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J Unexplored Med Data 2019;4:5.10.20517/2572-8180.2019.02© The Author(s) 2019.
Open AccessReview

Lymphedema after treatment of breast cancer: a comprehensive review

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Department of Surgery, Division of Surgical Oncology, University of Alabama at Birmingham, Birmingham, AL 35233, USA.

Correspondence Address: Dr. Catherine Parker, Department of Surgery, Division of Surgical Oncology, University of Alabama at Birmingham, Birmingham, AL 35233, USA. E-mail: ccparker@uabmc.edu

    Science Editor: Kandace McGuire | Copy Editor: Cai-Hong Wang | Production Editor: Jing Yu
    ...

    © The Author(s) 2019. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

    Abstract

    Lymphedema is a chronic and morbid complication that can result from breast cancer treatment involving surgery and/or radiation therapy. Breast cancer related lymphedema (BCRL) can result in functional and psychological problems that can affect a patient’s quality of life. Lymphedema is a pathologic condition of the lymphatic system in which protein-containing fluid accumulates in the interstitial tissue leading to tissue inflammation, fibrosis, and adipose hypertrophy. Clinical manifestations of lymphedema include swelling, induration, skin changes, and decreased functionality of the affected limb. A common risk factor associated with BCRL is the management of the axilla. Advances in research have shown sentinel lymph biopsy to be equally effective as axillary lymph node dissection in staging the axilla, in appropriate cases. In addition, with breast-conserving therapy it has been shown that radiation therapy also increases the risk of BCRL. Overall, approximately 1 in 6 women treated for breast cancer will develop lymphedema within months to years after diagnosis and treatment. Lymphedema is a progressive disease with a subclinical phase that can last for years before becoming clinically evident. While management of breast cancer has improved, it is important that we develop a coordinated and standardized approach to better diagnose, assess, and manage BCRL. This includes patient education, a thorough physical examination, access to confirmatory testing when necessary, a conservative multimodality treatment plan that includes compression and decongestive therapy, and being able to offer operative management when conservative management is ineffective.

    Introduction

    It has been estimated that in 2018, there were over 2 million new diagnoses of breast cancer worldwide[1]. The American Cancer Society reported an estimated 252,710 new cases of invasive breast cancer diagnoses among women and 2,470 cases in men in 2017. In the United States, the lifetime risk of being diagnosed with breast cancer increased from 1 in 11, in the 1970s, to 1 in 12, currently, partly due to increased detection in screening, hormone replacement therapy after menopause, the rising prevalence of obesity, and changes in reproductive patterns[2]. By 2026, estimated breast cancer survivors were predicted to reach over 4 million, and 45% of them would be older than age 50 years[3]. Treatment of breast cancer includes surgery, chemotherapy, endocrine therapy, and radiation therapy but there are some adverse events related to these treatments. One of these complications is lymphedema of the upper extremity, a chronic condition, which can be a challenge to both patients and clinicians. Various studies demonstrate a wide variety of incidence rates in which approximately 16.6% of breast cancer survivors develop lymphedema[4]. This variation depends on the extent of breast and axillary surgery as well as the use of adjuvant radiation therapy[5,6].

    Lymphedema is defined as a set of pathophysiologic conditions in which protein-containing fluid accumulates in soft tissues due to an interruption of lymphatic flow which can result in inflammation, fibrosis, and hypertrophy of adipose tissue. It is a chronic disease that can be difficult to treat and is often associated with both physical and psychologic morbidity. Due to the increased incidence of breast cancer diagnoses, some requiring axillary lymph node surgery and/or radiation, it is important that we understand the possible prevention, management, and early detection of BCRL to reduce the degree of morbidity associated with BCRL. There is a continued effort in research and new advances in the field to improve management of BCRL.

    Methods

    We performed PubMed/MEDLINE and Cochrane searches of the English-language literature. Studies of all dates were included to provide adequate background as well as to capture new studies that have emerged in the past 5 years. General keywords used for this search were lymphedema, breast-cancer related lymphedema, decongestive lymphatic therapy, lymphedema management, and axillary lymph node surgery. Published guidelines and resources from the International Society of Lymphology, the National Comprehensive Cancer Network, the American Society of Clinical Oncology, the American Society of Breast Surgeons, and the American Physical Therapy Association, were also included for review. In addition, relevant publications were manually reviewed for additional resources relevant to this review.

