Version July 2025
INTRODUCTION —
Treatment of breast cancer is one of the most common causes of secondary lymphedema. Surgical removal of lymph nodes (lymphadenectomy) and radiation therapy to the lymph nodes are the main causes of lymphedema in patients with breast cancer. However, breast cancer-related lymphedema (BCRL) can also occur due to obstruction of the lymphatic channels or lymph nodes from infiltration with tumor cells (lymphangitic carcinomatosis). BCRL may occur in the trunk, upper arm, forearm, or hand on the side of breast cancer treatment.
Quality of life is impacted in patients with BCRL [1-4]. Worrying about the development of lymphedema can also impact breast cancer survivors after therapy, leading to mental health conditions [5-8]. As such, appropriate counseling and preventive strategies are key.
Screening for lymphedema and preventive strategies in patients with breast cancer are reviewed. The diagnosis and management of lymphedema, including other etiologies and surgical treatment of lymphedema, are reviewed separately.
●(See "Pathophysiology, classification, and causes of lymphedema".)
●(See "Clinical features, diagnosis, and staging of peripheral lymphedema".)
●(See "Management of peripheral lymphedema".)
●(See "Surgical treatment of primary and secondary lymphedema".)
CLINICAL FEATURES —
Lymphedema occurs when the load exceeds the transport capacity of the lymphatic system, which leads to swelling resulting from the accumulation of protein-rich fluid (lymph) and fibroadipose tissue in the interstitium [9]. (See "Pathophysiology, classification, and causes of lymphedema", section on 'Pathophysiology'.)
Incidence and onset — Breast cancer and its associated treatments (eg, lymph node surgery, regional nodal irradiation) is one of the most common causes of upper extremity lymphedema (table 1). The incidence and presentation of BCRL are reviewed briefly below. The clinical examination and diagnosis of lymphedema are reviewed separately. (See "Clinical features, diagnosis, and staging of peripheral lymphedema", section on 'Limb swelling'.)
Upper extremity edema — BCRL of the upper extremity is typically characterized by slowly progressive swelling in the upper arm, forearm, or hand ipsilateral to the nodal surgery (eg, axillary lymph node dissection [ALND], sentinel lymph node biopsy [SLNB]), or regional lymph node radiation (RLNR) treatments. Symptoms of upper extremity lymphedema may include limb pain and discomfort, and with progression, restricted range of motion, nonpitting edema, and skin changes. (See "Clinical features, diagnosis, and staging of peripheral lymphedema", section on 'Limb swelling'.)
In a systematic review conducted prior to the modern era of breast surgery, the pooled incidence of upper extremity BCRL was 22 percent [10]. Most studies used objective limb measurements. With improving breast cancer treatment, prospective lymphedema surveillance, and timely lymphedema intervention, rates of progression to higher-stage lymphedema are decreasing and appear to be much lower in the modern era than reported in the systemic review. (see 'Clinical staging' below)
In a separate systematic review, the greatest risk of BCRL was within the first two years following diagnosis and treatment [11]. However, the type of treatment appeared to influence the time course, and later onset can occur. In a prospective study of over 2100 participants who received surgery for breast cancer and were prospectively screened for lymphedema, the cumulative incidence at two and five years was 19 and 31 percent for ALND plus RLNR; 13 and 25 percent for ALND alone; 4.3 and 12 percent for SLNB plus RLNR; and 3.7 and 8.3 percent for SLNB alone [12].
The timing of onset of upper extremity lymphedema is variable. In one study, the risk of lymphedema peaked between 6 and 12 months in the ALND without RLNR group, between 18 and 24 months in the ALND with RLNR group, and between 36 and 48 months in the group receiving SLNB with RLNR [12].
Breast or chest wall edema — Breast edema can accompany upper extremity edema after nodal surgery or can occur in patients who undergo breast-conserving surgery (with or without breast radiation), and chest wall edema can occur after mastectomy. Patients complain of ipsilateral breast or chest wall pain, swelling, and heaviness [13,14]. Clinical assessment may reveal skin thickening, peau d'orange, breast tenderness to palpation, erythema of the skin, hyperpigmentation, or pitting edema [15]. In patients with such symptoms or signs, the possibility of inflammatory breast cancer recurrence should be considered and ruled out, potentially with biopsy. The approach to patients with possible inflammatory breast cancer is discussed elsewhere. (See "Inflammatory breast cancer: Clinical features and treatment".)
