Lymphedema
Affecting the Breast and Trunk
By Joachim Zuther, on October 5th,
2011
Lymphedema affecting the chest, breast and posterior thorax, also
known as trunkal lymphedema, is a
common problem following breast
cancer surgery, but is often difficult to diagnose, especially if the patient
does not also present with lymphedema of the arm, or it may be
dismissed as a side-effect of breast cancer
surgery, which will
resolve by itself over time.
While trunkal lymphedema is often not reported,
poorly documented and available studies are not easy to
compare,
the literature suggests an incidence of up to 70% of lymphedema affecting the
trunk and/or breast
following breast cancer treatment.
Given
the fact that the breast, anterior and posterior thorax and the upper extremity
share the axillary nodes
as regional lymph nodes, it is predictable
that disruption of lymphatic drainage pathways by partial or
complete removal of axillary lymph nodes, with or without radiation
therapy can cause the onset of swelling
in the chest wall and
breast on the same side. The swelling can either be subtle or quite obvious in
presentation and may be present with or without swelling in the
arm.
The disruption of the natural lymphatic drainage pattern is further
complicated by scars on the upper trunk
wall following lumpectomy,
mastectomy, and reconstructive breast surgery, biopsies or drain sites.
Fibrotic
tissues in the chest wall or armpit following radiation
treatments may further inhibit sufficient lymphatic
drainage.
Certain breast reconstructive procedures, such as the
TRAM-flap reconstruction also disrupt lymphatic
drainage in the
abdominal area, which may cause the onset of additional swelling in the lower
trunkal
(abdominal) area.
Like lymphedema in the
extremities, swelling affecting the breast, chest and posterior thorax is
typically
asymmetrical in appearance if compared with the other
side. However, there are often other symptoms
present prior to the onset of visible swelling, which may include altered sensation (numbness, tingling, diffuse
fullness and pressure, heat), pain and decreased
shoulder mobility. Once lymphedema is visibly present, the
swelling
may include the entire thorax wall, or may be localized to the armpit, the
scapula, the area over the
clavicle or around mastectomy/lumpectomy
scar lines, around the reconstructed breast or implants, or it may
be limited to the breast tissue only.
The breast in patients who
underwent lumpectomy or reconstructive surgery may be larger and heavier, or
the shape and height of the breast tissue may change due to
fibrotic tissue, resulting in added psychological
distress due to
problems involving clothing, bra fit and body image issues.
Post-operative
swelling following breast cancer surgery is to be expected and generally lasts
up to about
three months; it appears almost immediately following
surgery and places additional stress on the lymphatic
system by
contributing to the lymphatic workload. The difference between “normal”
post-operative edema
and lymphedema is its perseverance following
the completion of treatment, and the presence of changes in
tissue
texture, such as lymphostatic fibrosis.
While several methods are
available to assess trunkal and breast edema (skin fold calipers,
bioimpedance),
subjective examination of the anterior and posterior
aspect of the thorax and breast focused on the
observation of signs
of swelling (asymmetry, bra strap and seam indentations, orange peel
phenomenon,
changes in skin color), palpation of the tissue texture
and comparison of skin folds between the affected and
non-affected
side, remain the most practical means for assessment of lymphedema affecting
the trunk. Serial
photographs depicting the anterior and posterior
view are helpful tools in assessing changes before and after
treatment.
Most of the symptoms associated with trunkal lymphedema
can be treated successfully with Complete
Decongestive Therapy
(CDT), to include Manual Lymph Drainage (MLD), especially if combined with
self-
MLD, skin care, exercises and compression therapy.
Fortunately, trunkal swelling responds well to
treatment, often with
markable improvement within 10 treatments. Treatment may be necessary only
during
the initial period following breast cancer treatment to
facilitate edema removal and wound healing, or it may
be applied at
a later point; trunkal lymphedema with or without the involvement of the arm
may appear at
any time following surgery for breast
cancer.
Manual Lymph Drainage: In case of localized trunkal lymphedema
without involvement of the arm, MLD
techniques concentrate on the
neck, the anterior and posterior aspects of the upper trunk, as well as the
inguinal lymph nodes, followed by techniques focused to redirect
lymphatic fluid from congested areas into
areas with sufficient
lymphatic drainage. If necessary, additional techniques aimed to soften
fibrotic tissues
may also be applied.
For patients who underwent
TRAM-flap procedures, careful attention should be given to address scar tissue
that could lead to trapping of lymphatic fluid.
During the
initial stages of the treatment, patients should be instructed in self-MLD and
encouraged to
perform self treatment for at least 20-30 minutes
daily.
Skin Care: Patients who have lymphedema are susceptible to infections
of the skin; areas between skin folds
or the underside of the
breast are particularly prone to skin damage and infections. Edematous areas
should
be kept clean and dry and suitable ointments or lotions
formulated for sensitive skin, radiation dermatitis and
lymphedema
should be applied.
