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BREAST CANCER: TREATING LYMPHEDEMA

Advances in managing and treating lymphedema

Fighting cancer comes with many challenges, both emotional and physical, from confronting the diagnosis, to choosing a treatment plan, to undergoing the procedures designed to fight the disease. For many cancer patients, the side effects that come with treatment can prove life-changing, too. Lymphedema is one such symptom that can impact patients who undergo surgery or radiation, with sometimes-lasting effects. But advances in the field offer new options for an improved quality of life.

Lymphedema occurs when lymphatic fluid accumulates, causing painful and sometimes-debilitating swelling under the skin. The fluid buildup occurs most frequently in the arms or legs, often as a result of disease or treatment that damages or removes one or more lymph nodes. The standard of care for managing lymphedema includes physical therapy, manual lymph drainage, light massage and exercises to help stimulate the lymphatic system and reduce swelling. Patients may also wear compression garments, such as sleeves or bandages, or use pumps to lessen further fluid buildup.

For some patients, though, standard therapies don't bring sufficient relief. In those cases, when the swelling and discomfort persist for six to 12 months despite therapeutic intervention, emerging microsurgical procedures may be an option. "Advancements in microsurgery have expanded treatment options for patients who do not respond to physical therapy alone," says Dr. Daniel Liu, a Plastic and Reconstructive Surgeon at our hospital outside Chicago. "These innovative procedures hold great promise."

The lymph node transfer

One option is the vascularized lymph node transfer surgery, an intricate microsurgery that may help patients with advanced cases of lymphedema that leave the affected area misshapen from pronounced swelling. In such cases, when lymphatic fluid has built up over time, the skin can harden and thicken. The lymph node transfer aims to address these symptoms by removing healthy lymph nodes from one part of the body and transplanting them to the site of the missing or damaged lymph nodes. "For example, in a woman who's been treated for breast cancer and missing working lymph nodes in the armpit, we often borrow good lymph nodes from the groin area and transfer them, along with blood supply, to the armpit," says Dr. Liu. Reconstructive surgeons divide the blood vessels supplying the harvested lymph nodes and reconnect them at the lymphedema site. Dr. Liu likens the procedure to an organ transplant, only this one is performed entirely on the same body.

The procedure typically lasts three to four hours and involves a special dye used to illuminate the lymph nodes. Using a high-powered microscope, doctors perform a procedure called reverse lymphatic mapping to reduce the risk of lymphedema at the harvest site. "We use very sophisticated techniques to properly reconnect the blood vessels and lymph channels in the healthy tissue so that excess lymph fluid can drain away," says Dr. Liu, who performs the lymph node transfer with the assistance of another highly trained microsurgeon. By combining the expertise of two doctors, the procedure can be shortened, allowing the patient to spend less time on the operating table and under anesthesia. While the surgery will not eliminate lymphedema completely, it may offer welcome relief.

The lymphaticovenular bypass

Another surgical option, called the lymphaticovenular bypass, connects a small number of lymphatic vessels in the affected area directly to tiny blood vessels in the same area. The rerouting is designed to increase the flow of lymphatic fluid into the bloodstream in order to reduce swelling.

Unlike the lymph node transfer, which is designed to treat advanced lymphedema, the bypass is more appropriate for patients in the early stages of lymphedema, when symptoms such as mild tingling, swelling or heaviness may develop. During this stage, a slight dent in the skin may be noticeable when the affected area is pressed with a finger. This is called pitting edema and occurs when protein-rich lymphatic fluid begins to accumulate under the skin. The lymphaticovenular bypass is designed to relieve the swelling that causes the edema and other lymphedema-related discomfort. "Bypass surgery is easier to recover from because it is much less invasive than transfer surgery, but lymphaticovenular bypass is only appropriate for patients with early lymphedema who do not yet have pronounced swelling," says Dr. Liu.

The bypass, like the lymph node transfer, requires "specialized technology in terms of operating microscopes, fine microsurgical instruments, as well as experience in microsurgery," says Dr. Liu. "With the current technology, we have the ability to connect dilated lymph vessels in the arm or the leg to small veins of similar size to offload the pressure."

Determining who is a good fit for lymphedema surgery

The microsurgery options are not recommended for everyone with lymphedema. Dr. Liu says patients should first try non-invasive therapies, like exercises and compression sleeves, before considering surgery. Those who don't find relief, though, should consult their doctor about the full spectrum of options. Patients who have been treated for any one of a number of cancers may find that they are a candidate for a lymph node transfer or lymphaticovenular bypass. "Commonly we see lymphedema in breast cancer patients, but it can also affect patients with melanoma, gynecologic malignancies or abdominal tumors as well," says Dr. Liu. "Patients who have lymphedema have it for a very long time, and we need to make sure they receive optimal treatment using existing methods that don't involve surgery first. The importance of physical therapy cannot be underestimated." Reconstructive surgeons regularly collaborate with physical therapists to make sure patients undergo a thorough therapeutic regimen before considering surgery, are adequately evaluated for surgical options and receive post-operative therapy to promote symptom relief.

Dr. Liu says taking time to talk to patients about their options and their condition, being clear and transparent and allowing time to answer questions are important to quality of care. "It's easy to deliver medical facts in the preoperative visit, but it's also important to address all the emotional and social concerns that patients are sometimes afraid to even bring up," he says.

If you believe lymph node transfer or lymphaticovenular bypass surgery may be an option for you, Dr. Liu recommends that you ask your doctor these questions:

  • What is your experience treating early- versus late-stage lymphedema?
  • What can I do before surgery to improve my post-operative outcomes?
  • What activity restrictions may I have to follow after surgery?

Lymphaticovenular bypass and lymph node transfer play an important role in the evolving treatment landscape for lymphedema. "Surgery has not replaced physical therapy yet, but it has now become an important adjunct to the multidisciplinary treatment of lymphedema," Dr. Liu says. "Providing treatment options can help maintain a better quality of life, which is extremely important for these patients and the people who love them."

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