Lymphedema, what to know to reduce the risk

Lymphedema, what to know to reduce the risk

Next March 6 will be World Lymphedema Day, a condition that can occur following the removal of lymph nodes, which happens in many cases of breast cancer surgery. To put it simply, it is the accumulation of lymphatic fluid that causes the operated arm to swell. Is it possible to prevent it? And how to treat it once it has developed. We asked him Antonella Mannaphysiotherapist expert in lymphatic diseases in the Physiotherapist department of specialist rehabilitation directed by Arnaldo Andreoli of the Sacco Hospital in Milan, and volunteer Andos Odv – National association of breast operated women – Milan Committee.

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Doctor Manna, how frequent is lymphedema today in women operated on for breast cancer?

“It is certainly much less widespread than in the past, but many cases still occur. Incidence estimates from the World Health Organization referring to 2020 indicate that the problem still occurs in 20-25% of women undergoing removal of axillary lymph nodes and the percentage rises to 35-40% when radiotherapy is associated with the operation. These numbers are not very low, considering the thousands of women who undergo surgery every year. The risk exists, although it is very small, even in those who only carry out the removal of the sentinel lymph node, i.e. the first one encountered in the lymphatic pathway starting from the breast and which is analyzed to understand whether the tumor has already spread to the axillary cavity. In this case, the possibility ranges from 3 to 20% and depends, for example, on where the lymph node is positioned.”

In general, what does the risk depend on?

“There are many factors at play: from the type of surgical technique but also from the anatomy of each woman. And, obviously, from how much she exposes herself to the risk of infections in the operated limb. With the removal of the lymph nodes, in fact, the system lymphatic system is more or less damaged, with repercussions on the immune system at a local level. Any insult to the limb, therefore, can generate infections or inflammation which can then lead to the development of lymphedema, or worsen it”.

How long does the risk remain after the operation?

“This is a very important question, because women are almost always unaware of the fact that the risk remains throughout their life. In my experience I have met women who developed it more than 10 years after emptying the axillary cavity, in one case had been triggered by a simple blood pressure measurement. And another important message to convey is that the moment in which it will develop is not predictable, because the physical conformation also changes over time. Unfortunately, once lymphedema has developed, it becomes a chronic condition: it is not possible to make it ‘disappear’. I certainly say this not to scare patients, but because I am firmly convinced that the first prevention is information and awareness. Unfortunately I see every day how little knowledge there is of this complication of breast cancer treatment”.

Are there any prevention strategies?

“Yes, but it is very difficult to give general advice that is valid for everyone. The ideal would be to be able to evaluate the lymphatic system instrumentally, which however, in clinical practice, is impossible to implement. All women operated on for breast cancer they should have a physiatric visit: even in this case, however, it would be important for the physiatrist to be part of the multidisciplinary team of a Breast Unit or to be trained in the specific risk. Patient associations can be a good point of reference to know where to turn. In practice, the most effective strategy is to know the risk factors to minimize them.”

Which ones are they?

“We know, for example, that smoking and being overweight increase the risk. Furthermore, venous sampling, injections and, even more so, more invasive operations must be avoided in the operated arm. Another case that I followed occurred later to a coronary angiography, even though the patient had reported that she had undergone axillary emptying. Furthermore, particular attention must be paid to insect bites. A class 1 compression glove, the lightest, is generally recommended for those who do jobs that require repetition of the same movements or if you have to face a long journey”.

Are there any “warning” symptoms?

“One symptom to pay attention to is the feeling of heaviness in the arm or swelling in the evening. That’s the time to turn to a specialist and you should look for centers specialized in lymphedema. There aren’t many, especially public ones.”

When lymphedema develops, what strategies do you have, beyond surgery?

“The evaluation is always personalized. The gold standard is complex decongestive therapy, which involves a more intensive initial phase which has the aim of draining and decongesting the limb through skin care, multilayer lymphological bandage, lymphatic drainage and gymnastics of the bandaged limb. This is then followed by a long maintenance phase, entrusted to the patient, which includes the use of the elastic-compressive brace. The important thing is to always contact a physiatrist and never a beauty centre: these interventions must be prescribed by doctors and performed by expert physiotherapists. The brace is evaluated together by the rehabilitation team and the orthopedic technician, and personalized based on the type and needs of the patient. For those who want to know more, I recommend the book “Free to live with lymphedema”, published recently. Where this condition is addressed from different points of view, including that which is very dear to me: laughter therapy”.

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