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DR. CHEN WAS QUOTED IN US NEWS & WORLD REPORT ABOUT LYMPHEDEMA
Are There Surgical Options for Breast Cancer–Related Lymphedema?
Severe cases of lymphedema may be treated with surgery.
By Elaine K. Howley, Contributor | Aug. 24, 2017
Treatment for breast cancer can bring many unintended and potentially unpleasant side effects. One of the more common side effects of surgery for breast cancer is lymphedema. If you’ve had a lumpectomy or mastectomy, your doctor may have also removed some lymph nodes from the axilla area, essentially the armpit. This is a standard means of checking whether the cancer has spread, and sentinel lymph node biopsies and axillary lymph node dissections are common procedures for breast cancer patients.
However, after these surgeries some patients will develop lymphedema – an uncomfortable, chronic condition in which lymph fluid collects at the site of removed lymph nodes. Lymphedema causes swelling that can limit your limb functionality. The Memorial Sloan Kettering Cancer Center reports that about 15 to 25 percent of patients who’ve undergone an axillary lymph node dissection will develop lymphedema. The National Cancer Institute reports patients who’ve undergone sentinel node biopsies have a 5 to 17 percent risk of developing lymphedema.
Lymphedema can develop any time after your treatment has concluded, so you’ll always have to be vigilant for symptoms – a heaviness or tightness in the limb, swelling and discomfort in the arm on the same side where your breast cancer surgery occurred. Current treatment protocols include decongestive therapy, lymphatic massage and compression therapy, all of which help move the fluid beyond the point of blockage. Most patients will achieve some level of symptom reduction using these methods. But for patients who don’t see improvement or those who have severe cases of lymphedema, surgical procedures may be recommended.
Breastcancer.org reports that surgery for breast cancer–related lymphedema “is considered experimental and isn’t widely available.” Surgical procedures can include liposuction of the affected limb, vascularized lymph node transfer and lymphovenous bypass. Breastcancer.org reports that “surgery is viewed as an option of last resort for severe lymphedema that does not respond to treatment.” However, a few plastic surgeons are using surgery as a tool to deal with severe lymphedema that doesn’t respond well to other management approaches, and developments in the field could lead to wider use of these techniques in the future.
Currently, it seems lymph node transfer surgeries hold the most promise for reducing the volume of fluid build up in the limb.
In liposuction for lymphedema procedures, fat stored in the affected limb is removed with a vacuum-type tool. “This doesn’t cure the lymphedema,” Breastcancer.org reports, “but it can get the arm down to a size the patient would then have to maintain with bandaging at first, followed by wearing a compression sleeve during the day and using other forms of compression at night.”
In a Q&A posted on the Cleveland Clinic’s website, plastic and reconstructive surgeon Dr. Graham Schwarz notes that “while liposuction can reduce limb volume, it does not obviate the need for lifelong compressive therapy for maintenance. In contrast, following a successful VLNT, compression therapy is used initially but may not be needed long-term.”
Similarly, lymphovenous bypass surgeries have limited applications and success, says Dr. Richard Klein, section chief for plastic and reconstructive surgery at Orlando Health Aesthetic and Reconstructive Surgery Institute. “That surgery has been around a little bit longer than lymph node transfer,” he says. Lymphovenous bypass surgery “revolves around finding one to three lymphatic [channels] in the extremity, and making a small incision to bypass it into a vein that’s adjacent to it. So basically, I’ve just short-circuited the lymphatic system into the venous system. It doesn’t work very well, it works for limited areas, and those little connections often have a tendency to clot, so it’s not usually as successful as lymph node transfer,” he says.
Lymph Node Transfer
Klein, who completed the first vascularized lymph node transfer surgery in Florida in 2013, says newer surgical techniques are superior to older approaches to surgically treating lymphedema. In a lymph node transfer, healthy lymph nodes from another part of the patient’s body are removed and placed at the site of the blockage that’s creating the lymphedema.
“We select the [donor] area carefully so it doesn’t cause lymphedema where we harvest it from, and then we move a small cluster of lymph nodes with a small artery and a vein to the location where they’re needed. Then, we reattach the arteries and the veins. Over a period of a couple of months, the lymph nodes will start creating new lymphatic channels between them and the surrounding tissues. The idea is for them to connect with the lymphatic channels that had previously been cut and then new channels form that can begin draining the limb that’s blocked.”
Klein says he’s been doing these surgeries for over four and a half years and has worked with many patients with breast cancer–related lymphedema. In a study published recently in The Annals of Surgical Oncology, Klein presented findings from a group of 50 upper extremity lymphedema patients who underwent the VLNT procedure. “We had a 60 percent volume reduction overall in our first 50 patients,” measured at three-month intervals within 12 months after surgery. “But the improvement is not only in volume reduction. There’s also an improvement in pain. We had an 80 percent improvement in pain and a 70 percent reduction in recurrent infections.” He says the sensation of tightness and heaviness in the limb was also reduced for this sampling of patients, and some have been able to discontinue use of compression garments.
However, not all patients will have such big improvements from this type of surgery. Dr. Constance Chen, a board-certified plastic surgeon and member of the medical advisory committee of the National Lymphedema Network, says that, “typically, patients state that they feel that their limb with lymphedema feels less heavy and painful, but it is sometimes difficult for the outside observer to see significant and measurable changes. The most important thing to consider is that lymph node transfer is not a magic bullet, and results are usually limited at best.” The aim, she says, should be to enable patients to have “improved use of the limb when compared to their use before surgery. Patients get the best results with significant lymphedema therapy after surgery, and it is unlikely that their lymphedema will completely resolve. The hope is that the symptoms of their lymphedema will improve, even if it is still visible.”
Chen says the ideal candidate for this type of surgery “would be someone who is a healthy, nonsmoker at his or her ideal body weight.” In addition, the best candidates for surgery “have maximized conventional lymphedema treatment and have stage 1 or 2 lymphedema,” she says. It’s critical that patients not be smokers, she says, “because nicotine causes clotting and vasoconstriction that would prevent successful microsurgical transfer of lymph nodes.” Patients with comorbidities – other potentially deadly diseases and conditions – should also avoid the surgery. “Obese people may have a higher tendency to develop lymphedema at the donor site,” so they may also want to avoid the surgery.
Vascularized lymph node transfer surgery is still relatively new and only available at “about half a dozen centers around the country,” Klein says. Because it’s not a very common procedure, if you’re considering having this surgery, “you want to go to places that have a comprehensive program. The operation is just a minimal part. You have to get the lymph repaired by a lymphedema therapist. And then there’s all that post-operative care that’s done by the lymphedema therapist. There’s a whole protocol that needs to be followed,” he says. If your lymphedema is getting the best of you, talk to your doctor about your options and whether surgery is something you should consider.
Original source from U.S.News