QUESTION CORNER: FOCUS ON BREAST AND CHEST WALL LE

by Nicole L. Gergich MPT, CLT-LANA and Lesli Bell PT, CLT-LANA

Q. Are the symptoms of trunk edema different than arm edema?
A. Although lymphedema is usually identified by swelling, there are typically other symptoms that are present before the onset of visible edema. Altered sensations in the breast and trunk can occur prior to the onset of swelling. These may include, but are not limited to, pins and needles, numbness, aching, and diffuse fullness.(1) The location of pain or discomfort may be ambiguous, as well, and may be outside of the immediate surgical site. It is not uncommon to experience edema in the armpit, around the scapular region, along the lateral chest wall, or around and including a reconstructed breast or implant. The affected breast may be larger than the unaffected breast, creating discomfort with bra or clothing fit. Pitting and fibrosis (hardening of tissue) may or may not be present. However, if fibrosis is present, it can appear on the trunk or breast. It has been reported that lymphedema of the breast also may mimic an infection and, in extreme cases, inflammatory breast cancer.(5) It becomes important for the patient and healthcare professionals to closely examine the tissue and assess the symptoms before treating.

Q. I had a lumpectomy and radiation on my right breast and chest. There are now areas that feel hard, leathery, and uncomfortable. From time to time, it even feels swollen. What is this?
A. Patients who undergo surgery for breast cancer with or without radiation therapy may have tissue changes to the affected chest wall following treatment. The changes that occur with radiation sometimes involve scarring of tissue. This is called fibrosis. There also may be discolored areas of the skin after radiation therapy. As a result of these tissue changes, symptoms may occur including: hardening of the tissue; tightness across the chest; breast/chest edema or lymphedema; pitting edema; fullness in the axilla; and pain.(3,4)

Many of these symptoms can be managed successfully with therapeutic interventions. Lymphedema in the area of the radiation field can be reduced or removed with Complete Decongestive Therapy (CDT). This should include Manual Lymphatic Drainage (MLD) by a trained lymphedema therapist, infection precautions, self-lymphatic drainage and appropriate compression of the chest.

Foam chip pads may be useful, if applied with caution, over the hardened areas. The foam chip pads may be put directly on the affected area, held in place by a chest/trunk compression garment or bandaging. Compression should not impede drainage of the lymphatic vessels in the affected upper quadrant, or increased pooling and symptoms may occur. Adjustability of the compression garment or bandage is preferred since the edema/fibrosis is dynamic and may change with variables such as weather and activity. Also, it is important to move the chip pad around the affected area so as to break up the fibrosis more effectively. The effects of this treatment are realized as a remarkable softening of the leather-like skin and significant decrease in pain, which will improve lymphatic drainage from the affected quadrant. Of course, if the skin is not intact, fragile, or otherwise compromised, use of foam chip pads and/or compression should be forestalled until adequate healing has occurred.

Q. Is compression necessary for chest/trunk edema like it is for the arm or leg?
A. Yes, if lymphedema is present in any body region, all four components of decongestive therapy should be employed for optimal outcomes. Compression may be the most difficult part of the CDT tetrad when dealing with truncal edema. The shape of the trunk and the amount of movement the compression device has to endure to maintain consistent structure is often a barrier to adequate consistent compression. Sitting, standing, and twisting are all common trunk motions that we need to be able to do in our daily activities. However, these movements, along with constant inspiration and expiration, will cause the bandages to bunch and roll unless proper structure is given to the bandage complex. In addition, the compression principles of CDT must be altered to accommodate the lack of active muscle pumping in the breast and trunk. The rationale with using short-stretch bandages is to activate the muscle pumping of large muscles that contribute to fluid evacuation.(5) However, in the trunk, there is limited muscle tone in the breast tissue and limited ability to create forceful contraction in the smaller scapular and thoracic muscles. Therefore, compression to the trunk and breast often warrants medium to high-stretch bandages to apply compression appropriate for fluid evacuation.

Creative foam applications are a mainstay in Phase 1 CDT. Foam applications such as chip pads or custom-cut, flat foam pieces will maximize the effect of the compression bandages by distributing consistent pressure over a greater surface area within the bandage structure. Compression needs to be continued in Phase 2 to maintain volume reduction (5) results. Adequate, consistent, and sustainable compression for the trunk has, in the past, been difficult to achieve. Fortunately, there now exist a number of specialty garments and devices that adequately apply compression for chest/trunk edema and also contribute to independent patient self-management. Lymphedema-specific bras, custom foam-chip vests, and pre-made chip pads are available to assist with maintaining the positive results of CDT. The key to success is regular, consistent compression on the trunk/chest wall with regular self-manual lymphatic drainage and foam support when needed.

REFERENCE LIST

1 Petrek JA, Senie RT, Peters M, Rosen PP. Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer 2001; 92(6):1368-1377.

2 Loprinzi CL, Okuno S, Pisansky TM, Sterioff S, Gaffey TA, Morton RF. Postsurgical changes of the breast that mimic inflammatory breast carcinoma. Mayo Clin Proc 1996: 71(6):552-555.

3 Baron RH, Fey JV, Raboy S, Thaler HT, Borgen PI, Temple LK et al. Eighteen sensations after breast cancer surgery: A comparison of sentinel lymph node biopsy and axillary node dissection. Oncol Nurs Forum 2002; 29(4): 651-659.

4 Johansson S, Svensson H, Denekamp J. Dose response and latency for radiation-induced fibrosis, edema, and neuropathy in breast cancer patients. Int J Radiat Oncol Biol Phys 2002; 52(5): 1207-1219.

5 Földi E. The treatment of lymphedema. Cancer 1998; 83(12 Suppl American): 2833-2834.

Nicole Gergich, MPT, CLT-LANA, is a physical therapist and lymphedema specialist at the Hospital of the University of Pennsylvania in Philadelphia, an active member of the NLN Medical Advisory Committee and LANA Board member.

Lesli Bell, PT, CLT-LANA, is the owner of Timberlane Physical Therapy Practice and co-owner of Bellisse®.