Breast Cancer Surgical Treatment Complications & Lymphedema
Article prepared by Women's Health & Education Center (WHEC) in association with the Department of Obstetrics and Gynecology of St. Elizabeth Medical Center, Boston (USA)Complications after any operation can be minimized with thorough preoperative evaluation, meticulous technique, hemostasis, and wound closure. In addition to the standard oncologic evaluation, preoperative evaluation includes assessment of the patient's overall physiologic condition, with particular emphasis on tolerability of anesthesia, uncontrolled diabetes, hypertension, anemia, coagulopathy, or steroid dependency. The purpose of this document is to review commonly used approaches for the care of the post-mastectomy wound and addresses the complications encountered in these patients. Rehabilitation of the post-mastectomy patients produces problems of varying complexity. Pathophysiology, prevention, and management of lymphedema are also discussed. Mastectomy is a safe operation with low morbidity and mortality. Although the incidence of post-operative complications is low, physicians should be aware of the morbidity unique to mastectomy and axillary node dissection. Care of the Post-mastectomy Wound:Technique at operation and wound closure is an essential part of wound repair. Meticulous hemostasis must be confirmed before closure. Closed-suction drains should be placed into the mastectomy wound site, because most patients will develop a seroma. We prefer closed-suction catheter drainage of the mastectomy wound, commercially available as Blake (Ethicon) or Jackson-Pratt tubing (Baxter) and each system should be placed appropriately placed at operation to allow superomedial and inferolateral positioning to ensure thorough, dependent aspiration. After the wound is closed, the tubing is connected to ensure removal of all wound contents (eg, clots, serum). Suction catheter drainage, as a rule, is necessary for 5 to 10 days postoperatively. Routinely, catheters are removed only when less than 30 ml of serous or serosanguineous drainage is evident for two consecutive 24-hour intervals. The skin is closed in two layers using absorbable suture. A light, dry gauze dressing is applied to the incision. Pressure dressings over the dissected skin flaps are unnecessary and do not decrease the amount and rate of seroma formation (1). Postoperatively, the wound is carefully inspected with regard to flap adherence, and the patient is encouraged to resume preoperative activity. In most circumstances, the breast cancer patient is allowed to begin the gradual resumption of pre-surgical activities. Younger women usually regain full range of motion of the arm and the shoulder soon after drain removal, whereas some older patients may require intense (supervised) exercise for several months before attaining their former levels of activity. Home-visits from the healthcare providers of the Visiting Nurse Association are of particular value for psychosocial and physical recovery of post-mastectomy patient. Complications of Mastectomy:- Wound Infection: after modified radical mastectomy the rates of wound infections range from 2.8% to 15%. Infection of the mastectomy wound or ipsilateral arm may represent serious morbidity in the post-operative patient and produces disability that may progress to late post-operative lymphedema of the arm. Cellulites seen in the early post-operative period, responds to antibiotic treatment in most cases. When abscess formation does occur, attempts should be made to culture the wound for aerobic and anaerobic organisms with immediate Gram-stain of identifiable strains to document the bacterial contaminant. The predominant organisms are S. aureus and S. epidermidis. Factors that may increase the risk for infection include open biopsy before mastectomy, increasing age, prolonged suction catheter drainage, and alterations of host defense mechanisms.
- Seroma: it is a collection of serous fluid within a surgical cavity that is clinically evident. After mastectomy, seromas occur in the dead space beneath the elevated skin flaps and represent the most frequent complication of mastectomy, developing in approximately 30% of cases (2). With surgical ablation of the breast, the intervening lymphatics and fatty tissues are resected en bloc; thus the vasculature and lymphatics of the gland are transected. Therefore, transudation of lymph and the accumulation of blood in the operative field are expected. Operative technique should minimize lymphatic spillage and transudation of serum to allow rapid adherence of the skin flaps to deep structures without compromise of blood flow to skin flaps or the axilla. The use of closed-system suction catheter drainage over the last 20 years has greatly facilitated the reduction in protracted serum collections. Patients with a higher body mass index (BMI) have an increased rate of seroma formation. The incidence of seroma formation also increases with age (3). Most oncology surgeons recommend – allowing arm mobility immediately after surgery but delay a structured exercise routinely until after the drains have been removed.
