The Management of the Swollen Arm in Carcinoma of the Breast

Abstract

The terms “brawny arm” and “lymphedema” have been given to the swollen arm which may complicate the inoperable, recurrent, or postoperative case of mammary cancer. Referring to those patients who have been subjected to radical mastectomy and have subsequently developed this unfortunate sequel without recurrence, Halsted coined the term elephantiasis chirurgica (surgical elephantiasis). In about 10 per cent of those with advanced mammary cancer edema of the arm occurs on the side of breast involvement. Lymphedema is more common where recurrence has followed surgery and is most frequently observed as a sequel to the radical operation, even if there has been no return of the disease (25 per cent). Brawny arm was formerly considered due to compression of the axillary vein by tumor tissue, and this view may be substantiated in certain cases. The axillary vein, however, may be excised in most instances without causing more than transient edema of the arm. This swelling is soft, in contrast to the brawny induration which is a result of lymphatic obstruction. The extirpation of the axillary lymph nodes and vessels is not wholly responsible for stasis. This complication arises when the smaller lymphatics about the shoulder have been occluded by the infiltration of tumor tissue or the fibrosis following irradiation, or postoperative infection. Halsted was convinced that postoperative infection was responsible for lymphedema when there was no recurrence of the disease. For this reason he advised loose approximation of the skin edges and Thiersch grafts in all cases where radical mastectomy was performed. He argued that necrosis of the edges of the incision followed the closure under tension and necrosis led to infection of the operative field. A low-grade streptococcal infection will cause a fibrosis of the lymph channels and once this is present in the skin there is a predisposition to subsequent attacks. A vicious circle is established.