Lymphedema is the build-up of fluid in the soft tissues of the body that occurs when the lymph system is damaged or obstructed.
Lymph, the white blood cell containing fluid important in fighting infection, normally circulates around the body through a series of small channels or vessels. Lymph nodes are small filters in the lymph channel system that clear the lymph fluid of particles and act as storage units to house the infection-fighting white blood cells. Normally, the lymph fluid circulates continuously around the body as an integral part of the immune system. If something interrupts this flow, the fluid backs up and leaches into the soft tissue causing lymphedema.
Primary lymphedema is caused by the abnormal development of the lymph system, with symptoms seen as early as at birth. More commonly seen is secondary lymphedema, which results from physical blockage to the flow of the lymph fluid from infection, surgical removal of lymph nodes or tissue, damage to the lymph structures from surgery or radiation therapy, or scarring of tissue with resultant obstruction. As an example, the development of upper extremity lymphedema is an unfortunate post-operative/post-radiation risk after several different types of breast cancer treatments. Women undergoing lumpectomy with axillary (or underarm) lymph node sampling or dissection, women undergoing mastectomy with lymph node sampling or dissection, and women receiving post-operative axillary radiation therapy are all at risk for developing some degree of lymphedema of the arm located on the same side as the breast surgery; the incidence of development ranges from 7 percent to 47 percent.
The initial signs and symptoms of lymphedema may be subtle, such as the feeling of arm heaviness or rings being too tight for the fingers. As it progresses, tightness of the skin, obvious arm/hand swelling and difficulty moving joints can occur. Because lymphedema is difficult to treat once it is apparent, the ideal for lymphedema treatment is to make the diagnosis before it is noticeable. Unfortunately, traditional methods of early detection such as arm girth measurement and water displacement measurements are variable and frequently unreliable.
At the Midstate Medical Group Surgical Specialists, we are piloting an early lymphedema diagnosis and treatment program utilizing ImpediMed’s L-Dex™ bio-impedance spectroscopy device. The device measures the volume of fluid in an “at-risk” arm (the arm on the side of the cancer surgery) by passing a low frequency current through electrodes on the patient, determining the resistance to the current, and comparing obtained values on the “at risk” arm to the other arm. Ideally, measurements would begin prior to cancer surgery on the patient to get a baseline reading, and then are compared every 3 months for the first 2 years after surgery, every 6 months from years 3 to 5 post-surgery, and once a year thereafter. While the risk of developing post-operative lymphedema is greatest within the first 2-3 years after cancer surgery, it is still considered a lifetime risk.
The greatest feature of the L-Dex is its ability to detect lymphedema before it is noticeable. A study published by the NIH in 2008 clearly showed that when lymphedema is diagnosed at a sub-clinical stage, it could be successfully treated with wearing a compressive garment on the affected limb for several weeks. Following removal of the garment, patients had complete resolution of the lymphedema with no further intervention required. Progression to clinically obvious lymphedema, and thus to advanced, disfiguring stages, is prevented. Early detection and treatment of lymphedema in the post-operative breast cancer patient is a tremendous advancement in the care of our breast cancer patients.
Dr. Elizabeth Riordan is a general surgeon with the MidState Medical Group Surgical Specialists and is also Director of Breast Services. Her office phone number is 203.238.2691.