- Pneumothorax: it is rare complication, develops when the surgeon perforates the parietal pleura with extended tissue dissection or with attempts at hemostasis for perforators of the intercostals musculature. Pneumothorax is more commonly seen in patients undergoing a radical mastectomy after removal of the pectoralis major musculature. Respiratory distress is recognized in the operative or the immediate post-operative periods and pneumothorax is confirmed with a chest X-ray. Immediate intervention with closed thoracostomy drainage of the pleural space is essential as soon as pneumothorax is verified.
- Tissue Necrosis: a commonly recognized complication of breast surgery is necrosis of the developed skin flaps or skin margins. Bland and colleagues observed an incidence of 21% for minor and major necrosis of mastectomy skin flaps with associated wound infection. Local debridement is usually not necessary in minor areas of necrosis (<2 cm2 area). Larger areas of partial or full-thickness skin loss require debridement and on occasion the application of split-thickness skin grafts. Rotational composite skin flaps and subcutaneous skin tissue can be used from the lateral chest wall or the contralateral breast to cover the defect.
- Hemorrhage: it is reported as a post-operative complication in 1% to 4% of patients and is manifested by undue swelling of flaps of the operative site. Early recognition of this complication is imperative. Aspirating the liquefied hematoma and establishing patency of the suction catheters can treat hemorrhage. The application of a light compression dressing reinforced with Elastoplast-tape should diminish the recurrence of this adverse event. Early severe hemorrhage is most often related to arterial perforators of the thoracoacromial vessels or internal mammary arteries. Direct suture ligation is advisable. Miller and associates (4) concluded that use of the electrocautery for the development of skin flaps in the performance of a mastectomy reduces blood loss without incurring a greater incidence of wound complications.
- Neuro-Vascular Structures Injuries: injury to the brachial plexus is a rare complication of mastectomy and avoided by meticulous (cold scalpel) sharp dissection in and about the neuro-vascular bundle and through the development of tissue planes that parallel the neurilemma and the wall of the axillary vein to allow en bloc resection of lymphatic structures and fatty tissue. The sensory innervation of the breast is derived from the lateral and anterior cutaneous branches of the second through the sixth intercostals nerves. The patient usually experiences moderate pain in the operative site, shoulder, and arm in the immediate post-operative period. Because of the necessity of extensive flap development, the patient may note hyperesthesia and paraesthesia, as well as occasional "phantom" hyperesthesia in the mastectomy site. Phantom breast syndrome is a continued sensory presence of the breast after it has been removed. It is a phantom pain in 17.4% of cases, and in 11.8% of cases, and it presents as a non-painful phantom sensation such as itching, nipple sensation, and premenstrual-type breast discomfort (5).
Less common are injuries to the thoracodorsal nerve and the long thoracic nerve (respiratory) of Bell. The thoracodorsal, or subscapular, nerve innervates the lattissimus dorsi muscle in its course with the thoracodorsal (subscapular) vessels and is commonly sacrificed when lymphatics are discovered to be involved with metastases at axillary dissection. Injury or transaction of the long thoracic nerve of Bell produces instability and unsightly prominence of the scapula ("winged scapula"). The patient sustaining such an injury will often complain of shoulder pain at rest and with motion for many months after the procedure. All attempts should be made to preserve this nerve, yet its involvement with invasive neoplasm or nodal extension may require that it be sacrificed to ensure adequate en bloc extension.The lateral and medial pectoral nerves to the pectoralis major muscles and the motor innervation to the pectoralis minor exit the brachial plexus to enter the posterior aspects of these muscles in proximal axilla. Preservation of the pectoralis major and its function is the objective of the modified radical mastectomy. Thus maintenance of the integrity of the medial and lateral pectoral nerves is paramount to ensure subsequent function of the pectoralis major. LymphedemaLymphedema is the accumulation of protein-rich fluid in soft tissues as a result of interruption of lymphatic flow. It occurs most frequently in the extremities, but it can also be found in the head, neck, abdomen, lungs, and genital regions. In post-mastectomy patients, chronic lymphedema has the potential to become a permanent, progressive condition. If it is allowed to progress, the condition can become extremely treatment resistant and in most cases cannot be completely relieved with either medical or surgical means. Lymphedema is divided into two forms: Primary lymphedema and Secondary lymphedema. Primary lymphedema is associated with developmental abnormalities of the lymphatic system, may be manifested in neonates (congenital), adolescents (praecox), or patients older than 35 years (tarda). Secondary lymphedema is the most common form of lymphedema. This usually occurs after oncologic surgery or radiation therapy. The condition occurs as a result of damage by metastatic disease to the lymphatic system, post-radiation changes to the underlying skin structures, or surgical removal of one or more lymphatic nodal basins. Contributing Factors of Lymphedema:Six contributing factors have been shown to influence the incidence of brachial edema after treatment for breast cancer: radiation therapy; obesity; age; operative site; incision