The Lymphedema Chronicles: Subclinical Lymphedema After Treatment For Breast Cancer
Introduction: Sentinel lymph node biopsy has had a major impact in reducing the number of patients requiring axillary lymph node dissection. Yet axillary lymph node dissection and the potential for lymphedema continued for some patients even those who have only had sentinel lymph node biopsies. There is evidence to suggest that even subclinical lymphedema in some instances can lead to clinical or visible lymphedema with its accompanying reduction in quality of life (Disipio et.al., Lancet Oncology. 2013; 14:500-15.). Though a progressive condition, arm lymphedema is reversible in its early stages which may make treatment more successful and less oppressive. A prospective screening-based approach has been recommended by the National Cancer Network, the International Society of Lymphology, the American Society of Breast Surgeons, and the National Comprehensive Cancer Network. Bucci et.al., (Annals of Surg Oncology. 2021;28:86) from the Massachusetts General Hospital, has screened more than 5500 patients (study cohort 1790 patients) for breast cancer-related lymphedema. Patients are screened preoperatively, and throughout and beyond the breast cancer treatment using a perometer and patient-reported outcome measures. A perometer measures limb volume with parallel-acting light curtains made of photosensors and LEDs with which the limb is illuminated and scanned (see accompanying image). (Another method for estimating body composition to evaluate lymphedema is bioimpedance analysis. In bioimpedance, a week of electric current flows through the body, and voltage is measured to show the resistance in that body part.)
Results
Subclinical lymphedema is difficult to detect since it presents with no visible swelling. The definition of subclinical lymphedema in this study was a volume difference between limbs of < 10% although a volume difference of less than 10% can still be associated with clinical symptoms of lymphedema. In this study self-reported swelling, heaviness, tightness, and numbness were accepted as well as a diagnosis of subclinical lymphedema by perometer. The authors wished to assess the rate of subclinical lymphedema progression, in women who underwent axillary surgery, either complete axillary lymph node dissection or sentinel node biopsy. Most importantly they wanted to assess whether some patients with a 5-10% increase in limb volume went on to develop clinical lymphedema (perometer reading of >10%). Of the 790 patients who underwent sentinel lymph node biopsy, 331 (24.4%) had subclinical lymphedema (5-10% difference in the volume of one arm versus the other), 11% of which progressed to clinical lymphedema. Of the 431 patients who underwent axillary lymph node dissection (39.7%), 171 (39.7%) experienced subclinical lymphedema with 39% of these patients progressing to clinical lymphedema.
The authors concluded, “that patients with subclinical lymphedema after axillary node surgery or more likely to progress to clinical lymphedema than those who do not experience subclinical changes.” It is important that patients are made aware of the risk factors and adjust their lifestyle to reduce the risk of patients with subclinical lymphedema progressing to clinical lymphedema. According to a study by the Cleveland Clinic, additional risk factors for lymphedema include the number of lymph nodes removed, the number of nodes with cancer metastasis, use of taxane chemotherapy, increased body mass index, and radiation. Exercise is also known to increase venous flow and lymphatic fluid to the circulatory system. It is thought that exercise is also essential to prevent and treat lymphedema and all patients should be encouraged to exercise. Exercise will increase venous flow and lymphatic fluid return to the circulatory system. Remember, that the risk is highest in the first three years after surgery and markedly higher in women who have had chemotherapy.
Comment
Clearly, early changes of subclinical lymphedema in most instances will allow them more successful treatment outcomes. In some institutions and even in private offices, evaluation of limb volume is carried out using bioimpedance, or a perometer, preoperatively, within two weeks after surgery, and every 3 to 4 months during the first three years. For patients that are in 2 to 4 weeks from surgery and still do not have signs of subclinical lymphedema, no intervention is carried out. Those found to have subclinical lymphedema, are placed on a course of decompressive therapy, and instructed on using a compression sleeve. After using the sleeve for approximately a month, lymph edema has disappeared, no further intervention is required. If subclinical payment is still present, and patients will continue the use of a compression sleeve and decompressive therapy as needed.
Dr. Alan Stolier, MD, FACS, clinical breast oncologist, shares his expert medical perspective with a series of educational and scientific articles.