EDUCATE. WHAT IS LYMPHEDEMA?
What does the lymphatic system do?

The lymphatic system is made up of lymph capillaries, lymph collectors, and lymph nodes.  The lymphatic system is responsible for 3 major functions:

  1. Absorption of fluid and other solid molecules from the spaces surrounding the cells and transportation of it back to the blood circulation. This includes proteins.  75 – 100 grams of protein are transported by the lymphatic system every day. 
  2. In the small intestines, long-chain triglycerides, cholesterol, and the fat soluble vitamins A, D, E, and K are absorbed into the lymphatic system.
  3. Immunological functions: White blood cells (lymphocytes) are created by the lymphatic system and have the ability to respond to foreign cells and destroy and eliminate them from the body.

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What is Breast Cancer Related lymphedema (BCRL)?
Lymphedema occurs when there is an alteration of the lymphatic system resulting in an accumulation of lymphatic fluid. Lymphatic fluid is mostly made up of water, protein, bacteria, fatty acids, white blood cells, and foreign debris. Eventually the lymphatic system’s transport capacity, or maximum amount of lymph fluid that can be drained in a single day, is reached and the excess fluid begins to result in swelling of the extremity and possibly the corresponding trunk.

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How is lymphedema managed?
Management of lymphedema should begin with efforts to prevent the disease. Education should be provided during a pre-operative evaluation and education session to all patients going through treatments that put them at risk for lymphedema. During the evaluation circumference measurements and, if available, a bioimpedance spectroscopy measure should be obtained. Studies show that early detection and treatment of lymphedema significantly reduce the incidence and progression of the disease.

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What factors increase the risk of developing breast cancer related lymphedema?
Factors that increase the risk of developing breast cancer related lymphedema are cumulative in nature. These factors include the type of breast surgery, the number of lymph nodes removed, and if radiation therapy is a part of the treatment plan.

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James B Saviers II, MS, OTR/L, CLT-LANA Lymphedema Specialist/Occupational Therapist

James Saviers has been practicing as an occupational therapist since 2007. For the past 11 years, he has specialized in lymphedema and is a lymphedema therapist certified by the Lymphology Association of North America. James graduated with his Bachelors of Science in Exercise Sports Science from the University of Tulsa in 2003 and his Masters of Science in Occupational Therapy from the University of Oklahoma in 2007. James currently practices in Little Rock, Arkansas.

“I agree very strongly with the mission of Learn Look Locate because education in the early stages of breast cancer diagnosis can significantly reduce the risks of developing chronic conditions associated with breast cancer treatment, such as lymphedema and orthopedic issues.”

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What does the lymphatic system do?

The lymphatic system is made up of lymph capillaries, lymph collectors, and lymph nodes. The lymphatic system is responsible for 3 major functions:
  1. Absorption of fluid and other solid molecules from the spaces surrounding the cells and transportation of it back to the blood circulation. This includes proteins.  75 – 100 grams of protein are transported by the lymphatic system every day. 
  2. In the small intestines, long-chain triglycerides, cholesterol, and the fat soluble vitamins A, D, E, and K are absorbed into the lymphatic system.
  3. Immunological functions: White blood cells (lymphocytes) are created by the lymphatic system and have the ability to respond to foreign cells and destroy and eliminate them from the body.

Lymph Capillaries: Originating in the spaces between the cells, lymph capillaries are larger than blood capillaries so are able to absorb lymphatic fluid along with large molecules. Lymphatic fluid is mostly made up of water, protein, bacteria, fatty acids, white blood cells, and foreign debris.

Lymph Collectors: These structures do not depend on the heart like the arteries and veins. Instead, they pump lymph fluid themselves to the lymph nodes and eventually back to the blood circulation.

Lymph Nodes: There are 600 – 700 lymph nodes in the human body. Although they are spread throughout the body they tend to be grouped in certain areas of the body. These include the abdomen (largest number), head and neck, axilla (under arms), and inguinal (groin) areas. Lymph nodes vary in size and shape (2 – 30 mm long). The function of lymph nodes are:

  • Elimination of waste: The lymph nodes filter bacteria, toxins, and dead cells from the lymph fluid to be eliminated from the body.
  • Production of white blood cells: Important in destroying bacteria, viruses, and preventing infections.
  • Regulate protein in the lymph fluid: Determine the amount of protein and therefore the amount of water circulating through the lymphatic system.

What is Breast Cancer Related lymphedema (BCRL)?

Lymphedema occurs when there is an alteration of the lymphatic system resulting in an accumulation of lymphatic fluid. Lymphatic fluid is mostly made up of water, protein, bacteria, fatty acids, white blood cells, and foreign debris. Eventually the lymphatic system’s transport capacity, or maximum amount of lymph fluid that can be drained in a single day, is reached and the excess fluid begins to result in swelling of the extremity and possibly the corresponding trunk.
Breast cancer related lymphedema (BCRL) is considered to be secondary lymphedema, because the lymphatic system is altered or damaged due to the removal of lymph nodes for biopsy, radiation therapy, and scar tissue resulting from surgery and radiation.

