Submitted Successfully!
To reward your contribution, here is a gift for you: A free trial for our video production service.
Thank you for your contribution! You can also upload a video entry or images related to this topic.
Version Summary Created by Modification Content Size Created at Operation
1
Gianluca Franceschini
 + 1251 word(s) 1251 2021-05-17 11:34:30 |
2 Format correct
Vicky Zhou
 Meta information modification 1251 2021-05-25 05:07:24 |

Video Upload Options

We provide professional Video Production Services to translate complex research into visually appealing presentations. Would you like to try it?
No, upload directly Yes

Confirm

Are you sure to Delete?
Yes No
Cite
If you have any further questions, please contact Encyclopedia Editorial Office.
Franceschini, G. Breast Cancer-Related Lymphedema. Encyclopedia. Available online: https://encyclopedia.pub/entry/10016 (accessed on 20 November 2024).
Franceschini G. Breast Cancer-Related Lymphedema. Encyclopedia. Available at: https://encyclopedia.pub/entry/10016. Accessed November 20, 2024.
Franceschini, Gianluca. "Breast Cancer-Related Lymphedema" Encyclopedia, https://encyclopedia.pub/entry/10016 (accessed November 20, 2024).
Franceschini, G. (2021, May 24). Breast Cancer-Related Lymphedema. In Encyclopedia. https://encyclopedia.pub/entry/10016
Franceschini, Gianluca. "Breast Cancer-Related Lymphedema." Encyclopedia. Web. 24 May, 2021.
Breast Cancer-Related Lymphedema
Edit
This entry is adapted from the peer-reviewed paper 10.3390/jpm11050402

Breast cancer-related lymphedema (BCRL) represents a global healthcare issue affecting the emotional and life quality of breast cancer survivors significantly. The clinical presentation is characterized by swelling of the affected upper limb, that may be accompanied by atrophic skin findings, pain and recurrent cellulitis. Cardinal principles of lymphedema management are the use of complex decongestive therapy and patient education. Recently, new microsurgery procedures have been reported with interesting results, bringing in a new opportunity to care postmastectomy lymphedema. However, many aspects of the disease are still debated in the medical community, including clinical examination, imaging techniques, patient selection and proper treatment.

breast cancer lymphedema lymphaticovenous anastomosis vascularized lymph node transfer lymphatic microsurgery radiotherapy

1. Introduction

Breast cancer-related lymphoedema (BCRL) remains a significant clinical issue for breast cancer survivors in that it causes severe physical and psychological discomfort. With the ever-increasing incidence of breast cancer, more patients are undergoing breast surgery that may include sentinel lymph node biopsy (SLNB) and/or axillary lymph node dissection (ALND) [1][2]. Chest wall radiotherapy is also commonly performed in patients with previous ALND, whereas axillary radiotherapy is sometimes indicated as an alternative to ALND in selected patients [3][4]. Both axillary surgery or radiotherapy can cause lymphedema with significant impairment of the normal lymphatic drainage producing an abnormal collection of protein-rich fluid within the upper limb. Despite improved early detection and evolving approaches to minimize surgical intervention increasing conservative surgery procedures with fewer ALND [5]; BCRL remains however a significant healthcare burden [6].
According to reports the incidence of BCRL varies and is approximately 20% at one year and increases to 40% at ten years after breast cancer treatment with a cumulative incidence of 28% [4][7]. Indeed, lymphedema is significantly more likely to occur following ALND than after SLNB alone [8][9]. Lymphedema can to develop within days postoperatively and can continue to present until 11 years after breast cancer treatment [10].
The impact of a lower quality-of-life on patients with lymphedema is unquestionable and there is a higher likelihood of poorer general health [11]. Besides, complications of lymphedema including repeated episodes of cellulitis and ulceration, may require antibiotic therapy and hospitalization.
Cardinal principles of lymphedema treatment are patient education and control of concomitant diseases that may worsen swelling. Upper limb swelling is primarily controlled through the use of complex decongestive therapy (CDT) such as manual lymphatic drainage, bandages, compression garments and individualized exercises to reduce limb swelling [12]. Historical surgical treatments for lymphedema such as Homans’ operation and Charles’ procedure are palliative and nowadays largely abandoned [13]. Instead, a more recent volume reduction approach is circumferential liposuction [14][15]. In recent years, microsurgical and supermicrosurgical techniques, such as lymphaticovenous anastomosis (LVA) [16][17] and vascularized lymph node transfer (VLNT) [18] have gained popularity as they can potentially reconstitute lymphatic flow and, ideally, reduce the use of compression garments.
The recent introduction of severity staging using lymphoscintigraphy [19][20], and indocyanine green (ICG) [16][21] has helped the patient selection and improved the reported outcomes as it allows preoperatively to evaluate the lymphatic obstruction and the lymphatic flow patterns.