The incidence of lymphedema after breast-conserving surgery varies due to study methodology [16,17]. In one prospective observational cohort of patients treated with breast-conserving surgery and radiation, the incidence and timing of breast lymphedema were evaluated for 24 months [18]. The prevalence of breast lymphedema was highest (12.4 percent, 95% CI 10.0 to 14.7) at six months postoperatively as measured objectively using tissue dielectric constant. This timeline was consistent with findings from another study [19]. (See "Breast-conserving therapy".)
Clinical staging — Lymphedema is staged (International Society of Lymphology [ISL]) based on the examination of the upper extremity and the volume difference between the extremities as stage 0 through stage III (table 2), which correspond to subclinical lymphedema, mild lymphedema, moderate lymphedema, and severe lymphedema [20]. Due to surgical de-escalation, refinement of radiation protocols, increased knowledge, and prospective surveillance, the incidence of higher-stage lymphedema has decreased over the past 10 to 15 years. (See "Clinical features, diagnosis, and staging of peripheral lymphedema", section on 'ISL clinical stage'.)
It is important to note that the onset of lymphedema several years after the primary surgery without obvious trauma should raise suspicion for a tumor, which always needs to be evaluated. Recurrence of breast cancer in the axillary area or the development of lymphangiosarcoma should be excluded using breast imaging. (See "Clinical manifestations and evaluation of locoregional recurrences of breast cancer" and "Clinical features, diagnosis, and staging of peripheral lymphedema", section on 'History' and "Clinical features, diagnosis, and staging of peripheral lymphedema".)
RISK FACTORS
For upper extremity lymphedema — The strongest risk factor for the development of upper extremity BCRL is axillary lymph node dissection (ALND) and to a lesser extent, regional lymph node radiation (RLNR) [21]. Other risk factors include body mass index (BMI)>25 kg/m2 at the time of breast cancer diagnosis, cellulitis, patient report of cording, early or low volume swelling, Black race, Hispanic ethnicity, and specific patient-reported symptoms [13,21-31]. There are also other factors that, together with lymph node surgery and/or regional nodal irradiation may influence BCRL risk, such as the occurrence of hematoma, seroma, body weight changes, and medication effects [32-34].
The risk of upper extremity edema appears to be independent of whether the patient has a mastectomy or breast-conserving therapy, assuming that the incidence is adjusted for other risk factors, in particular ALND.
Axillary lymph node dissection — Axillary lymph node removal is the primary cause of upper extremity lymphedema in patients with breast cancer [9,11,16,21,28,35-39]. The risk of BCRL is related to the type of axillary surgery performed. Lymphedema is unlikely to develop if lymph nodes are not removed unless there is a combination of extensive injury from surgery, postoperative infection, other trauma, or radiation to the axilla/extremity. In a review of 282 patients who did not undergo axillary lymph node removal, zero cases of BCRL occurred at 10-year follow-up [40].
In the remote past, the risk of clinically important, and at times severe, BCRL was quite high because of the performance of axillary lymph node clearance resecting level I, II, and III lymph nodes (which could include the removal of 30 or more lymph nodes), as well as the removal of subcutaneous fat from the axilla. Since the late 1980s, the approach to axillary node dissection, when it is required, has evolved such that most surgeons dissect only level I and II lymph nodes while leaving the subcutaneous tissues intact. Level III lymph nodes are only removed if gross disease is noted in these lymph nodes. (See "Technique of axillary lymph node dissection".)
Substantial data have demonstrated that sentinel lymph node biopsy (SLNB) is associated with a reduced, although not negligible, incidence of BCRL of 3 to 8 percent. For example, in a prospective cohort of 2171 females objectively evaluated for BCRL from preoperative baseline for a median 48 months, two- and five-year incidences of lymphedema were 7.1 and 13.7 percent for the entire cohort; 19 and 31.2 percent post-ALND plus RLNR; 12.7 and 24.6 percent post-ALND; 4.3 and 12.2 percent post-SLNB plus RLNR; and 3.7 and 8.3 percent post-SLNB alone. BCRL was defined as a >10 percent relative increase in upper extremity volume, as measured using a perometer, arising three months postoperatively. (See "Clinical features, diagnosis, and staging of peripheral lymphedema", section on 'Extremity measurements'.)
