Lymphedema & Arm Discomfort After Breast Cancer

Q: I recently underwent surgery for breast cancer, and now my arm and hand feel odd. There may be some swelling as well. I don't have pain, but I'm worried about it. Is this lymphedema? What should I do about it?

Strange feelings in the arm on the side of breast surgery are very common. In an altered sensation from any cause, the part of the body affected can feel swollen or painful. If there is visible swelling, this is called lymphedema, which occurs after the removal of lymph nodes because of cancer, including breast cancer.

Lymphedema is the response of the immune system to the blockage of fluids in traveling to lymph nodes, which are part of the body’s immune system. Several conditions can be confused with lymphedema.

Conditions Resembling Lymphedema

Neuropathy. The altered sensation in the armpit or upper arm is a form of neuropathy (feeling of pins and needles or numbness) and can feel like pain, tenderness, a buzzing, numbness, heaviness, or swelling that occurs when the small skin nerves are interrupted by surgery.

In breast cancer, the altered sensation may affect only a small area in the axilla (armpit) around the incision, or it may extend into the chest, down the inside and back of the arm, and to the shoulder blade. Tylenol (acetaminophen) will generally relieve the discomfort, but if you also have neuropathy, your doctor may prescribe a medication for that. It is generally recommended not to use heat in areas where lymph nodes have been removed, or where the sensation is altered.

Axillary Web Syndrome. Another condition that can be confused with lymphedema is axillary cording, or axillary web syndrome–a thin cord that may occur after removal of lymph nodes that is tender or painful and can also feel swollen. This condition can extend down the inside of the arm, which may cause pain when extending the arm. There is no evidence that this syndrome leads to lymphedema. It is natural that the vessels in the lymph nodes would be irritated and sore.

Treatment would involve gentle stretching parallel to the axillary cord. Physical and occupational therapists who treat lymphedema are also skilled at treating axillary web syndrome. Left untreated, the loss of motion from this condition can lead to a frozen shoulder. However, just because a lymphedema therapist is treating this condition does not mean that the condition involves lymphedema.

Chemotherapy-Induced Neuropathy. Other neuropathies, such as chemotherapy-induced neuropathy (CINP), can also resemble lymphedema. Because some patients with breast cancer receive chemotherapy before surgery, the patient may have CINP before the surgery. CINP usually affects the nonsurgical and the surgical side, but it can become asymmetrical (affecting only one side) after breast cancer surgery. A patient who has neuropathy before surgery can have worse CINP on the surgical side.

Mastectomy-Related Thoracic Outlet Syndrome. When a woman receives implants in the chest after mastectomy, her arm and hand may have numbness and swelling. After the reconstruction surgery, patients tend to hunch the shoulders forward and tense the neck muscles to relieve the pressure. This posture can narrow the area under the neck (the collarbone), where the neck nerves enter the arm. These symptoms often become worse when the patient lifts the arm overhead.

Medical Evaluation

After surgery in breast or lymph nodes in the armpit, many early symptoms feel worse when the patient lifts the arm overhead, so a medical evaluation may be needed to find the cause.

Physiatrists can evaluate and sort out all of these conditions to prescribe medications or therapies for them. Physiatrists also evaluate and treat lymphedema. They can determine when the condition actually is lymphedema, or if you are at risk for lymphedema, and they can treat it as early as possible.

If symptoms of numbness, heaviness, or swelling in the arm on the side of the surgery persist for more than 2 weeks, they should be evaluated by a trained professional. Severe symptoms or change in color, warmth, fever, weakness, dramatic swelling, continuing sensory loss, or severe pain should be evaluated immediately.

Risks for Lymphedema

All patients who have had lymph nodes removed are at some risk for lymphedema. Patients who have lymphedema in the arm after sentinel lymph node surgery usually have milder cases of lymphedema. After axillary node surgery, the risk for lymphedema in the arm is 20% to 40%.

Lymphedema today is no longer what it used to be when most patients had radical mastectomy. Today, breast surgery does not remove all the axillary lymph nodes. The surgeon only removes as many nodes as are needed to determine the stage of cancer and treatment.

Lymphedema is strongly associated with obesity and lack of exercise.

Role of Exercise

The best ways to minimize the risk for lymphedema are exercise and maintaining a healthy weight. In the past, patients were told not to use the arm after breast cancer surgery, but that is no longer the case. Weight lifting and physical activity, when done gradually, reduce the risk for lymphedema. It is therefore important to maintain good muscle mass and strength to reduce obesity and the risk for lymphedema after breast cancer.

Sometimes the unusual sensory symptoms occur during exercise on the side of the surgery. That can be disconcerting, and fear can become a barrier to healthy exercise.

If that is the case, it is best to work with a lymphedema specialist to minimize the symptoms, and to determine whether the patient should wear a sleeve during exercise.

Usually these symptoms can be prevented by using a gradually increasing circuit-style exercise regimen, alternating arm exercises and leg exercises, and interspersing weight-lifting exercises with cardio, stretching, and core work.

Treatment

The body is able to compensate for the loss of lymph nodes. Swelling is very common in the first year after treatment when the lymphatic system is healing. Early treatment of lymphedema, even when swelling is minimal, improves the chances of reversal. So, it is important to report swelling to a medical professional.

Unusual sensations associated with swelling after breast cancer surgery should be evaluated by a physiatrist specializing in lymphedema and/or a lymphedema therapist. Deep massage in the armpit after lymph node surgery should be avoided, which is why it is recommended to see a lymphedema therapist or a rehabilitation physician (a physiatrist), who is familiar with lymph node surgeries and the risk for lymphedema.

The most effective treatment for lymphedema is complete decongestive therapy that is performed by lymphedema therapists.