Investigation of cause of lymphedema of the upper extremity after radical mastectomy.

Abstract

The pathogenesis of lymphedema of the upper extremity following a radical mastectomy is not as yet completely understood. A conspicuously swollen arm may be the only noticeable evidence of a radical mastectomy. Rarely a lymphan-giosarcoma of the edematous arm may ensue after a prolonged period (1). Since the only known treatment of the condition is its prevention, we have been encouraged to investigate this problem. Our interest was stimulated by a patient in whom thrombophlebitis of the veins of the forearm occurred following a radical mastectomy. The arm was bandaged with elastoplast for a period of two months. To our surprise swelling of the arm did not develop in spite of the severe thrombophlebitis. As a result of this experience, prophylactic bandaging of the arm of all patients subjected to radical mastectomy was tried. In 50 consecutive cases in which this procedure was employed, no appreciable edema of the arm, such as could be classified as moderate or severe, ensued. The routine use of this prophylactic measure was the subject of a previous publication (2). This experience led us to believe that venous obstruction is probably the primary factor in the production of lymphedema of the arm. To substantiate this assumption, we have undertaken to investigate this problem by measurements of venous pressure, venograms, and use of anticoagulants. Halsted (3) in 1921 published a paper entitled “Swelling of the Arm After Operations for Cancer of the Breast—Elephantiasis Chirurgica—Its Causes and Prevention.” It was his opinion that “although blocking of the lymphatics and occasionally also of the veins is the underlying factor, infection plays a conspicuous part in the determination of the amount of swelling and the time of its manifestation.” Devenish and Jessop (4) attributed postoperative swelling to lymphatic obstruction and regarded the rise in venous pressure occurring during exercise as a factor in edema formation after the occurrence of such obstruction. They stated that postoperative swelling occurs in 1 of 6 cases. Macdonald (5) considered obesity the most important predisposing factor in the genesis of lymphedema. In his opinion, the sequence of events is fat necrosis in the operative field, followed by secondary infection with regional (perivenous) axillary lymphangitis and resulting sclerosis and obstruction. He advocates resection of the axillary vein in cases with axillary lymph node involvement to permit more complete dissection and as a prevention of swelling of the arm. Veal (6) pointed out that there are three types of edema—lymphangitic, venous, and a combination of the two. He included cases with recurrent cancer in his study and, making use of venograms, formulated the following conclusions: “Edema resulting from obstruction of the axillary and subclavian veins is by far the most common cause of swelling of the arm following operation.