NEW YORK CITY—Lymphedema can't be prevented, but there are strategies to reduce the risk of developing the condition and prevent its exacerbation. That was the word here at the Breast Cancer Rehabilitation Seminar at Beth Israel Medical Center from Bonnie B. Lasinksi, MA, PT, CI, CLT-LANA, Clinical Director of Lymphedema Therapy and the Boris/Lasinksi School of Woodbury, Long Island.
Indeed, Ms. Lasinksi's own research and the work of others in her field shows that the technique called complete decongestive therapy (CDT), which encompasses proper bandaging, lymphatic massage, exercise, and skin care, can significantly improve lymphedema.
In an intact lymphatic system, a cascading system of superficial and deep lymph vessels and nodes transports, concentrates, and filters lymph, before returning the fluid to the venous system, she explained.
Unfortunately, cancer treatment can often cause sufficient impairment of lymph flow to trigger lymphedema, the condition in which a section of the body can no longer properly filter lymph.
Protein in the stagnant lymph fluid in the tissue spaces leads to chronic inflammation, fibrosis, macrophage inactivity (and thus increased risk of infection), decreased oxygenation, thickening of the skin, hypertrophy of subcutaneous tissues and in rare cases, angiosarcoma (Stewart-Treves Syndrome).
Statistics on the incidence of lymphedema in breast cancer patients vary with the type of surgery performed, the standards of measurement used, and the length of time the patients are followed postoperatively.
Breast cancer survivors remain at lifelong risk for developing edema, so a study that only follows patients for a year or two cannot accurately gauge the overall risk.
Given these variables, it's not surprising that Jeanne A. Petrek, MD, et al reported in 2000 that the incidence of lymphedema in patients who received axillary dissection plus radiation treatment ranged from 6% to 40% in studies of varying lengths and methodologies.
Although many surgeons thought that sentinel lymph node biopsy would eliminate post-breast cancer lymphedema altogether, Dr. Stephen Sener's group at Northwestern was surprised in 2001 to find a 3% incidence of lymphedema after sentinel lymph node biopsy alone without radiation.
What Not to Do
Although state-of-the-art lymphedema treatment can generate impressive results, Ms. Lasinski said that several modes of treatment either have little effect at all or can even make matters worse.
For instance, many therapists formerly used compression pumps to try to treat breast cancer lymphedema. “If the axillary nodes are scarred or absent, and lymphedema is present in the hand or arm, transport of lymphatic fluid through the axilla is impaired and the edema fluid needs to be moved to a normally draining area, either across the chest to the unaffected axilla or down the trunk into the inguinal lymph nodes,” she warned.
“Just forcing fluid to the proximal portion of limb can result in an increase of edema in the proximal portion of the limb or into the chest wall, breast, or lateral trunk on that side.”
Some other treatments also have drawbacks. The benefits of microsurgical techniques such as lymphovenous anastomosis rarely last more than six to 12 months, and scarring or postoperative infections often result in more severe lymphedema after such surgery.
Hakan Brorson, MD, PhD, in Sweden has used liposuction to treat longstanding cases of fibrotic edema, but even he recommends the liposuction technique only for advanced cases of lymphedema that have not responded to CDT.
Although often prescribed by doctors, compression garments themselves can actually do more harm than good if they are used to treat lymphedema rather than to maintain results, Ms. Lasinski said.
“When a limb is swollen, the last thing you want to do is a put a compression garment on it. Compression garments are designed to hold a limb that has already been reduced, and for that they work quite well. Custom made-to-measure garments that have been designed to fit the individual's particular size and shape can deliver particularly strong results.”
There are no quick fixes when it comes to lymphedema, but rather a full regimen of steps that patients and lymphedema therapists can take to reduce the severity of lymphedema, Ms. Lasinski said, specifying the following comprehensive lymphedema management:
* Lymphedema Recognition—The earlier a therapist catches lymphedema, the easier to treat it. Ms. Lasinski emphasized the importance of teaching breast cancer therapy patients that swelling or heaviness in a limb can be early signs of lymphedema.
* Manual Lymphatic Drainage—Using an extremely light technique, lymphedema therapists can provide lymphatic drainage massage that moves lymph from the part of the body with the impaired lymphatic system to an area where the lymph drainage is intact. Certified lymphedema therapists know to work on the normal part of the body first to prepare that section to receive fluid from the limb with lymphedema, she noted.
* Bandaging—After the lymph has been moved via manual lymphatic drainage, multi-layered short-stretch compression bandages that stretch only 70% (as opposed to the 120% stretch of an Ace bandage) can be used to bandage the limb. Ms. Lasinski emphasized that compression bandages rather than compression garments are needed to treat lymphedema, because the bandages can be wrapped in such a way that they fit more securely and treat the entire limb, including the most distal part.
* Proper upper-extremity bandaging technique begins with the application of finger bandages, followed by a stockinette followed by the low-stretch bandages, she continued. The therapist can use foam pads under the bandages to protect bony areas or to soften hardened tissues. “Sometimes you don't see much reduction in swelling until you start the softening,” Ms. Lasinski said.
* Infection Prevention—Since the microphages in the lymphedema fluid do not function properly, patients are particularly vulnerable to infection. Ms. Lasinski counsels her patients to maintain moist skin through the use of neutral or low pH soaps, to avoid using chemical depilatories on the affected limb, to use an electric razor to prevent nicks in the skin, and to rigorously disinfect any cuts that do occur on the affected limb.
* Education and Continuing Care—Ms. Lasinski emphasized the importance of educating the patient in self-maintenance of the improvements made during therapy. Therapists should develop patient-specific home exercise programs for each patient and teach patients how to perform modified manual lymph drainage on themselves, how to bandage their affected limb for nighttime compression or before taking an airplane flight, how to watch out for the warning signs of cellulitis, and what to do if they suspect that potentially life-threatening infection.
Statistics on the success of complete decongestive therapy look promising. A 1998 study by Dicken Shiu-Chung Ko, MD, of 299 lymphedema patients who received an average of 15.7 days of CDT found 59% average reductions in the lymphedema in their upper extremities.
After nine months, compliant patients who had followed home care advice retained 90% of their initial reduction, while even noncompliant patients maintained 67% of their initial reduction.
A study by Ms. Lasinski in 2002 analyzed 146 patients with lymphedema in one arm or one leg treated with a single course of CDT (average of 18 treatments) and found 68% reductions in the 112 patients with upper-extremity lymphedema.
Amazingly, a follow-up examination five years later found that the average reduction in individuals with one affected arm had increased to 75%.
While noncompliant patients who did hardly any self-care saw their reduction dip to 53% of the initial measurements, somewhat-compliant patients saw an increased reduction of 78% of the initial levels.
Fully compliant patients achieved a 94% reduction from their original measurements—a 39% increase over the original reduction right after treatment.