Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema, Recommendations from an Expert Panel

Part 2: Preventive and Therapeutic Options

Sarah A. McLaughlin , Sarah M. DeSnyder, Suzanne Klimberg , Michael Alatriste , Francesco Boccardo, Mark L. Smith, Alicia C. Staley, Paul T. R. Thiruchelvam, Nancy A. Hutchison, Jane Mendez, Fiona MacNeill, Frank Vicini, Stanley G. Rockson, and Sheldon M. Feldman. Ann Surg Onco, August 2017

Main findings

The American Society of Breast Surgeons (ASBrS) convened an international, multidisciplinary expert panel to review current data and guidelines on all aspects of lymphedema diagnosis and management to acknowledge the gravity of this public health issue facing breast cancer survivors. The Panel sought to collate clear and meaningful recommendations for providers regarding lymphedema diagnosis, treatment, and prevention. Diagnosis, education, and future directions were discussed in Part 1. Part 2 focuses on prevention and treatment.

Risk reducing behaviors:

  • To prevent lymphedema, clinicians continue to recommend risk-reducing behaviors (RRB) that have largely been supported only by pathophysiology principles and expert clinical experience.
  • The Panel agrees that within the context of an early detection/surveillance program incorporating baseline and follow-up assessments, the routine application of many risk-reducing behaviors is not supported. Use of the ipsilateral arm for IVs or blood pressures is not contraindicated, although most patients prefer to use the contralateral arm. Personalized risk-reduction strategies are more appropriate than blanket application of behaviors.

Exercise for at-risk and affected lymphedema patients:

  • The Panel agrees that clinicians should encourage at-risk and affected lymphedema patients to exercise. Resistance and aerobic exercise is safe. Patients with BCRL should work with a trained lymphedema professional to learn to exercise safely.

Surgical prevention:

  • Axillary reverse mapping (ARM) entails mapping upper extremity (UE) lymphatics with blue dye at the time of sentinel lymph node (SLN) mapping in the breast with technetium-99, allowing for 22–30 differentiation of lymphatics draining the breast (hot) and the UE (blue).
  • The lymphatic microsurgical preventive healing approach (LYMPHA) is a surgical approach for the primary prevention of arm lymphedema after axillary nodal dissection.32,33 The LYMPHA procedure couples lymphovenous anastomosis with ALND by dunking the transected main lymphatic(s) trunks into a lateral branch of the axillary vein distal to a competent valve. Initial studies used a transit index greater than 10 as measured by lymphscintography, body mass index (BMI) greater than 30 kg/m2 , or both as criteria for the procedure.
  • The Panel agrees that emerging data on preventive surgical strategies with ARM and LYMPHA are promising and should be explored further with appropriate patients.

Treatment:

  • Combined decongestive therapy remains the cornerstone of management.
  • Patients with symptoms or measured changes should be referred for lymphedema therapy evaluation, formally educated, and provided with graduated intervention according to the International Society of Lymphology (ISL) staging and individual presentation.

Radiographic imaging:

  • Lymphoscintigraphy should be performed when the etiology of swelling is unclear or patients are not responding to standard treatment.
  • Indocyanine green (ICG) fluorescence (using near-infrared spectroscopy) is superior to standard lymphoscintigraphy in identifying early lymphedema. It demonstrates the location and path of lymphatic vessels and dermal backflow and provides a dynamic functional assessment. Currently, ICG fluorescence lacks the quantification feasible with radionuclide lymphoscintigraphy.

 

Lymphovenous bypass

  • Microsurgical reconstructive procedures are more effective for early lymphedema because functional lymphatics remain and minimal fibroadipose deposition occurs. Multiple proximal LVAs may treat or cure early-stage lymphedema, enabling some patients to give up compression and physiotherapy after a few postoperative months.

Lymph node transfer

  • Considered a treatment rather than a cure for lymphedema. Changes in lymphatic function are gradual and may take months to years before patients achieve the full benefit.

Liposuction

  • Lymphatic liposuction with long-term compression is effective for severe late-stage BCRL unresponsive to conservative management.