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Lymphedema after Mastectomy

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Lymphedema is a visible and palpable fluid accumulation in the interstitium (intercellular space). It is caused by mechanical failure of the lymphatic system, so that the interstitial liquid can no longer be removed sufficiently through the lymphatic vessels. This leads to the reflux and accumulation of liquid in the intercellular spaces (edema). In addition to the limbs, the face, neck, trunk and genitals may also be affected. Lymphedema is a symptomatic description, not a diagnosis.
The cause of accumulation of the fluid and therefore edema is due to cell damage that occurs for example in the case of an inflammation or damage from surgery. In these cases inflammatory molecules are released, which accumulate in the interstitial spaces and attract water. Under normal conditions this liquid can be reabsorbed well when the drainage of the lymphatic system works well.
The different stages of lymphedema are subdivided into various stages listed below:
Stadium 0
Stage Latency (subliminal edema): no symptoms still appear.
Stadium 1
Reversible stage: edema with high protein content, few, small, localized tissue changes. The edema is still soft, can be easily pressed with the finger creating a "dent".
Elevating the limb (where possible) reduces the swelling to a certain extent.
Stadium 2
Spontaneously irreversible phase: in this phase the fibrosclerotic changes and the proliferation of fat tissues occur. The edema is more pronounced and does not respond (reduces) more to the raising of the limb. Pressing with the finger leaves no or very superficial dent in the skin.
A distinction is made between primary and secondary lymphedema.
In the primary (rare) form, the lymphatic vessels and / or lymph nodes are not, or are only partially malformed, due to a developmental disorder. Whole extremities or body regions can be affected here. The complete absence of the lymphatic vessels of a region of the whole body is not compatible with life and leads to death in the womb or shortly after birth.
There are also congenital forms (hereditary lymphedema), such as Milroy's disease and Meige's disease, previously called Nunner-Milroy-Meige syndrome.
In secondary lymphedema (majority of cases), drainage pathways are mechanically inadequate due to pathological changes such as:
- B. Tumor diseases, trauma, lymphangitis (inflammation from viruses, bacteria, fungi, parasites, etc., in rheumatic diseases), chronic venous insufficiency (CVI), diabetes mellitus, or due to surgery such as, surgical scars, irradiation radiology, removal of lymph nodes after tumor removal, venipuncture for bypass surgery.
The therapy of choice is Complex Physical Decongestion Therapy (KPE).
The following are summarized:
- Manual lymphatic drainage: manual lymphatic drainage is a special drainage technique that softens lymphoid tissue and lymph nudged towards the abdomen and thorax area and vice versa without increasing blood circulation. With a variable pressure, the skin and the subcutaneous adipose tissue are drained. With special grips, the therapist stimulates the correct movement of the lymphatic vessels, thus favoring the transport of the lymph. With a consistent application - depending on the severity one or more times a week - the volume of the edema is reduced. The therapeutic effect lasts for approximately 24 hours. Therefore, a compression must be added
Compression treatment:
Lymphatic drainage of the machine: special lymphatic pumps are connected to the boots of the legs or to the cuffs of the arms. The sleeves, which have different air chambers, are then pressurized. The lower chamber has the highest pressure. Then begins a cycle in which the chambers are inflated in sequence.
Skin care
Compression bandages / compression stockings: Compression bandages are used to wrap the affected arms or legs. The external pressure supports the removal of the lymphatic fluid and therefore the breaking of the lymphatic backlog. In addition to compression bandages, the professional bandage also includes padded cushions and padded foam padding. If the inclination of the swelling decreases, the bandages can be replaced by compression sleeves or stockings. These are specially made gloves, compression sleeves or leg stockings made of solid flat knit material, suitable only for the treatment of lymphedema and not for those of venous diseases.
Movement therapy during compression: regular exercise promote lymphatic flow and reduce lymphatic blockage. Compression bandage or socks are worn to increase the effect of decongestion exercises. The therapist develops a program of exercises suitable for the patient based on where the lymphedema is located.
Moreover, in the context of super microsurgery, lymphatic drainage can be restored and therefore permanently the lymphatic water deposits are reduced.
Therapy with food and pharmacological supplements
Coumarin as well as other flavonoids such as troxerutin have shown a remarkable draining effect both in mastectomy lymphoedema but also in the lymphedema of venous diseases.
Doses of coumarin from 4 to 40 mg have shown already appreciable clinical improvements. Doses of 100 mg of coumarin or 300 mg of Troxrutrine have been able to give a marked improvement of the edematous status with a significant improvement in the patient's quality of life. Coumarin for a localized coadjuvant therapy can also be given locally due to its considerable absorption through the skin. Cumarin and troxerutin at listed doses favor the destruction of proteins accumulated in the interstitial fluid, the primary cause of lymphedema.
On the other hand, treatment with diuretics alone initially reduces the volume of the vascular fluid. The oncotic attraction of plasma accumulates only briefly and does not positively change the protein concentration of edema. Thus a yo-yo effect is observed. To achieve the desired action of the diuretic constantly, it is necessary to act against the proteins accumulated in the interstitial liquids.

