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Lymphedema: Postmastectomy complications (P1)

Lymphedema: Postmastectomy complications (P1)

Edited by: at 10/10/2023

Lymphedema is a complication secondary to mastectomy depending on the extent of axillary lymph node dissection. When the lymphedema is not treated in time and correctly can cause deformation of the affected limb that affects the quality of life of the patients. As a chronic and incurable condition that does not affect life expectancy, lymphedema imposes medical, social, physiological and functional sequelae of the patient. With complex decongestant therapy patients can prevent or reduce the adverse effect on the affected limb and control lymphedema.

Dr. Isabelle Aloi Timeus Salvato

Breast cancer is the most common malignant neoplasm that affects women, both in the United States and Europe, as in Mexico. The treatment of breast cancer requires a multidisciplinary management, where the surgery occupies a fundamental place and where the breast is treated with conservative or total surgery; Lymph node dissection is required for its staging, which may be selective or radical; This classification is necessary for the patients of new diagnosis, because according to this will be the treatment that each patient requires. The standard procedure for axillary lymph node dissection is resection of levels I and II.1 Sentinel lymph node and lymphatic mapping have emerged as an alternative. However, these procedures are not free of complications, some of which are exclusively related to the breast and others to axillary lymph node dissection.2 Some of these complications are:

- Wound Infections

- Seromas

- Bruising

- Brachial plexopathy

- Decreased arm mobility

- Axillary insensitivity

- Lymphedema

Lymphedema is the most common complication after axillary lymph node surgery for breast cancer. The cosmetic deformity can not be hidden with normal clothing; Physical discomfort and disability of the upper extremity are associated with growth, and recurrent episodes of cellulitis and lymphangitis frequently occur in this condition. From 13 to 27% of breast cancer patients will present lymphedema; 3-5 this risk increases depending on the extent of axillary dissection and may occur post-treatment throughout the patient's life. Lymphedema is a progressive subcutaneous soft tissue edema due to the accumulation of lymph, a protein rich fluid. Lymphedema arises due to interference with normal lymph drainage from the lymph to the blood, a condition called "Mechanical Insufficiency" of the vascular lymphatic system, which results in the characteristic edema of the affected limb. It usually occurs in the extremities (arms and / or legs) but also in the face, head, torso and genitals. Because lymphedema is a chronic and progressive disease, it should not be left untreated as it may result in disfigurement (elephantiasis), fibrosis (hardening) of the affected limb, delayed wound healing, formation of cysts and lymphatic fistulas, and Susceptibility to repeated infections. Usually an adult body returns 2 liters of lymph daily to the bloodstream but the lymphatic system has the capacity to transport ten times this amount if necessary due, for example, to an infection. It is because of this additional capacity that the body can counteract the accumulation of fluid in the tissues and temporarily prevent edema.

When lymphedema occurs, this additional capacity does not exist, that is, the normal volume of lymph produced daily by the body is greater than the capacity of the system. Therefore, the body can not avoid fluid accumulation and the result is edema (Figure 1). There are certain risk factors to present this complication in the immediate postoperative period, such as the formation of hematomas or seromas, extensive surgeries of external superior quadrants. Lymphedema is rarely caused by infections; However, it can be increased with cellulitis and infections of the arm, use of radiotherapy at the axillary level and obesity. The risk of lymphedema is greater after total axillary dissection, although there are already reported cases of lymphedema after sentinel node surgery. Other causes that can cause lymphedema are infections, trauma, heat, pressure changes and others. The first signs and symptoms of the disease are subtle, such as: feeling of heaviness in the extremity, tightness of the skin, reduced mobility of the wrist, clothes that are suddenly tight in the arm, jewelry or bracelets Of clock that are tight, slight edema in the arm. If these symptoms occur it is important to start treatment as soon as possible to reduce complications. Not all lymphedema manifest immediately. The main reasons why lymphedema can manifest years later are:

- The remaining lymph vessels become fatigued and stop working

- The patient suffers from infections that overload the system and also damage the lymphatic vessels

- The patient suffers a trauma (blow, burn, sting, wound) in the affected limb, which triggers lymphedema

Another complication is brachial plexopathy derived from poor arm position in the operating room. The American Society of Anesthesiology recommends that the arm be placed at 90o of maximum abduction of the shoulder and well supported on padded paddles.7 This condition is also called "Stewart-Treves Syndrome", named after the researcher of the same name, First to report cases that demonstrated the relationship between lymphedema postmastectomy and malignancy in the area. In this syndrome typical bluish and red spots appear or nodules in the affected arm. This disease usually appears 10 years after the initial treatment. Treatments include chemotherapy, radiation, limb amputation, all with poor results. These patients usually die from lung or visceral metastases with a 2-year survival time.

Kinesiology and Physiotherapy in Álvaro Obregón