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Lymphedema and the Lymphatic System

The Lymphatic System

The lymphatic system is part of the immune system and its main function is to drain and filter fluid. The lymphatic system helps develop and distribute white blood cells throughout the body to help protect it from foreign substances. It also functions to drain and filter fluid away from regions of the body. It works by collecting excess fluid (lymph) from the spaces between your body’s tissues, moving it through the lymph vessels, where it is eventually filtered through lymph nodes, before returning to the circulatory system. The role of these lymph nodes is to destroy pathogens and filter out waste products and fluid. The filtered lymph is then carried out of the node to continue its return to the circulatory system.

Lymphedema

Lymphedema Overview 

Lymphedema is a condition that develops as a result of an alteration in the pathways that drain lymph fluid. Lymphedema is a buildup of excess lymph fluid in the body, which leads to swelling in areas like the arms, hands, legs, neck, shoulders, as well as other regions of the body.

Lymphedema can occur as an inherited condition, caused by problems with the development of lymph vessels in your body. This is known as primary lymphedema. Secondary lymphedema occurs when a condition or procedure damages the lymph nodes or lymph vessels. Lymphedema that develops after breast cancer surgery would be considered a secondary lymphedema.

Lymphedema and Breast Cancer Treatment 

In breast cancer, a disruption of lymphatic flow can occur when lymph nodes are removed from the underarm for biopsy or treatment of breast cancer. The underarm lymph nodes, or axillary lymph nodes, are responsible for draining the lymphatic vessels from the arm, the neck, and the majority of the breast. The removal of these lymph nodes or damage to the lymphatic channels can reduce or block lymph drainage. Radiation can also disturb the flow of lymph fluid in the arm, chest, and breast in the same manner as surgery, further increasing the chances of developing lymphedema.

Whenever there is a disturbance in the pathway that drains lymphatic fluid, and the remaining lymph vessels cannot compensate, a buildup of excess fluid will occur and this swelling is known as lymphedema. The formation of lymphedema after breast cancer surgery is typically something that develops slowly over time. However, it can develop at any time after surgery. If the condition does develop very soon after surgery, it is usually only a mild case and goes away within a week or two. Most women that develop lymphedema after a mastectomy or lumpectomy do so many months and sometimes even years after their operation and, in these cases, swelling can range from moderate to severe.

As surgical techniques and radiation have improved over the years, there are fewer cases of lymphedema seen today than in previous years. On average, the condition develops in one in four breast cancer patients who have undergone breast cancer surgery and lymph node dissection. The risk doubles for individuals who receive radiation treatments to the underarm, in addition to a lumpectomy or mastectomy.

Symptoms of Lymphedema

The degree of swelling that occurs with lymphedema varies but symptoms of lymphedema can include:

  • Swelling of the limb, including fingers or toes
  • Swelling to the underarm or breast
  • A feeling of heaviness in the limb or the breast 
  • Restricted movement in the limb 
  • Recurring infections in the affected limb
  • Thickening of the skin in the affected area 
  • Pain to the affected area, often described as a tightness or throbbing

Prevention and Control

Although it is not possible to predict who will develop lymphedema, there are some steps patients can take to lessen their risk. Also, if you have developed lymphedema this condition can be controlled and managed by following the guidelines listed below.

Tips to Prevent and Control Lymphedema: 

Manage activity

  • Ask your doctor about daily stretching exercises that can be performed after your surgery to maintain your range of motion and decrease scar tissue formation. 
  • Do not suddenly increase the amount of physical work performed with the arm on the surgery side. Lymph production is directly proportional to blood flow. Overly strenuous arm exercises that increase blood flow in the arm can increase lymph production, and therefore, increase the risk of lymphedema.

Elevate affected limb

  • When sleeping or sitting, try to keep your arm elevated with a pillow and avoid lying on your surgery side for extended periods.

Practice proper skincare

  • Take extra care of your skin to avoid infections. Do your best to protect skin from cuts, burns and sores. Wash your hands frequently and wear gloves when doing house or yard work. Apply moisturizer to chapped skin and use insect repellent to avoid bug bites.
  • Wear comfortable clothing and jewelry that does not squeeze or pinch your arm or hand. A tight sleeve or bracelet for instance can cause fluid to build up in the arm and lead to lymphedema.

Eat a balanced, nutritious, diet

  • Avoid alcohol and drink plenty of water.
  • Avoid foods high in salt and fat. Try to stick to healthy foods that are high in fiber like fruits, vegetables and whole grains.

These are just a few of the steps you can take to manage and prevent lymphedema. There are also nonsurgical and surgical treatment options available to both treat and prevent lymphedema.

Nonsurgical Treatment

At this time, there is no known cure for lymphedema. Nonsurgical treatment of lymphedema focuses on reducing the accumulation of lymphatic fluid within the soft tissue and symptom management.

Nonsurgical treatments include: 

  • Manual lymphatic massage 
  • Compression bandages and garments
  • Lymphatic compression pumps 
  • Physical therapy targeted to break up scar tissue (cold laser therapy, dry needling, etc)

Always contact your physician at the first signs of lymphedema or if you suspect an infection is developing.

Lymph Node Transfer

Up until recently, lymphedema has primarily been managed using a combination of nonsurgical treatments including lymphatic massage, therapeutic exercises, skin care, and compression garments. Fortunately, advances in the field of microsurgery have resulted in a relatively new procedure: Vascularized Lymph Node Transfer. Although there is still no cure for lymphedema, this procedure is proving to be successful in the treatment of lymphedema and is also being implemented in an attempt to prevent lymphedema in high risk patients.

The lymph node transfer procedure involves harvesting one or two lymph nodes from the groin area, along with their supporting artery and vein. The lymph nodes are taken from the groin because this area is considered a low-risk lymph node basin, meaning the risk for developing subsequent lymphedema to the surrounding area is low. These lymph nodes are then microsurgically transplanted to the under arm. The lymph node transfer can be performed as a stand-alone procedure or in conjunction with a Deep Inferior Epigastric Perforator DIEP flap. The DIEP flap uses a patient’s excess abdominal tissue to reconstruct the breast. In patients requiring breast reconstruction, the lymph nodes are removed attached to the DIEP flap. The flap is then transferred to the chest where the DIEP flap is placed into the breast pocket and the attached lymph nodes are positioned into the axilla. With the aid of a surgical microscope, blood flow is then re-established by connecting the blood vessels of the lymph node flap to the blood vessels of the chest wall. This procedure is performed routinely by Dr. Spiegel but requires a high degree of technical skill and surgical precision.

After the lymph node transfer procedure, patients resume manual lymphatic massage and wear compression garments. Usually within a week, the newly placed lymph nodes begin to take effect and soon after, most patients begin seeing an improvement in soft-tissue swelling. Patients typically notice a reduction in discomfort and heaviness in the affected area and may continue to see improvement for up to 6 months.

*Hover over illustrations to learn more

The lymphatic system of the breast is illustrated in green. There is a basin of lymph nodes in the underarm (axillary) region. One, or all of these lymph nodes, may need to be removed during your breast cancer surgery. This may lead to the development of lymphedema.

The blood vessels that supply the belly tissue have small branching vessels that also provide blood flow to the inguinal (groin) lymph nodes, depicted in brown. This lymph node basin contains many lymph nodes. One or two lymph nodes can be harvested with their small branching blood supply and transferred to the chest as a stand-alone procedure or during DIEP flap reconstruction. The blood supply is reattached at the chest and the lymph node is positioned to the underarm to improve lymph drainage.

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