Cardiovascular · Year 1 · from Cardiovascular
Case 2: Lymphedema Secondary to Breast Cancer Treatment
Patient Presentation
Demographics: 52-year-old female
Chief Complaint: Progressive right arm swelling for 6 months
History of Present Illness: A 52-year-old female with history of right breast cancer treated 2 years ago with mastectomy and axillary lymph node dissection followed by radiation therapy presents with progressive right arm swelling over the past 6 months. She first noticed mild swelling after a long flight. The swelling has progressively worsened, now involving her entire arm and hand. She reports a feeling of heaviness and tightness. She has had two episodes of cellulitis in the affected arm in the past year.
Physical Examination:
- Vital Signs: BP 124/78 mmHg, HR 72 bpm, SpO2 98% on room air
- Right upper extremity:
- Circumference: 38 cm at forearm (left: 26 cm)
- Non-pitting edema (firm, woody texture)
- Positive Stemmer sign (unable to pinch skin fold at base of second digit)
- Skin thickening with peau d'orange appearance
- No erythema or warmth (no active infection)
- Reduced ROM at wrist and elbow
- Left upper extremity: Normal
- Chest wall: Well-healed mastectomy scar, post-radiation skin changes
Workup
- Labs: CBC normal, albumin 4.0 g/dL (normal), TSH normal
- Lymphoscintigraphy: Absent or delayed transport in right upper extremity lymphatic channels, dermal backflow pattern
- Duplex ultrasound: No DVT, no venous obstruction
- CT chest (surveillance): No recurrent malignancy, no axillary masses
Diagnosis
Secondary lymphedema of right upper extremity following breast cancer treatment (axillary dissection and radiation)
Lymphatic System Correlation:
Normal lymphatic function:
- Interstitial fluid (filtered from capillaries) enters lymphatic capillaries
- Lymph flows through lymphatic vessels → lymph nodes → thoracic duct → venous system
- Clears ~2-4 L of fluid per day from interstitium
- Removes proteins, cells, and waste that cannot return via venules
Pathophysiology of lymphedema:
- Lymphatic disruption:
- Surgical removal of axillary lymph nodes interrupts drainage pathways
- Radiation causes fibrosis of remaining lymphatic vessels
- Protein accumulation:
- Proteins cannot be cleared from interstitium
- Oncotic pressure in interstitium draws more fluid (↑ πi)
- Chronic inflammation:
- Protein accumulation triggers inflammatory response
- Fibrosis and adipose deposition → non-pitting quality
- Impaired immunity:
- Reduced lymphatic clearance → increased infection risk (cellulitis)
Stages of lymphedema:
| Stage | Characteristics |
|---|---|
| 0 | Subclinical - impaired transport but no visible swelling |
| I | Pitting edema, reverses with elevation |
| II | Non-pitting, tissue fibrosis, does not reverse |
| III | Lymphostatic elephantiasis, severe skin changes |
Stemmer sign: Inability to pinch skin at base of digit = pathognomonic for lymphedema
Treatment
- Complete decongestive therapy (CDT):
- Manual lymphatic drainage (specialized massage)
- Compression bandaging → transition to compression garments
- Exercise therapy
- Skin care (moisturize, prevent infections)
- Compression garments: 20-30 mmHg, custom-fitted
- Pneumatic compression devices: Adjunct therapy
- Infection prevention:
- Avoid blood draws, BP cuffs on affected arm
- Skin care, treat cuts promptly
- Prophylactic antibiotics for recurrent cellulitis
- Surgery (severe cases):
- Lymphovenous anastomosis
- Vascularized lymph node transfer
- Liposuction (for late-stage fatty deposition)
Clinical Image
Image Description: Photograph showing lymphedema of the upper extremity following breast cancer treatment. Note the significant swelling affecting the entire arm with skin thickening and non-pitting character typical of chronic lymphedema.
Source: Wikimedia Commons - Lymphedema arm License: CC BY-SA 3.0 URL: https://commons.wikimedia.org/wiki/File:Lymphedema.jpg