type and history of infection. Adding radiation therapy has been shown to increase the incidence of lymphedema from 20% to 52%. The incidence of lymphedema is lessened if transverse rather than oblique incisions are used (6). The extent of axillary dissection is an important contributing factor. Limiting the axillary dissection to level I and II nodes and preserving the level III nodes and lymphatic collateral channels around the shoulder may decrease the incidence of acute and chronic lymphedema. Recent technology has introduced the concept of lymphatic mapping and sentinel lymph node (SLN) biopsy for women with invasive breast cancer. With the hypothesis that the histology of the SLN reflects the histology of the remaining nodes in the basin, full nodal staging information can be garnered with a simple lymph node biopsy of one or more nodes. This approach may limit the possibility of lymphedema to only those women with histologic evidence of metastatic disease in the axilla. Diagnosis and Symptoms:Diagnosis can be established on the basis of an accurate history and a thorough physical examination. Assessment of the progression of edema is essential in the postoperative care of patients. Photography at preoperative and postoperative visits can be very useful in determining the onset and progression of lymphedema. Circumferential measurements using reference points to bony landmarks may also be a practical and simple way to follow patient's lymphedema. Differences in circumferential measurement between two opposing limbs are noted at multiple landmarks. These measurements are totaled for each limb and compared. If there is a difference of greater than 10 cm, lymphedema exists. Water displacement is the most accurate method of documenting changes in edema. This would appear to be the best objective criterion with which to judge lymphedema and response to therapy. However, these techniques are time consuming and are limited to facilities that have the equipment to perform study. Bioelectrical impedance techniques are the most recent developments for evaluating accumulation of fluid in affected extremities. Symptoms of chronic lymphedema are usually elicited by taking an accurate history of the patient. Patients complain of an overall increase or "fullness" of the extremity, with a corresponding "heaviness" and decreased functional ability. Treatment Options:- Prevention:
The radical mastectomy of the past has been replaced with more conservative procedures that have the potential for decreasing the incidence of lymphedema. The new technique of lymphatic mapping and sentinel lymph node biopsy promises to provide full nodal staging information with a simple lymph node biopsy. Lymphedema should be non-existent after this procedure. Primary healing creates less fibrosis than does scarring by secondary intention. Attention to detail and good surgical techniques of sharp dissection, adequate hemostasis, suction drainage, and closure without tension should lessen the chance of postoperative lymphedema. Wound infection and sepsis should be avoided, suggesting a role for perioperative antibiotics. Radiation therapy after lumpectomy should not include axilla, unless the chance of recurrence in the axilla is overwhelming. If axillas are included in the radiation field, the incidence of lymphedema may be as high as 52%.
- Medical Treatment:
The initial treatment of chronic secondary lymphedema should be managed through non-surgical measures. Physical therapy, in conjunction with compression garments or sequential-gradient compression-type pumps, has been recently added to the overall care of patients with chronic lymphedema. Medical management should involve a multidisciplinary approach in the patient's long-term care. This includes patient education, instruction in home physical therapy exercises, maintenance of normal range of motion and strength in the affected extremity, and preservation of existing motion.
Lymphedema Checklist Guidelines (7):
DO'S – - Do Keep skin clean
- Do moisturize skin
- Do elevate limb while sleeping and traveling
- Do wash with hypo-allergenic soaps and cleaners
- Do use electric not straight razors to remove hairs
- Do use mild detergents for clothes
- Do keep temperature in house constant
- Do eat a balanced nutritional diet
- Do treat infections early and throughout with antibiotics prescribed by your doctor
- Do exercise: walk, swim, prescribed isometrics
- Do wear prescribed garments and/ or bandages
- Do avoid cuts, burns, and insect bites
- Do avoid sunburn – use sun-block
- Do wear loose-fitting clothing
DON'TS –
NO PROCEDURES SHOULD BE PERFORMED ON THE AFFECTED EXTREMITY.- No blood drawing
- No injections
- No intravenous dye x-ray studies
- No acupuncture
- No liposuction
- No blood pressure testing
- No heavy, traumatic, or repetitive exercises
- No picking up heavy objects
Diuretics are of minimal aid in the treatment of chronic lymphedema resulting from oncologic surgery or metastatic spread of the disease. Compression pumps are rapidly becoming a major factor in medical management of patients with chronic lymphedema. Researchers have recently focused attention on recreating the beneficial effects of massage through mechanical or compressional means, leading to the development of compression devices. These compression machines are based on two basic principles. The first is the single-cell compartment system providing absolute pressure. These devices offer no direction for fluid transport, which causes some backflow of lymphatic fluid. The second-generation devices are multi-cell systems based on sequential compression of the extremity. It delivers compression at the same pressure in each garment section from distal to proximal. However, this does not imitate the normal muscular and vascular activities of an extremity.