A separate study suggested that ALND is the biggest contributor to lymphedema, rather than nodal irradiation. In an analysis of the PREVENT trial including 881 patients treated for early breast cancer, the rates of chronic breast cancer lymphedema after three years (defined as ≥10 percent relative volume change compared with pre-surgery tape measurement) were 26 percent with ALND with or without RLNR; 4.4 percent with SLNB; and 4.2 percent with SLNB plus RLNR [41]. Additionally, severe BCRL (eg, trophic skin changes, elephantiasis) is rare after SLNB. However, for those who do develop BCRL after SLNB, lymphedema can still be problematic, especially when surgical risk is compounded with other risk factors (eg, RLNR, elevated BMI, cellulitis). The choice between axillary dissection and SLNB is discussed elsewhere (See "Overview of management of the regional lymph nodes in breast cancer", section on 'Axillary management'.)
Regional lymph node radiation as a possible risk factor — Some studies have suggested a risk of BCRL with RLNR treatment [21,42-48], but not breast/chest wall radiation alone [49-52]. However, other studies have not confirmed RLNR as an independent risk factor, suggesting that ALND is the primary contributor to lymphedema risk.
As examples of representative data regarding regional lymph node irradiation [21,41,42]:
●In a large prospective study of 1476 females, the two-year cumulative incidence of lymphedema (defined as tape measurement increase ≥10 percent compared with baseline) was 3.1 percent for breast/chest wall radiation alone compared with 22 percent for RNLR. RLNR implied mainly covering the supraclavicular lymph nodes and undissected level-III axillary nodes [42].
●In a study that included 2100 patients, the cumulative incidence of lymphedema at five years (defined as ≥10 percent relative arm-volume increase) was 31 percent for ALND plus RLNR versus 25 percent for ALND alone [12]. The corresponding rates were 12 percent for SLNB plus RLNR and 8.3 percent for SLNB alone.
Other studies suggest that regional lymph node irradiation does not significantly increase risk, beyond that conferred by axillary dissection:
●To quantify the relative impact of axillary surgery versus nodal radiation on BCRL, a prospective cohort of 1815 patients with baseline objective upper extremity volume measurements were followed a median of 53 months [21]. The incidence of BCRL (all stages) differed significantly for those who received ALND compared with SLN plus RLNR (25 versus 8 percent). Although the risk of BCRL increased due to regional axillary radiation (from 25 to 30 percent in patients with ALND and from 8 to 11 percent (HR 1.33) in patients with SLN), these differences were not statistically significant.
●Similarly, as discussed above, the PREVENT trial suggested that regional nodal irradiation did not increase the risk of lymphedema over axillary dissection alone. (See 'Axillary lymph node dissection' above.)
These data suggest that the main contribution to the risk for BCRL is the extent of axillary surgery. Thus, the key prevention strategy for BCRL should be reducing the extent of axillary surgery when possible. (See 'Axillary lymph node dissection' above.)
Other potential risk factors — Other potential risk factors include the following:
●BMI and weight fluctuations – Obesity alone may impair lymphatic function and lead to the development of BCRL [25,45,53]. As an example, in one study patients with a BMI >30 at breast cancer diagnosis had a significantly increased risk for BCRL compared with those who had a BMI of <25 (hazard ratio [HR] 4.46, 95% CI 2.10-9.48) [25].
Weight gain also contributes to the development of lymphedema. One study reported a positive correlation between upper extremity volume increases after BCRL treatment and postoperative weight gain during treatment [54]. However, weight loss does not appear to be protective against BCRL [55,56].
●Infection – Infection (surgical site infection, cellulitis) in the ipsilateral extremity increases the risk of lymphedema and the development of lymphedema even many years after breast cancer treatment. Moreover, infection increases the risk of worsening lymphedema. A large, nationwide Danish study of nearly 38,000 patients reported that the incidence of BCRL was 6.7 per 100 person-years in patients with surgical site infection (defined as antibiotics during the first three months after breast cancer treatment) and 4.9 per 100 person-years for patients without infection [57]. The highest risk was 3 years after breast cancer treatment. In a separate cohort study of patients prospectively followed for BCRL, cellulitis was significantly associated with increases in upper extremity volume [23].
Patients with BCRL are also at an increased risk for infection. (See "Breast cellulitis and other skin disorders of the breast".)
●Seroma – Studies examining the role of postoperative chest wall, breast, or axillary seroma in BCRL risk are limited although there is an anecdotal consensus that there is an association. In a small retrospective study, patients who developed symptomatic seroma had roughly 8 to 11 times the odds of developing upper extremity swelling or chest/breast swelling, respectively, compared with those who did not [58].
