Lymphedema

The range of reported lymphedema in patient who undergo pelvic lymph node dissection is between 5-30%. However, it is important to note that the range varies widely based on several factors such as the tools to measure lymphedema or the medical comorbidities of the patient such as obesity, diabetes, hypertension, and cardiovascular disease. The range of reported lymphedema in patient who undergo pelvic lymph node dissection is between 5-30%. However, it is important to note that the range varies widely based on several factors such as the tools to measure lymphedema or the medical comorbidities of the patient such as obesity, diabetes, hypertension, and cardiovascular disease.

Radiotherapy is a significant risk factor for lymphedema (breast as well as extremity). Selection of patients who will or will not benefit from radiotherapy. And trading off risk of lymphedema against risk of salvagable local recurrence can be discussed with the patient The best risk reduction is to perform less axillary surgery, and thus cause less mechanical disruption of the lymphatics. The results of the American College of Surgeons Oncology Group Z0011 trial (published Feb 2011) showed that full dissection is not always necessary even if the sentinel node is positive. If we surgeons know that a full dissection must be done, then preop evaluation by a lymphedema specialist is helpful for baseline arm measurements.

In 1992 I was told I would be bedridden for the rest of my life. I had my lymph nodes removed during a malignant melanoma surgery. My leg was as wide as my waist when I woke up from the surgery. I was told not to exercise for a full year. (I waited 9 months and just HAD to start exercising again!) The swelling went down very slowly. Twenty years later, I still deal with lymphedema on a daily basis. I maintain it well... sleep with my leg elevated, wear compression stocking, and I know which exercises reduce or increase the swelling. I recently published a book on my experience as a cancer patient and the twenty years since. Sentinel lymph node biopsy has revolutionized melanoma surgery, staging, prognosis, and aids in the decision for adjuvant therapy after definitive surgery. However, like all things there is some down side including pain and restriction of motion (usually limited to post operative period), numbness/paraesthesias (which can be permanent) and most problematic - lymphedema. The cause of post sentinel lymph node biopsy lymphedema is poorly understood but does not appear to be related to the number of lymph nodes removed (average sentinel node biopsy has 2-3 nodes). Complicating the issue further is the actual method of deciding if lymphedema is present. The methods vary from circumferential measurements above and below the elbow/knee at specified distances, perometry (measuring shadow size of each extremity), water displacement (volumetric analysis) and bioeimpedence (as extracellular fluid increases the ability to transmit electrical charge through the limb decreases). With all of those caveats, the risk of lymphedema after sentinel lymph node biopsy is ~5-10%; after a full lymphatic dissection, it is ~15-60% (and above that if the nodal area is radiated).

Obesity is a risk factor. In terms of the surgery itself, lymphedema rates are reduced with sentinel node biopsy (2-5%) compared to full axillary dissection (20-35%). Radiation to the axilla and supraclavicular nodes increases lymphedema risk. Obesity is a risk factor. In terms of the surgery itself, lymphedema rates are reduced with sentinel node biopsy (2-5%) compared to full axillary dissection (20-35%). Radiation to the axilla and supraclavicular nodes increases lymphedema risk.

First, I hope that you have undergone adequate lymphedema treatment. There are treatments available and most are now covered by insurance. Treatments include compression sleeves, manual lymph drainage (MLD) by specialty trained lymphedema therapists, special bandaging, sequential gradient pump, or some medications (although diuretics have proven to have little effect). Of course if your lymphedema is ever caused or made worse by an infection, then antibiotics should be prescribed.

You mention feeling isolated and embarrassed by the lymphedema. This may be due to the fact that you feel the lymphedema is a sign that you had cancer and the diagnosis in itself is one that you struggle with. It may be difficult for you to tell people why you have lymphedema if asked, or you may be afraid that you will be asked and the cancer is an experience you don’t want to talk about. Did you have body-image concerns prior to the cancer that have been exacerbated by the lymphedema? If you answered yes to these questions, you may have underlying emotional issues that are unresolved and that are triggering your embarrassment and isolation. I would strongly recommend seeking out a therapist who can help you overcome these painful issues. You can also reach out to lymphedema societies that provide ongoing support for patients who suffer from lymphedema: the National Lymphedema Network at 1-800-541-3259 or http://www.lymphnet.org; the Lymphedema International Network at http://www.lymphedema.com. First, I hope that you have undergone adequate lymphedema treatment. There are treatments available and most are now covered by insurance. Treatments include compression sleeves, manual lymph drainage (MLD) by specialty trained lymphedema therapists, special bandaging, sequential gradient pump, or some medications (although diuretics have proven to have little effect). Of course if your lymphedema is ever caused or made worse by an infection, then antibiotics should be prescribed.