    Pathophysiology

    The underlying mechanism of lymphedema is dysfunction in the lymphatic transport system. Three primary functions of the lymphatic system include maintaining fluid balance, serving as a nutritional adjunct, and aiding in host defense against disease[7,8]. The lymphatic system maintains fluid balance by removing excess fluid from capillaries that accumulates in the interstitium in order to maintain the steady state of the interstitial pressure. Lymphatic fluid, known as lymph, is drained by blind-ended lymphatic capillaries. It is then filtered through lymph nodes and ultimately reenters the circulatory system, via the thoracic duct, where the peripheral venous blood enters the right atrium of the heart[9]. Under normal conditions, the same amount is transported to the interstitium as is transported from it, a balance that is disrupted in lymphedema due to reduced lymph transport capacity, thus leading to fluid accumulation and swelling. Disruption of this system subsequently leads to a decrease in oxygen tension resulting in reactive tissue fibrosis and chronic tissue inflammation. In addition, the buildup of protein in the interstitium leads to an increased osmotic pressure which drives fluid into the interstitium causing edema and the clinical manifestations of lymphedema[9,10].

    According to traditional definitions, lymphedema is divided into two types: primary and secondary. Primary lymphedema is often classified according to the age at which the edema first appeared: congenital lymphedema, (present at birth), lymphedema praecox (onset at time of puberty or as late as third decade of life), and lymphedema tarda (typically appears after age 35)[11]. Secondary lymphedema is due to an extrinsic disruption of, or obstruction of the lymphatic system due to trauma. The forms of trauma include surgery to the axilla, radiation therapy, chemotherapy, or inflammation and scarring from metastasis to the lymph nodes[8,10]. More recently, Damstra et al.[12] reports that as all interstitial fluid is transported by lymphatics, the overload of fluid can be relative, based on lymphatic impairment and dysfunction of the lymphatic system (afterload impairment), or absolute, based on increased filtration rate (preload is raised). Under this classification, the traditional categories of primary and secondary lymphedema would be considered afterload impairment.

    In the United States, secondary lymphedema is most commonly due to malignancy or its related therapy[10]. These malignancies include, but are not limited to, breast cancer, melanoma, and lymphoma. Breast cancer treated with surgery and/or radiation accounts for the majority of upper-extremity lymphedema. Studies have demonstrated BCRL rates of 24% to 49% after mastectomy and 4% to 28% after lumpectomy, with a history of axillary lymph node surgery[13-18].

    Lymphatic drainage of the breast

    One of the most common causes of upper extremity lymphedema is breast cancer and its related treatment. The axilla has approximately 20 to 30 lymph nodes, but this can vary. The axilla receives drainage from 75% of the ipsilateral breast, regions of the upper back and shoulder, lower neck, the chest and the upper anterolateral abdominal wall[19]. These nodes are further divided into 6 groups: axillary vein (lateral), external mammary, scapular and subscapular, central, subclavicular, and interpectoral groups. Surgeons typically define the axillary lymph nodes in relation to the pectoralis minor muscle: levels I, II, and III-lateral to, posterior to, and medial to the pectoralis minor muscle, respectively.

    Breast cancer related lymphedema

    Breast cancer, depending on the stage and other factors, can be managed surgically with or without involvement of the axillary lymph nodes. Axillary lymph node surgery includes ALND or SLNB. ALND typically involves removal of level I and II nodes whereas SLNB involves removing those lymph nodes identified as the first node(s) to receive lymphatic drainage from the site of the tumor and should be the first site of lymphatic spread[20].

