Lactnet friends,

Several weeks ago, Darlene wrote:

<I have permission to post about a colleague who had a right upper quadrant
breast resection followed with radiation completed one year ago, for DCIS.
 She is now pregnant for the first time, 4 months.  She is experiencing a
lot of uneven swelling and significant pain in the right breast.  Left
breast is getting larger, nipple changing, but no pain.

Has anyone had other clients with breast complaints post-radiation?  What is
the likelihood of her being able to breastfeed on the affected breast?

 Thank you,
 Darlene Coyne, IBCLC, APRN, BC>
Darlene says she has received no other replies other than my private reply
to her. On the off chance that any others might be interested, I have
decided to post my reply to her. I have added a few extra thoughts since I
wrote it to her.

<No, I can't say I have had a client with such a problem. But I have sort of
a hobby of reading about breast anatomy, and have also done some reading on
lymphedema, so I thought I might just share a few thoughts with you.

50% of the milk making tissue is in the upper outer quadrant of the breast.
So it would be logical to expect, depending on how much of the right upper
outer quadrant was removed and ducts interrupted from the Tail of Spence,
that her right breast would now be expected to produce (and be able to
transfer) at least that much less milk, even if she chooses to continue to
lactate on that side. The inner upper quadrant, if I remember, produces
about 25 %, and the lower two quadrants together make up the remaining 25%.
Some lymph nodes may have gotten removed with the other tissue. Although
some ducts from the tail of Spence might have been interrupted, perhaps we
could presume that none of the ducts in the other quadrants were interrupted
by the surgery if it was confined to the RUOQ.

She will of course, begin to lactate at first because it will happen in
response to the drop in placental hormones. I would definitely encourage her
to think about trying to breastfeed on the affected breast, with your
written plan and close follow-up, perhaps with the application of ice packs
for 20 minutes q.2-3 hours over the Tail of Spence. However, should she
choose to do so at any point in the process, it is entirely possible to
involute a breast gradually and feed a baby on one breast only, as is done
by the boat women in China, and in other cases I have heard about in cases
of abcesses on one side, etc. This would still require initial management of
engorgement on the right side, perhaps with ice packs as above, during the
height of swelling, with some minimal, slowly-decreasing milk removal over
the first several weeks till involution seems to be occurring comfortably. I
recommend being very careful about breast pumping, at least till after 2
weeks, perhaps using hand expression.

Surgery itself, and the resultant scarring, interrupts lymphatic drainage
channels. I believe I read somewhere that radiation also causes a certain
amount of this, too. It may have been impossible to avoid removing some
lymph nodes too during the procedure. So I would expect that there would be
a tendency toward lymphedema and that may well be responsible for some of
the lumpiness and pain you describe in the right breast. The left breast
sounds as if it is proceeding with normal pregnancy development.

At this time, I suggest referral to a physical therapist trained in
lymphatic drainage of the breast in breast cancer patients. Perhaps some
assessment of the potential for lymphedema during the pregnancy itself would
be in order, and treatment might bring some comfort, while the education she
receives, and her comfort using those techniques might make it easier for
her to manage engorgement and to make her final decision. The patient has a
right to request the surgical operation sheet and the pathology sheet if she
wishes the PT to help her explore the extent and location of the tissue
removed in relation to the Tail of Spence, including information about lymph
nodes. This information might also be helpful in your management of
engorgement on the right side.

(I hope that you know/learn about and teach her prenatally the technique I
developed called Reverse Pressure Softening [RPS], so as to be prepared to
use it on at least the L. nipple-areolar complex [NAC]. I would recommend it
be used from birth [not waiting for any swelling to begin] onward through
the first 2 weeks of lactation, so that the areola be at its most pliable at
every feeding from birth, and that latching and initiation of breastfeeding
would go smoothly on at least the unaffected side from the very beginning.
I suggest providing the PT, and perhaps her OB, with a copy of my article on
RPS in Vol. 20, May 2004 JHL so she could give further guidance as to
whether or not to use RPS on the affected side. Since this mother's
potential for drainage of interstitial fluid is potentially compromised by
the surgery and possibly the radiation, for her sake, I hope she negotiates
with the physician not to receive a lot of IV fluid, particularly IV Pitocin
induction, because of the potential for it to cause excess interstitial
fluid that often complicates normal engorgement.This effect of excess IV
fluid on the Colloid Osmotic Pressure and the production of excess tissue
fluid, is thoroughly explained in the article.)

If pumping is used, I recommend the vacuum be no higher than medium, and
that sessions be short and more frequent, so as not to attract excess
interstitial fluid toward the NAC. With the permission of the PT, the
possible use of RPS for 1-2 minutes before each pump session on the affected
side would also be helpful in avoiding complications in the NAC area.

In the US, I don't believe any medication to totally suppress lactation is
given any more, due to side effect complications from the various drugs. I
think I heard of one in Europe calle Cabergoline, but I know nothing else
about it. But I hope she would not even consider suppressing all lactation
and missing the joys of breastfeeding. I have a feeling you will give her
every encouragement to proceed with normal initiation of lactation, with
expectations on managing swelling tempered by the guidance of the PT.

I hope my thoughts have been somewhat helpful.

K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA>

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