Section written by: Dr.Sminu Shah, OncoPhysiotherapist. Contact : firstname.lastname@example.org
The Lymphatic System
The Circulatory System consists mainly of arteries, veins and lymphatic system. Arteries carry blood from heart to peripheries. 90 percent of this blood is carried back to the heart by veins; the remaining 10% of fluid (proteins, other molecules, etc.) gets filtered into the tissues and is called the 'lymph' . This lymph finally enters tiny 'lymphatic channels', which transport it into the regional 'lymph nodes'. These nodes are like collecting stations of the lymph and they transport this lymph further into the circulation. The lymphatic channles are located just below the skin, in the fatty tissue. But they are there everywhere, all around in the body. Lymph may pass from one nodal station to the next via 'lymphatic channels'. Ultimately, one of the last nodal stations will drain the lymphatic fluid into the blood and the lymph reaches back into the blood stream. Lymphatic system helps in circulating body fluids and provides defense against pathogens.
What is 'lymphedema'?
What would happen if we were to remove the 'lymph nodes' mentioned above? Since these nodes are collecting points of the lymph and it is these nodes, which guide the lymph further, if we were to remove the nodes, the lymphatic pathway will be broken and there will be nothing to collect this lymph and push it further. (The lymph node is like a road bridge over a river. Suppose a bridge over a river collapses, what happens to vehicles on the road before the bridge? They wont be able to go further. They will have to find some other route to go across the river). But the formation of lymph continues. So ultimately, there will be a lot of back pressure in these lymphatic channels; lymph continues to be formed, but it cannot go forward and starts accumulating in the channels and they get affected in many ways. In case of hands and arms, since most lymph channels are just below the skin, the skin tends to become thick. And the width of the arm starts increasing, because of lymph accumulation. This is 'lymphedema'. Please note, this is a very slow process. It happens over months or years.
Cancer in any organ tends to spread to the regional lymph nodes. Hence, When we treat cancer, one of the most important aspects of surgery is to remove the lymph nodes to which the cancer of that organ, because these nodes receive the cancer cells, cancer can grow in them, and in turn, like lymph, the nodes will propagate the cancer cells into the body. But because if removal of nodes, as has been explained above, the lymphatic flow gets disturbed and results into thickening of skin and increase in size of arm which is called 'lymphedema'. For all practical purposes, since this website deals with only breast cancer, we will restrict our discussion to lymphedema of the upper limb only.
Who is at risk of developing Lymphedema?
Anything which affects the pathway of lymph flow in the axilla (arm pit), is at risk of developing lymphedema. In context of breast cancer, these would include surgery where an axillary dissection has been done, and radiation.
What are the symptoms of Lymphedema?
The following can be the symptoms of upper limb lymphedema:
Swelling of the forearm (or hand or arm), is the most common symptom
Skin becomes 'hard' and cannot be 'pinched'
Reduced flexibility and persistent 'depression' in the skin over a pressure site
Pain can develop in later stages
Whom and when do I need to approach?
If you notice a persistent swelling in your hand that is worsening day by day, you need to approach your surgeon who will refer you to a qualified Onco-physiotherapist who will assess your condition and help you according to the condition
Is it reversible?
In early stages (Stage 0, 1) are reversible completely whereas Stage 2a -2b can be reversed/Maintained. Stage 3 can be changed to soft texture. Compliance is the main part of treatment as we have a management and not a complete cure for the condition. And since reversibility and better outcomes are limited to earlier stages, it is essential that one should report to the doctor early on, after noticing symptoms over a few weeks.