Breast cancer-related dysfunction of the lymphatic system and subsequent lymphedema of the upper extremity is a somewhat common and potentially serious complication of the treatment for breast cancer. It is estimated that 15% to 20% or as many as one in four patients with invasive breast cancer develop upper extremity lymphedema during or sometime after the course of treatment.

Current treatment usually involves removing a portion or all of the breast accompanied by excision or irradiation of adjacent axillary lymph nodes, the principal site of regional metastases. Axillary dissection places a patient at risk not only for upper extremity lymphedema but also for loss of shoulder mobility and limited function of the arm and hand. In addition, chemotherapy or hormonal therapy may also be employed.

Axillary dissection and removal of lymph nodes interrupt and slow the circulation of lymph, which in turn can lead to lymphedema. Radiation therapy can cause fibrosis of tissues in the area of the axilla, which obstructs the lymphatic vessels and contributes to pooling of lymph in the arm and hand. The extent of the axillary dissection and exposure to radiation is associated with the degree of risk for lymphedema to develop. In addition, shoulder motion can become impaired as the result of incisional pain, delayed wound healing, and skin ulcerations (associated with radiation therapy), and postoperative weakness of the muscles of the shoulder girdle.

A comprehensive approach to postoperative management that emphasizes patient education and includes therapeutic exercise and other direct interventions to prevent or treat lymphedema and other impairments or functional limitations are key to successful outcomes.

As with most cancers, the diagnosis of breast cancer and the ensuing treatments have an enormous emotional impact on patients and their families. The advent of breast cancer-related lymphedema not only has an impact on a breast cancer survivor’s physical function but is known to have a significantly adverse effect on health-related quality of life, making prevention of lymphedema and, if it develops, aggressive treatment high priorities for management.

Surgical Procedures

Surgical treatment of breast cancer falls into two broad categories¾mastectomy and breast-conserving surgeries¾both of which are coupled routinely with partial or complete axillary node dissection. Differences in surgical procedures are related to the extent of removal of breast tissue and surrounding or underlying soft tissues. A course of radiation therapy routinely follows surgery to decrease the risk of regional recurrence of the disease. Chemotherapy also may be initiated postoperatively to prevent the systemic spread of the disease.

Mastectomy

Mastectomy involves removing the entire breast. In addition, a mastectomy may involve removing the fascia over the chest muscle. With late-stage, invasive disease, a radical mastectomy in which the pectoralis muscles also are excised may be required, leading to significant muscle weakness and impaired shoulder function.

Breast-Conserving Surgery

Options for resecting the tumor and preserving a portion of the breast include lumpectomy, which involves excision of the mass and a margin of healthy surrounding breast tissue, or segmental mastectomy (also known as quadrectomy), which is excision of the affected quadrant of the breast. These procedures are being used increasingly, rather than mastectomy, in combination with adjuvant therapy for patients with stage I or II tumors.

There are now multiple randomized clinical trials that show that the 10- to 20-year survival rate for patients with stage I or II disease who underwent breast-conserving surgery combined with radiation therapy is equivalent to that achieved by patients who underwent mastectomy alone or mastectomy with adjuvant therapy.

Patients who undergo breast-conserving procedures without removal of lymph nodes are still at risk for developing postoperative lymphedema and impaired shoulder mobility because of potential complications from radiation therapy and biopsy of at least one lymph node.

Dissection of Axillary Lymph Nodes (Lymphadenectomy)

As mentioned, at this time axillary lymph node dissection is a standard part of mastectomy and breast-conserving surgery, although the extent of node removal is controversial. A minimum of a level I axillary node dissection and removal of the sentinel node in the axilla at the lateral borders of the breast is required for biopsy to assess regional lymph node involvement and for staging the disease. More extensive dissection for metastatic disease removes the nodes under the pectoralis minor muscle or around the clavicle.

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