue into larger collecting vessels (ie, deep lymphatics). The deep lymphatics drain into the axillary lymph nodes where foreign material is filtered and where antigen-presenting cells interact with T and B cells to activate immune responses [1]. The lymphatics of the breast drain into the internal mammary nodes medially, and the axillary and supraclavicular nodes laterally and superiorly (figure 1). The lymph draining from the left upper body (upper extremity, chest wall, upper back, shoulder, and breast) enters the venous circulation through the thoracic duct, which opens into the venous angle between the left subclavian vein and left internal jugular vein (figure 2) [1]. The lymph draining from the right upper body drains into the right venous angle via the right lymphatic duct.

INCIDENCE AND RISK FACTORS

Breast cancer and its associated treatments are one of the most common causes of upper extremity lymphedema. In a systematic review that included 72 studies (n = 29,612 women), the overall incidence of arm lymphedema in breast cancer survivors was 17 percent [2]. The incidence varied based on the mode of diagnosis; it was 13, 15, and 20 percent based on clinical information, formal measurement (eg, arm circumference), and self-assessment, respectively. (See "Clinical features and diagnosis of peripheral lymphedema", section on 'Diagnosis'.)

Risk factors — The main risk factors for breast cancer associated lymphedema (BCAL) include dissection/disruption of axillary lymph nodes, radiation therapy, local infection, and obesity, but other factors may also contribute.  

                      

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