●Chemotherapy – Data correlating chemotherapy and the incidence of BCRL are mixed, with some studies reporting that chemotherapy is associated with BCRL development, and others that it is not [41,59-61]. However, it is unlikely that receiving chemotherapy is an independent risk factor for BCRL given that such patients receiving chemotherapy have likely received more aggressive local treatments (eg, surgery, radiation) for their cancer.
●Race or ethnicity – An increased risk of lymphedema has been noted in some populations; however, it is not clear whether this is an independent risk factor. The type of breast cancer surgery offered to the patient may differ and other known risk factors may be more prevalent in these populations [30,31,62].
In a review of 31, 274 females from the SEER database in the United States (5.6 percent Black Americans, 89.1 percent White Americans), the use of SLNB increased from 2002 through 2007 for Black and White patients with pathologically node-negative breast cancer [62]. However, SLNB rates remained lower in Black compared with White patients throughout the study period. This racial disparity in SLNB use carried over to lymphedema risk. However, a large prospective cohort study found that nonobese Black individuals had a higher risk of BCRL compared with White individuals, which was not fully explained by known risk factors [30]. In a separate cohort study, Black race and Hispanic ethnicity (compared with White race) were independently associated with an increased risk of BCRL (OR 3.9 and 3.0, respectively) [31].
●Cording – Cording (axillary web syndrome) is the development of a fibrous structure in the axilla that can also involve the medial aspect of the upper extremity.
Study findings in this area are contradictory. A study of 1181 patients prospectively screened from preoperative baseline reported that patients who reported cording were 2.4 times more likely to develop BCRL compared with those who did not [22]. Other studies noted no relationship between cording and BCRL [63,64]; however, these studies have limitations including a poorly defined BCRL diagnostic measurement methodology (eg, not including a preoperative baseline measurement).
The physiology of cording has been somewhat elusive. In one study, biopsies of axillary web syndrome cords revealed dilated lymphatic vessels with a thickened wall and luminal occlusion. These suggest that axillary cording represents lymphatic vessel thrombosis and that recanalization may eventually restore lymphatic flow consistent with the transient nature of the condition [65].
●Type of breast reconstruction – In one study, autologous breast reconstruction was associated with a significantly reduced risk of BCRL compared with no reconstruction [32]. Other studies have reported that immediate implant reconstruction does not increase the risk of BCRL compared with mastectomy without reconstruction [33,34,66,67].
●Postoperative low-level arm swelling – Patients who develop low-level upper extremity volume increases after breast cancer surgery may have a higher risk of progression to clinically significant BCRL. Often, these initial low-volume increases are subclinical, with the absence of symptoms or visible BCRL [13,14]. When identified using prospective surveillance, it presents an opportunity for early intervention. (See 'Screening for lymphedema' below.)
In a study that screened 1790 patients, 39.7 percent of those who underwent ALND (431 patients) experienced low-volume swelling, and 39.2 percent of these progressed to BCRL. Among those who underwent SLNB (1359 patients), 24.4 percent experienced low-volume swelling, and among these, 11.5 percent progressed to BCRL. Relative to those who did not experience low-volume swelling, the risk of developing BCRL was significantly higher for those who developed early (<3 months postoperatively) or late (≥3 months postoperatively) low-volume swelling.
•For ALND and low-volume swelling (early: HR 2.60, 95% CI, 1.58-4.27; late: HR, 3.14, 95% CI, 1.95-5.05)
•For SLNB and low-volume swelling (early: HR 6.75, 95% CI, 3.8-11.98; late: HR 3.02, 95% CI, 1.65-5.50)
For breast lymphedema — Reported risk factors associated with breast lymphedema after breast-conserving treatment include ALND [16,19,68], increased BMI [69], site of tumor in the breast [69], incision location [16], previous surgical biopsy [16], adjuvant chemotherapy [19], radiation parameters (eg, irradiated breast volume, locoregional radiotherapy, increasing boost volume, the use of a photon boost) [17,19], higher breast density, a large tumor, a higher specimen weight, infection, acute postoperative toxicity, and diabetes mellitus [17].