You mention feeling isolated and embarrassed by the lymphedema. This may be due to the fact that you feel the lymphedema is a sign that you had cancer and the diagnosis in itself is one that you struggle with. It may be difficult for you to tell people why you have lymphedema if asked, or you may be afraid that you will be asked and the cancer is an experience you don’t want to talk about. Did you have body-image concerns prior to the cancer that have been exacerbated by the lymphedema? If you answered yes to these questions, you may have underlying emotional issues that are unresolved and that are triggering your embarrassment and isolation. I would strongly recommend seeking out a therapist who can help you overcome these painful issues. You can also reach out to lymphedema societies that provide ongoing support for patients who suffer from lymphedema: the National Lymphedema Network at 1-800-541-3259 or http://www.lymphnet.org; the Lymphedema International Network at http://www.lymphedema.com.

The standard treatment for lymphedema is lymphatic massage and compression under the guidance of a physical therapist specifically trained in lymphedema management. There is no question that is the most effective treatment. In addition, there is one trial that was conducted in France and published in 1996 which demonstrates some efficacy using an extract of Ruscus (Butcher’s Broom) and Hesperidin Methyl Chalcone ( a citrus flavonoid) called CYCLO 3 FORT. In that trial all 57 patients received manual lymphatic drainage (lymphatic massage) and the patients that received CYCLO 3 FORT had less edema at the end of 3 months. Butcher’s Broom can cause diarrhea. The standard treatment for lymphedema is lymphatic massage and compression under the guidance of a physical therapist specifically trained in lymphedema management. There is no question that is the most effective treatment. In addition, there is one trial that was conducted in France and published in 1996 which demonstrates some efficacy using an extract of Ruscus (Butcher’s Broom) and Hesperidin Methyl Chalcone ( a citrus flavonoid) called CYCLO 3 FORT. In that trial all 57 patients received manual lymphatic drainage (lymphatic massage) and the patients that received CYCLO 3 FORT had less edema at the end of 3 months. Butcher’s Broom can cause diarrhea.

I do also have that tingling sensation, mostly located in the upper arm and to the back. I also agree it is enhanced when I'm swollen, even if at first look it may not appear by much. I was told to exercise my arms with light weight would help build muscles and provide natural draining. I must say that since I included a more structured program, my Lymphedema is mostly under control and the tingling is less frequent. It just feels strange to have the tingling while at the same time if I scratch at my upper arm, I almost feel nothing, like still under local anesthesia.

Mary Yes, I have. When this happens, I'm generally more likely swollen or "full " at that time. The best way I find relief from this is to lightly use a netted bath sponge that's on a long handle and gently massage -starting from my hand working my way up my arm, then over to the center of my chest. Once I'm finished with that, I put my compression sleeve/glove on for full relief. Unfortunately, pain meds don't help with this type of pain.

Would love to! Tips for managing lymphedema (mainly for lower-extremity, but can also apply to arms)

1. Learn Vodder (MLD) massage method to help move fluid. You stay stronger, healthier, and...It will save your mind!
2. Keep your body clean and dry always.
3. After a shower (I don't recommend a bath; dirty water) dry off using a blow-dryer -(with a heat-control switch) to dry hair around groin area. Don't let get too warm here. (Reason: bacteria loves moisture).
4. Pay particular attention to foot care. Keep toe nails clean and clipped.
5. I use Sea Breeze on my toe nails, and moisturize with Clinique (yellow) Dramatically Different Moisturinzing lotion (it has salicytic acid in it-normally for face break-outs, it does something to keep the nails healthy.
(This advice is only if your feet are in general good health to begin with)
Otherwise, start with plain, non-scented soap and water and moisturizer. Moisturizers are different than water. After cleansing, they provide a "barrier" to the skin.
These steps are hugely important when wearing "compression garments". You don't need to put garments on over a dirty body. Skin infections are hard to heal on an affected limb. Prevention is key here.
6. Keep compression garments clean. Since they are right next to your skin, when clean, they can absorb sweat, and if dirty they will promote infection.
7. Keeping the legs or arm elevated when resting is a must. I sleep with a foam wedge under my legs. Do whatever you can to help stop the pull of gravity on them- the limb(s) need to be at a level above your heart.
8. If you work, take breaks every 30 min. to hour if you can. Moving around is good. When sitting, move your ankles in circular motions. Ask your boss for special privilege. Explain your issue with your manager.
9. Stay calm. The more fretful you get about things, the worse your lymphatic system will act. Talk it out, pray or meditate-whatever it takes.
10. Eat pure, fresh, whole foods as much as is within your means. Processed foods, and salt additives wreak havoc on lymphedema.
Would love to! Tips for managing lymphedema (mainly for lower-extremity, but can also apply to arms)

