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  • 457.0 Postmastectomy lymphedema syndrome
  • 457.1 Other lymphedema

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  • I89.0 Lymphedema, not elsewhere classified
  • I97.2 Postmastectomy lymphedema syndrome

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Description

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  • Occurs when lymph system is damaged or blocked and buildup of lymph fluid occurs in soft tissues, causing swelling
  • Obstruction of lymphatic vessels or lymph nodes
  • Increased water and protein in the interstitial space3
  • Lymphedema can occur as a result of surgery, chemotherapy, or radiation causing interruption of the lymphatic system
  • Post-mastectomy, axillary, or sentinel lymph node dissection affects upper extremities
  • Considered secondary lymphedema

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Essentials of Diagnosis

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  • Detailed medical history (e.g., surgical procedures, chemotherapy, radiation)
  • Presence of non-pitting edema
  • MRI or CT
  • Circumferential upper-extremity measurement

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General Considerations

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  • Commonly occurs following breast cancer surgery
  • Axillary or sentinel node dissections and radiation therapy increase risk of occurrence
  • Classification for lymphedema3
    • Mild: less than 3 cm difference between the affected and unaffected limb3
    • Moderate: Between 3 and 5 cm difference between the unaffected and affected limb3
    • Severe: 5+ cm difference between the unaffected and affected limb
  • Graded 1 (least severe) to 4 (most severe) 3
  • Pitting only present in stages 1 and 23

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Demographics

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  • Parallels those of breast cancer

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Signs and Symptoms

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  • Pitting/non-pitting lymphedema of extremity
    • Pitting only present in stages 1 and 23
  • Skin feeling tight or shiny
  • Decreased flexibility/ROM in the hand or wrist
  • Difficulty fitting into clothing in one specific area
  • Ring, wristwatch, bracelet tightness
  • Usually unilateral
  • Asymmetrical appearance
  • Localized presentation
  • Warmth, tenderness
  • Redness

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Functional Implications

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  • Stiffness, limited ROM
  • Sensory disturbances
  • Decreased resistance to infection
  • Susceptibility to skin breakdown
  • Decreased self-care, ADLs

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Possible Contributing Causes

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  • Lymphadenectomy
  • Limb constriction
  • Overuse
  • Obesity
  • Radiation fibrosis
  • Delayed wound healing
  • Scarring of left or right subclavian lymphatic ducts
  • Breast cancer surgery
  • Diagnostic dissection
  • Mastectomy
  • Radiation

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Differential Diagnosis

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  • Edema3
  • Cellulitis
  • Dermatologic manifestations of cardiac or renal disease
  • Erysipelas
  • Filariasis
  • Lymphangioma
  • Thrombophlebitis
  • Venous insufficiency

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Imaging

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Diagnostic Procedures

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  • Doppler study
  • Surgical history (axillary lymph node dissection [ALND], modified radical mastectomy)
  • Visual inspection
  • Circumferential measurements

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  • Common clinical findings include
    • Increased circumferential limb girth
    • Postural changes
    • Neuromuscular deficits
    • Integumentary complications (atrophic skin changes)
    • Edema
    • Decreased ROM
    • Decreased strength
    • Pain (axillary cording post-mastectomy with lymph node dissection)

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Medication

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Medical Procedures

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  • Surgical (limited success)
    • Liposuction
    • Removal of abnormal lymphatic tissue
    • Venous graft
    • Amputation
    • ...

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