SCREENING FOR LYMPHEDEMA —
Screening for BCRL is associated with potential benefits and drawbacks. Taken together, the considerations discussed below have led to endorsement for surveillance by selected Societal Panels, including the National Comprehensive Cancer Network (NCCN), International Society of Lymphology (ISL), American Society of Breast Surgeons (ASBrS), National Lymphedema Network (NLN) and the US National Accreditation Program for Breast Cancer (NAPBC) [20,70-74]. When adopted by treatment centers, successful prospective surveillance is best administered by a multidisciplinary team of oncology and rehabilitation professionals (table 3). However, we recognize that prospective screening in the multidisciplinary clinic is logistically challenging, and therefore a risk stratification approach may be suggested.
Potential benefits of screening — The goal of screening would be to identify patients with subclinical BCRL with the intent to treat using general care strategies to help limit progression to moderate or severe lymphedema (table 2). The management of established lymphedema is reviewed separately. (See "Management of peripheral lymphedema".)
However, it is uncertain whether the identification of subclinical lymphedema limits the progression to clinically important disease. Some observational studies have reported that screening and early treatment of subclinical lymphedema is associated with a reduction in the later development of symptomatic lymphedema [75-83]. In a study of 196 patients with breast cancer, a surveillance program that included preoperative limb volume measurement and interval postoperative follow-up detected subclinical lymphedema (defined as a 3 percent difference in extremity circumference) in 43 patients (22 percent). In these patients, early treatment using a compression sleeve and gauntlet reduced affected limb volume. The mean affected limb volume increase was 83 mL at onset compared with baseline. After the intervention over 4.4 weeks, a mean of 48 mL volume decrease was observed and was maintained at an average follow-up of 4.8 months [77]. The impact on quality of life was not reported.
Studies are evaluating whether prospective surveillance and treatment of BCRL in its early stages might be more cost-effective than treating it later when lymphedema can become refractory to treatment and result in repeated hospitalizations due to infection [84]. Lymphedema-related US hospitalizations from 2012 to 2017 resulted in more than 1 billion USD in reimbursed costs [84]. In one review, the estimated annual cost to manage early-stage lymphedema via prospective surveillance was USD $636 per patient screened compared with USD $3125 per patient managed for higher-stage BCRL using a traditional model of care [85]. Further analysis is necessary to assess cost-effectiveness, given that not all early-stage BCRL would progress to later stages even in the absence of early treatment.
Potential drawbacks of screening — The goal of early diagnosis and intervention can only be achieved within the context of a prospective surveillance program, which may be challenging from the standpoint of resource allocation.
One concern about screening is overdiagnosis, and therefore increased treatment for those who might never develop clinically important BCRL, even though they have subclinical lymphedema. Careful risk stratification is warranted.
Furthermore, there is concern that prospective surveillance may draw attention to lymphedema in the population treated for breast cancer which may increase patient worry and anxiety. However, two studies have not shown this to be the case [86,87]. One of these prospectively screened 247 patients treated for breast cancer (including ALND) for a median of 8 months with arm volume screening. Fear of lymphedema was high at 73 percent postoperatively. However, 81 percent of the cohort reported that lymphedema screening helped alleviate their fear of BCRL [86].
Regardless of potential cost-effectiveness, screening for BCRL requires the incorporation of the chosen strategy into the normal clinical workflow of care and management of patients with a diagnosis of breast cancer, which may challenge the available resources.
Risk-stratified approach — A potential risk-stratified approach (table 3) is described below.
●Baseline measurement – Ideally, presurgical measurements (see 'Limb measurements and diagnostic thresholds' below) of both upper extremities are performed for all patients who are diagnosed with breast cancer. These may be performed, for example, in the surgeon's office, with an objective measurement tool, such as girth measures converted to volume. Although patients may only undergo SLNB with their initial breast cancer surgery, they may later be at higher risk and benefit from closer monitoring.
Preoperative baseline measurement improves the accuracy of BCRL diagnosis. In a study of 1028 patients prospectively screened for BCRL, misdiagnosis was high (40 to 60 percent) in the absence of integrating a presurgical baseline measurement due to preoperative baseline arm asymmetry [88]. In this study, preoperative arm asymmetry of >5 and >10 percent was present in 29 and 2.9 percent, respectively.
●Ongoing screening – Prospective surveillance programs may offer a risk-stratified approach (see 'Risk factors' above). For example, patients at higher risk (ie, ALND) undergo ongoing screening measurements [28,41], while patients at lower risk (ie, SLNB) may be followed with clinic visits as resources allow, or with an increased focus on patient education and home self-monitoring.
