The incidence of upper extremity lymphedema is a common complication of axillary lymph node dissection and radiotherapy in the axillary area. In recent years, the incidence of moderate and severe upper extremity lymphedema after axillary lymph node dissection does not exceed 5%. The degree of lymphedema is related to individual factors. Some patients with underdeveloped lymphatic communication branches in the upper extremities are prone to lymphedema. The incidence of postoperative lymphedema is high in elderly and obese breast cancer patients.
1. Clinical manifestations
Lymphedema of the upper extremity on the affected side of breast cancer can occur at any time after surgery, either immediately after surgery or 30 years later. Acute lymphedema is characterized by thickening of the affected upper limb, which can be detected visually if the circumference of the upper limb increases more than 50px. Chronic lymphedema presents with a rubbery swelling of the upper arm. Lymphedema can cause pain, limb deformation, and dysfunction in the affected upper limb, and can be followed by infection, which further causes sclerosis and occlusion of the lymphatic lumen and aggravates the edema. The International Lymphatic Society classifies it into three stages.
Stage I: The earth limb is sunken edema, and the edema disappears when the limb is elevated.
Stage II: The edema is non-concaveable, with moderate fibrosis of the upper limb tissues, and the edema does not disappear with limb elevation.
Stage III: elephantiasis with cartilage-like hardness of the upper limb and exophytic papilloma of the skin.
There are three degrees of edema according to the extent and degree of edema.
Degree I: volume increase of <10% in the upper arm, usually not obvious, not easily detected by the naked eye, mostly occurring in the proximal medial and posterior aspect of the upper arm.
Degree II: The volume increase of the upper arm is 10%-80%, and the swelling is obvious, but generally does not affect the activities of the upper limb.
Degree III (severe): the volume of the upper arm increases >80%, the swelling is significant, the involvement is extensive, and the whole upper limb can be affected, and there is severe upper limb activity impairment.
2.Cause
(1) Axillary lymph node dissection surgery removes the axillary lymph nodes and also cuts and ligates the lymphatic vessels, thus blocking the return path of lymphatic fluid, resulting in impaired lymphatic fluid return to the upper limbs. A large amount of protein-containing lymphatic fluid is retained in the interstitial space of the tissue, causing swelling of the relevant parts of the tissue and, over time, thickening of the skin and subcutaneous tissues, edema and fibrotic tissue hyperplasia. Post-operative axillary fluid accumulation, infection and scar contracture also impede lymphatic and venous return to the upper limbs.
(2) Radiotherapy in the axillary area of breast cancer can cause venous occlusion and destruction of lymphatic vessels in the radiation field, and also affect the lymphatic return of the upper limb due to local muscle fibrosis compressing the veins and lymphatic vessels.
3.Prevention
(1) Standardize the operation of axillary lymph node dissection, do not damage the axillary venous trunk, and do not perform over-range dissection.
(2) Try to avoid excessive physical work, trauma and venipuncture of the affected limb after surgery, and prevent infection.
(3) For breast cancer patients with no metastasis in the axilla, the earliest sentinel lymph node that may have metastasis can be removed and sent for pathological examination (i.e. sentinel lymph node biopsy) to determine the status of the axillary lymph nodes. The technique requires a high degree of accuracy and should be decided by the medical institution in which it is performed according to the available equipment and technical conditions.
4.Treatment
Mild postoperative upper limb lymphedema can be relieved within a few months, while severe upper limb swelling is difficult to recover on its own, and the effects of various non-surgical and surgical treatments are limited.
(1) Local massage by elevating the affected limb: the elbow can be padded at night rest so that the upper arm is higher than the level of the chest wall. Local massage when the patient elevates the affected limb, the massager double ding buckle into a ring, from the distal side to the proximal side with a certain pressure continuous squeeze nudge, each from top to bottom repeatedly pushed 10-15 minutes, several times a day, can promote reflux.
(2) Use elastic bandage to compress the upper limb as appropriate to reduce swelling, or combine with massage and use elastic bandage immediately after massage. Some hospital rehabilitation clinics use pressure pumps instead of manual massage to promote reflux. An inflatable cuff is placed on the edematous limb and inflated intermittently to promote centripetal flow of edematous fluid. The air pressure pump is suitable for early stage of lymphedema and is less effective in those with obvious subcutaneous fibrosis.
(3) Dietary salt intake should be controlled.
(4) Ganglion closure to release vascular and lymphatic vascular spasm and improve circulation.
(5) Surgical treatment: The aim is to reduce the load on the lymphatic system (removing edematous hyperplastic lesions) or to improve the lymphatic system transit capacity (promoting lymphatic reflux and reconstructing lymphatic channels), and some studies have achieved better results according to the literature.
The treatment of postoperative upper limb edema of breast cancer, which aims to reduce the accumulation of lymphatic fluid and improve lymphatic reflux to obtain long-term remission and avoid reappearance, is a hot spot of domestic and foreign research at present.