Lymphadema, post-mastectomy

• 457.0 Postmastectomy lymphedema syndrome
• 457.1 Other lymphedema

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

• 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation1
• 6H: Impaired circulation and anthropometric dimensions associated with lymphatic system disorders2

Description

• 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

Essentials of Diagnosis

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

General Considerations

• 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

Demographics

• Parallels those of breast cancer

Signs and Symptoms

• 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

Functional Implications

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

Possible Contributing Causes

• 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

Differential Diagnosis

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

Imaging

• Indirect lymphangiography
• Direct lymphography
• Fluorescent microlymphography
• MRI
• Lymphoscintigram

Diagnostic Procedures

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

• 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)

Medication

• Diuretics (limited success)
• Benzopyrines

Medical Procedures

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