•For patients who are selected for ongoing screening in the clinic, visits may include history and clinical examination, asking about symptoms of lymphedema, and repeating objective measurements and comparing them with the preoperative baseline measurements. Patient reports of swelling, change in arm size, or heaviness are associated with BCRL [24,89]. Validated patient-reported outcome measures are available for clinic use.
•There is no consensus on how frequently measurements should be performed. The frequency of visits for patients following treatment for breast cancer may also be risk-stratified according to BCRL risk (see 'Risk factors' above) (table 4). However, given that the highest risk of developing lymphedema is within the first four to five years of treatment [12], and that the goal of early intervention is to limit the progression of the disease, ideally, patients would be followed through this period [28].
●Patient education – Patient education should be integrated into each clinic visit. Patients should be taught how to self-monitor for signs and symptoms of BCRL. (See 'Information for patients' below.)
Limb measurements and diagnostic thresholds — Upper extremity screening measurements may be made using a variety of methods. The choice of measurement tool may differ by facility, depending on clinic resources and workflow. (See "Clinical features, diagnosis, and staging of peripheral lymphedema", section on 'Extremity measurements'.)
Regardless of the method of volume measurement (eg, upper extremity girth measurements converted to volume, optoelectronic limb volumetry, bioimpedance spectrosopy), calculation of relative volume change (RVC) is helpful [90]:
●RVC = [A2U1/U2A1 - 1] x 100% (A = affected extremity volume, U = unaffected extremity volume, 1 is on pre-op baseline, and 2 is on follow-up)
The generally accepted threshold for subclinical BCRL using limb volume is RVC 5 to <10 percent. Another option for upper extremity assessment includes bioimpedance spectroscopy, with diagnostic L-Dex threshold of >6.5 unit increase from baseline indicating early or subclinical BCRL.
However, it should be noted that the diagnosis of BCRL is clinical and should not be based on objective diagnostic thresholds alone. The diagnosis is rather an integration of objective measurements, patient symptoms, and trajectory of limb changes. BCRL may be present even when objective diagnostic thresholds are not exceeded. Further details of these methods are discussed elsewhere. (See "Clinical features, diagnosis, and staging of peripheral lymphedema", section on 'Diagnosis'.)
PREVENTION OF LYMPHEDEMA
Choosing the most appropriate local treatment for breast cancer — Primary prevention strategies aim to avoid the occurrence of lymphedema and promote patient well-being. For those with breast cancer, the only measure that effectively reduces the risk of developing lymphedema is using sentinel lymph node biopsy for axillary lymph node staging rather than axillary node dissection for appropriate patients [91,92]. (See 'Axillary lymph node dissection' above.)
When lymph node dissection is necessary, other surgical techniques may also be effective for primary prevention, including minimizing the extent of lymph node dissection and axillary reverse mapping, as discussed elsewhere. Prophylactic lymphatic reconstruction is under investigation [93]. (See "Technique of axillary lymph node dissection", section on 'Axillary reverse mapping' and "Surgical treatment of primary and secondary lymphedema", section on 'Lymphatic bypass procedures'.)
Studies regarding reduction of the volume of radiation have not consistently demonstrated a lower incidence of BCRL [49-51,94-98]. These results may be due to erroneous BCRL assessment, methodology, and differences in statistical analysis, but perhaps are mostly due to the observation that RLNR itself only marginally contributes to BCRL, and that the absolute risk increase of BCRL is only 3 to 5 percent across all studies. Therefore thousands of patients would be needed to power a study to detect a subtle risk reduction [52,99]. (See 'Regional lymph node radiation as a possible risk factor' above.)
Possible early treatment for select patients
Those with prior axillary lymph node dissection — Patients with prior axillary lymph node dissection (ALND) are at high risk for lymphedema, irrespective of whether they also received axillary radiation; as such, in addition to general measures and exercise, prophylactic compression therapy may be offered to such patients, given the limited evidence that it reduces lymphedema. However, compression sleeves may be associated with discomfort and should be appropriately fitted. Wearing compression sleeves may also produce cosmetic concerns. Shared decision-making is important when considering early intervention. Patients with other risk factors (eg, obesity or prior infection), may be the most likely to benefit. (See 'Other potential risk factors' above.)
