After the initial breast cancer diagnosis, days are crammed with tests and your brain can become overloaded with what seems like a never-ending list of decisions about treatment. The patient is the center of a large and complex health care team. But once those initial, traditional treatments are history – surgery, chemotherapy, radiation – it’s time to cope and recover from side effects.
Some side effects are less well-known by lay people (or even other doctors, such as cardiac specialists) and may be less well-described by the care team.
One of these side effects is breast cancer–related lymphedema. A form of secondary lymphedema, it is a debilitating byproduct of breast cancer treatment (lymph node removal, either sentinel node biopsy or axillary, and radiation therapy).
Although swelling is the primary sign of lymphedema, it is not the only symptom. Other symptoms, in decreasing order, include arm heaviness, arm firmness, increased arm temperature, seromas, arm tightness, limited arm movement, tingling in affected arm, arm aching and limited finger movement.
The arm is not the only place where breast cancer patients may experience lymphedema, however. It can also occur in the shoulder, breast and thoracic regions. Because these are hard-to-measure areas, researchers have not documented the incidence of lymphedema in these areas.
Untreated lymphedema can have serious consequences, with infections and skin ulcers (open sores that don’t heal) that can be life-threatening. There’s also the possibility of extreme swelling and thickening of the skin (elephantiasis). Unfortunately, elephantiasis is the all-too-common image displayed when searching lymphedema. That can make minor swelling seem insignificant (or even invisible).
Case in point: my physical therapist had to bang me on the head twice to get me to try to see a specialist. She saw changes in early 2018 that I did not see/comprehend. (I was seeing her for PT post-radiation therapy. It’s not easy trying to reach over your head when your side has been irradiated for six weeks. Radiation causes extensive scarring of tissue your eyes cannot see.)
Primary versus secondary lymphedema
Primary lymphedema is a genetic condition that may present at birth or later in life. Secondary lymphedema results from something that causes permanent damage to the lymphatic system.
Primary lymphedema is identified by deficiency in the lymphatic system such as abnormal/missing lymph nodes or lymph vessels that do not properly drain fluid from tissues.
In addition to cancer or cancer treatments (lymph node removal and/or radiation), secondary lymphedema may occurs from trauma or infection.
Left untreated, lymphedema can progress to elephantitis. I was diagnosed at stage 2; I could not wear my wedding ring. Stages illustrated here:
System and treatment
The lymphatic system is as important as the vascular system. It’s just not understood beyond, perhaps, tonsillitis or that ‘sore throat with swollen lymph nodes.’ Its primary function is to transport lymph, a fluid that carries infection-fighting white blood cells, throughout the body
The lymphatic system consists of lymphatic vessels that are similar to capillaries, veins and arteries with one BIG caveat: there is no equivalent of the heart. The lymphatic system does not have a “pump.” The vessels are connected to lymph nodes, which filter the lymph.
Unlike the cardiovascular system, the lymphatic system is not a closed system. The human circulatory system processes an average of 20 litres of blood per day through capillary filtration, which removes plasma from the blood. Roughly 17 litres of the filtered plasma is reabsorbed directly into the blood vessels, while the remaining three litres remain in the interstitial fluid. One of the main functions of the lymphatic system is to provide an accessory return route to the blood for the surplus three litres.
Breast cancer specialists assess axillary lymph nodes as part of the process to determine how advanced a patient’s cancer might be. I had 14 nodes tested (four with initial lumpectomy, another 10 with the double mastectomy).
A Certified Lymphedema Therapist (CLT) is your guide to treatment possibilities, which can include manual lymphatic drainage (MLD), compression bandaging, custom compression garments and exercise.
There are currently two surgical options to regain lymphatic function:
Lymphovenous Anastomosis Bypass Surgery
Lymphedema is a chronic debilitating condition that most commonly results from treatment of cancer in the industrialized modern world. While lymphedema can certainly affect the upper and lower extremities, this article focuses on the surgical treatment of lymphedema following the treatment of breast cancer…
Although it was first described in the 1960s, the field of lymphedema surgery and supermicrosurgical treatment of lymphedema through a lymphovenous bypass (LVB) or lymphaticovenular anastomosis (LVA) has only recently become more common and is considered one of the gold standard treatments for lymphedema
With this minimally invasive micro-surgery, a specialist uses a high-powered microscope to connect lymphatic vessels less than half a millimeter in size are to small veins. The goal is to improve the flow of lymphatic fluid out of the arm or leg and reduces the discomfort and swelling.
Vascularized lymph node transfer
Vascularized lymph node transfer (VLNT) is one of the most promising new microsurgeries. VLNT involves the transfer of functional lymph nodes (LNs) from a healthy donor site to an area of the body with damaged or diseased lymphatic drainage. The goal of the transplant is to restore physiologic LN drainage and improve lymphedema. Donor LNs are commonly found in the groin, axilla, neck, omentum, or submental region. Imaging can be used for preoperative planning to identify donor sites with the richest number of LNs.
This is a transfer, not a transplant, because the surgeon removes lymph nodes from your body, preserving their blood supply and reattaching the lymph nodes to blood vessels in the affected arm or leg. This is also microsurgery but it is more invasive. If the donor the lymph nodes are near an extremity, your surgeon will perform tests are performed to reduce the risk of creating lymphedema in a new limb.