1. Learn Vodder (MLD) massage method to help move fluid. You stay stronger, healthier, and...It will save your mind!
2. Keep your body clean and dry always.
3. After a shower (I don't recommend a bath; dirty water) dry off using a blow-dryer -(with a heat-control switch) to dry hair around groin area. Don't let get too warm here. (Reason: bacteria loves moisture).
4. Pay particular attention to foot care. Keep toe nails clean and clipped.
5. I use Sea Breeze on my toe nails, and moisturize with Clinique (yellow) Dramatically Different Moisturinzing lotion (it has salicytic acid in it-normally for face break-outs, it does something to keep the nails healthy.
(This advice is only if your feet are in general good health to begin with)
Otherwise, start with plain, non-scented soap and water and moisturizer. Moisturizers are different than water. After cleansing, they provide a "barrier" to the skin.
These steps are hugely important when wearing "compression garments". You don't need to put garments on over a dirty body. Skin infections are hard to heal on an affected limb. Prevention is key here.
6. Keep compression garments clean. Since they are right next to your skin, when clean, they can absorb sweat, and if dirty they will promote infection.
7. Keeping the legs or arm elevated when resting is a must. I sleep with a foam wedge under my legs. Do whatever you can to help stop the pull of gravity on them- the limb(s) need to be at a level above your heart.
8. If you work, take breaks every 30 min. to hour if you can. Moving around is good. When sitting, move your ankles in circular motions. Ask your boss for special privilege. Explain your issue with your manager.
9. Stay calm. The more fretful you get about things, the worse your lymphatic system will act. Talk it out, pray or meditate-whatever it takes.
10. Eat pure, fresh, whole foods as much as is within your means. Processed foods, and salt additives wreak havoc on lymphedema.

I would love to. Vodder (German) Manual Lymphatic Drainage (MLD) method is a fantastic, non-invasive way to move(decongest engorged vessels) lymphedema.

Light massage (with bare hands) is used first to massage clusters of "healthy, working lymph glands". On me, these are under my armpits, and along the sides, and on the frontal part of my torso (my upper body).

When I massage these good parts, they become "active" and "get moving" to allow the bottom part of my lymphatic system (which stays sluggish from scarring and hurt from radiation) to "move". In other words, it's kind of like a train car stopped on a track. No other trains can keep going, if this one disabled "car" won't move on. Or, like a stream that has a log in it causing it to be backed up, upstream. Same concept.

In clinic, once the fluid gets moving, a "wrap" method is usually done. It involves stretchy Ace-type bandages. It puts "pressure" on the limbs affected to encourage even more movement once the lymphatics are "awake"-so to speak. However, this part of the treatment must be done by trained professional (as should the other), because wrong wrapping can actually DAMAGE delicate lymph vessels, and can disrupt "blood pressure". The lymphatic system (a person's waterway) and blood system are inter-connected.

I cannot "wrap" myself, even though they taught me. A person must keep their limb (legs or arm) up above gravity while in treatment (above the heart) or it just does no good. It's really hard to do that part myself, so I just do the massage, and use the compression garments to keep it maintained.

It's an excellent method, and I would recommend it to anyone. I would not use another myself. I have been in touch with the man who runs the Vodder School over in Germany, and asked him if any US physicians had contacted him to be educated about it, and he said that "No- unfortunately physicicans in the US have been slow to catch on." (which is an understatement in my opinion) I don't understand why- it perplexes me.

The Vodder team does have teaching clinics here though, alot in Florida.

Learning to maintain the lymphedema saved my mind. At times I felt like it would "drown me". Getting control of it was a definite plus for me! I would love to. Vodder (German) Manual Lymphatic Drainage (MLD) method is a fantastic, non-invasive way to move(decongest engorged vessels) lymphedema.

