LYMPHEDEMA OVERVIEW

Lymphedema is swelling caused by a build-up of fluid, usually in the arms in patients who have been treated for breast cancer. Lymphedema is one of the most troubling complications that can develop after breast cancer surgery. Many patients find that lymphedema worsens the physical and emotional strain of dealing with breast cancer.

The risk of developing lymphedema depends upon the type of surgery had, the time since surgery, and if radiation therapy was used. Generally, patients who undergo more extensive surgery, have many lymph nodes removed, or have radiation therapy to the axilla (arm pit) after surgery are more likely to develop lymphedema. Most patients who develop lymphedema do so within two years after their surgery, but it is important to note that it is a lifetime risk.

More detailed information about lymphedema is available by subscription. (See "Clinical manifestations and diagnosis of lymphedema" and "Prevention and treatment of lymphedema".)

WHAT IS LYMPHEDEMA?

Lymph is a clear fluid that contains mostly protein and white blood cells (the blood cells that fight infection). Lymph vessels drain lymph from the body's tissues and organs. The fluid is filtered through lymph nodes (also called glands) and eventually drains into the bloodstream (figure 1).

Lymphedema can develop if surgery or radiation treatment affects the lymph nodes and vessels. Patients who have multiple lymph nodes removed (a full axillary node dissection) are more likely to develop lymphedema than those who have only sentinel lymph node biopsy. Patients who have both surgery and radiation treatment are at even higher risk.

Lymph node biopsy and dissection are discussed in detail in a separate topic review. (See "Patient information: Surgical procedures for breast cancer — Mastectomy and breast conserving therapy (Beyond the Basics)".)

LYMPHEDEMA SYMPTOMS

The initial symptoms of lymphedema may include:

• A heavy sensation or an aching discomfort in the arm
• Swelling of the affected arm or upper chest
• Fatigue of the arm
• Numbness or tingling of the arm

In some cases, these symptoms develop before swelling is noticeable. Let your doctor or nurse know as soon as possible if you develop any of these symptoms; recognizing and treating lymphedema in the early stages may prevent or slow its worsening over time.

PREVENTING WORSENING OF LYMPHEDEMA

Patients with lymphedema can do several things to prevent it from getting worse over time. Expert groups recommend the following:

• Avoid trauma and injury to the affected arm. Blood draws, IV lines, injections, and acupuncture should be avoided in the affected arm, if at all possible. Avoid tight fitting clothing, blood pressure monitoring, or any activity that could interfere with lymph flow in the affected arm.
• Try to prevent infection. Practice careful skin and nail hygiene. Use skin moisturizers to prevent dry, cracked skin. Use an antibiotic cream or ointment on small skin cuts, such as paper cuts. Use protective gloves for household work and gardening. Use an electric razor rather than a razor blade to remove hair in the arm pit.
• Avoid heavy exercise and lifting heavy objects with the affected arm immediately after surgery. These activities may increase blood flow, which can worsen edema. Gentle stretching and range of motion exercises, provided by a healthcare professional, may be used immediately after surgery. Check with your doctor before resuming an exercise program after breast cancer treatment.
• Avoid exposure to extreme temperature changes to include hot tubs, steam baths, and saunas. Spending time in hot humid climates may worsen lymphedema.
• Some patients notice worsening of their lymphedema during air flight. Changes in the air pressure during flight can trigger swelling. If you have a confirmed diagnosis of lymphedema, you should wear some form of compression therapy while traveling by air. It is important that the compression garments be well fitted because if the garment is not properly fitted, it can reduce lymph flow. If you are at risk for developing lymphedema, you should understand the risk factors associated with air travel and should make a decision to wear compression based on your individual risk factors. Ask your doctor or physical therapist if you should be fitted for a sleeve to wear during air travel.
• Keep your weight under control. Obesity can worsen lymphedema and may limit the effectiveness of compression pumps or sleeves.
• Avoid resting your arm below your heart or sleeping on your arm for prolonged periods.
• Contact your doctor or nurse if the affected arm develops a rash, becomes red, blistered, painful or warm to the touch, or if you get a fever (temperature greater than 100.4ºF or 38ºC). These symptoms could signal a possible infection that could cause the beginning or worsening of lymphedema.
• If you develop lymphedema many years after surgery or have worsening lymphedema, contact your doctor or nurse immediately.

LYMPHEDEMA TREATMENT

There is no cure for lymphedema. The main goals of treatment are to control swelling, relieve symptoms, and prevent the swelling from worsening over time. Treatment should begin as soon as possible. A healthcare provider or program with expertise in treating lymphedema can be especially helpful.

Because medicines are of little benefit and can sometimes be harmful, the most common approaches do not involve medicines. Instead, a therapy program that combines massage, skin care, exercise, and compression garments (compression bandages or a lymphedema sleeve) is recommended.

IMPACT OF LYMPHEDEMA

While lymphedema is not a life-threatening condition, it can have a major impact on your quality of life. A change in how your arm looks can be distressing.

• After breast cancer surgery, many patients are worried about how they look; having a swollen or misshapen arm can make this worse.
• If lymphedema affects the ability to use your arm, this can affect your quality of life, particularly if it is your dominant arm (eg, right arm if you are right-handed).
• Lymphedema can reduce tissue healing and occasionally causes chronic pain. For these reasons, prevention and early treatment of lymphedema are recommended.

CLINICAL TRIALS

Progress in treating breast cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies.

One example of a clinical trial that is investigating ways to reduce the incidence of lymphedema after breast cancer therapy is called CALGB 70305. This trial is currently enrolling women to determine if a combination of education, use of light arm weights with exercise, a light compression sleeve with vigorous activity, and regular breathing exercises can reduce the risk or severity of lymphedema after axillary lymph node dissection. Women are encouraged to enroll if possible. More information can be found online at www.cancer.gov/clinicaltrials/CALGB-70305.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Breast cancer (The Basics)
Patient information: Ductal carcinoma in situ (DCIS) (The Basics)
Patient information: Lymphedema after breast cancer treatment (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Surgical procedures for breast cancer — Mastectomy and breast conserving therapy (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Clinical manifestations and diagnosis of lymphedema
Prevention and treatment of lymphedema

The following organizations also provide reliable health information.

• National Cancer Institute

      1-800-4-CANCER
      (www.nci.nih.gov)

• People Living With Cancer: The official patient information website of the American Society of Clinical Oncology

     (www.cancer.net/portal/site/patient)

• National Comprehensive Cancer Network

     (www.nccn.com)

• American Cancer Society

      1-800-ACS-2345
     (www.cancer.org)

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

• Susan G. Komen Breast Cancer Foundation

      (www.komen.org)

• National Lymphedema Network

    (www.lymphnet.org)

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