Doctor, I have a swelling in the arm… What do I do?
Radha, a 45 year old was treated for breast cancer 5 years back. She underwent a complete breast removal with removal of the nodes followed by chemotherapy and radiation. She was doing well and disease free. A week ago she called me saying she had a swelling in the arm, pain and redness around the elbow and forearm. She was also running a temperature of 100.2F. On probing further, she said she had injured her finger on the same side as surgery, a couple of days ago.
I knew at once she had developed lymphedema set off by an infection in her injured finger.
Lymphedema is known to occur in 15-25 % of women who undergo removal of lymph nodes from the armpit during surgery for breast cancer and can happen weeks, months or years after surgery.
What is lymphedema?
Lymphedema is a swelling in the limb, which is precipitated by surgery of the draining lymph nodes or radiation or infection. Protein-rich fluid, fat globules and debris accumulate in the subcutaneous tissue. Persisitent accumulation leads to brawny swelling.Infection along these vessels can give rise to redness, pain and accompanying fever. Early intervention is the best way to deal with it. And better still is prevention!
How does one prevent lymphedema?
� Avoid pricks and needles on the arm on the operated side.
� Blood pressure measurement should be avoided on the side of surgery.
� One should not lift heavy weights (more than 5 kgs) with the arm on the operated side.
� Cuts, stings, insect bite should be avoided.
� Tight garments, bracelets and rings should not be worn on the affected side.
� Be careful while paring your nails. Avoid waxing of the arm on the affected side.
� In case of any accidental cuts, wash the wound carefully and apply antiseptic ointment at once.
� If there is redness or swelling in the arm, report back immediately to your treating physician.
� If you wish to undertake a trip by flight, kindly ensure you have an arm sleeve (custom made) for the arm on the operated side during the duration of the flight.
What are the measures to deal with lymphedema?
Those arm exercises, which are initiated in the postoperative period, should be sustained and developed as a habit for the future. Isotonic exercises intended to improve lymphatic circulation should be an integral part of the exercise program. Overexertion is not recommended.
External compression is intended to aid the muscle in pumping action to drain the lymph out of the limb. External compression can be achieved by multilayer bandaging or compression garments. A combination of both yields better results.
Multilayer bandaging technique
This method, if executed diligently, can achieve substantial reduction in the girth of the affected arm. A Lymphedema Kit consisting of a cotton tubular sleeve, a foam padding, finger bandages and elastic bandages is what is used to perform the bandaging. The Physiotherapists can teach the precise method of bandaging and with practice one can do it on one’s own. One may need to redo the bandage after about 6 hours as it tends to loosen over time. It is advisable not to do bandaging if there is any vascular compromise in the limb or neuropathic problem. It is also to be avoided in case of active infection.
Compression sleeve fashioned from seamless material is best worn during the day. Graduated compression, maximum distally, allows for the lymph to be drained towards the heart. These garments are best custom made and should be replaced every six months.
Pneumatic compression ( Lymphapress)
Pneumatic compression is delivered using a sleeve connected to a motor driven pump with the intention of assisting in lymphatic fluid return. It is best used in combination with a compression sleeve or bandaging.
It is important to take care of the skin of the arm. Please ensure there are no cuts, pricks or tight clothing or jewelry on the arm. The skin should be kept clean and moist to prevent cracks or fissures from developing. Nails should be pared with care. In case of injury or cut, please apply an antiseptic lotion or ointment and cover the wound. If, however, redness, pain or fever develops, then one would need to be put on antibiotics and anti-inflammatory drugs. Any infection will only cause the lymphedema to worsen.
Manual or self-lymphatic drainage
Gentle massage of the arm starting distally and moving proximally allows for displacement of fluid in the desired direction. The massage should be gentle so as to stimulate the skin lymphatics to play an effective role in draining the fluid. While a physiotherapist may perform a massage over 45 minutes to an hour, one can do it by self for about 20 minutes and get similar results.