INTRODUCTION:

Women who have been treated for breast cancer may be at risk for Arm. Breast and chest swelling called lymphedema (limf-uh-dee-muh). Most women who have been undergone Mastectomy are less likely to develop this side effect. The risk of Lymphedema is higher for women who have undergone surgery and radiation therapy to treat Breast Cancer. Removing lymph nodes and vessels changes the way lymph flows in that side of the body. Radiation to the lymph nodes in the under arm can affect the flow of lymphatic fluid in the arm and the Breast area in the same way, further increasing the risk of Lymphedema.

Arm lymphedema, the accumulation of protein rich fluid in the interstititial spaces of the ipsilateral arm, develops in 10% -35% of patients who undergo axillary dissection and or/nodal radiation therapy for breast cancer. This progressive and debilitating condition is without a known cure.

Patients at risk for the development of lymphedema:

Several factors predict a higher risk for the development of lymphedema. These aspects include a greater extent of the axillary surgery, more positive axillary nodes, a post operative axillary hematoma, seroma, or infection and the use of nodal radiation. Patients with poor shoulder mobility and obesity are at a higher risk.

Pathophysiology:

The lymphatic system uses filtration to collect lymph and large molecules that reach the interstitial spaces from the intravascular space. The lymph in the interstitial space increases oncotic pressure and draws water into the lymphatic spaces. The lymphatic vessels usually do not contain a basement membrane; allowing large molecules to enter that cannot be absorbed readily by venous return.

In the disease state, lymphatic drainage is compromised by the interruption or obstruction of the lymphatic system that leads to accumulation of fluid in the limb. Compromise of lymphatic drainage may result from the removal of the lymph nodes or Obstruction of the lymphatic channels by tumor, scar tissues, or infection. In this state of functional overload, accumulation of macromolecules produces edema, and the resulting inflammatory reaction leads to fibrosis, propagating a vicious cycle of lymphedema.

Measurement:

The most common method of lymphedema measurement is the circumference of 10cm above the olecranon process. Optimal sequential measurement would be made preoperatively and at fixed intervals after surgery. An increase >2 cm in circumference relative to the preoperative baseline is diagnostic of lymphedema. A second test is an arm comparison. Most individuals do not have a >2 cm difference in arm circumference between the dominant and non-dominant limbs. The highly accurate technique is the water displacement, which measures the volume of water displaced by the submersed arm.

Diagnosis:

The differential diagnosis of new ipsilateral arm edema in a patient with a history of breast cancer includes a recurrent tumor, deep venous thrombosis as well as lymphedema. Evaluation of lymphedema is usually initiated by patient complaints of arm heaviness and fullness often accompanied by visible asymmetry.

Management:

The simplest method of treatment includes elevation of the extremity above the level of the heart, especially at night. Patient should be lifted with an elastic sleeve for maintenance after the initial reduction in swelling. In recent years, there has been increased interest in complex or complete decongestive physiotherapy, also known as complex physical therapy. This approach involves the use of skin care, gentle massage and manual lymphatic drainage, with the application of multi layer bandaging followed by a compression garment. Manual lymphatic drainage is thought to stimulate the lymph vessels to contract and move fluid toward functional lymph node basins. The multilayer bandaging is performed immediately after the manual lymph drainage and the arm is wrapped from the finger tips to the axilla with maximal distal pressure. The bandaged extremity is the guided through range of motion and joint exercises.

The second phase of therapy includes fitting the patient with specially measured garments with 30-50 mm Hg of compression. Therapies emphasize the use of low –stretch multilayer bandages at night and continued skin and nail care. Pneumatic pumps have been used extensively in the past. Oldest models include a single chamber non segmented device, which may cause back floe that can exacerbate the distal swelling. Fortunately newer models have multiple chambers and provide sequential compression.

Surgery:

Surgical management of lymphedema is mainly of historic interest, but may be considered after the failure of all conservative measures. The physiologic approach entails microsurgical microsurgical attempts to create lymphatic-to –venous shunts or lymphatic venous anastamosis to increase the lymphatic flow. The reductive approaches include removal of excess subcutaneous fat and placement of dermal flap within the muscle to encourage lymphatic anastamosis of the superficial to deep channels.

Prevention:

The use of sentinel node biopsy has been shown to reduce the rates of lymphedema. Randomized prospective trials have confirmed that sentinel node biopsy is effective with low axillary failure rates Patients in whom lymphedema is detected and treated soon after its initial appearance have a higher rate of recovery and fewer long term sequelae. Patients should be instructed to report signs of new lymphedema immediately, and early signs of infection should be treated with antibiotics, limb elevation and compression. Newer studies are looking at finding the lymph nodes that drain the arm before surgery so that they can be preserved when possible. The procedure is called axillary reverse mapping.

Do’s and don’t’s in the prevetion of lymphedema:

· Avoid infection

· Whenever possible, have the blood drawn from the unaffected arm.

· Keep the hands and cuticles soft and moist by regularly using moisturizing lotions or creams.

· Wear protective gloves when doing household chores, that use chemical cleansers or steel wool and while washing dishes.

· Wear a thimble while sewing to avoid needles pricks.

· Avoid extreme cold. It causes rebound swelling as you warm up and cause chapping of the skin.

· Wear loose jewellery, clothing, and gloves. Avoid anything that forms a snug band around the arm or wrist.

· Do not have blood pressure taken on the affected arm.

· On a long or frequent ravel wear a compression sleeve.

· Use the affected arm for normal daily activities.

· Exercise regularly but try not to over tire the shoulder and the arm. Avoid doing strenuous exercises.

· Avoid gaining weight.

CONCLUSION:

The increasing number of breast cancer survivors and the high prevalence of disease will continue to make lymphedema a significant consequence of Breast cancer treatment. Effective care requires a multimodal approach and clinical research towards prevention and improving management of lymphedema.

REFERENCES:

1. Asha Sharma, Chintamani, Lewi’s Medical Surgical Nursing, South Asian Edition, Elsevier India;2011:673

2. Hinkle Janice, Cheever H. Kerry, Brunner and Suddarth’s Textbook of Medical Surgical Nursing Vo113ed;2014:1698-1699

3. Monahan Donavan Fraces, Neighbors Mariamme, Phipps Medical Surgical Nursing,8^th ed, Elsevier, India; 2007:1771

Received on 26.11.2014 Modified on 02.12.2014

Int. J. Nur. Edu. and Research 3(1): Jan.-March, 2015; Page 101-102

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