Together awareness and innovation are reducing lymphedema risk and improving management for patients who develop the condition.
By Mia James
Emmie Cheses has been in the very fortunate position of being able to take preventive action against lymphedema. When Emmie, of Columbus, Ohio, was diagnosed with breast cancer with lymph node involvement at age 45, she was able to undergo prophylactic surgery with an innovative technique known as lymphovenous bypass to significantly reduce the risk of lymphedema.
The procedure is one of two current innovations in lymphedema treatment—the other being vascularized lymph node transfer. Both approaches stand to revolutionize outlooks for both patients at risk of the condition and those looking for effective treatment.
“Lymphedema is an imbalance of production of lymphatic fluid and the clearing of that fluid,” explains Roman Skoracki, MD, professor of plastic surgery and division chief of reconstructive oncological plastic surgery at The Ohio State University Comprehensive Cancer Center–Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC–James). “In other words, lymphedema makes it so the lymphatic system cannot clear lymphatic fluid at the same rate at which it is produced.”
The lymphatic system is a major part of the body’s immune system—a network of organs, nodes, ducts, and vessels that make and move lymphatic fluid from tissues to the bloodstream. Lymph nodes are found, among other areas, under the arm (axillary), in the neck, and in the groin.
As a result of this imbalance of fluid production and clearing, the fluid—which carries blood cells (mostly blood cells called lymphocytes)—accumulates in the affected area of the body and causes that area to swell. This swelling, or lymphedema, usually occurs in the extremities (arms and legs).
“I liken the lymphatic system to a French drain for a home,” says Dr. Skoracki. These drains, placed outside of houses, are trenches filled with gravel or rock that contain a perforated pipe to redirect surface and groundwater away from an area. “The lymphatic system,” he explains, “is composed of leaky vessels that allow fluid and large protein molecules to come in and also has a pump mechanism (muscles and valves) to move fluid through.” When the lymphatic system is functioning properly, it pushes fluid to the lymph nodes to filter and recycle in the bloodstream.
When this process is interrupted due to lymph node damage or removal, however, the fluid doesn’t get pumped through and instead accumulates to cause the swelling associated with lymphedema. Damage, says Dr. Skoracki, in the industrialized world is often the result of interventions during cancer treatment but can also be caused by other health issues, such as infection and inherited conditions.
“The majority of lymphedema cases are due to disruption of the lymph system during cancer treatment,” he explains. Specifically, lymph nodes are at risk when cancer has spread to them, and they need to be removed—such as in breast cancer that spreads to the axillary nodes. Radiation therapy around the lymph nodes can also damage them, as can tumors that have a direct impact on the nodes.
A Patient Takes Charge
Even though lymphedema management and care is a growing therapeutic area, Emmie decided she wanted to do everything possible to prevent the side effect from developing in the first place. As an active mother, she felt she could not accept the risk of any loss of function.
“I was concerned that lymphedema would change my life,” Emmie says. Not only do her responsibilities as a mom demand the mobility and use of her arms, she’s also a tennis player and loves outdoor pursuits.
Emmie quickly learned that she had considerable risk of lymphedema with the diagnosis of breast cancer with lymph node involvement and its prescribed treatment. In addition to surgery to remove the cancer, she would undergo axillary node dissection (removal of these nodes) with chemotherapy and radiation.
“I did a lot of reading,” she says, “and I learned that with my treatment plan, my risk of lymphedema was higher than with fewer modalities.” Armed with this information, she planned prophylactic lymphovenous bypass surgery with Dr. Skoracki.
Emmie was able to combine the lymphovenous bypass procedure with the breast cancer surgery. This greatly minimized the impact of the additional intervention, as Dr. Skoracki used the same incision to perform the bypass procedure and to remove the cancerous axillary nodes.
How Innovations In Lymphedema Treatment Work
The surgery that Emmie had—lymphovenous bypass—is a relatively new treatment that has been used for about 10 to 15 years, according to Dr. Skoracki. He explains that it involves creating a shunt, or detour, for the lymphatic fluid when its usual course is blocked—another vessel in which the fluid can travel. He likens it to building an on-ramp to link traffic from a congested road to an open road. “The bypass creates a connection to carry away excess fluid,” he says. During the procedure, he creates two to seven bypasses.
Lymphovenous bypass is considered minimally invasive because the lymph vessels are located right under the skin. Dr. Skoracki adds that he sees results quickly, and patients can generally go home after spending one night in the hospital for antibiotics.
The other innovative lymphedema treatment, vascularized lymph node transfer, is the newer of the two procedures. It was pioneered in Taiwan and Europe about eight years ago, says Dr. Skoracki. In vascularized lymph node transfer, the surgeon takes a group of healthy lymph nodes—or a “cluster,” as he explains—from a donor site and places them in the area with lymph node damage.
“The transferred lymph nodes,” says Dr. Skoracki, “sprout channels to reconnect to surrounding lymphatic channels. So, once transplanted, these nodes establish themselves and become part of the lymphatic system in their new location.
Results with lymph node transfer are not as quick as with the bypass procedure. The nodes have to make their own connections, which takes about three months. Transfer is also the more invasive of the two, as it requires two incisions: the donor and transfer sites. Dr. Skoracki says that patients stay in the hospital for a few days after surgery to make sure the transfer worked.
With these two options in lymphedema procedures, doctors are able to choose which approach is best for each patient. According to Dr. Skoracki, the outcomes with lymph node bypass and transfer are similar, but because bypass is less invasive it’s his first-line preference for eligible patients.
“The bypass is generally my first choice,” he explains. “I reserve the lymph node transfer for those patients who are not candidates for the bypass or received insufficient relief from the bypass procedure.” In general, patients for whom bypass is not appropriate have had lymphedema for a while and have developed so much scarring that the superficial lymphatic channels (the ones accessed just under the skin) are no longer usable, making bypass ineffective.
A Bright Future
Almost two years after breast cancer treatment and lymphovenous bypass, Emmie’s outcome is looking positive. “As of now I’m doing well,” she says. She is, however, still vigilant in her lymphedema prevention, ever conscious of the fact that treatment reduced the risk of lymphedema but didn’t completely eliminate it.
“I’m very careful with my right [affected] arm,” Emmie says, explaining that she basically takes the same precautions she would if she had lymphedema. This includes no blood pressure cuffs or needle sticks on her right arm, and she wears a compression sleeve when she flies. Emmie says that she will also do the prescribed stretches and physical therapy indefinitely to keep risk at bay.
What These Innovations Mean On A Larger Scale
Emmie was fortunate that she had, in Dr. Skoracki, convenient access to a surgeon who is performing both lymphovenous bypass and vascularized lymph node transfer, but not all patients have the same opportunity. There are currently few surgeons performing either procedure in the United States, and each requires a specialized microsurgery facility.
Dr. Skoracki is hopeful, however, that by contacting facilities that are known for performing the procedures, such as The OSUCCC— James (cancer.osu.edu), patients can find accessible centers and physicians who are doing the techniques. He also says that the innovations bring attention to lymphedema treatment overall: “It’s an exciting time. There’s so much interest in lymphedema on so many levels, which is good news for advances in awareness, therapies, and surgery.”
When you consider, as Dr. Skoracki notes, that lymphedema has had (and still has, to some extent) a reputation for being incurable, effective treatment in the form of lymphovenous bypass and vascularized lymph node transfer is incredibly impressive progress. And with improvements in management with drainage, physical therapy, and compression, this is most certainly a very promising time for anyone affected by or at risk of lymphedema.