    Incidence and risk factors

    It has been posited that SLNB confers less morbidity than ALND and was determined to provide accurate staging of the axillary nodal basin. Larson and colleagues found a correlation between the risk of lymphedema formation and the number of removed lymph nodes; when greater than 10 nodes were removed, the risk of edema was 28% vs. 9% if 1 to 10 nodes were removed[21]. In addition, the literature demonstrates an average risk of lymphedema with ALND to be 28%, with a range of 11% to 57%[22]. This variation in incidence over many large trials is secondary to the method of detection of lymphedema, how closely lymphedema is monitored, surgical technique, and length of follow-up[21-23]. Smaller studies have shown that the number of positive lymph nodes, postoperative radiation therapy, extent of surgery, obesity, and other patient characteristics contribute to the risk of lymphedema and thus the varying rates of incidence[23-25]. The Axillary Lymphatic Mapping Against Nodal Axillary Clearance trial demonstrated that lymphedema was observed in approximately 5% of patients who had SLNB vs. 13% of those who had ALND[26]. The National Surgical Breast and Bowel Project (NSABP-32) randomized 5,400 patients to SLNB followed by ALND vs. SLNB alone demonstrating an 8% risk of BCRL with SLNB[19,27]. The American College of Surgeons Oncology Group organized a prospective international, multicenter study, trial Z0010, in which upper extremity edema was demonstrated in 7% of patients with SLNB, performed by a wide range of surgeons (including, but not limited to, level of experience)[28]. Overall, many randomized controlled trials (from 2002 to 2014), have demonstrated decreased incidence of BCRL after SLNB vs. ALND, with follow-up ranging from 12 months to 60 months[29-37].

    In 2007, Thompson et al.[38] introduced the technique of axillary reverse mapping (ARM) to describe the drainage of the arm within the axilla to facilitate reducing the risk of lymphedema after axillary lymph node surgery. The technique involves preoperative injection of technetium sulfur colloid into the subareolar plexus along with intradermal injection of blue dye into the ipsilateral upper extremity. Over the years, studies have demonstrated that identifying the lymphatic drainage using ARM helped to reduce the risk of disruption of lymphatics and subsequent BCRL, when combined with axillary lymph node surgery[38-40].

    In addition to axillary lymph node surgery being a risk factor for BCRL, it has been shown that radiation therapy is an independent risk factor for the development of BCRL with reported rates of 2% to 5%, even in the absence of lymph node surgery[41,42]. Target areas for radiation therapy depends on many factors, including but not limited to, type of surgery, lymph node involvement and patient characteristics such as age and co-morbidities. These target areas include the whole breast, partial breast, and regional lymph nodes. Whole breast radiation therapy (WBRT) generally includes treatment of the entire breast with modifications of treatment field boundaries based on whether a patient has had mastectomy versus lumpectomy. Partial breast radiation is focused therapy to a limited area of the breast and is delivered as accelerated partial breast irradiation. Regional node irradiation (RNI), is therapy to specific regional node basins alone or in conjunction with WBRT depending on the extent of disease. The European Organization for Research and Treatment of Cancer after Mapping of the Axilla: Radiotherapy or Surgery randomized controlled trial demonstrated a 13% risk of lymphedema in those with ALND and WBRT vs. 5% for SLNB, WBRT, and RNI[43]. It also showed that axillary radiotherapy provides comparable axillary control compared to completion ALND after a positive SLNB. The National Cancer Institute of Canada Clinical Trials Group conducted a study which demonstrated a BCRL incidence of 4.5% after ALND and WBRT vs. 8.4% after ALND, WBRT and RNI[44]. Radiation to the axilla is associated with 2 to 4.5 times greater risk of lymphedema and 8 to 10 times greater risk when a patient receives ALND and radiation treatment[45-47].