Light massage (with bare hands) is used first to massage clusters of "healthy, working lymph glands". On me, these are under my armpits, and along the sides, and on the frontal part of my torso (my upper body).

When I massage these good parts, they become "active" and "get moving" to allow the bottom part of my lymphatic system (which stays sluggish from scarring and hurt from radiation) to "move". In other words, it's kind of like a train car stopped on a track. No other trains can keep going, if this one disabled "car" won't move on. Or, like a stream that has a log in it causing it to be backed up, upstream. Same concept.

In clinic, once the fluid gets moving, a "wrap" method is usually done. It involves stretchy Ace-type bandages. It puts "pressure" on the limbs affected to encourage even more movement once the lymphatics are "awake"-so to speak. However, this part of the treatment must be done by trained professional (as should the other), because wrong wrapping can actually DAMAGE delicate lymph vessels, and can disrupt "blood pressure". The lymphatic system (a person's waterway) and blood system are inter-connected.

I cannot "wrap" myself, even though they taught me. A person must keep their limb (legs or arm) up above gravity while in treatment (above the heart) or it just does no good. It's really hard to do that part myself, so I just do the massage, and use the compression garments to keep it maintained.

It's an excellent method, and I would recommend it to anyone. I would not use another myself. I have been in touch with the man who runs the Vodder School over in Germany, and asked him if any US physicians had contacted him to be educated about it, and he said that "No- unfortunately physicicans in the US have been slow to catch on." (which is an understatement in my opinion) I don't understand why- it perplexes me.

The Vodder team does have teaching clinics here though, alot in Florida.

Learning to maintain the lymphedema saved my mind. At times I felt like it would "drown me". Getting control of it was a definite plus for me!

Yes we do but at the health care system i go to alot of the Doctors don't know hardly anything about lymphedema. It has been an uphill struggle since diagnoses. I learned alot fast, and been told by Doctor's I was wrong, turns out they were. Have had to file complaints against a few. It's crazy!! Yes we do but at the health care system i go to alot of the Doctors don't know hardly anything about lymphedema. It has been an uphill struggle since diagnoses. I learned alot fast, and been told by Doctor's I was wrong, turns out they were. Have had to file complaints against a few. It's crazy!!

There are exercises developed by lymphedema experts specifically to decongest the swollen limb. They tend to combine stretching protocols with decongestion protocols utilizing the "muscle pump", that is, causing the major arm and leg muscles to slowly expand and contract and squeezing the skin against a compression garment or bandaging. There are a number of videos available demonstrating these specialized exercises.

Our favorite is the Video "Remedial Exercises For the Upper Extremities" by Klose Norton Training & Consulting is available for $34.95 + $5.00 s&h for NLN members, $39.95 + $5.00 s&h for non-members from:
National Lymphedema Network
1611 Telegraph Avenue, Suite 1111
Oakland, CA 94612-2138

Edema Exercises for Patients with Arm (Leg) Lymphedema by Dr. Vodder School in Austria

Focus on Healing through Movement & Dance by Sherry Lebed Davis which you can order thru the NLN 1-800-541-3259 $28.00 + 5.50 s/h for members, 32.95 + 5.50 s/h for non-members. Or you can order it from the producer, Enhancement Inc.1-800-366-6038 for 29.75 + 3.00 s/h.

Arm Exercises Video by Dr. Vodder School - North America, 2000.

Dr. Judith Casley-Smith, 94 Cambridge Terrace, Malvern SA 5061, Australia, E-mail: casley@enternet.com.au, includes swimming exercises for lymphedema in her book, "Exercises for Patients with Lymphedema of the Arm and a Guide to Self-Massage and Hydrotherapy". She also has one for the legs. You receive it when you order her "Exercise Video" for both arms and legs. Price for overseas including postage & insurance is Economy $60, Air $65. She asks that payment be in a personal check in your own currency on you own band, but please add $15 for conversion.

There are exercise routines described in some of the lymphedema books, but I favor the videos since the demonstrations are more understandable than the dry words and static sketches or photos.

Joe Zuther had an excellent article in his January 6, 2011 blog called "Decongestive and Breathing Exercises for Lymphedema."
There are so many benefits to exercise, especially for those with lymphedema. Exercise helps maintain a healthy weight, increases range of motion, and muscle contractions are a good way to keep the lymphatic fluid flowing throughout your body. If you are starting an exercise program or returning to exercise, there are some precautions to take to make sure you can continue to exercise while managing the lymphedema.