Exercises: Trunkal lymphedema is often associated with
restrictions in thorax and shoulder movements,
which should be
evaluated by a Physical or Occupational Therapist. Specific exercises
addressing these
issues and to increase range of motion and function
with daily activities should be performed.
Depending on the location and
quality of scars, mobilization of adhered scar tissue by a qualified therapist
may be necessary to improve range of motion. Breathing and aerobic
exercises further facilitate
decongestion by improving drainage in
superficial and deep lymphatic pathways.
Compression Therapy: Oftentimes
compression of the affected area may be challenging due to tenderness of
the tissue, or irritated skin secondary to
radiation therapy.
However, in order to address fluid accumulation and to avoid worsening of the
swelling,
the application of compression bandages and/or
compression bras or vests is very important. Compression
bandages
are applied circumferentially around the chest with special care not to impair
blood supply to
grafts and/or healing scars.
Due to the lack
of muscle pump activity in the trunkal area, the use of wide-width (15-20cm)
medium and
long-stretch bandages is preferable over the normally
used short-stretch bandages for lymphedema affecting
the
extremities.
Custom cut or commercially manufactured foam pads or foam chips
may be inserted underneath the
bandages or compression bra/vest to
increase localized pressure in areas of excess fluid pooling, or to soften
localized fibrotic tissue. Flat foam pieces can be used to shape and
stabilize the compression bandages and
to distribute the pressure
evenly over a greater surface area.
The patient should be fitted with a
specially designed lymphedema bra or compression vest following
decongestion of the trunk to assist with maintaining the positive
results of CDT. Compression bras and vests
have minimal seams and
wide straps, are available as off-the-shelf or custom-made garments and ensure
that
the trunk and breast tissues are properly supported.
Compression bras and vests should fit comfortably,
provide
sufficient support around the trunk and not squeeze breast tissue; pockets to
accommodate a
prosthesis can be sewn into these
garments.
Patients using regular bras or sports bras should make sure to
avoid narrow bra straps and obtain bra strap
pads or wideners, if
necessary, to avoid restriction of lymphatic pathways on the
shoulder.
Additional
Resources:
http://www.stepup-speakout.org/breast_chest_trunckal_lymphedema.htm
http://www.lymphoedema-uk.com/journal/0101_breasttrunk.pdf
Affecting the Breast and Trunk
By Joachim Zuther, on October 5th,
2011
Lymphedema affecting the chest, breast and posterior thorax, also
known as trunkal lymphedema, is a
common problem following breast
cancer surgery, but is often difficult to diagnose, especially if the patient
does not also present with lymphedema of the arm, or it may be
dismissed as a side-effect of breast cancer
surgery, which will
resolve by itself over time.
While trunkal lymphedema is often not reported,
poorly documented and available studies are not easy to
compare,
the literature suggests an incidence of up to 70% of lymphedema affecting the
trunk and/or breast
following breast cancer treatment.
Given
the fact that the breast, anterior and posterior thorax and the upper extremity
share the axillary nodes
as regional lymph nodes, it is predictable
that disruption of lymphatic drainage pathways by partial or
complete removal of axillary lymph nodes, with or without radiation
therapy can cause the onset of swelling
in the chest wall and
breast on the same side. The swelling can either be subtle or quite obvious in
presentation and may be present with or without swelling in the
arm.
The disruption of the natural lymphatic drainage pattern is further
complicated by scars on the upper trunk
wall following lumpectomy,
mastectomy, and reconstructive breast surgery, biopsies or drain sites.
Fibrotic
tissues in the chest wall or armpit following radiation
treatments may further inhibit sufficient lymphatic
drainage.
Certain breast reconstructive procedures, such as the
TRAM-flap reconstruction also disrupt lymphatic
drainage in the
abdominal area, which may cause the onset of additional swelling in the lower
trunkal
(abdominal) area.
Like lymphedema in the
extremities, swelling affecting the breast, chest and posterior thorax is
typically
asymmetrical in appearance if compared with the other
side. However, there are often other symptoms
present prior to the onset of visible swelling, which may include altered sensation (numbness, tingling, diffuse
fullness and pressure, heat), pain and decreased
shoulder mobility. Once lymphedema is visibly present, the
swelling
may include the entire thorax wall, or may be localized to the armpit, the
scapula, the area over the
clavicle or around mastectomy/lumpectomy
scar lines, around the reconstructed breast or implants, or it may
be limited to the breast tissue only.
The breast in patients who
underwent lumpectomy or reconstructive surgery may be larger and heavier, or
the shape and height of the breast tissue may change due to
fibrotic tissue, resulting in added psychological
distress due to
problems involving clothing, bra fit and body image issues.