    In addition to the known risk factors for BCRL, there are conflicting studies about adjuvant and neoadjuvant chemotherapy as possible risk factors for BCRL. Some studies indicate that adjuvant chemotherapy is a potential risk factor for BCRL[4,48-53]. DiSipio et al.[4] did a meta-analysis of 72 studies published from 2000 to 2012 to assess the incidence rates of BCRL, and a meta-analysis of 29 studies published from 2000 to 2012, to assess the risk factors. This study demonstrated that about 75% of the studies reviewed indicated chemotherapy as a risk factor for developing BCRL[4]. Kilbreath et al.[48] did a recent large, prospective cohort study, using objective limb measurements which showed that patients who had taxane-based chemotherapy were at risk for arm swelling at 6 months and 12 months; those that experience arm swelling at 6 and 12 months were at greater risk for BCRL at 18 months (6 months OR: 5.6; 95% CI: 2.0-16.9) (12 months OR: 13.5; 95% CI: 4.8-38.1). These findings were also supported by Zhu et al.[52] who also found a correlation between taxane-based adjuvant chemotherapy and the cumulative incidence of BCRL. Conversely, Swaroop et al.[54] did not find any correlation between taxane-based chemotherapy and the development of BCRL, however there was some correlation between docetaxol to be a risk factor for mild swelling compared to no chemotherapy and non-taxane based chemotherapy. While there are new studies looking at neoadjuvant therapy as a risk factor for the development of BCRL, the findings are inconclusive. Specht et al.[55] showed that there was an increased risk of BCRL in patients found to have residual nodal disease after neoadjuvant chemotherapy. However, at this time more research needs to be done further assess the effects of neoadjuvant chemotherapy as a risk factor.

    A well-studied, independent risk factor for BCRL is high BMI, defined as BMI > 30 kg/m2[35,50,56-60]. Jamallo et al.[62] and other smaller studies have also correlated this finding that women with BMI of 30 kg/m2 or greater, were at least 3.6 times more likely to develop BCRL[53,61]. Furthermore, Jamallo et al.[62] found that post-operative weight fluctuations greater than 10 pounds per month, either lost or gained, increased BCRL[53]. With this information, counseling patients about healthy weight, as well managing weight fluctuations, can contribute to helping to decrease the incidence of BCRL with this well-known, modifiable risk factor.

    Clinical presentation

    The clinical manifestations of lymphedema are secondary to an inflammatory response to the chronic accumulation of protein-containing interstitial fluid and adipose tissue. Lymph stasis, or decreased flow, has been shown to contribute to lipogenesis and fat deposition which later leads to increased fibrocyte activation and connective tissue growth[63-65].

    Many rating scales exist to characterize the clinical progression of lymphedema. The International Society of Lymphology has developed a staging system to classify lymphedema based on the physical appearance of the limb [Table 1][66]. Within each stage, severity based on limb volume difference can be further characterized as minimal (< 20% increase), moderate (20%-40%), or severe (> 40%) increase[20]. A more recent classification system developed by Campisi et al.[67] uses clinical presentation as well as lymphoscintigraphy findings to classify lymphedema[Table 1][8]. Additionally, Chang et al.[68] incorporates ICG lymphangiography to classify lymphedema which further aids in surgical planning in lymphedema of the upper extremity [Table 1].

    Table 1

    Staging and grading of lymphedema[8,6668]

    StageInternational society of lymphologyCampisi et al.[67]Chang et al.[68]
    0Latent or subclinical Patients complain of heavy sensation and/or numbness in arm May exist for months to years before overt edema occurs
    1Early accumulation of protein-rich fluid May have soft, pitting edema: limb elevation leads to complete resolution of swelling No fibrosisA. No clinical edema despite the presence of lymphatic dysfunction as demonstrated on lymphoscintigraphy
    B. Mild edema that spontaneously regresses with elevation Limb excess volume: 0%-20%
    Many patent lymphatic vessels, with minimal, patchy dermal backflow
    2Limb elevation alone rarely reduces swelling Fibrosis present: reduces ability of skin to indent with pressurePersistent edema that regresses only partially with elevation Limb excess volume: 21%-40%Moderate number of patent lymphatic vessels, with segmented dermal backflow
    3Lymphostatic elephantiasis: no pitting edema present Severe fibrosis and hypertrophic skin changes such as hyperkeratosis, fat deposits and warty outgrowthsPersistent, progressive edema; recurrent erysipeloid lymphangitis Limb excess volume: 41%-60%Few patient lymphatic vessels, with extensive dermal backflow involving the entire arm
    4Fibrotic lymphedema with column limb Limb excess volume: > 60%No patent lymphatic vessels seen, with severe dermal backflow involving the entire arm and extending to the dorsum of the hand
    5Elephantiasis with severe limb deformation, including scleroinductive pachydermitis and widespread lymphostatic warts Limb excess volume: > 60%

