Breast cancer is one of the most frequent causes of mortality among women, with a high incidence in both developed and developing countries (1,2). Fifty percent of breast cancer cases are diagnosed at an advanced stage and include lymph node metastatic infiltration, necessitating more aggressive and costly treatment (3) and increasing the risk of post-treatment complications (4–8).

Aggressive surgery in advanced stage breast cancer cases interrupts the main lymphatic drainage route in the upper limbs and is the most important factor in the formation of lymphedema (5). The pathogenesis of post-mastectomy lymphedema associated with axillary dissection is in particular attributed to the small number of lymphatic vessels in the dissected area (9,10). According to Glass et al, the more extensive the axillary dissection, the greater the risk of complications (11).

Once lymphedema has become established, it is incurable. Neither surgical nor drug treatments for lymphedema have shown success (12,13). However, lymphedema can be avoided, treated and controlled with daily preventive measures (14). The prevention of lymphedema has been attempted using intraoperative techniques that take a more conservative approach towards the axillary chain, such as the investigation of the sentinel lymph nodes. Through this, selective resection that is safe and less mutilating becomes possible, with satisfactory results, although it is limited to patients without evidence of lymph node macrometastasis (5,7,15–17).

Preventive measures, such as lymphatic self-massage, hydration, kinesiotherapy, manual lymphatic drainage and the use of elastic compression armbands, have been gaining increasing attention (12,18). None is more important than the others, but used together they may be effective in controlling and preventing lymphedema. The only requirement is that the patient must be taught how to carry out the procedures on a daily basis (18–21). Self-massage, also known as simple manual lymphatic drainage, is a version of manual lymphatic drainage in which the patient learns the procedure and is able to perform it alone, at home. It involves a series of gentle circular movements, starting with stimulation of the axillary lymph node chain contralateral to the surgical manipulation and of the inguinal chain homolateral to the surgical manipulation. This is followed by gentle movements at a site distant from the area of congestion, moving gradually towards the swollen limb (12,18,22,23).

Lymphoscintigraphy is an effective technique for evaluating the lymphatic systems of the upper and lower limbs (5,24,25). It provides functional information regarding drainage and obstruction in this system, with details on the morphology of the lymph vessels and lymph nodes (26). In relation to lymphedema following radical mastectomy, lymphoscintigraphy has only been used to assess lymphedema that has already become established. In such cases, it is performed before and after physiotherapy (26–29) in order to investigate the effectiveness of the therapy.

This study was inspired by the notion that the prevention of lymphedema is the most effective way to diminish morbidity, and that physiotherapeutic measures should begin as early as possible for breast cancer patients undergoing axillary dissection. It was in particular motivated by the scarcity of the literature on the subject, and aimed to evaluate the effectiveness of early physiotherapeutic stimulation on lymph flow progression in these breast cancer patients.

This randomized experimental study included 22 women who underwent radical mastectomy or quadrantectomy associated with ipsilateral axillary lymph node dissection between 2005 and 2008. Patients were over 18 years of age and had unilateral breast cancer. They were seen between 15 and 60 days after surgery, and presented arm range of motion corresponding to more than 120° of shoulder flexion. Patients were excluded if they had undergone previous chemotherapy or radiotherapy, if they were known to have had lymphatic disease prior to the axillary dissection, if they presented inflammatory or infectious processes associated with the upper limb, or if the lymphoscintigraphy results could not be analyzed.

Patients gave their free and informed consent for participation in the study. The study was approved by the Research Ethics Committee of Barretos Cancer Hospital.

The 22 patients underwent two lymphoscintigraphy examinations, for a total of 44 procedures. The first examination on each patient was performed between 15 and 60 days after surgery. This was considered to be a control examination, and was performed without physiotherapeutic stimulation. The second examination was performed 7±3 days after the first. For this second examination, the patients were randomized into two groups: the ‘with physiotherapeutic stimulation’ (WPS) group, in which patients received physiotherapeutic stimulation while the lymphoscintigraphy examination was being conducted, and the ‘without physiotherapeutic stimulation’ (WOPS) group, in which patients received an examination under conditions similar to the first.

Among the 22 patients studied, 12 were in the group which received physiotherapeutic stimulation (WPS) and 10 were in the group which did not (WOPS). The two groups were homogenous in terms of the medians of the variables: age in years (47.5 vs. 52.0; p=0.198), weight in kilograms (65.6 vs. 64.2; p=0.373), height in meters (1.60 vs. 1.52; p=0.080), body mass index in kg/m² (26.7 vs. 26.3; p=0.843) and number of lymph nodes dissected (17.5 vs. 18.0; p=0.691).