a) Radiotherapy (action against free radicals, protective, antioxidant)

Radiotherapy is the medical application of ionizing radiation to humans and animals to treat or delay the progression of the disease. Radiation can come from radioactive equipment or preparations. The areas of specialization for this special application of electromagnetic waves are radiotherapy and radiology.
As ionizing electromagnetic beams, mainly gamma radiation, X-rays and electron beams are used. In recent years, treatment facilities have been built with neutrons, protons and heavy ions (often carbon ions). Non-ionizing radiation such as microwaves and heat radiation, light and UV therapy and ultrasonic wave treatment are not assigned to radiation therapy.
Radiotherapy includes the treatment of benign and malignant diseases and is performed by specialists in radiology or radiotherapy with the assistance of specialized personnel

Action mechanism
The effect of irradiation is based on the transfer of energy to the irradiated tissue in the dispersion processes. The radiation is directed on the biomolecules that are essential for cell growth as in the case of tumors.
Free radicals resulting from the destruction of Biomolecules are highly toxic and react chemically with cellular components. The damage resulting to the genetic material of the tumor cells, (in particular DNA by double strand breaks), are responsible for the destructive effect, thus preventing the tumor cell from proliferating (mitosis), or even leading them directly to apoptosis (death ). The optimal dose of radiation reaches> 90% tumor destruction with <5% serious side effects.
A reduction of the oxidative effects of free radicals, which can expose their damage in different districts than where the tumor mass can be obtained in the periods immediately after radiotherapy with antioxidants, such as Vitamin C, Zinc, Selenium, Lipoic acid (thioctic acid ) and more.
Particular attention deserves the protection of the immune system which, once weakened by free radicals and radiotherapy reduces its anti-tumor, antibacterial and antiviral activity with consequent further problems for the patient.

b) Immunostimulant
The immune system is a set of cells and tissues that has the function of defending the body from foreign agents such as bacteria, viruses, fungi but also from cells of the body that for some mutation take on a 'foreign' appearance, like cancer cells.
The main tools that the immune system uses to perform its functions are the lymphocytes (or white blood cells) that flow in the blood and lymph, thus reaching all areas of the body. The Natural Killer (NK) lymphocytes that have the role of destroying cancer cells are particularly important for their action against cancer.
A study by the University of Leeds (United Kingdom), published in Breast Cancer Research, investigated the effects of chemotherapeutic drugs on immune cells and antibodies, showing that the levels of some of these - B lymphocytes and a type of T lymphocytes , called T helper (CD4 + T) - remain altered even after nine months from the end of the therapy.
This results in the most common side effects of chemotherapy: myelosuppression (decrease in the production of blood cells, therefore also immunosuppression), mucositis (inflammation of the lining of the digestive tract) and alopecia (hair loss).
The study indicates that chemotherapy leads to an alteration of the cells of the immune system, which can last for more than 9 months. It has been known for years that patients receiving chemotherapy may be more susceptible to bacterial or viral infections due to the reduction of protective cells in their blood, and precautions in this regard are included in the treatment plans.
Not known was that the effect could last several months beyond the end of therapy.

The implications of this result may be different. The authors suggest that a decrease in B cells (cells that produce antibodies) and a reduction in antibody levels against some infectious agents (pneumococcus, tetanus) may result in less protection against infections even for prolonged periods after the end of treatment .
The growth of Natural Killers lymphocytes can however be stimulated by the intake of Echinacea purpurea and other subspecies of the family of this plant, as demonstrated by a study. (Natural killer cells from aging mice treated with extracts from Echinacea purpurea are quantitatively and functionally rejuvenated.) Currier NL1, Miller SC PMID: 10978684)
The increase mediated by Echinacea purpurea in the number of NK cells was in fact parallel with an increase in their anti-tumor lithic functional capacity.


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