    Diagnosis

    Diagnosis of BCRL is based on consideration of risk factors, associated symptoms, and clinical signs and is typically made during physical examination. Clinically evident lymphedema will present with various levels of pitting edema, which can involve any aspect of the upper extremity, usually first noticeable in the digits of the hand. Affected patients may complain of increased heaviness and decreased activity of the affected limb. Because BCRL can develop months to years after onset of lymphatic insult, it is important that patients are assessed for this during follow-up appointments even when there is no complaint of BCRL symptoms. Literature has demonstrated that most women present with BCRL within the first two years of diagnosis and treatment[69-71]. A study of 1,713 women who underwent breast-conserving therapy showed that 40% of them who presented with arm edema had mild edema at diagnosis[72]. While BCRL is the likely diagnosis, when evaluating women treated for breast cancer, there are other causes of limb swelling, such as other malignancy, upper extremity deep venous thrombosis, and infection that must also be considered. Therefore, if indicated, it is important to carry out appropriate studies, to exclude these diagnoses.

    The literature has described a wide variety of noninvasive methods for evaluating limb volume when lymphedema is clinically evident. Options include bioelectrical impedance analysis (BIA), tape measurement, perometry, and water displacement[73]. BIA determines the opposition to flow of an electric current (electrical impedance) through body tissue which is then used to estimate total body water[74]. The resistance of flow of electric current is due to differences in conductivity of different tissues. Based on these factors, the device is able to selectively measure water content without quantifying adipose or fibrous tissues[75-77]. Studies have demonstrated that the results of BIA are affected by body temperature and body hydration status so using it may not always be accurate[78].

    A common method used to diagnose upper-extremity edema is circumferential and volumetric measurement using anatomical landmarks[79]. Affected and unaffected arm circumferences are measured sequentially at 4 points: the metacarpal-phalangeal joints, the wrist, 10 cm distal to the lateral epicondyles, and 15 cm proximal to the lateral epicondyles. Differences of 2 cm or more, or if converted to volume, 10% or a 200 mL increase, at any point compared with the contralateral arm are considered by some experts to be clinically significant[80,81]. This method requires consideration of patient factors such as baseline discrepancies between dominant and nondominant limbs, muscle mass differences, body habitus, and post-treatment changes that may occur. Because it has been found that pre-treatment sequential measurements may prove to be clinically meaningful in order to have a baseline to improve accuracy of post-treatment assessment and diagnosis, newer methods have emerged to more accurately classify BCRL. It has been shown that quantification methods that include absolute volume changes to diagnosis BCRL are inaccurate and vary from patient to patient. The arm size of patients diagnosed with breast cancer have been shown to vary within a broad range[82]. Volume change correlates with preoperative arm volume, patient weight, and BMI however relative volume change (RVC) is independent of patient weight. In order to move towards creating a standardized classification of BCRL, RVC would be a more appropriate measure than absolute volume change[83]. Furthermore, for patients undergoing unilateral breast surgery, Ancukiewicz et al.[84] established a method for measuring RVC by considering the pre-operative and post-operative follow-up ipsilateral arm volumes and the pre-operative and post-operative follow-up volumes on the contralateral arms. This method uses the contralateral arm as a control and assumes any weight gained by the patient is distributed equally between the arms[82,84]. This method established by Ancukiewicz et al.[84], however, cannot be applied to women undergoing bilateral mastectomy. A revised version of this model, established by Miller et al.[85] includes the patient’s weight at each arm measurement (pre-operative and post-operative measurements). As assumed by the unilateral method, Miller et al.[85] demonstrated a 1:1 linear relationship between change in patient weight and volume of the contralateral arm in those undergoing unilateral breast surgery, which lead to the proposal of a weight-adjusted formula to quantify arm volume in patients undergoing bilateral breast surgery.