1. Always wear a compression garment while exercising. If you don't have one, call your hospital and get fitted for one. Also, Invest in a well-fitted bra, a tight bra can restrict the flow of fluid

2. Start with either exercise bands (don't wrap them around your hands) or light weights.

3. Alternate an upper body exercise with a lower body exercise. By alternating between the upper and lower body, you give the opposite body parts time to rest and time for fluid to move out of the affected area. For example, do bicep curls, then leg raises.

4. Listen to your body. Don't fatigue or strain the affected area, don't work through the pain. Stop if you feel tightness or swelling in the affected area. Start slow and work up to your former level of fitness.

My bonus tip for you: When I have a client with lymphedema, I will have them stop in between sets and massage themselves. I have them put their arm overhead and gently press (almost like petting) the area to aide in moving the fluid.

Let me know how you make out!!

For more information on exercise and cancer, go to http://www.movingonfromcancer.com

I've had lymphatic massage and a compression garments for my left arm to help with my lymphedema. »Interestingly enough, it was my osteopath who started loosening some on my arm and pectoral muscles that did the best job of all. I was an inch bigger in the upper arm before I saw him a few times and after a few weeks both arms were back to the exact same size. Now I wear my compression garment only for airflight. What a relief and do I need to tell you it's not very sexy during summer time! LOL Typically using lymphatic massage or compresion garments. Garments are offered FREE through http://crickettsanswerforcancer.com
Yes. I said FREE! :) Good luck!

Lymphedema in the breast cancer patient is caused by removal of axillary lymph nodes with subsequent inflammation and scar formation in the axilla. Radiation therapy further increases the chance of lymphedema. DIEP flap breast reconstruction does not result in more scarring in the axilla and should not cause or aggravate lympedema. With approximately 2000 DIEP breast reconstructions over the past 20 years, no patient has developed lymphedema as a side effect of this surgery.

In 2003 I began vascularized lymph node transfer to the axilla to reduce or eliminate lymphedema. In 2006 I combined the DIEP flap with lymph nodes the restore form and function by reconstructing the breast and treating the lymphedema in one operation. At an international microsurgery symposium I met Corinne Becker, MD. She has been successfully treating lymphedema with vascularized lymph node transfer for many years and is the world leader in this area.

The lady who posed the question is a candidate for combined DIEP/lymphnode transfer to restore both form and function.

Sincerely,
Bob Allen,MD Lymphedema in the breast cancer patient is caused by removal of axillary lymph nodes with subsequent inflammation and scar formation in the axilla. Radiation therapy further increases the chance of lymphedema. DIEP flap breast reconstruction does not result in more scarring in the axilla and should not cause or aggravate lympedema. With approximately 2000 DIEP breast reconstructions over the past 20 years, no patient has developed lymphedema as a side effect of this surgery.

In 2003 I began vascularized lymph node transfer to the axilla to reduce or eliminate lymphedema. In 2006 I combined the DIEP flap with lymph nodes the restore form and function by reconstructing the breast and treating the lymphedema in one operation. At an international microsurgery symposium I met Corinne Becker, MD. She has been successfully treating lymphedema with vascularized lymph node transfer for many years and is the world leader in this area.

The lady who posed the question is a candidate for combined DIEP/lymphnode transfer to restore both form and function.

Sincerely,
Bob Allen,MD

We primarily have experience using perforator flaps for breast reconstruction, so I’ll answer from that perspective. Arm lymphedema does not directly affect breast reconstruction, although there are reports of arm lymphedema improving after reconstruction using your own tissue (such as DIEP, GAP, or other perforator flaps). Trunk lymphedema (including breast), while not affecting the survival of the flap, can result in prolonged edema of the breast skin overlying the flap, leaving the reconstructed breast with a heavy, “wooden” character. We have seen this edema gradually resolve in some patients, however, over a period of up to two years, and it is possible that the flap is actually helping with this.

Richard M. Kline Jr., M.D. We primarily have experience using perforator flaps for breast reconstruction, so I’ll answer from that perspective. Arm lymphedema does not directly affect breast reconstruction, although there are reports of arm lymphedema improving after reconstruction using your own tissue (such as DIEP, GAP, or other perforator flaps). Trunk lymphedema (including breast), while not affecting the survival of the flap, can result in prolonged edema of the breast skin overlying the flap, leaving the reconstructed breast with a heavy, “wooden” character. We have seen this edema gradually resolve in some patients, however, over a period of up to two years, and it is possible that the flap is actually helping with this.

