Physical Therapy Intervention to Augment Outcomes Of Lymph Node Transfer Surgery for a Breast Cancer Survivor with Secondary Upper Extremity Lymphedema: A Case Report.

BACKGROUND AND
PURPOSE: Lymphedema is an incurable complication of breast cancer treatment that affects roughly 20 percent of women. It is often managed via complete decongestive therapy, which includes manual lymph drainage, therapeutic compression, skin care, and exercise. Lymph node transfer is a new and expensive surgical intervention that uses one's own lymph nodes and implants them in the affected upper extremity. Previous research has investigated augmenting lymph node transfer surgery with complete decongestive therapy, but there is a lack of evidence regarding the success of focusing lymph drainage against the normal pressure gradient toward a surgical flap located on the wrist. The patient's main motivation for the surgical intervention was to alleviate her daily burden of complete decongestive therapy. The purpose of this case report was to compare the methods and results of pre-surgical complete decongestive physical therapy to a post-operation modified approach that directed lymph fluid away from the major lymphatic ducts and instead toward a surgical flap on the wrist of a patient with lymphedema. CASE DESCRIPTION: A 65-year-old female presented with secondary upper extremity lymphedema following breast cancer treatment. Her circumferential measurements and L-Dex score corroborated this diagnosis, and she had functional deficits in upper extremity range of motion. She was seen for 10 visits of traditional complete decongestive therapy prior to her lymph node transfer surgery and 24 treatments of modified complete decongestive therapy over the course of six months following surgery. OUTCOMES: At six months, the patient had minor improvements in the Functional Assessment of Chronic Illness Therapy-Fatigue, Disabilities of the Arm, Shoulder and Hand questionnaire, range of motion, and upper extremity strength. However, her circumferential measurements and L-Dex scores showed a meaningful increase in limb girth. DISCUSSION: The patient's smallest upper extremity volumes were documented before the operation after two weeks of complete decongestive therapy. The surgical intervention supplemented by modified complete decongestive therapy resulted in increased limb girth after six months. Although the patient was able to stop wearing her compression garment while continuing independent manual lymph drainage and upper extremity wrapping, the post-surgical intervention was not a success because the patient's circumferential measurements remained meaningfully higher than at her initial examination. Further research is needed to determine the long-term effects of this surgery when coupled with physical therapy intervention, and whether it has better outcomes than the standard conservative treatment of complete decongestive therapy alone.