    Furthermore, the National Cancer Institute, which has standardized reporting of adverse events in clinical trials classifies levels of lymphedema based on percentage interlimb volume/circumference discrepancies, under the Common Terminology Criteria for Adverse Events, v4.0 (CTCAE)[69]:

    Level 1: 5%-10%;

    Level 2: > 10%-30%;

    Level 3: > 30% - Lymphorrhea and gross anatomic deviation from normal contour may occur. This level interferes with activities of daily living;

    Level 4: Although rare, the progression to malignancy, such as lymphangiosarcoma, can occur, for which limb amputation may be warranted. In other classification systems, this level may also be referred to as “end-stage” lymphedema.

    The CTCAE criteria offers both subjective (interlimb discrepancy) and objective measures to accurately classify lymphedema which offers a more standardized assessment of lymphedema.

    It is known that there is a subclinical phase of BCRL and recent studies of this phase have emerged. Specht et al.[86]did a prospective study that screened 1,173 patients with perometry and found that low-level volume changes (RVC of > 3% and < 5%, and > 5% and < 10%) within 3 months of surgery were significantly associated with development of BCRL[86]. For volume changes of RVC of > 5% and < 10% were significantly associated with development of BCRL greater than 3 months post-operatively, while an RVC of > 3% and < 5% within 3 months of surgery was not associated with BCRL development[86]. Findings from this study suggest that patients with an RVC from > 3% to < 5% within 3 months of surgery and > 5% to < 10% at any point should be monitored closely with clinical exams and are candidates for early intervention if warranted. For suspected cases of subclinical BCRL, based on abovementioned risk factors, additional tests can be done to confirm the diagnosis.

    Radionuclide imaging of the lymphatic system, lymphoscintigraphy, may be necessary although it is not a widely used technique[86]. Lymphoscintigraphy is a relatively noninvasive technique which involves an intradermal injection of radiolabeled colloid in the distal aspect of the affected limb followed by imaging of the lymphatic vasculature[10,70]. This method can delineate the lymphatic anatomy and function. Common abnormal findings include absent or delayed radiotracer transport and poorly visualized lymphatic collectors and lymph nodes[71].

    Computed tomography (CT) and magnetic resonance imaging (MRI) can also be used to delineate lymphatic dysfunction and can complement findings of lymphoscintigraphy. These imaging modalities can also be used alone if lymphoscintigraphy is not available. CT imaging has been shown to have a 97% sensitivity (SN) and a 100% specificity (SP) in confirming the diagnosis of lymphedema. MRI has been shown to have superior soft tissue imaging than CT, it offers better detail of lymphatic anatomy, and has equivalent SN and SP[10,87]. MRI findings associated with lymphedema include, “honeycombing” of the subcutaneous tissue due fibrotic tissue and fluid accumulation surrounding adipose tissue, epifascial fluid lakes, and the absence of edema within muscle compartments[88-91].

    In addition to current modalities for detecting and diagnosing BCRL, recent studies have explored the utility and efficacy of using indocyanine green (ICG) to improve the performance of sentinel lymph node mapping. Struk et al.[92] performed a prospective trial of a cohort of 198 consecutive early breast cancer patients eligible for sentinel lymph node biopsy to assess the value of the combination of ICG and methylene blue (MB) dye in patients undergoing SLNB. The nodal detection rate of ICG, MB, and ICG with MB samples was 97, 89, and 99.5% (P < 0.001), respectively, with the combination method yielding a superior identification result[92]. The addition of ICG to the MB method resulted in the identification of more lymph nodes (median 3 vs. 2) and more positive axillae (22.7% involved axillae were discovered by fluorescence only) than either method alone[92]. This study concluded that ICG with MB dual tracing modality, without involvement of radioactive isotopes, exhibits great potential as an alternative to traditional standard mapping methods[92]. This study gives insight into ICG with MB as a viable alternative for accurately mapping the lymphatics prior to axillary lymph node surgery. Furthermore, the findings of this study, along with other studies have shown that the use of ICG lymphography is an additional, reliable method to evaluate the upper extremity lymphatic drainage of those patients with clinically evident BCRL[93-97]. ICG lymphography can detect lymphatic channels up to 2 cm deep from the surface of the skin and can show lymphatic channels, lymphatic valves, and lymphatic flow immediately after injection of ICG[98]. The ICG lymphography patterns are of two types: linear and dermal backflow (DB), with linear patterns defining normal lymphatic flow and DB patterns defining extremity lymphedema. DB is further classified according to severity of the lymphedema[97,98].