An association between physiotherapeutic stimulation and the positive progression of lymphatic flow was present in all three phases of the lymphoscintigraphic examinations. The images of the dynamic and static phases were more representative of the stimulation than the later whole body scan phase (Table I).

In the WPS group, a significant increase in the number of lymph nodes between the first and second whole body scan examination was observed (p=0.007). In the WOPS group, there was no significant difference between the medians (p=0.102) (Table II).

A significant increase in the velocity of the lymphatic flow between the first and second examination was observed in the WPS group compared to the WOPS group, as represented by the difference in the median angular coefficient ratio of the second examination compared to the first examination (p=0.014) (Table III).

Additional analysis of the drainage bundles in the upper limb showed a predominance of lymphatic flow progression through the cephalic bundle in both groups, which was intensified after physiotherapeutic stimulation. Progression through the basilic bundle as the only route was less frequent than progression through both bundles simultaneously (Table IV).

With advances in breast cancer treatment and consequent increases in survival rates, quality of life has become a major concern for breast cancer patients (31). The occurrence of post-mastectomy lymphedema predisposes individuals to incapacitating diseases, with great socioeconomic impact (10,16). Early diagnosis and intervention, such as skin care (19,32), kinesiotherapy and self-massage (12,18,19), may significantly reduce the incidence of complications (32). Research on improving quality of life has indicated that the prevention of lymphedema is the best strategy for breast cancer patients. Prior knowledge of normal lymphatic circulation and its changes in the presence of obstruction has directed techniques of physiotherapeutic stimulation. Various lymphatic drainage techniques have been used for stimulating lymphatic flow and treating lymphedema, such as those proposed by Vodder, Leduc and Földi. The technique proposed by Földi (23) was chosen for the present study, since it is routinely used at our institution.

Although several studies have used lymphoscintigraphy to document the behavior of lymphedema and to make before and after treatment comparisons (26–29), there is a lack of documentation regarding the immediate postoperative period. The effects of physiotherapeutic stimulation during this period motivated the present investigation. The aim of the study was to evaluate whether manual physiotherapeutic stimulation, which can easily be performed by patients themselves, might improve the progression of lymphatic flow.

We observed that the technique of early physiotherapeutic stimulation was effective regarding lymphatic flow progression in the WPS group compared with the WOPS group. In this respect, several authors have reported increased lymphatic transportation using the same procedure (33–36) among patients with established lymphedema.

As shown in Table I, all patients except one showed the progression of lymphatic flow to the lymph node chain, even if this occurred at a later stage. The one exception did not present progression even with stimulation; however, this patient had the greatest number of lymph nodes dissected (n=34). This finding is concordant with Clodius et al (9), who reported that the pathogenesis of the lymphedema is attributed to the presence of fewer lymphatics in the dissected area.

There are two common drainage routes in the upper limbs: the basilic route, which feeds into the axillary lymph nodes, and the cephalic route, in the apical lymph nodes. There are also two infrequent routes, the cervical and internal mammary routes (30,37,38). The lymphatic vessels of the upper limbs flow out into the lymph nodes of the axillary region (37,38), and therefore the basilic route is the principal drainage route. In the event of obstruction in the axillary region, the drainage route along the cephalic vein becomes important. This was observed in our study: patients in the WPS group showed this collateral route, while patients in the WOPS group did not.

As a strategy for stimulating lymphatic circulation in cases of the obstruction of normal lymphatic flow, alternative routes need to be considered, such as the cephalic route. Furthermore, anastomoses of the lymphatic capillaries need to be considered. These deviate lymphatic flow in a direction opposite to the normal course (38), thereby stimulating an alternative drainage route. In a systematic review, Moseley et al concluded that, although self-massage only promoted a small reduction in the volume of the limb, this was more beneficial than doing nothing for the swollen limb (35). Williams et al also reported that the technique was important when no treatment for lymphedema was available (18).

Considering that inflammation due to surgical aggression hinders the passage of lymphatic drainage (39) and causes increased limb volume, protein stagnation and the risk of complications, the findings from our study reinforce the need to stimulate early lymphatic drainage. Self-massage is a technique that is easy for patients to perform, and they should be given guidance in this respect by the professionals involved in rehabilitation.