2. Treatments for BCRL

Current treatment options for BCRL include conservative and surgical treatments; however, determining the best treatment method for each patient remains challenging.

2.1. Conservative Treatments

CDT is widely accepted the universal first-line therapy for extremity lymphedema. It includes manual lymph drainage (MLD), skin care, specialized exercises, compression garments and self-education [6]. CDT is divided into Phase I Decongestion, and Phase II Maintenance and should be individualized to improve its effectiveness and contain costs.
Several advantages can be obtained by a CDT including: (1) reduction of lymphedema volume, pain and arm heaviness, (2) improvement of lymphatic drainage, (3) acceptable quality of life and (4) reduction of episodes of cellulitis [22][23]. Although conservative therapy alone may provide enough symptomatic relief, it depends essentially on patient compliance and their capacity to wear life-long compression garments.

2.1.1. Manual Lymphatic Drainage

Manual lymphatic drainage (MLD) is a massage method increasing the transport capacity of the lymph collectors and moving lymph fluid and protein absorption when the lymphatic ducts are still functioning. A meta-analysis showed that, compared with other CDT modalities, additional MLD is unlikely to produce a proper reduction in the lymphedematus limb circumference [24]. In the other hand, another systematic review found that when MLD was used in combination with compression garments, provide increased swelling reduction in BCRL patients compared to the compression bandages alone, especially for moderate lymphedema stages [25].

2.1.2. Compression Bandages and Compression Garments

Compression bandages are an important part of CDT maintaining the therapeutic effects of MLD. Compression bandages apply: (1) a resting pressure during the limb relaxed and (2) a working pressure when muscles contraction push the skin against resisting bandages. Low-stretch bandages produce the highest working pressure with multi-layered compression bandaging.
Compression garments are an essential part of CDT and with the aim to keep the volume reduction achieved with MLD and bandaging. Compression garments produce a two-way stretch in both longitudinal and transverse direction with the greatest pressure above the wrist and less pressure in the arm. The longitudinal pressure facilitates the joint movements. Generally, patients with BCRL wear a full arm sleeve and, frequently, a glove to prevent dermal backflow. There is no consensus regarding suitable compression values. Class 2 compression garments with 30–40 seamless are often recommended to be wear at least 12 h per day [19]. Of note, compression garments should be custom-made by a certified and experienced therapist in fitting garments for lymphedema patients.

2.1.3. Exercises and Life-Style

Exercises are an integral part of CDT with the aim (1) to promote lymph flow, (2) to mobilize the joints, and (3) to strengthen the muscles. It is widely known that participation in exercises during and after oncological treatment can improve the physical and psychosocial condition, ameliorating the quality-of-life [26]. Recent studies reported that gradual weight-lifting program does not worsen the risk of BCRL compared to patients without exercises [27][28].

2.2. Surgical Treatments

Many surgical procedures to treat BCRL have been propose as follow: (1) physiologic procedures (lymphaticovenous anastomosis, vascularized lymph node transfer) and (2) excisional procedures (reduction or liposuction) (Table 1).
Table 1. Available Treatments for Patients with Breast Cancer-Related Lymphedema.
Treatment Indication Advantages Disadvantages
Complex Decongestive Therapy
  • CLG 0-I
  • Reduction lymphedema volume, pain and arm heaviness
  • Improvement lymphatic function
  • Acceptable quality of life
  • Reduction episodes of cellulitis
  • It is a purely symptomatic treatment
  • Needs patient compliance
  • Life-long compression garments.
Lymphovenous anastomosis
  • CLG I- early II
  • Safe
  • Reduces of Circumference
  • Reduces callulitis
  • Technically difficult
  • Needs supermicrosurgery instruments
  • Needs high resolution microscope
  • Needs ICG lymphography
  • Difficult to monitor the anastomoses patency
Vascularized Lymph Node Transfer
  • CLG late II-III-IV
  • Improvements in circumferential measurements, episodes of cellulitis, and quality of life
  • Requires intraoperative techniques of greater complexity
  • Higher risk for postoperative re-exploration and the flap inset
  • Risk of donor-site lymphedema
Liposuction
  • CLG III-IV
  • Decrease limb size
  • Reduces episodes of cellulitis
  • Improve quality of life
  • Risks of swelling recurrence
  • Life-long compression garments
CLG: Cheng’s Lymphedema Grading.