The strongest prevention study available sought to determine whether prophylactic compression sleeves prevent BCRL after ALND. In this study, 307 patients who had undergone ALND were randomly assigned to compression (wearing a sleeve until 3 months after completing adjuvant treatments) or control [100]. The compression group had a lower risk at one year of developing BCRL compared with the control group as measured by bioimpedance spectroscopy (42 versus 52 percent, HR 0.61, 95% CI 0.43-0.85), or relative volume change to ≥10 percent from baseline (14 versus 25 percent, HR 0.56, 95% CI, 0.33-0.96). It should be noted that adherence to compression was not reported, and the sleeve prescription was 8 hours per day, which is not the standard practice in the United States. There were no statistically significant differences between the compression and no compression groups in any of the four specified quality of life scales.
Those exceeding screening measurement thresholds — Some UpToDate experts, particularly those who advocate for routine screening for lymphedema with baseline and follow-up measurements, may offer treatment for those exceeding a relative volume change of 5 to <10 percent, and for subclinical (Stage 0) lymphedema and symptoms (table 2). (See 'Limb measurements and diagnostic thresholds' above.)
Management of such patients includes general measures, exercise, and possibly compression garments, which have been shown to be effective in limited preliminary data [76-82,101,102]. (See "Management of peripheral lymphedema", section on 'Intensity of treatment'.)
Two studies have compared compression with no compression to treat subclinical BCRL.
●In a randomized trial, among 75 females with relative volume change of 5 to <8 percent, class I compression reduced the percentage of patients who experienced at least 2 percent relative volume change six months later (16 versus 57 percent, with and without compression, respectively) [101]. Subjective symptoms did not differ between the groups, except at one month, where the compression group experienced more reduced tension.
●Similarly, in a study that prospectively followed a high-risk cohort of 186 patients after ALND, participants who developed subclinical lymphedema according to bioimpedance spectroscopy received early intervention, including compression therapy [79]. Early intervention was associated with a lower rate of progression to clinical lymphedema compared with the control group (4.4 versus 36 percent). However, the control group had preoperative baseline preoperative bioimpedance spectroscopy measurements but due to insurance constraints had only tape measurements postoperatively.
Other guidance
Approach to venipuncture and blood pressure monitoring — As with screening, avoidance of venipuncture or ipsilateral blood pressure monitoring in those who do not have BCRL may be best approached by risk-stratified groupings.
●Low risk for BCRL – For patients at low risk of BCRL (eg, SLNB only) (see above) who do not have lymphedema, there is no credible evidence that using the ipsilateral upper extremity for isolated intravenous catheter placement, venipuncture, or blood pressure measurements increase the risk of lymphedema. Therefore, patients do not need to avoid the ipsilateral upper extremity for these medical procedures.
●Significant risk for BCRL – Whether to avoid intravenous catheter placement, venipuncture, or blood pressure measurement in patients with significant risk factors for the development of lymphedema (eg, ALND, ALND plus RLNR) (see above) but who do not have lymphedema is controversial. We support shared decision-making, with consideration of individual risk factors and patient preference.
•Patients with a contralateral, not-at-risk extremity may elect to use that extremity for medical procedures; however, if necessary, isolated medical procedures may be done on the at-risk extremity, given evidence suggesting that isolated procedures in the at-risk arm are not associated with increased arm volume [103]. This approach is consistent with guidance from the International Society of Lymphology (ISL), the American Society of Breast Surgeons, the Society for Ambulatory Anesthesia (SAMBA), and the NCCN [20,71,72,104].
•Avoiding intravenous catheter placement, venipuncture, and blood pressure measurements in the ipsilateral upper extremity in postoperative patients who are at risk of but have not developed BCRL has not been shown to alter the development of lymphedema or complications following breast cancer surgery [23,60,103-107].
-A prospective study investigated the association between factors thought to increase the risk for lymphedema in 632 patients treated for unilateral breast cancer and followed routinely for BCRL from preoperative baseline [23]. Of 632 patients reporting 3041 possibly inciting events (including blood pressure measurements, blood draws, injections, trauma, airline flights), 63 patients developed lymphedema. Only 25 of the 3041 events were reported by those who developed lymphedema (10 blood draws, 3 injections, 12 blood pressure measurements). On multivariate analysis, there were no significant associations between increases in upper extremity volume and blood pressure readings, blood draws, or injections.
-The same group went on to investigate these associations in 327 patients who had undergone bilateral breast cancer surgery [26]. Findings were consistent with the unilateral study; isolated blood pressure readings, blood draws and injections were not associated with increased upper extremity volumes.
