Upper extremity edema after breast cancer surgery is a common complication, mostly occurring in patients with axillary lymph node dissection. It can occur either immediately after surgery or several months or even years after surgery. The symptoms and pathogenesis of edema in these two cases are both related and different.
The edema that appears immediately after surgery is mainly due to damage to the local soft tissues of the axilla during axillary debridement, resulting in local soft tissue edema in the affected axilla and poor reflux due to compression of blood vessels, plus local pressure dressing of the wound after surgery, further aggravating the obstruction of reflux and resulting in edema of the entire upper limb. At this time, the edema can be heavy, and the swelling is more uniform in various places, and edema can also appear on the back of the hand, and even the movement of the fingers can be affected.
The edema in this case can be gradually restored within 1-2 months with the recovery of the local soft tissue edema and the removal of the compression bandage. Of course, the problem of lymphatic reflux is also present at this time, but due to the rapid onset of edema (often within a few days after surgery), the amount of lymphatic fluid retained in the affected upper extremity is small and not enough to be the culprit of edema.
Of course, if a good lymphatic return bypass cannot be established after surgery, and if other factors are involved, the total amount of lymphatic fluid retained in the affected upper extremity will gradually increase over time, resulting in edema that does not completely subside after surgery or that occurs again after it has subside, which is called lymphedema.
American Physical Therapy Association is divided into 4 stages according to their clinical symptoms and signs.
1. Stage 0: also known as subclinical reversible stage, which is an acute stage
Symptoms: Self-perceived “heaviness” or “fullness” of the upper extremities; complaints of difficulty in wearing rings and watches; recurrent swelling of the hands or upper extremities.
Signs: Invisible edema of the upper extremity, with 0-1cm increase in circumference or 0-80ml increase in volume compared with that before surgery; no indentation by finger pressure.
2.Stage 1: also known as clinically reversible stage, subacute stage
Symptoms: consciousness of “heaviness” or “fullness” of upper limbs; inability to wear rings and watches; swelling of hands or upper limbs most of the time.
Signs: edema is mild, but fullness is seen in the affected limb, with an increase of 1-2 cm in circumference or 80-120 ml in volume compared with that before surgery; mild depressed edema by finger pressure.
3.Stage 2: Also known as clinically irreversible stage, belongs to early chronic stage
Symptoms: Self-perceived “heaviness” or “fullness” of the upper extremity; inability to wear rings and watches; swelling of the hand or upper extremity continues throughout the day; swelling begins to affect function and aesthetics.
Signs: visible swelling, non-depressed edema after finger pressure; 2-4cm increase in circumference or 120-200ml increase in volume compared with that before surgery.
4.Stage 3: Also known as clinically irreversible stage, which is a chronic stage
Symptoms: conscious “heaviness” or “fullness” of the upper extremity; inability to wear rings and watches; swelling of the hand or upper extremity continues throughout the day; swelling begins to affect function and aesthetics; recurrent skin infections and cellulitis.
Signs: clinical rubbery disease with non-depressed edema on acupressure; increase in circumference >4 cm or volume >200 ml from preoperative; skin pigmentation.
In general, the progression from stage 0 to stage 3 is a gradual process of aggravation, which may take several years or even longer. It is important to note that this is only a staging from the point of view of the overall development of the disease, and the signs and symptoms of each patient do not necessarily correspond exactly to their staging. Clinically, we have observed that the signs and symptoms of different stages sometimes cross over. For example, some patients only have swelling of the hand, which can last for the whole day, and non-depressed edema is obvious after acupressure, but there is no swelling of the upper arm or forearm; while some patients only have obvious swelling of the forearm or upper arm, with an obvious abnormal appearance, but the back of the hand is normal and there is no non-depressed edema. Therefore, the specific staging needs to be determined by combining various aspects such as subjective symptoms and circumference and volume increase.
Another point is that this staging is not combined with the course of the disease, but simply in terms of symptoms and signs. It is also noted that the circumference of the affected limb in a small number of patients, under the influence of some factors (such as infection, injury, weight bearing, etc.), can increase in size by 2-4 cm within one or two months, and can progress from stage 0 to stage 3 according to the staging criteria. Although it is also stage 3, its treatment effect is better than that of patients with a long course of disease (5-6 years or even more than 10 years), and the effect time is shorter.
The significance of this staging does not lie in telling its specific criteria, but in distinguishing between reversible and irreversible edema treatment. From its staging, it can be seen that it is perfectly possible to recover from stage 0 and stage 1 edema, while stage 2 and stage 3 edema is more difficult to recover and takes longer. The earlier they are treated clinically, the better the swelling will be reduced and the more likely they will heal.
In general, it is possible to recover edema that occurs immediately after surgery, and it is also possible to recover edema that occurs for a longer period of time after surgery. It is possible to prevent the occurrence and development of postoperative lymphedema as long as we treat it promptly and in a proper way. In our daily life, we should pay attention to and protect the affected limbs from all kinds of unfavorable factors as much as possible, and find out the problems and treat them as early as possible.