Women who have been or will be treated for breast cancer may be at risk of developing arm, breast, and chest swelling called lymphedema. Lymphedema occurs when lymph fluid that cannot be properly drained builds-up and causes swelling. Most women will not develop this side effect, but unfortunately, many will.
A network of lymph vessels collect watery, clear lymph fluid from the tissues of our body, much like veins collect blood. Lymph fluid is made up of proteins, water, salts and cells of the immune system. This fluid is carried to lymph nodes - small collections of tissue which act like filters and contain white blood cells that help us fight infection.
When one or more lymph nodes are removed as occurs during a sentinel lymph node biopsy or an axillary lymph node dissection, the way the lymph fluid flows in that side of the upper body is changed. These changes make it harder for fluid in the chest, breast, and arm to flow out of this area. If the remaining lymph vessels and lymph nodes cannot sufficiently compensate for those that were removed, excess fluid builds up and causes the swelling known as lymphedema. When lymphedema develops, it typically does so slowly over time. Patients who experience a sudden marked increase in swelling should be checked by their breast surgeon to evaluate for possible recurrence of tumor or disease.
All women who have lymphedema are advised to take some simple precautions to help control swelling, reduce complications and prevent long-term changes in the tissues that occur in response to chronic fluid build-up.
Treatment varies depending upon the severity of lymphedema. The available treatments for lymphedema can be divided into two categories - medical and surgical.
The goals of lymphedema treatment are to reduce swelling, prevent swelling from getting worse, and decrease the chances of complications. Standard medical (non-surgical) treatment usually involves Manual Lymphatic Drainage (MLD), a type of medical massage designed to move the accumulated fluid out of the affected hand and arm. Complete Decongestive Therapy (CDT) combines MLD with meticulous skin care and hygeine, exercises, bandaging and the use of a specially fitted compression sleeve or stocking. Treatments are usually prescribed by a woman’s breast surgeon or oncologist and are performed by an experienced physical therapist with special training in lyphedema therapy.
While these techniques can be effective, they are can also be uncomfortable, inconvenient, and time-consuming. Strict compliance is essential, and since these treatments are palliative and not curative, treatment lasts a lifetime. When lyphedema is not controlled with standard treatments, surgery may offer relief.
Historically, surgical treatment of lymphedema was often ineffective, produced grotesque deformity and had horrific associated complications.
Superior surgical treatments are now, however, available to help treat patients with lymphedema. Vascularized Lymph Node Transfer and Lymphaticovenous Anastamosis, palliative but not curative procedures, offer hope to women with lymphedema.
Vascularized lymph node transfer can be performed as an isolated procedure or combined with a breast reconstruction procedure such a DIEP flap. This microsurgical procedure transfers a subset of lymph nodes from a low-risk lymph node basin to a limb with symptomatic lymphedema. The lymph nodes are transferred as a flap to the armpit or wrist of the affected extremity. Blood flow is re-established in the lymph node flap by attaching, with the aid of an operating room microscope, the blood vessels of the flap to blood vessels found in the recipient site.
Lymphaticovenous anastamosis or lymphaticovenular bypass was initially described over two decades ago as a means of treating lymphedema. More recently, “supermicrosurgical” modifications to the original procedure have been made to improve upon the original procedure. With the help on an operating room microscope and specially designed instruments, it is possible to divert blocked lymphatic vessels into the circulatory system by connecting them to tiny blood vessels called venuoles. Bridges established in this way allow drainage of lymphatic fluid into the vascular system.
These reconstructive procedures may be an attractive option for women when medical treatment options do not provide adequate relief of symptoms of lymphedema.