3. Conclusions

BCRL is a debilitating and chronic and condition that can severely affect the patient’s quality of life. An improvement in identification, prevention, and management of affected patients is imperative in reducing BCRL. A particular attention should be given to all stages of breast cancer treatment in order to reduce the incidence of BCRL. The use of new technologies for performing mastectomies and sentinel lymph node biopsy or axillary lymph node dissection could be useful [29][30][31][32]. Accurate physical examination and assessment of the lymphedema severity are essential to provide more predictable outcomes. A prompt management of the disease in a multidisciplinary team is the key to obtain good results [33][34][35][36][37][38][39][40][41]. Despite the fact lymphedema is still considered an incurable disease, in the last decade promising results with significant reduction of the limb swelling and improvement of psychosocial well-being have been shown.

References

  1. Starnoni, M.; Pinelli, M.; Franceschini, G.; De Santis, G. A Rare Case of Nipple-Areolar Complex Partial Necrosis following Micropigmentation: What to Learn? Plast. Reconstr. Surg. Glob. Open 2019, 7, e2494.
  2. Starnoni, M.; Baccarani, A.; Pinelli, M.; Pedone, A.; De Santis, G. Tattooing of the nipple-areola complex: What not to do. A case series. Ann. Med. Surg. 2020, 55, 305–307.
  3. Zhang, J.; Wang, C. Axillary radiotherapy: An alternative treatment option for adjuvant axillary management of breast cancer. Sci. Rep. 2016, 6, 26304.
  4. Rebegea, L.; Firescu, D.; Dumitru, M.; Anghel, R. The incidence and risk factors for occurrence of arm lymphedema after treatment of breast cancer. Chirurgia 2015, 110, 33–37.
  5. Giuliano, A.E.; McCall, L.; Beitsch, P.; Whitworth, P.W.; Blumencranz, P.; Leitch, A.M.; Saha, S.; Hunt, K.K.; Morrow, M.; Ballman, K. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: The American College of Surgeons Oncology Group Z0011 randomized trial. Ann. Surg. 2010, 252, 426–432.
  6. Rockson, S.G. Lymphedema after Breast Cancer Treatment. N. Engl. J. Med. 2018, 379, 1937–1944.
  7. DiSipio, T.; Rye, S.; Newman, B.; Hayes, S. Incidence of unilateral arm lymphoedema after breast cancer: A systematic review and meta-analysis. Lancet Oncol. 2013, 14, 500–515.
  8. Wernicke, A.G.; Shamis, M.; Sidhu, K.K.; Turner, B.C.; Goltser, Y.; Khan, I.; Christos, P.J.; Komarnicky-Kocher, L.T. Complication rates in patients with negative axillary nodes 10 years after local breast radiotherapy after either sentinel lymph node dissection or axillary clearance. Am. J. Clin. Oncol. 2013, 36, 12–19.
  9. McLaughlin, S.A.; Wright, M.J.; Morris, K.T.; Giron, G.L.; Sampson, M.R.; Brockway, J.P.; Hurley, K.E.; Riedel, E.R.; Van Zee, K.J. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: Objective measurements. J. Clin. Oncol. 2008, 26, 5213–5219.
  10. Armer, J.M.; Stewart, B.R. Post-breast cancer lymphedema: Incidence increases from 12 to 30 to 60 months. Lymphology 2010, 43, 118–127.
  11. Vassard, D.; Olsen, M.H.; Zinckernagel, L.; Vibe-Petersen, J.; Dalton, S.O.; Johansen, C. Psychological consequences of lymphoedema associated with breast cancer: A prospective cohort study. Eur. J. Cancer 2010, 46, 3211–3218.
  12. Badger, C.M.; Peacock, J.L.; Mortimer, P.S. A randomized, controlled, parallel-group clinical trial comparing multilayer bandaging followed by hosiery versus hosiery alone in the treatment of patients with lymphedema of the limb. Cancer 2000, 88, 2832–2837.