Post-operative
swelling following breast cancer surgery is to be expected and generally lasts
up to about
three months; it appears almost immediately following
surgery and places additional stress on the lymphatic
system by
contributing to the lymphatic workload. The difference between “normal”
post-operative edema
and lymphedema is its perseverance following
the completion of treatment, and the presence of changes in
tissue
texture, such as lymphostatic fibrosis.
While several methods are
available to assess trunkal and breast edema (skin fold calipers,
bioimpedance),
subjective examination of the anterior and posterior
aspect of the thorax and breast focused on the
observation of signs
of swelling (asymmetry, bra strap and seam indentations, orange peel
phenomenon,
changes in skin color), palpation of the tissue texture
and comparison of skin folds between the affected and
non-affected
side, remain the most practical means for assessment of lymphedema affecting
the trunk. Serial
photographs depicting the anterior and posterior
view are helpful tools in assessing changes before and after
treatment.
Most of the symptoms associated with trunkal lymphedema
can be treated successfully with Complete
Decongestive Therapy
(CDT), to include Manual Lymph Drainage (MLD), especially if combined with
self-
MLD, skin care, exercises and compression therapy.
Fortunately, trunkal swelling responds well to
treatment, often with
markable improvement within 10 treatments. Treatment may be necessary only
during
the initial period following breast cancer treatment to
facilitate edema removal and wound healing, or it may
be applied at
a later point; trunkal lymphedema with or without the involvement of the arm
may appear at
any time following surgery for breast
cancer.
Manual Lymph Drainage: In case of localized trunkal lymphedema
without involvement of the arm, MLD
techniques concentrate on the
neck, the anterior and posterior aspects of the upper trunk, as well as the
inguinal lymph nodes, followed by techniques focused to redirect
lymphatic fluid from congested areas into
areas with sufficient
lymphatic drainage. If necessary, additional techniques aimed to soften
fibrotic tissues
may also be applied.
For patients who underwent
TRAM-flap procedures, careful attention should be given to address scar tissue
that could lead to trapping of lymphatic fluid.
During the
initial stages of the treatment, patients should be instructed in self-MLD and
encouraged to
perform self treatment for at least 20-30 minutes
daily.
Skin Care: Patients who have lymphedema are susceptible to infections
of the skin; areas between skin folds
or the underside of the
breast are particularly prone to skin damage and infections. Edematous areas
should
be kept clean and dry and suitable ointments or lotions
formulated for sensitive skin, radiation dermatitis and
lymphedema
should be applied.
Exercises: Trunkal lymphedema is often associated with
restrictions in thorax and shoulder movements,
which should be
evaluated by a Physical or Occupational Therapist. Specific exercises
addressing these
issues and to increase range of motion and function
with daily activities should be performed.
Depending on the location and
quality of scars, mobilization of adhered scar tissue by a qualified therapist
may be necessary to improve range of motion. Breathing and aerobic
exercises further facilitate
decongestion by improving drainage in
superficial and deep lymphatic pathways.
Compression Therapy: Oftentimes
compression of the affected area may be challenging due to tenderness of
the tissue, or irritated skin secondary to
radiation therapy.
However, in order to address fluid accumulation and to avoid worsening of the
swelling,
the application of compression bandages and/or
compression bras or vests is very important. Compression
bandages
are applied circumferentially around the chest with special care not to impair
blood supply to
grafts and/or healing scars.
Due to the lack
of muscle pump activity in the trunkal area, the use of wide-width (15-20cm)
medium and
long-stretch bandages is preferable over the normally
used short-stretch bandages for lymphedema affecting
the
extremities.
Custom cut or commercially manufactured foam pads or foam chips
may be inserted underneath the
bandages or compression bra/vest to
increase localized pressure in areas of excess fluid pooling, or to soften
localized fibrotic tissue. Flat foam pieces can be used to shape and
stabilize the compression bandages and
to distribute the pressure
evenly over a greater surface area.
The patient should be fitted with a
specially designed lymphedema bra or compression vest following
decongestion of the trunk to assist with maintaining the positive
results of CDT. Compression bras and vests
have minimal seams and
wide straps, are available as off-the-shelf or custom-made garments and ensure
that
the trunk and breast tissues are properly supported.
Compression bras and vests should fit comfortably,
provide
sufficient support around the trunk and not squeeze breast tissue; pockets to
accommodate a
prosthesis can be sewn into these
garments.
Patients using regular bras or sports bras should make sure to
avoid narrow bra straps and obtain bra strap
pads or wideners, if
necessary, to avoid restriction of lymphatic pathways on the
shoulder.
Additional
Resources:
http://www.stepup-speakout.org/breast_chest_trunckal_lymphedema.htm
http://www.lymphoedema-uk.com/journal/0101_breasttrunk.pdf