Exercise — Following treatment of breast cancer, once any wounds have healed and provided there are no surgical complications that may interfere (eg, need for a drain), we advise that exercise and weight training is safe to initiate [20,100,103,108-112]. Guidelines are available from the American College of Sports Medicine to inform exercise programs for those who have been treated for breast cancer [113].
Several studies have demonstrated the safety of upper body exercise in those treated for breast cancer [75,108,113,114]. As an example, in the Physical Activity and Lymphedema (PAL) Trial, which provides the strongest evidence available, resistance exercise in those at risk for BCRL, when done in a supervised, slowly progressive manner, was safe and did not incite lymphedema compared with no exercise [108,115,116].
Some but not all trials have supported that exercise may improve extremity mobility and potentially prevent lymphedema [20,30,31,63-67,69]. In one trial, 116 patients with unilateral ALND were randomly assigned to education, early physiotherapy, and progressive active and action-assisted shoulder exercises, or to education alone [76]. After 12 months of follow-up, fewer of those treated with prophylactic physiotherapy developed lymphedema compared with those who received education alone (7 versus 25 percent; risk ratio 0.28, 95% CI 0.10 to 0.79). In a later trial that randomly assigned 158 patients aged 18 to 75 years to progressive resistance training (early supervised; later on unsupervised) or usual care, upper extremity volume or lymphedema incidence at one year was similar between the groups [117].
Air travel — Studies suggest that air travel does not increase the risk of BCRL, and therefore no specific preventive measures are needed are needed in patients without lymphedema [118-120]. The approach to patients with lymphedema is discussed elsewhere. (See "Management of peripheral lymphedema", section on 'General measures'.)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lymphedema" and "Society guideline links: Breast surgery".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Lymphedema (The Basics)")
●Beyond the Basics topics (see "Patient education: Lymphedema after cancer surgery (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Breast cancer-related lymphedema – Breast cancer-related lymphedema (BCRL) is due to obstruction of the lymphatic channels of the breast or those located in the axilla. (See 'Clinical features' above.)
•Upper extremity lymphedema – Symptoms of upper extremity lymphedema include heaviness, perceived change in size or swelling, and with progression, limb pain and discomfort, restricted range of motion, nonpitting edema, and skin changes.
•Breast lymphedema – Symptoms and signs of breast lymphedema include pain, swelling, heaviness, erythema, and peau d'orange in the breast on the side of treatment.
An onset of lymphedema several years after the primary surgery without obvious trauma should raise suspicion for tumor recurrence of breast cancer in the axillary area or the development of lymphangiosarcoma. (See "Clinical manifestations and evaluation of locoregional recurrences of breast cancer".)
●Risk factors – For patients with breast cancer, axillary lymph node dissection (ALND) is the strongest risk factor for lymphedema. However, it can occur with sentinel lymph node biopsy (SLNB) as well, but at a much lower rate than with ALND. Other possible risk factors include body mass index (BMI), infection, seroma, race or ethnicity, and possibly cording. (See 'Risk factors' above.)
●Screening for lymphedema – Our approach is as follows (see 'Risk-stratified approach' above):
•For patients who are diagnosed with breast cancer, presurgical measurement of both arms improves the accuracy of BCRL diagnosis.
•A risk stratification approach may be used in the clinic, in which high-risk patients receive ongoing screening at regular intervals in the clinic, and low-risk patients may undergo less frequent clinic screening or home-based self-monitoring and patient education (table 3).
•Prospective screening visits in the clinic may include history and physical examination of the breast and upper extremity, asking about symptoms of lymphedema, and repeating objective measurements and comparing them with preoperative baseline measurements.
•Patient education should be integrated into prospective surveillance and patients should be taught how to self-monitor for signs and symptoms of BCRL.
●Prevention – Some experts offer prophylactic compression sleeves to patients who have undergone ALND, as well as to patients who experience a relative volume change of 5 to <10 percent if pre- and postoperative measurements are available. However, compression sleeves may be associated with discomfort, and wearing them may cause cosmetic concerns. As such, shared decision-making is important when considering early intervention. Patients with other risk factors (eg, obesity or prior cellulitis) may experience the most benefit. Exercise may also be effective in reducing the progression to clinical lymphedema. (See 'Possible early treatment for select patients' above.)
ACKNOWLEDGMENT —
The editorial staff at UpToDate acknowledge Emile R Mohler, III, MD, who contributed to an earlier version of this topic review. UpToDate also acknowledges Dr. Mohler's work as our Section Editor for Vascular Medicine.
