MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

I have mentioned lymph drainage before. It is a gentle massage technique applied along the lymph vessels and nodes to stimulate lymph flow. All sorts of extraordinary claims are made for this treatment. In  particular, lymphoedema after surgery for breast cancer, which can be a debilitating complication, is claimed to be preventable with this approach. This seems vaguely plausible, but does it really work?

This study tested whether manual lymphatic drainage (MLD) or active exercise (AE) are associated with improvements in shoulder range of motion (ROM), wound complication and changes in the lymphatic parameters after breast cancer (BC) surgery, and whether these parameters have an association with lymphoedema formation in the long run.

The researchers conducted a clinical trial with 106 women undergoing radical BC surgery. Women were matched for staging, age and body mass index and were allocated to AE or MLD, twice weekly during one month after surgery. The wound was evaluated two months after surgery. ROM, upper limb circumference measurement and upper limb lymphoscintigraphy were performed before surgery, and 2 and 30 months after surgery.

The incidence of seroma, dehiscence and infection did not differ between groups. Both groups showed ROM deficit of flexion and abduction in the second month postoperative and partial recovery after 30 months. Cumulative incidence of lymphoedema was 23.8% and did not differ between groups (p = 0.29). Concerning the lymphoscintigraphy parameters, there was a significant convergent trend between baseline degree uptake (p = 0.003) and velocity visualization of axillary lymph nodes (p = 0.001) with lymphoedema formation. A reduced marker uptake before or after surgery predicted lymphedema formation in the long run (>2 years). None of the lymphoscintigraphy parameters were shown to be associated with the study group. Age ≤39 years was the factor with the greatest association with lymphedema (p = 0.009). In women with age ≤39 years, BMI >24Kg/m2 was significantly associated with lymphedema (p = 0.017). In women over 39 years old, women treated with MLD were at a significantly higher risk of developing lymphedema (p = 0.011).

The authors concluded that lymphatic abnormalities precede lymphedema formation in BC patients. In younger women, obesity seems to be the major player in lymphedema development and, in older women, improving muscle strength through AE can prevent lymphedema. In essence, MLD is as safe and effective as AE in rehabilitation after breast cancer surgery.

I am not sure I agree with these conclusions; to me, they seem a bit over-optimistic. The results fail to show that MLD is clinically effective, as both AE and MLD might be equally ineffective. In fact, in the discussion section of the paper the authors state that their study suggests that AE may be more effective than MLD for the prevention of lymphedema in women older than 39 years.

So far, only very few controlled clinical trials tested the MLD effects in the prevention of lymphedema after  breast cancer. Some suggested that MLD administered early in the postoperative period can effectively prevent lymphedema, whereas others failed to find positive effects of MLD. Thus the question whether MLD is effective for lymphoedema after breast cancer remains open.

For once, the call for more and better research seems justified.

7 Responses to Lymph-drainage: we need more and better research

  • I’m not really sure why manual lymphatic drainage is being discussed in an alternative medicine Web site. It is a standard treatment for established upper-limb lymphoedema after treatment for breast cancer, which is a very difficult problem to manage, and it is used in addition to compression sleeves (which are very uncomfortable). The main problem is that the services available to NHS patients are in high demand and the waiting lists are long, and when I was working MLD was provided locally by the palliative care system.

    I haven’t come across it as prophylaxis against lymphoedema, though from reading this paper it doesn’t appear to be any better than exercise, which is much cheaper and easier to implement. The authors freely discuss the limitations of their study, including the very important fact that it was not randomised.

    Probably the most interesting piece of information in the paper is that the pre-operative drainage of the limb, as measured by scintolymphography, appears to be predictive of the risk of subsequent lymphoedema. This is worth further investigation, as if it is true it may inform oncological treatment decisions (such as radiotherapy technique and dose).

    The two main risk factors for lymphoedema after breast surgery are well established. These are irradiation of the lymph nodes, and level of lymph node dissection. The current standard of care is sentinel node biopsy, which involves identifying the lymphatic drainage of the tumour using a radioactive marker, then biopsying the first few nodes, examining them immediately (using a “frozen section” to prepare the specimen quickly) and only extending the dissection if the “sentinel node” is involved.

    One thing that struck me about this paper was the sub-optimal oncological treatment that the subjects had received. Thankfully none had had a Halstead mastectomy – this mutilating operation, involving removal of the underlying ribs as well as the breast, was dropped in the UK before I qualified as a doctor in 1986, and I am rather worried that it was even mentioned in the trial. Neither are modified radical mastectomies performed very much these days, many tumours being amenable to wide local excision of the lump followed by radiotherapy to the breast. I was also surprised at the number of patients who had their supraclavicular fossae irradiated as this is something else that we try to avoid (due to the risk of overlapping field boundaries at the brachial plexus, which can lead to brachial plexopathy, a much more serious problem than lymphoedema).

    Coming back to manual lymphatic drainage as treatment for lymphoedema, as opposed to prevention, although it is widely used I don’t know to what extent it has been subjected to good trials. In my experience patients seem to find it helpful, but the improvements certainly aren’t dramatic. I think there is a need for more data here.

  • I achieved my certificate from
    http://www.lymphologicum.de/das-lymphologicum/netzwerkfibel/die-autoren/oliver-gueltig.html
    at Kneipp School for Physical Therapists
    https://www.kneippschule.de
    And we were told to follow a standard including (in Germany called:)
    ML / KPE (komplexe physikalische Entstauungstherapie means lymphatic or phlebologic compression bandage and other special supply articles ) I don’t know wether this is a standard known outside of German speaking countries at all. MLD alone doesn’t make sense.

  • A dear friend of mine was suffering from terminal cancer (and died just over 12 months ago) and when I mentioned it to an acquantaince, she suggested lymphatic drainage as a possible cure because her sister ‘does it’. I don’t recall speaking to that person again, voluntarily.

    In some people’s minds, LD is far more capable than the scant information suggests. Then again, the feeble-minded will believe in anything without evidence.

    • My wife’s niece emailed saying asparagus juice (as recommended by a doctor who has no footprint in reality) would be helpful against her breast / liver cancer.
      Similarly, this is a person who I’ve no intention of meeting again.
      Characteristic of such buffoons is the “I want to remember him / her how (s)he was” excuse for not visiting in their final months. BS tarnishes grief, too.
      Sorry to hear of your sadness, Frank.

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