Consultant – Orthopaedic Surgeon
Speciality interests include:
Lower extremity: trauma, sports surgery, knee, patella dislocation, tendon problems, foot and ankle surgery, and the management of degenerative joint disease in younger patients.
Visiting on Sep 21-22, 2019Request an Appointment
Breast cancer-related lymphedema (BCRL) is one of the main complications of breast cancer and its therapies and can have a significant impact on the quality of life of breast cancer survivors. With the increased use of multimodality therapy including surgery, local-regional radiation therapy, and certain systemic chemotherapeutic agents, the number of cases of BCRL may continue to increase. Breast cancer survivors may find lymphedema more distressing than mastectomy, because hiding the physiological manifestations and loss of function is harder, which in turn leads to decreased quality of life.
How does BCRL evolve?
BCRL consists of the accumulation of lymph fluid in the areas that surround the cells (the interstitial spaces), which is caused by a defect in the lymphatic system. It is marked by an abnormal increase of tissue proteins, swelling (edema), chronic inflammation and fibrosis hardening (fibrosis). As fibrosis develops, normal tissues are replaced by scar-like structures that create obstructions that make lymph drainage more difficult. Because this lymph cannot drain properly, the protein molecules accumulate in the tissues and cause more fibrosis and a greater danger of infection.
How can we reduce the incidence of BRCL?
Absolute prevention is not yet fully possible in BCRL. However, advances in cancer diagnostic imaging and surgical techniques have reduced the risk of lymphedema and newer tools/techniques have allowed earlier detection of subclinical lymphedema. When diagnosed early, lymphedema can be controlled more effectively, preventing worsening of the condition. In fact, the volume of edema at the time of diagnosis is the single best predictor of successful treatment underscoring the importance of early diagnosis. So early detection and intervention remain the primary strategy for reducing the incidence of chronic BCRL.
Methods to reduce the development of BCRL are largely operative or physical:
Operatively we see that earlier breast cancer detection has allowed for less invasive surgical procedures (including Sentinel lymph node biopsy) to assess and treat only the regional lymph nodes, which have reduced the risk of BCRL.
Physically, the diagnosis of BCRL has been based on several techniques including circumferential arm measurements, water displacement, and patient symptoms. Routine limb volume measures are used to detect increased swelling and to monitor changes over time. Routine arm measurements are recommended after treatment to allow for earlier diagnosis and intervention. Other diagnostic modalities for BCRL have continued to evolve with newer techniques, including lymphoscintigraphy available that have increased sensitivity, allowing for the subclinical detection of BCRL and therefore, early intervention.
Early intervention is found to reduce arm volumes while limiting the need for further, more aggressive therapies. Awareness of risk factors of BCRL such as high BMI, weight gain after breast cancer treatment, poorer performance status, post-operative swelling (which has been associated with later lymphedema development), the number of nodes removed, infection, chemotherapy, axillary irradiation and lymphedema family history can be used to guide individualized education and support in developing BCRL risk- reduction behaviors.
The recommendations for the follow-up care and monitoring of breast cancer survivors are: