Case discussion

PRESENTED BY: SAVIO T ALPHONSE

42 year old lady non case of carcinoma left breast , status post left MRM and
chemoradiotherapy done 8 years back comes to your opd with chief complaints of
left upper limb heaviness and swelling from past 3 years . On examination there is
diffuse swelling of left upper limb.

Discuss the diagnosis and management of the above case

Probable diagnosis: Lymphedema
secondary to modified radical
mastectomy
Surgeries for carcinoma breast
Total (simple) mastectomy:
Along with the tumour, entire breast,
areola, nipple, skin over the breast,
including axillary tail are removed.
There is no axillary dissection.
Often the patient is subjected to
radiotherapy later (External) to axilla.
Pectoral fascia is removed along with
breast specimen; breast tissue
superficial to axillary fascia is removed.
Total mastectomy with axillary clearance:

Commonly used procedure. Total mastectomy is done

along with removal of axillary fat, fascia and lymph

nodes

Level I and II axillary nodes are removed along

with total/simple mastectomy

Modified radical mastectomy [MRM]:

Patey’s operation: It is total mastectomy along

with clearance of all levels of axillary nodes and
removal of pectoralis minor muscle. It is enblock
dissection of breast and axilla.

An elliptical incision is made from medial aspect

of the second and third intercostal space
enclosing the nipple, areola and tumour
extending laterally into the axilla along the
anterior axillary fold.
Upper and lower skin flaps are raised. Breast with tumour is raised from the medial aspect of the
pectoralis major muscle.
Dissection is proceeded laterally with ligating pectoral vessels. Once dissection reaches axilla, lateral
border of pectoralis major muscle is Cleared with level I nodes. Pectoralis minor is divided from coracoid
process to clear level II nodes.
Medial and lateral pectoral nerves should be preserved (otherwise atrophy of pectoral muscle occurs).
Later from the apex of axilla level III nodes are cleared. Nerve to serratus anterior, nerve to latissimus
dorsi, intercostobrachial nerve, axillary vein, cephalic vein and pectoralis major muscle are preserved.
Wound is closed with a suction drain
Scanlon’s operation: It is a modified Patey’s operation wherein instead of
removing pectoralis minor, it is incised to approach the affected level III lymph
nodes.

Auchincloss modified radical mastectomy: Here pectoralis minor muscle is left

intact and level III lymph nodes are not removed—commonly done now.

Mastectomy specimen should be carefully inspected and sent to pathology

department.
LYMPHOEDEMA

● It is accumulation of fluid (lymph) in extracellular and extravascular fluid

compartment, commonly in subcutaneous tissue.
● It is primarily due to defective lymphatic drainage.
● It is increased protein rich interstitial fluid.
Classification
Kinmonth classified lymphoedema as:

● Primary without any identifiable lymphatic disease.

● Secondary is acquired due to definitive cause.
Pathophysiology of Lymphoedema

● Decreased lymphatic contractility, lymphatic valvular insufficiency

● Lymphatic obliteration by infection, tumour or surgery → lymphatic

hypertension and dilatation causing lymph stasis→ accumulation of
proteins, glycosamines, growth factors, and bacteria
● There is more collagen formation, deposition of proteins, fibroblasts,
ground substance causing fibrosis in subcutaneous and outside deep
fascia.
● Muscles are normal without any oedema but may get hypertrophied.
SECONDARY CAUSES

● Trauma
● Surgery—inguinal block or axillary block
dissection/postmastectomy with axillary clearance
● Filarial lymphoedema due to Wuchereria bancrofti
● Tuberculosis
● Syphilis
● Fungal infection
● Advanced malignancy—hard, fixed lymph nodes in axilla or in
inguinal region
● Postradiotherapy lymphoedema
● Bacterial infection
BREAST CANCER ASSOCIATED LYMPHEDEMA RISK
FACTORS
The main risk factors for breast cancer-associated lymphedema (BCAL)
include
● Invasive cancer diagnosis
● Dissection/disruption of axillary lymph nodes
● Radiation therapy
● Local infection
● Obesity
CLINICAL FEATURES

● Progressive upper extremity swelling

● Skin changes
● Limb pain and discomfort
● Restricted range of motion- can be associated with presence of
thickened bands or cord tissue
● Nonpitting edema.
● Superficial phlebitis of the chest wall veins (Mondor disease) has also
been associated with upper extremity lymphedema
DIAGNOSIS AND STAGING

Clinical staging — Lymphedema is staged (International Society of

Lymphology) based on the examination of the upper extremity and the
volume difference between the extremities
Stage 0- subclinical lymphedeme
Stage I-;mild lymphedema
Stage II- moderate lymphedema
Stage III- severe lymphedema
NATURAL HISTORY AND MONITORING

● Following treatment for breast cancer, the onset of lymphedema

is insidious and is typically characterized by slowly
progressive swelling of the upper extremity ipsilateral to the
axillary node dissection or radiation treatments
● At first, the swelling may be apparent only in the proximal portion
of the limb, or it can affect only a portion of the distal limb
including the digit
● swelling over the ipsilateral breast and/or upper chest wall.
PRIMARY PREVENTION

● Involves using sentinel lymph node biopsy for axillary lymph node
staging rather than axillary node dissection
● Limiting extent of lymph node dissection
● Monitor the ipsilateral limb
● Exercise/physiotherapy
● Compression therapy
MANAGEMENT
● Conservative treatment
For patients with upper extremity lymphedema, we measure blood pressure in
the contralateral arm, particularly in any setting in which blood pressure is being
closely monitored (eg, in an intensive care unit, recovery room, or during
procedures).
Multimodality regimen that includes general measures for care, physiotherapy
(eg, simple lymphatic drainage, manual lymphatic drainage, complete
decongestive therapy), and compression therapy (compression bandaging,
compression garments, intermittent pneumatic compression), the type and the
intensity of which depend upon the clinical stage.
● For patients with mild lymphedema (International Society of Lymphology [ISL]
stage I), we suggest physiotherapy in the form of manual lymphatic
drainage and compression garments, rather than more intensive therapy
(Grade 2B).
● Manual lymphatic drainage (MLD) is a massage-like technique that is typically
performed by specially trained physical therapists, but a self-help maneuver
(simple lymphatic drainage) has also been used for mild cases.
● Light pressure is used to mobilize edema fluid from distal to proximal areas
● For patients with moderate-to-severe lymphedema (ISL stages II to III) and no
contraindications, we suggest intensive physiotherapy, usually in the form of
complete decongestive therapy, rather than less intense therapy (Grade 2B).
● Complete decongestive therapy (CDT) refers to a two-phase (treatment
phase, maintenance phase) multicomponent technique that is designed to
reduce the degree of lymphedema and to maintain the health of the skin and
supporting structures.
● Patients with severe lymphedema (ISL stage III) may also benefit from
intermittent pneumatic compression (IPC) in addition to CDT.
● IPC (also called sequential pneumatic compression) devices employ a plastic
sleeve or stocking that is intermittently inflated over the affected limb.
● Most pneumatic compression pumps sequentially inflate a series of chambers
in a distal-to-proximal direction.
● For selected patients with lymphedema or complications related to
lymphedema, surgery to help alleviate pain and discomfort and reduce the
risk of infection, among other goals, may be reasonable to consider. Surgery
is most effective for patients with early-stage lymphedema (ie, prior to tissue
fibrosis and severe adipose deposition); however, surgery is also possible and
effective in patients with late-stage lymphedema.
Surgeries
Surgeries for lymphoedema has been classified as:

a. Excisional

Charle’s operation.

Homan’s operation.
b. Physiological
Omentoplasty.
Nodovenous shunt (Neibulowitz)
Lymphovenous shunt (O’Brien’s).
Ileal mucosal patch.
Here either communication between superficial and deep lymphatics are created
or new lymphatic channels are mobilised to the site.
Omentoplasty (Omental pedicle): As omentum contains plenty of
lymphatics.omental transfer with pedicle will facilitate lymph drainage.
c. Combined: Both excision + creation of communication between superficial and
deep lymphatics.

Sistrunk operation.

Thompson’s operation.

Kondolean’s operation.
Limb reduction surgeries:
Sistrunk operation: Along with excision of lymphoedematous tissue, window cuts
in deep fascia is done, so as to allow communication into normal deep lymphatics.
Homan’s operation: Excision of lymphoedematous tissue is done after raising
skin flaps. Later skin flaps are trimmed to required size and sutured primarily.
Medial and lateral sides of the limb are done at separate sittings with 6 months
interval.
Thompson’s operation: Lymphoedematous tissue is excised
under the skin flaps. Epidermis and part of the dermis of one of
the skin flaps is shaved off using Humby’s knife. It is buried under
opposite flap, deep to the deep fascia like a swiss roll (Swiss roll
operation or buried dermal flap operation).
Problems here are formation of epidermal cysts and sinus.
Kondolean’s operation: Along with excision of lymphoedematous tissue, vertical
strips of deep fascia is removed so as to open the deep lymphatics which creates
communication between superficial and deep lymphatics.

Macey’s operation: Here skin and subcutaneous tissue are peeled back with
deep fascia and split skin grafting is done over the denuded area. Overlying pad of
tissue is sutured back temporarily and after 10 days, it is trimmed away.

Miller’s procedure: It is excision of subcutaneous tissues under the skin flap with
deep fascia in two stages. First stage is done over the medial aspect of the limb;
second stage done after two months over lateral aspect of the limb.
Complications
● Skin thickening, abscess and maggot’s formation.
● Recurrent cellulitis, nonhealing ulcers, septicaemia.
● Lymphangiosarcoma; Stewart Treves syndrome (0.5%, occurs after 10
years),
● This syndrome is usually seen in upper limb after mastectomy.
● Recurrent streptococcal infection.
LYMPHANGIOSARCOMA
● Stewart Treves syndrome
● This syndrome is usually seen in upper
limb after mastectomy.
● Dreaded complication
● Can develop in long standing cases
that last for more than 8 to 10 years
● Presents with bluish or reddish
nodules over upper limb
● Skin/nodule biopsy is confirmative.
● Management : Forequarter
amputation- disarticulating upper limb
with scapula
● Poor prognosis
THANK YOU