Fluid Movement
- When the Lumph nodes and vessels become
- compromised after breast cancer theorpy, fluid
- may accumulate and produce swelling and other
- complications.
- by Alica Di Rado
- compromised after breast cancer theorpy, fluid
First, they face body-altering surgery, then months of chemotherapy
and finally a regimen of radiation treatments. As the tests and
scars fade into memory, though, breast cancer survivors may be
hit with a frustrating reminder of their past.
Lymphedema.
A swelling of the arm or leg (or occasionally another part of the body), lymphedema occasionally follows treatment of a variety of cancers. It is most often linked with breast cancer, and can even develop many years after surgery and radiation therapy.
The majority of women with breast cancer will never experience lymphedema. But some do.
Because lymphedema is more than just an unfortunate side effect, physicians provide patients with the information they need to recognize it, ease its symptoms early and protect themselves from complications. Yet physicians never know in advance who will develop it.
"Lymphedema is unpredictable-an unsolved dilemma," says Howard Silberman, M.D., professor of surgery and breast cancer specialist at the USC/Norris Comprehensive Cancer Center and Hospital. "We don't know exactly why it happens, but we think we know what factors contribute to it."
Any swelling from fluid that builds up in body tissues is known as edema, Silberman explains. Lymphedema, then, is edema involving the lymphatic system and the accumulation of lymph.
A network of lymph nodes and lymph vessels lace throughout the body carrying lymph fluid, much like blood vessels carry blood. White blood cells course through the pale lymph liquid to help fight infection, while small, bean-shaped lymph nodes trap bacteria and other tiny invaders so the immune system can get rid of them. The lymphatic system also absorbs extra fluid in tissue and returns it to the blood stream.
In a patient with cancer, spreading cancer cells often end up in lymph nodes, so surgeons frequently remove groups of nodes so pathologists can examine them for signs of cancer. In most breast cancer surgeries, doctors remove 10 to 40 axillary lymph nodes, intertwined lymph vessels and tissue from the underarm.
Removing lymph nodes and lymph vessels-or scarring them through radiation therapy-alters the way lymph fluid drains in the body. In breast cancer patients, the lymphatic system struggles to remove fluid from the arm and breast. Sometimes even tumors themselves can interfere with lymph flow.
"In lymphedema, the pressure in the lymph vessels can become so great that fluid oozes through the walls of the vessels," Silberman says. "It has nowhere to go but into the soft tissue."
As a result, a woman's shirtsleeves may begin to feel tight, watches no longer fit around the wrist and the arm may feel heavy. One arm may look significantly thicker than the other or feel numb.
Physicians often check the volume of the arm during follow-up office visits after breast cancer surgery, and ask about symptoms of discomfort.
"It's important to catch lymphedema early," says Brendon Twigden, P.T., a physical therapist who offers a lymphedema program for cancer patients at USC/Norris. "The sooner it is treated, the better the result. It is unwise to allow the condition to progress significantly and then come in for help."
The mantra for early lymphedema sufferers is simple: elevation, elevation, elevation.
Physicians can show patients exercises that involve elevating the arm above the heart to help circulate fluid, Twigden says. Some patients also benefit from a device that keeps the arm elevated while they sleep.
Since lymph flows in the body through the pumping action of surrounding muscles that push on lymph vessels, moving the affected limb and flexing muscles can help patients.
Twigden keeps an eye on just how much exercise lymphedema patients perform, though. "If a woman wants to go running, for example, I encourage her to do what is prudent," he says. "I'd suggest she start doing short distances initially to see how things go."
When symptoms nag patients and do not go away, USC/Norris oncologists refer them to Twigden, who then offers specialized physical therapy at the USC/Norris Hospital.
Twigden often stimulates the limb through the skin and performs a lymph drainage massage to squeeze out lymph fluid. The patient may then be fitted for a custom-made elastic pressure sleeve, which is designed to exert a specific amount of pressure on the limb. In certain cases, an inflatable sleeve can be placed around the limb, and a computer-controlled pump prompts the sleeve to slowly fill with air, pressing on the limb and pushing lymph fluid away.
At the same time, Twigden puts patients on a program of exercises that can help get them back to comfortably performing their daily activities, whether carrying groceries or combing their hair.
"About 50 percent of the patients get better right away," Twigden says. Others take more consistent work, and even then, lymphedema may never completely recede.
These patients-and any at risk for lymphedema-need to avoid infection, which prompts the body to make extra lymph fluid and, in turn, can set lymphedema in motion.
To reduce the likelihood of infection, doctors suggest keeping the cuticles and skin on the hands moisturized and clean. Bug bites and animal scratches should be avoided or treated with antibacterial cream. Protective gloves for gardening and yard work can help prevent cuts, too. Physicians also suggest shunning saunas and hot tubs.
Injections and blood draws should be done on the unaffected arm; some patients even wear a bracelet or necklace that alerts health professionals not to perform injections on a certain arm or leg.
In rare cases, limbs can swell so much that fluid begins to leak from the skin surface and break down the skin itself.
Physicians have recognized certain factors that may precipitate lymphedema or put patients at greater risk, Silberman says: obesity, vascular disease, high blood pressure, airline travel, advanced age, and having the breast tumor on the side of the dominant arm. The number of lymph nodes removed in surgery might be another factor.
As oncologists gain more experience with sentinel node biopsy-a new method to gauge cancer spread by removing only one or two lymph nodes-researchers suggest that cases of lymphedema will decline.
"Some people think that if you remove fewer lymph nodes in surgery, there is less chance of lymphedema," Silberman says. "But the current evidence is not clear."
Until more is known, patients at risk for lymphedema are best advised to watch for symptoms and discuss any problems with their physician-while moving on with life after cancer
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