  13. Karri, V.; Yang, M.C.; Lee, I.J.; Chen, S.H.; Hong, J.P.; Xu, E.S.; Cruz-Vargas, J.; Chen, H.C. Optimizing outcome of charles procedure for chronic lower extremity lymphoedema. Ann. Plast. Surg. 2011, 66, 393–402.
  14. Boyages, J.; Kastanias, K.; Koelmeyer, L.A.; Winch, C.J.; Lam, T.C.; Sherman, K.A.; Munnoch, D.A.; Brorson, H.; Ngo, Q.D.; Heydon-White, A.; et al. Liposuction for Advanced Lymphedema: A Multidisciplinary Approach for Complete Reduction of Arm and Leg Swelling. Ann. Surg. Oncol. 2015, 22 (Suppl. 3), S1263–S1270.
  15. Granoff, M.D.; Johnson, A.R.; Shillue, K.; Fleishman, A.; Tsai, L.; Carroll, B.; Donohoe, K.; Lee, B.T.; Singhal, D. A Single Institution Multi-Disciplinary Approach to Power-Assisted Liposuction for the Management of Lymphedema. Ann. Surg. 2020.
  16. Chang, D.W.; Suami, H.; Skoracki, R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast. Reconstr. Surg. 2013, 132, 1305–1314.
  17. AlJindan, F.K.; Lin, C.Y.; Cheng, M.H. Comparison of Outcomes between Side-to-End and End-to-End Lymphovenous Anastomoses for Early-Grade Extremity Lymphedema. Plast. Reconstr. Surg. 2019, 144, 486–496.
  18. Pappalardo, M.; Patel, K.; Cheng, M.H. Vascularized lymph node transfer for treatment of extremity lymphedema: An overview of current controversies regarding donor sites, recipient sites and outcomes. J. Surg. Oncol. 2018, 117, 1420–1431.
  19. Cheng, M.H.; Pappalardo, M.; Lin, C.; Kuo, C.F.; Lin, C.Y.; Chung, K.C. Validity of the Novel Taiwan Lymphoscintigraphy Staging and Correlation of Cheng Lymphedema Grading for Unilateral Extremity Lymphedema. Ann. Surg. 2018, 268, 513–525.
  20. Pappalardo, M.; Lin, C.; Ho, O.A.; Kuo, C.F.; Lin, C.Y.; Cheng, M.H. Staging and clinical correlations of lymphoscintigraphy for unilateral gynecological cancer-related lymphedema. J. Surg. Oncol. 2020, 121, 422–434.
  21. Yamamoto, T.; Yamamoto, N.; Doi, K.; Oshima, A.; Yoshimatsu, H.; Todokoro, T.; Ogata, F.; Mihara, M.; Narushima, M.; Iida, T.; et al. Indocyanine green-enhanced lymphography for upper extremity lymphedema: A novel severity staging system using dermal backflow patterns. Plast. Reconstr. Surg. 2011, 128, 941–947.
  22. Mobarakeh, Z.S.; Mokhtari-Hesari, P.; Lotfi-Tokaldany, M.; Montazeri, A.; Heidari, M.; Zekri, F. Combined decongestive therapy and reduction of pain and heaviness in patients with breast cancer-related lymphedema. Support Care Cancer 2019, 27, 3805–3811.
  23. Ochalek, K.; Partsch, H.; Gradalski, T.; Szygula, Z. Do Compression Sleeves Reduce the Incidence of Arm Lymphedema and Improve Quality of Life? Two-Year Results from a Prospective Randomized Trial in Breast Cancer Survivors. Lymphat. Res. Biol. 2019, 17, 70–77.
  24. Huang, T.W.; Tseng, S.H.; Lin, C.C.; Bai, C.H.; Chen, C.S.; Hung, C.S.; Wu, C.H.; Tam, K.W. Effects of manual lymphatic drainage on breast cancer-related lymphedema: A systematic review and meta-analysis of randomized controlled trials. World J. Surg. Oncol. 2013, 11, 15.
  25. Ezzo, J.; Manheimer, E.; McNeely, M.L.; Howell, D.M.; Weiss, R.; Johansson, K.I.; Bao, T.; Bily, L.; Tuppo, C.M.; Williams, A.F.; et al. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database Syst. Rev. 2015, CD003475.
  26. Hayes, S.C.; Reul-Hirche, H.; Turner, J. Exercise and secondary lymphedema: Safety, potential benefits, and research issues. Med. Sci. Sports Exerc. 2009, 41, 483–489.
  27. Ahmed, R.L.; Thomas, W.; Yee, D.; Schmitz, K.H. Randomized controlled trial of weight training and lymphedema in breast cancer survivors. J. Clin. Oncol. 2006, 24, 2765–2772.
