My mother, age 76, just had a second mastectomy in 18 months. The surgeon removed the breast and some lymph nodes under the arm in both cases. We have heard that she has to be cautious with her arms now, but we are not getting precise information about how and why, or what could result. Can you give us detailed information or point us in the right direction to obtain info about what activities are tolerated? What symptoms should we watch for? What about injuries -- especially minor nicks and cuts?

--Beth

The reason your mom needs to be careful about her arms is that removal of the lymph nodes interferes with the drainage of lymph from the arms. Lymph is the colorless fluid that bathes the body's cells. When lymph nodes are removed during breast cancer surgery, many of the channels that drain lymph are cut as well. This can disrupt the flow of lymph and allow the fluid to build up in the arms. The result is a swelling of one or both arms, a condition called lymphedema. The accumulated fluid is rich in protein and is an excellent medium for bacteria to grow in.

Pressure on the arm should be avoided (for example, taking a blood pressure reading) because this can further damage the lymph channels, leading to more swelling. Blood pressure can be taken in the legs if necessary. Blood draws and injections (or anything else involving a needle stick, such as acupuncture or tattoos) should also be avoided in the affected limbs, as penetration of the skin could introduce bacteria and lead to infection. Bug bites, nicks or cuts should be treated with an over-the-counter antibiotic ointment. Any signs of infection (pain, redness, warmth) should be reported to the doctor immediately so oral antibiotics can be given.

There is some suggestion that antibiotics should be given with dental work or gynecologic procedures (not including a Pap smear, though) to lower the risk of infection; this is because bacteria from the mouth or genital tract may enter the bloodstream during the procedure and take root in the protein-rich lymph fluid.

Women who have had sentinel node biopsy only (in which only one node is removed) do not have to take all these precautions. These steps are meant for women who have had multiple lymph nodes removed.

An excellent resource is the website of the National Lymphedema Network. Physical therapy and exercises can also help diminish excess fluid buildup. Many hospitals have special programs for women with breast cancer -- check with your doctor or the local branch of the American Cancer Society in your community for available therapy programs.