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Letters to the Editor  |   March 2006
Postmastectomy Lymphedema: A Call for Osteopathic Medical Research
Author Affiliations
  • KEN S. OTA, OMS II
    Western University of Health Sciences College of Osteopathic Medicine of the Pacific Pomona, California
Article Information
Osteopathic Manipulative Treatment / OMT in the Laboratory
Letters to the Editor   |   March 2006
Postmastectomy Lymphedema: A Call for Osteopathic Medical Research
The Journal of the American Osteopathic Association, March 2006, Vol. 106, 110-111. doi:
The Journal of the American Osteopathic Association, March 2006, Vol. 106, 110-111. doi:
To the Editor: Up to 40% of patients with breast cancer who have undergone traditional mastectomy with axillary lymph node dissection can experience postmastectomy lymphedema.1 Postmastectomy lymphedema most commonly presents as an obvious swelling of the upper arm on the side of the mastectomy, with impaired functionality of the limb. In addition to commonly noted local infections, this condition can lead to severely debilitating consequences if left untreated.1 
It is generally understood that imbalances between capillary filtration and lymphatic drainage are responsible for the physical manifestation of lymphedematous states.2 When the lymphatic flow is impaired (owing to events such as surgery, trauma, infection, and/or inflammation), excess fluid and protein accumulate in the interstitial space. However, the literature demonstrates additional evidence that hemodynamic factors at the site of lymphedema may also play a role in postmastectomy lymphedema.24 
Swartz et al5 suggest that the “driving force for [new lymphatic vessel development] is the need for organized interstitial fluid flow.” Considering this, postmastectomy lymphangiogenesis may be a repair mechanism that restores the optimal interstitial fluid flow. If this mechanism does occur, it may be subject to dysfunction in patients with postmastectomy lymphedema. Therefore, treatments aimed at facilitating optimal lymphatic system functioning may be of benefit in this population. 
Various treatment modalities have been studied for postmastectomy lymphedema. Some investigators conclude that surgery is effective,6,7 while others have found that physiotherapeutic techniques, such as lymphatic drainage, significantly reduce the severity of postmastectomy lymphedema.8,9 Considering the effectiveness of physiotherapeutic management8,9 and the invasiveness of surgery, it behooves the osteopathic physician to consider osteopathic manipulative treatment (OMT), specifically, lymphatic pump techniques, for this patient population. Some clinicians may question whether these techniques would be indicated for this condition due to the risk of metastasis. Of course, such osteopathic manipulative techniques should be used with sound medical judgment in these patients.10 It may be best to confirm that there is no residual cancer prior to initiating OMT. Furthermore, other contraindications for lymphatic pump techniques (ie, congestive heart failure) should be kept in mind during patient evaluation. 
Although it is suggested that lymphatic pump techniques can be used in patients with postmastectomy lymphedema,10 there are currently no studies regarding the effect of specific OMT modalities on postmastectomy lymphedema. It is crucial for the osteopathic medical community to have evidence-based clinical data to refer to when considering the appropriate OMT regimen for patients with postmastectomy lymphedema. As such, osteopathic clinicians and researchers may want to implement a study design specific to this topic to not only provide such clinical data to fellow physicians, but also to heighten the awareness of this relatively prevalent pathologic condition. 
Manipulation of the lymphatic system is an important component of osteopathic medicine. Thus, as agents of the osteopathic medical profession, we must strive to be at the forefront of research concerning treatments for lymphatic impairment. As Andrew Taylor Still, MD, DO,11 so eloquently wrote, the lymphatic system is that “which supplies the water of life.” 
Revis RR. Lymphedema. [eMedicine.com Web site]. October 25, 2005. Available at: http://www.emedicine.com/med/topic2722.htm. Accessed January 19, 2006.
Mortimer PS. The pathophysiology of lymphedema [review]. Cancer. 1998;83(12 suppl American): 2798–2802.
Djavanmard MP, Michl I, Korpan M, et al. Impaired hemorheology in patients with postmastectomy lymphedema. Breast Cancer Res Treat. 1996;38:283 –288.
Knott EM, Tune JD, Stoll ST, Downey F. Increased lymphatic flow in the thoracic duct during manipulative intervention. J Am Osteopath Assoc. 2005;105:447 –456.
Swartz MA, Boardman KC Jr. The role of interstitial stress in lymphatic function and lymphangiogenesis [review]. Ann NY Acad Sci. 2002;979:197 –210; discussion 229–234.
Liu Q, Zhou X, Wei Q. Treatment of upper limb lymphedema after radical mastectomy with liposuction technique and pressure therapy. [In Chinese] Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi.. (2005). ;19:344 –345.
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Didem K, Ufuk YS, Serdar S, Zumre A. The comparison of two different physiotherapy methods in treatment of lymphedema after breast surgery. Breast Cancer Res Treat.. (2005). ;93:49 –54.
Foldi E, Foldi M, Clodius L. The lymphedema chaos: a lancet. Ann Plast Surg.. (1989). ;22:505 –515.
Opipari MI, Perrotta AL, Essig-Beatty DR. Oncology. In: Ward RC, ed. Foundations of Osteopathic Medicine. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003;473 –474.
Still AT. The Philosophy of Osteopathy. 1899. Version 2.0. Inter Linea Web site. Available at: http://www.interlinea.org/atstill/eBookPhilosophyofOsteopathy_V2.0.pdf. Accessed February 13, 2006.