    The key to timely and accurate diagnosis of BCRL requires thorough history-taking and physical examination, early detection and coordination of the care team, which can be supplemented with various studies and imaging modalities in cases of subclinical BCRL.

    Treatment

    Conservative management

    The initial treatment of clinically evident BCRL should be conservative (non-operative). The mainstay of conservative therapy relies on the finding that reduction of pitting edema can be achieved with compression. This often involves multilayer inelastic lymphedema bandaging or controlled compression therapy, where the compression garment’s size is reduced regularly as the swelling decreases[99,100]. It has been shown that both of these methods alone significantly reduce excess edema volume by as much as 31% and 46%, respectively[100,101].

    Many devices have been created to provide massage through mechanical or compressional means that do not require experienced personnel[102]. The principle of these machines is to provide a pumping-like action with the goal of improving lymph and venous circulation to the affected limb. A review of the effectiveness of pneumatic compression therapy devices did not show a significant improvement when compared to the standard management of lymphedema[102].

    Complete decongestive therapy (CDT), first described in the 1800s, is considered the standard management of lymphedema. It is more labor-intensive than the abovementioned therapies and relies on principles of skin hygiene, limb compression, and exercise[19,103]. Vodder further demonstrated that the methods of CDT would augment lymphatic contractility, increase lymphatic flow, and reduce lymphatic fluid from accumulating in the affected limb[104]. CDT involves 2 phases of physical therapy. Phase 1 is typically 4 weeks and consists of skin care, manual lymphatic drainage, compression bandaging and specialized physical therapy exercise with subsequent lymphatic massage. Phase 2 involves applying low resistance short-stretch compressive bandages in a multi-layered fashion with the aim of enhancing lymphatic drainage[19,103,104]. A review of the literature, including randomized controlled trials, has shown that CDT leads to an average 50% reduction in excess volume in patients with pitting edema[105-107]. A systemic review of 26 studies of CDT also demonstrated decreased limb volume and improved quality of life[108]. However, some small randomized-controlled trials have shown no significant difference in extremity volume reduction when comparing CDT to compression garments over 4 to 6 weeks of therapy[100,109,110]. When patients were followed for a year, the lack of significant difference still existed[110]. Despite the finding of these smaller studies, CDT remains the standard therapy for lymphedema and has been found to be effective. A drawback of CDT is that it requires multiple health care providers and is labor-intensive, where maintaining the overall benefits depends largely on patient compliance and ability to continue required exercises and therapies.

    Aquatic lymphatic therapy (ALT) is another treatment modality for BCRL under the direction of a physical therapist[111-113]. ALT is based on the principles of the intrinsic properties of water including buoyant force, water viscosity, and hydrostatic pressure combined with compression therapy. It is done weekly, in a group setting and the patient is actively involved in their treatment. A recent systemic review of ALT did not show a significant benefit of ALT over standard land-based care for improving lymphedema status or physical function in people with upper extremity lymphedema[113].

    Pharmacologic agents have been studied for treatment of chronic lymphedema. This includes benzopyrones because they cause phagocytosis and proteolysis by macrophages which results in improved lymph flow and regulation of tissue osmolarity[114-116]. The resulting degradation of the excess protein decreases the oncotic pressure of the interstitium causing reduction in tissue edema. A Cochrane review of 15 randomized controlled trials could not conclusively comment on the effectiveness of benzopyrenes in the management of lymphedema[117].

    In addition to the various conservative therapy options, adequate patient education regarding activity levels, exercise, infection prophylaxis, and treatment expectations is important. BCRL is a chronic disease that has been shown to require a multidisciplinary and multimodal approach to management in order to be maximally successful. Patients must also understand that these therapies will alleviate their symptoms but are not curative. Thus, active patient participation and compliance with treatment plans is important.

    Operative management

    In selected patients with long-term complications of BCRL or those for whom an adequate trial of non-operative management has failed, operative management can be considered. Surgical options include resection, microsurgery, tissue-transfer, and liposuction.

