A 56-year-old woman diagnosed with cancer in her left breast underwent a mastectomy with axillary lymph node dissection. Postoperatively, she develops marked swelling of the left arm that has persisted for 6 months. Now on physical examination, her temperature is 36.9deg C. Her left arm is not tender or erythematous, and it is not painful with movement or to touch, but it is enlarged with a doughy consistency. Which of the following is the most likely mechanism for these findings?
The surgery disrupted lymphatic return, resulting in functional lymphatic obstruction and lymphedema of the arm. The lymphatic channels are important in scavenging fluid and protein that have leaked into the extravascular tissues from the intravascular compartment. Although the amount of fluid that is drained through the lymphatics is not great, it can build up gradually. Cellulitis is caused by an infection of the skin and subcutaneous tissue, and displays erythema, warmth, and tenderness. Congestive heart failure can lead to peripheral edema, which is most marked in dependent areas such as the lower extremities and over the sacrum (in bedridden patients). Decreased plasma oncotic pressure from hypoalbuminemia, or sodium and water retention with heart or renal failure, leads to more generalized edema. Phlebothrombosis leads to swelling with pain and tenderness, but it is uncommon in the upper extremities.
Cellulitis
Congestive heart failure
Decreased plasma oncotic pressure
Lymphedema
Hemodynamics