Lymph Node Biopsy: Lymph nodes may be removed during a biopsy, lumpectomy, or mastectomy and sent to a pathologist to test for the presence of cancer.  Sentinel Lymph Node Biopsy normally removes 1-3 lymph nodes closest to the site of the tumor.  If the lymph nodes are positive more lymph nodes could be removed, which is referred to as an axillary lymph node dissection.  A side effect of lymph node removal is the reduction in the transport capacity of the lymphatic system.

Radiation Therapy: Radiation therapy utilizes high-energy particles or waves, such as x-rays, gamma rays, electron beams, or protons, to destroy or damage cancer cells.  This can also lead to scarring of the soft tissues and damage to the lymph nodes and lymph vessels leading to reduced ability to transport lymphatic fluid.

Scar Tissue Formation: Surgeries and radiation therapy both lead to the formation of scar tissue.  The lymphatic system is very close to the surface of the skin and any scarring of the soft tissues can lead to the reduced ability of the lymphatic system to transport fluid.

Lymphedema is a chronic and progressive disease that can cause infections, significant changes to the tissues, and lead to loss of function if left untreated.  However, lymphedema is easily managed with early identification and treatment.

How is lymphedema managed?

Management of lymphedema should begin with efforts to prevent the disease.  Education should be provided during a pre-operative evaluation and education session to all patients going through treatments that put them at risk for lymphedema.  During the evaluation circumference measurements and, if available, a bioimpedance spectroscopy measure should be obtained.  Studies show that early detection and treatment of lymphedema significantly reduce the incidence and progression of the disease.

If lymphedema is diagnosed it is treated by a certified lymphedema therapist (CLT) through a process called complete decongestive therapy (CDT).  Here are links to find a lymphedema therapist in your area:

There are 2 phases to CDT.  A treatment or reduction phase and a maintenance phase. 

Treatment Phase: The treatment phase length of time depends on the patient’s response to therapy.  At the beginning of this phase baseline circumference measurements are obtained and then completed incrementally throughout the patient’s therapy sessions in order to show reduction.  The goal is to reduce the circumference of the affected body part to the point where the girth or volume measurements plateau.  Education regarding all aspects of CDT should be taught to the patient and their support system so the treatment is continued outside of direct treatment sessions and during the maintenance phase.  There are 4 components that comprise the treatment phase: 

  1. Skin and Nail Care: The CLT provides a thorough evaluation of the skin and nails, including the cuticles, to ensure there are no signs of cuts, scratches, areas of irritation, or signs of infection. A pH balanced moisturizer is applied to the limb prior to compression bandaging. 
  2. Manual Lymphatic Drainage: MLD is a manual therapy technique that is performed to stimulate the pumping mechanism of the lymphatic system enhancing uptake of lymphatic fluid. The CLT utilizes light pressure over the affected extremity and surrounding body parts to create a stretching or pumping of the skin. 
  3. Multi-Layer Compression Bandaging: MLC consists of layers of stockinet, cast padding, foam, and short stretch bandages that are applied to the affected extremity and worn continuously during the treatment phase. The bandages are removed each treatment session, the limb is washed, and the bandages are reapplied.  Short stretch bandages provide pressure during movement and not at rest.  This pressure during movement helps create a stimulation of the lymphatic system and increases the flow of lymphatic fluid towards the lymph nodes.  MLC also helps to soften tissues that may have become firm due to the presence of fluid in the tissues. 
  4. Therapeutic Exercise: The CLT provides a series of exercises that are performed at regular intervals throughout the day with the compression bandages in place in order to create a muscle and joint pump enhancing the movement of fluid. These exercises also assist in reducing the possibility of deconditioning while bandaging is ongoing.

Once volume reduction reaches a plateau the patient moves into the maintenance phase.  This phase consists of a life-long program of self-care including all 4 aspects of CDT.  Compression garments are worn during waking hours and the patient may choose to self-bandage at night.  Night time compression garments are also available to avoid bandaging. 

What factors increase the risk of developing breast cancer related lymphedema?

Factors that increase the risk of developing breast cancer related lymphedema are cumulative in nature.  These factors include the type of breast surgery, the number of lymph nodes removed, and if radiation therapy is a part of the treatment plan. 

  • Breast Surgery: Lumpectomy vs. Mastectomy
  • Lymph Node Excision: Sentinel Lymph Node Biopsy (SLNB) vs. Axillary Lymph Node Dissection (ALND)
  • Radiation Therapy: No radiation vs. radiation to the breast vs. radiation to regional lymph nodes

Additional risk factors include the stage of cancer at diagnosis, chemotherapy, post-surgical complications such as infection, seroma, and axillary web syndrome.

  • Advanced stages of cancer at diagnosis increase the risk of lymphedema.
  • Chemotherapy and the need for glucocorticoid agents such as dexamethasone can produce the adverse effect of swelling.
  • Infections such as cellulitis can have a significant impact on the lymphatic system including destruction of lymphatic tissues.
  • Seroma formation, requiring needle aspiration, following breast surgery significantly increase the risk of developing lymphedema symptoms.
  • Axillary web syndrome usually appears as a painful cord of tissue under the skin and has been associated with increased risk of developing lymphedema.

Individual patient risk factors including obesity and genetics are also thought to increase the risk of lymphedema.

  • Obesity at the time of diagnosis (BMI of 30) is a significant risk factor for developing lymphedema.
  • Genetics play a role in who will develop lymphedema. Primary lymphedema is a rare genetic condition caused by abnormal development of the lymphatic system.