Introduction
Breast cancer-related lymphedema (BCRL) is a potentially debilitating and often irreversible complication of breast cancer treatment. The risk of BCRL is proportional to the extent of axillary surgery and radiation. Other risk factors include obesity and infections. Minimize armpit surgery and Radiation has been shown to reduce the risk of BCRL.
Comprehensive multidisciplinary evaluation at initial diagnosis; early referral to physical therapy after surgery; and patient education about weight loss skin and nail care are the cornerstones of early lymphedema management.
End-stage lymphedema may benefit from referral to an orthopedic surgeon who specializes in lymphedema surgery [1].
Lymphatic Involvement
Intrinsic features of lymphatic physiology are the main pathways for tumor cell metastasis. An image illustrating the sentinel lymph node. The axillary lymph nodes drain 75 percent of the lymph fluid from the breast, so they can become enlarged in cancer.
- An increase in tumor size triggers an increase in intratumoral interstitial fluid pressure and the release of interstitial fluid as the system attempts to achieve homeostasis.
- Unlike blood vessels, lymphatic vessels are highly permeable; the flow rate is approximately 100-500 times slower and there is less shear stress due to vasodilation.
- Lymphatic pathways have advantages in facilitating tumor cell dissemination.
- Breast tumors particularly preferentially utilize the lymphatic system for tumor cell dissemination.
- Lymph nodes act as reservoirs where tumor cells take root and form metastatic tumors. The degree of lymph node involvement and regional nodal status are considered to be critical to patient prognosis.
- Implications of the procedure: All lymph fluid from one side of the upper body (chest, chest cavity, arms, and hands) goes to the axillary lymph nodes. The more lymph nodes and blood vessels that are removed, the more likely it is that this flow will be disrupted and potentially result in lymphedema. Axillary lymph node dissection and assessment is an essential and routine part of the staging and determination of adjuvant treatment modalities. Axillary lymph node dissection (ALND) can result in significant postoperative complications (60%) and serious complications, including Arm lymphedema Seroma Numbness Paresthesia Pain and infection.
- Lymphedema is of particular concern because it occurs in 6-30% of patients and has no cure.
- With improved screening methods, breast cancer can now be diagnosed and treated early, before lymph node metastasis. [2]
- Surgeons now support sentinel lymph node biopsy (SLNB) wherever possible. This procedure removes only the first few lymph nodes, the “sentinel nodes” that drain fluid from the breast. Sentinel nodes are identified by radioactive material or blue dye. If the sentinel lymph nodes are free of cancer cells, no additional lymph nodes need to be removed (to reduce the risk of lymphedema). [3]
2. Radiation therapy can also affect the lymphatic system.
- Radiation therapy can cause the formation of scar tissue that compresses or narrows remaining lymphatic vessels and lymph nodes. This further interferes with the flow of lymph from the arms and upper body.
- The risk of radiation-associated lymphedema is greatest with radiation delivered directly to the armpits, as this is where most lymph nodes are located, but radiation to the breast or chest area also increases the risk [3].
3. Adjuvant chemotherapy, especially docetaxel, is a risk factor for breast cancer-associated lymphedema [4][5] The use of docetaxel leads to hyperstabilization of microtubule assembly. Treatment of cells with docetaxel inhibits major cellular events such as mitotic cell division Endosomal uptake, secretion and transport [6].
Physiotherapy
Breast cancer-related lymphedema (BCRL) develops in more than one in five patients treated for breast cancer. Lymphedema can develop at any stage after cancer treatment, with most diagnoses being made between three months and 20 years. Early recognition and treatment of lymphedema lead to the best results.
Physical therapists work closely with clients and other members of the healthcare team to optimize function, increase participation, and manage symptoms, the swelling that occurs with lymphedema. Treatment usually includes:
- Quality patient education initiated early postoperatively and followed by evidence-based physical therapy is effective in reducing the risk of lymphedema in women undergoing ALND breast cancer surgery [7].
- Manual lymphatic drainage (MLD) is a hands-on therapy often used in BCRL and often as part of complex decongestant therapy (CDT).
- CDT is a quadruple conservative treatment that includes MLD compression therapy (consisting of a compression bandage, compression cuff or other type of compression garment), skin care, and lymphopenic exercise (LRE) [8].
Physical therapists should encourage clients to continue doing all the activities they enjoy. Studies have shown that occupations or hobbies at any level of activity are not associated with developing lymphedema. Resistance training has been shown to be safe and may help prevent lymphedema [9].
Image: Lymphoedma compression sleeve
For more physical therapy specific information, see Lymphedema and/or Breast Cancer
Practical Assessment and
References
- ↑ Tandra P, Kallam A, Krishnamurthy J. Identification and management of lymphedema in patients with breast cancer. Journal of oncology practice. 2019 May;15(5):255-62.Available from:https://ascopubs.org/doi/10.1200/JOP.18.00141 (accessed 27.1.2021)
- ↑ Rahman M, Mohammed S. Breast cancer metastasis and the lymphatic system. Oncology letters. 2015 Sep 1;10(3):1233-9.Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4533217/ (accessed 27.1.2021)
- ↑ Jump up to:3.0 3.1 Breast cancer org. Lymphoedema Available from:https://www.breastcancer.org/treatment/lymphedema/how/treat_impact (accessed 27.1.2021)
- ↑ https://lymphoedemaeducation.com.au/resources/risk-factors-for-breast-cancer%E2%80%91related-lymphedema-correlation-with-docetaxel-administration/ (accessed 27.1.2021)
- ↑ Aoishi Y, Oura S, Nishiguchi H, Hirai Y, Miyasaka M, Kawaji M, Shima A, Nishimura Y. Risk factors for breast cancer-related lymphedema: correlation with docetaxel administration. Breast Cancer. 2020 Sep;27(5):929-37.Available from:https://pubmed.ncbi.nlm.nih.gov/32270417/ (accessed 27.1.2021)
- ↑ Morse DL, Gray H, Payne CM, Gillies RJ. Docetaxel induces cell death through mitotic catastrophe in human breast cancer cells. Molecular cancer therapeutics. 2005 Oct 1;4(10):1495-504.Available from: https://mct.aacrjournals.org/content/4/10/1495(accessed 27.1.2021)
- ↑ Lu SR, Hong RB, Chou W, Hsiao PC. Role of physiotherapy and patient education in lymphedema control following breast cancer surgery. Therapeutics and clinical risk management. 2015;11:319.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4348127/(accessed 28.1.2021)
- ↑ Ezzo J, Manheimer E, McNeely ML, Howell DM, Weiss R, Johansson KI, Bao T, Bily L, Tuppo CM, Williams AF, Karadibak D. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database of Systematic Reviews. 2015(5).Available from:https://pubmed.ncbi.nlm.nih.gov/25994425/ (accessed 27.1.2021)
- ↑ Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, Bryan CJ, Williams-Smith CT, Greene QP. Weight lifting in women with breast-cancer–related lymphedema. New England Journal of Medicine. 2009 Aug 13;361(7):664-73.Available from:https://www.nejm.org/doi/full/10.1056/NEJMoa0810118 (accessed 28.1.2021)