    The underlying principles of resection involves removing subcutaneous tissue to the level of the underlying fascia, with or without removal of the skin. While this does not improve, or directly address the underlying lymphatic dysfunction, it serves to improve patient comfort level and increase functionality of the affected limb[118]. As a result, the lymphedema may return. In addition, the cosmetic outcome is usually not favorable. Thus, it is important to inform patients of the risks and benefits of excisional procedures.

    Alternatively, microsurgery is an option which involves directly correcting the underlying lymphatic dysfunction. In the literature, interposition autologous lymphatic-venous-lymphatic anastomoses has been described[119]. This procedure involves inserting large autologous venous grafts between lymphatic collectors above and below the site of obstruction to lymphatic flow[19,119]. Alternative anastomotic procedures exist and it has been shown that these procedures result in a mean volume reduction of 69% and an 87% reduction in the incidence of cellulitis[119]. However, the outcomes could not be adequately assessed due to missing information regarding pre-operative factors such as limb volume and the use of compression garments. It has been shown in other studies that when microsurgery is used in combination with compression therapy, specifically elastic bandaging, there was a decrease in arm volume between 22% and 30%[120,121]. The drawback of adequately analyzing the direct benefit of stand-alone microsurgical technique is that patients used in these studies were all instructed to wear continuous compression garments post-operatively.

    Because of the need for continuous compression garments, the popularity of tissue transfer for refractory lymphedema has been increasing. This technique involves harvesting groin nodes and reimplanting them in the axilla or hand. Many small retrospective and prospective studies have shown a volume reduction of 22% to 81%[121-128].

    Liposuction, also referred to as suction-assisted lipectomy, is based on the principle of fat hypertrophy that occurs as sequelae of long-standing lymphedema. This technique involves circumferential liposuction from hand to shoulder. The arm is then bandaged with compression to control post-operative bleeding and edema[129]. In addition, the patient wears a compression garment and the arm is elevated for up to 4 days. The patient is then closely followed with controlled compression therapy which is key to the post-operative management and the limb is assessed yearly. One study has shown no recurrences after a 15-year follow-up[129]. Other prospective studies have demonstrated a reduction in lymphedema ranging from 103% to 123%[130-132].

    Conclusion

    Many factors are involved with the increased incidence of breast cancer that is seen in the United States. As a result, breast cancer patients will be in the care of many providers while undergoing treatment. It is important that they are all aware of BCRL and the most effective way of screening and management of this chronic and sometimes debilitating disease. A thorough history and physical examination is the mainstay of appropriately addressing this disease. Clinical suspicion must be followed through with appropriate testing to confirm a diagnosis of BCRL and then appropriate follow-up and reassessment [Figure 1].

    Figure 1. Recommended management and treatment algorithm for BCRL

    In addition, patients must be well-educated by clinicians on the risk of lymphedema, and its implications prior to undergoing treatment. This allows patients to be well-informed, better equipped to participate in their care and assist with early detection and management of BCRL.

    Over the years, landmark trials have changed and improved the way breast cancer is managed with better overall outcomes. This includes the way the axilla is approached with regards to surgery, chemotherapy, and radiation therapy. Although the literature demonstrates a decreased risk of BCRL after SLNB, when compared to ALND, the incidence of BCRL remains significant and is a chronic, and sometimes debilitating disease, that warrants continued research into improving detection, management, and overall outcomes. A standardized, multidisciplinary approach is warranted in order to effectively treat and control this chronic condition that is sometimes not detected until years after a patient has been diagnosed and treated for breast cancer.

    Declarations

    Authors’ contributions

    Made substantial contributions to conception and design of the study and performed data analysis and interpretation: Ayre K, Parker C

    Performed data acquisition, as well as provided administrative, technical, and material support: Ayre K, Parker C

    Availability of data and materials

    Not applicable.

    Financial support and sponsorship

    None.

    Conflicts of interest

    All authors declared that there are no conflicts of interest.

    Ethical approval and consent to participate

    Not applicable.

    Consent for publication

    Not applicable.

    Copyright

    © The Authors 2019.

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