  28. Panchik, D.; Masco, S.; Zinnikas, P.; Hillriegel, B.; Lauder, T.; Suttmann, E.; Chinchilli, V.; McBeth, M.; Hermann, W. Effect of Exercise on Breast Cancer-Related Lymphedema: What the Lymphatic Surgeon Needs to Know. J. Reconstr. Microsurg. 2019, 35, 37–45.
  29. Baccarani, A.; Starnoni, M.; De Santis, G. Ultrasonic Cutting and Coagulating Device in Implant-based Breast Reconstruction. Plast. Reconstr. Surg. Glob. Open 2018, 6, e2020.
  30. Pinelli, M.; Starnoni, M.; De Santis, G. The Use of Cold Atmospheric Plasma Device in Flap Elevation. Plast. Reconstr. Surg. Glob. Open 2020, 8, e2815.
  31. Starnoni, M.; De Santis, G.; Pinelli, M. Fibula Free Flap Elevation without Tourniquet: Are Harmonic Scalpel Shears Useful? Plast. Reconstr. Surg. Glob. Open 2019, 7, e2409.
  32. Starnoni, M.; Pinelli, M.; De Santis, G. Setting of helium plasma device (J-Plasma) in flap elevation. J. Vasc. Surg. Cases Innov. Tech. 2020, 6, 446.
  33. Baccarani, A.; Aramini, B.; Casa, G.D.; Banchelli, F.; D’Amico, R.; Ruggiero, C.; Starnoni, M.; Pedone, A.; Stefani, A.; Morandi, U.; et al. Pectoralis Muscle Transposition in Association with the Ravitch Procedure in the Management of Severe Pectus Excavatum. Plast. Reconstr. Surg. Glob. Open 2019, 7, e2378.
  34. Benanti, E.; Starnoni, M.; Spaggiari, A.; Pinelli, M.; De Santis, G. Objective Selection Criteria between ALT and Radial Forearm Flap in Oral Soft Tissues Reconstruction. Indian J. Plast. Surg. 2019, 52, 166–170.
  35. Benanti, E.; De Santis, G.; Leti Acciaro, A.; Colzani, G.; Baccarani, A.; Starnoni, M. Soft tissue coverage of the upper limb: A flap reconstruction overview. Ann. Med. Surg. 2020, 60, 338–343.
  36. De Santis, G.; Mattioli, F.; Pinelli, M.; Martone, A.; Starnoni, M.; Fermi, M.; Presutti, L. Tip of the Tongue Reconstruction with Prelaminated Fasciomucosal Radial Forearm Free Flap. Plast. Reconstr. Surg. Glob. Open 2020, 8, e3226.
  37. Manfredini, B.; Morandi, U.; De Santis, G.; Catani, F.; Stefani, A.; Pinelli, M.; Baccarani, A.; Starnoni, M.; Artioli, F.; Aramini, B. Can surgery relieve pain and act as first-line treatment for a large metastasis of the sternum? Int. J. Surg. Case Rep. 2019, 63, 125–128.
  38. Starnoni, M.; Colzani, G.; De Santis, G.; Leti Acciaro, A. Management of Locked Volar Radio-ulnar Joint Dislocation. Plast. Reconstr. Surg. Glob. Open 2019, 7, e2480.
  39. Starnoni, M.; Colzani, G.; De Santis, G.; Acciaro, A.L. Median Nerve Injury Caused by Screw Malpositioning in Percutaneous Scaphoid Fracture Fixation. Plast. Reconstr. Surg. Glob. Open 2019, 7, e2292.
  40. Baccarani, A.; Pappalardo, M.; Starnoni, M.; De Santis, G. Plastic Surgeons in the Middle of the Coronavirus Disease 2019 Pandemic Storm in Italy. Plast. Reconstr. Surg. Glob. Open 2020, 8, e2889.
  41. Starnoni, M.; Baccarani, A.; Pappalardo, M.; De Santis, G. Management of Personal Protective Equipment in Plastic Surgery in the Era of Coronavirus Disease. Plast. Reconstr. Surg. Glob. Open 2020, 8, e2879.
More
© Text is available under the terms and conditions of the Creative Commons Attribution (CC BY) license; additional terms may apply. By using this site, you agree to the Terms and Conditions and Privacy Policy.
Upload a video for this entry
Information
Subjects: Oncology
Contributor MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Gianluca Franceschini
View Times: 574
Revisions: 2 times (View History)
Update Date: 23 Jun 2021
Table of Contents
    1000/1000
    Hot Most Recent
    ScholarVision Creations
    Feedback