Few drugs are being studied for treatment of chronic lymphedema. Benzopyrones can decrease the overall volume of high-protein-concentrate edema by stimulating proteolysis. Venalot, a benzopyrene is a drug that breaks down large protein molecules, facilitating absorption of the proteins into the vascular system at the level of the capillaries (8).
- Surgical Treatment:
Surgical treatment should be instituted for patients for whom previous medical modalities have failed or for those who have had long-term complications. There are new micro-surgical techniques that are currently being attempted using either lymphatic-venous shunts (LVSs) or lymphatic-venous anastomosis (LVA). These procedures allow a lymphatic egress of fluid into the venous circulation. They are done in conjunction with multiple limb fasciotomies and can improve lymphatic drainage through muscles and deep lymphatic circulation. Complications include thrombophlebitis and lymphangitis (9). Patients with diffuse interstitial fibrosis, the more traditional option of total superficial lymphangiectomy (Servelle's) or partial superficial lymphangiectomy (Kondoleon's) is recommended.
An alternative microsurgical technique described by Campisi, Boccardo, and Tacchella involves performing interposition autologous lymphatic-venous-lymphatic (LVL) anastomosis. This procedure represents an alternative to direct LVSs and is based on the abundance of large-caliber venous tributaries. The LVL anastomosis consists of inserting suitably large and lengthy autologous venous grafts between lymphatic collectors above and below the site of obstruction to lymphatic flow. Contraindications to this procedure include lymph node hyperplasia or aplasia and extensive obliteration of superficial and deep lymphatic collectors.
Summary:An accurate knowledge of physiology and pathophysiology of lymphedema is necessary to understand the rationale of treatment techniques available. An accurate assessment of the degree of impairment should be established before initiating either short- or long-term care. Although surgical intervention and treatment have been tried in the past, the standard of care now is a conservative medical management. A multidisciplinary approach is needed to maximize available treatment regimens. Surgeons, nurses, physical and occupational therapists play active roles in the care of chronic lymphedema patients. Appropriate patient education and instruction in self-care are paramount in the long-term care of patients. A realistic approach to the long-term care of this condition coupled with therapeutic and emotional support can ensure a productive and less debilitating lifestyle to patients with chronic extremity lymphedema. References:- O'Hea BJ, Ho MN, Petrek JA. External compression dressing versus standard dressing after axillary lymphadenectomy. Am. J. Surg. 177:450; 1999.
- Vinton AL, Traverso LW, Jolly PC. Wound complications after modified radical mastectomy compared with tylectomy with axillary lymph node dissection. Am. J. Surg. 161:584; 1991.
- Banerjee D et al. Obesity predisposes to increased drainage following axillary node clearance: a prospective audit. Ann. R. Coll. Surg. Engl. 83:268; 2001
- Miller PJ et al. Scalpel versus electrocautery in modified radical mastectomy. Am. Surg. 54:284; 1988.
- Kroner K et al. Long-term phantom breast syndrome after mastectomy. Clin. J Pain 8:346; 1992.
- Segerstrom K et al. Factors that influence the incidence of brachial edema after treatment of breast cancer. Scand. J. Plast. Reconstr. Surg. Hand Surg. 26:223; 1992.
- Bland & Copeland. The Breast: Comprehensive Management of Benign and Malignant Disorders. 3rd edition, Volume two. Pp 969; 2004. Publisher: Saunders; an imprint of Elsevier.
- Casley-Smith J, Morgan R, Piller N. Treatment of lymphedema of the arms and legs with 5,6-benzo- [alpha]-pyrone. N. Engl J Med 329:1158; 1993.
- Fillippetti M. et al. Modern therapeutic approaches to post-mastectomy brachial lymphedema. Microsurgery 15:604; 1994.
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