Can Early Detection Lead to Lymphedema Prevention?

Lymphedema is a condition that may manifest at any time after treatment for breast cancer. While it may appear within weeks of radiation, surgery, or other therapies, it may also occur at any point within five years, or longer, after a woman has undergone successful treatment for her cancer. Lymphedema prevention is a top concern for patients and their doctors post-treatment.

Needless to say, after surviving the ordeal of combating breast cancer, suddenly developing lymphedema feels like adding insult to injury. Not surprisingly, many women in this situation wonder how to prevent lymphedema. Unfortunately, there has been no clear answer to that question. However, this unfortunate situation may be poised to change somewhat, for the better.

Signs of Lymphedema  

The first signs of lymphedema often include slight swelling in affected tissues. Unlike normal swelling, which develops in response to an injury, this kind of swelling does not subside on its own. Rather, it persists and typically worsens over time. 

Lymphedema is a chronic condition characterized by unsightly and potentially painful swelling, typically in an arm (or both arms) among breast cancer patients. It results from the buildup in tissues of lymph, the clear fluid that typically circulates throughout the lymphatic system. Although its symptoms can be managed, there is no cure at present.

There is any number of potential causes of lymphedema, but among breast cancer patients this disorder of the lymphatic system is frequently related directly to therapies to treat the initial disease. For instance, doctors frequently find it necessary to remove lymph nodes during the course of breast cancer assessment and treatment.

Node removal is linked to the potential development of lymphedema, as is damage to lymph vessels and nodes due to radiation or chemotherapy. In fact, up to 25% of patients who undergo lymph node removal (axillary dissection) have traditionally experienced subsequent lymphedema. 

Early Detection — Early Intervention 

But recent advancements in early detection following treatment for breast cancer suggest it may be possible, as never before, to predict when this lymphatic drainage disorder may manifest. And that could lead to a reduction in the severity of any subsequent lymphedema. That’s because the sooner management of symptoms begins, the better the eventual outcomes will be.

Traditionally, doctors have assessed the status of potentially affected limbs by measuring arm circumference changes using a simple tape measure. But recently investigators have begun examining a simple — yet, more accurate and sensitive — method to detect emerging lymphedema at its earliest stages.

Called bioimpedance spectroscopy (BIS), this method uses a small, relatively convenient device to measure slight, early increases in arm water volume relative to the arm’s size preceding surgery. As soon as changes are detected, patients are prescribed graduated compression sleeves and gauntlets to help redistribute lymph out of arm tissues and back towards the heart for recirculation. 

Preliminary evidence from a well-controlled clinical trial suggests that this early intervention may help reduce the occurrence of “significant” lymphedema and reduce some of its complications. Indeed, anecdotally, breast treatment centers are reporting that use of the devices has resulted in progression to clinical lymphedema among less than 10% of high-risk patients. If confirmed by further research, this would represent a significant improvement over the present figure of 25% incidence among patients who have undergone lymph node removal.

Experts think this early detection could stem the tide of clinically relevant lymphedema among breast cancer patients. While lymphedema is a chronic, irreversible condition by the time it’s typically diagnosed in its earliest stages, it is potentially reversible if managed soon enough. 

Better Technology — Better Outcomes

BIS represents an advancement over similar, less sophisticated technologies, which are not capable of differentiating between intracellular and extracellular water content within tissues. Lymphedema results in a buildup in fluid in the spaces between cells (the extracellular matrix), so it’s helpful to know how much fluid is contained within cells, and how much is bathing the spaces between cells. Too much of the latter constitutes early lymphedema. 

Although this test is not yet standard, it appears to offer significant advantages over the present system, whereby doctors measure arm circumference using a simple tape measure. Proponents suggest administering this simple test at baseline — before therapies begin — and again immediately after any treatments, followed by repeat assessments every six months thereafter. 

The procedure involves removing any tight-fitting clothing, lying on one’s back, and having electrodes attached at the hands and feet. A slight electrical current is then passed through the body, providing the necessary information to detect any undue swelling. This simple tissue fluid measurement test is described as relatively quick and painless, taking little more than five minutes.

Although this technology is relatively new for this purpose, recent studies have concluded that the methodology is superior to — or similar to — at least four alternative methods for making this assessment. It’s also less invasive than most other methods. For instance, a procedure known as Indocyanine green (ICG) lymphography is presently considered the gold standard for diagnosing lymphedema. But it involves injecting a fluorescent dye into affected tissues. 

However, a 2018 study concluded that BIS resulted in too many false-negative results to be preferable to ICG lymphography. It remains to be seen, then, whether one or the other of these will become preferable for the early diagnosis — and possible prevention of — lymphedema following lymph node removal or damage.   

References

Coroneos CJ, Wong FC, et al. Correlation of L-Dex Bioimpedance Spectroscopy with Limb Volume and Lymphatic Function in Lymphedema. Lymphat Res Biol. 2018 Nov 2. doi: 10.1089/lrb.2018.0028. [Epub ahead of print]

Earthman C, Traughber D, Dobratz J, Howell W. Bioimpedance spectroscopy for clinical assessment of fluid distribution and body cell mass. Nutr Clin Pract. 2007 Aug;22(4):389-405.

Qin ES, Bowen MJ, Chen WF. Diagnostic accuracy of bioimpedance spectroscopy in patients with lymphedema: A retrospective cohort analysis. J Plast Reconstr Aesthet Surg. 2018 Jul;71(7):1041-1050. doi: 10.1016/j.bjps.2018.02.012. Epub 2018 Apr 9

Ridner SH, Dietrich MS, et al. A Randomized Trial Evaluating Bioimpedance Spectroscopy Versus Tape Measurement for the Prevention of Lymphedema Following Treatment for Breast Cancer: Interim Analysis. Ann Surg Oncol. 2019 May 3. doi: 10.1245/s10434-019-07344-5. [Epub ahead of print]