Richard M. Kline Jr., M.D.

Sentinel node dissection reduces the rate of upper limb lymphedema, but the following breast irradiation brings with it an increased rate of breast lymphedema, which is more difficult to manage because of the absence of a muscle pump to aid in the draining of affected areas, the difficulty in providing compression, and the severe risk of recurrent infection (delayed breast cellulitis). Currently, there is no cure for lymphedema.
Lymphedema can be treated in several ways. Mild lymphedema can be treated by elevating the affected limb and the use of compression bandages. More severe lymphedema requires additional wrapping and is treated by lymphedema specialists. Exercise is also part of both prevention and treatment of lymphedema. Fortunately, lymphedema is less common due to the use of sentinel lymph node biopsy, which reduces the risk of lymphedema developing.

Watch a video about lymphedema and lymphedema treatment. http://www.cancerquest.org/lymphedema-introduction
Read about lymphedema treatment. http://www.cancerquest.org/treatment-for-lymphedema

The widespread use of tangential breast irradiation for local control of recurrence has brought a new kind of lymphedema, different from the upper limb lymphedema commonly related to axillary surgery and radiation -- BREAST LYMPHEDEMA. The incidence of breast lymphedema, sometimes referred to as "delayed breast cellulitis" has been found to be on the order of 23% (clinical) and over 70% preclinical (Reference Rönkä 2004-5 and other investigators). So the reduction of number of nodes dissected for staging has reduced the risk of upper limb lymphedema from 24 to 7 percent, but the adjuvent radiotherapy to the breast increases risk of breast lymphedema a similar amount. Yes, it is; though the risk for lymphedema is markedly reduced with sentinel node biopsy compared to full axillary dissection.

In addition to degree of dissection, other risk factors for lymphedema have been identified: obesity, advanced age and extensive axillary involvement with tumor.

Lymphedema is a major problem , however its incidence has fallen dramatically with the sentinel node biopsy technique. It will continue to fall with results of a recent study demonstrating no recurrence or survival difference in patients with two positive nodes whether they did or did NOT have a full node dissection. Lymphedema is a major problem , however its incidence has fallen dramatically with the sentinel node biopsy technique. It will continue to fall with results of a recent study demonstrating no recurrence or survival difference in patients with two positive nodes whether they did or did NOT have a full node dissection.

Reverse Axillary Mapping is a brilliant idea (in a string of brilliant ideas) from Dr. Suzanne Klimberg - a professor of surgery at the University of Arkansas in Little Rock. In addition to mapping the breast to find the sentinel nodes that drain the breast, she thought 'Why don't we map the arm lymphatics at the same time and avoid injuring them?' This decreases the chance of getting lymphedema of the arm (swelling caused by extra fluid in the arm because the outflow has been disturbed). In her series of patients, she has a very low incidence of arm swelling.

The technique involves injecting a small amount of blue dye in the upper inner aspect of the arm. The blue lymphatics that drain the arm can then be identified and avoided at the time of sentinel lymph node biopsy (unless clinically full of cancer). The breast sentinel nodes are identified by injecting the breast with a radioactive dye that drains and makes the sentinel nodes slightly radioactive. These radioactive lymph nodes are identified with a gamma radiation detector and removed at the time of surgery. Reverse Axillary Mapping is a brilliant idea (in a string of brilliant ideas) from Dr. Suzanne Klimberg - a professor of surgery at the University of Arkansas in Little Rock. In addition to mapping the breast to find the sentinel nodes that drain the breast, she thought 'Why don't we map the arm lymphatics at the same time and avoid injuring them?' This decreases the chance of getting lymphedema of the arm (swelling caused by extra fluid in the arm because the outflow has been disturbed). In her series of patients, she has a very low incidence of arm swelling.

The technique involves injecting a small amount of blue dye in the upper inner aspect of the arm. The blue lymphatics that drain the arm can then be identified and avoided at the time of sentinel lymph node biopsy (unless clinically full of cancer). The breast sentinel nodes are identified by injecting the breast with a radioactive dye that drains and makes the sentinel nodes slightly radioactive. These radioactive lymph nodes are identified with a gamma radiation detector and removed at the time of surgery.