Innovative Surgeries Can Treat Lymphedema

An expert discusses 2 new surgical treatments for breast cancer-associated lymphedema.

Lymphedema can be a debilitating after-effect of breast cancer treatment, and until recently, mainly conservative treatments, such as physical therapy and massage, have been used to treat the condition.

However, 2 new surgical treatments are generating excitement among providers caring for survivors with lymphedema, explained Hani Sbitany, MD, associate professor of plastic and reconstructive surgery at Mount Sinai.

In an interview with Oncology Nursing News, Sbitany discussed these new treatment methods, as well as the scientific backing behind them.

Why is breast cancer-related lymphedema so concerning, and what are the usual causes?

Lymphedema after treatment for breast cancer is incredibly concerning because in the small percentage of women who encounter it, it can be very debilitating. It becomes very difficult for them to use the affected extremity or limb that the lymphedema occurs in. It has a very negative impact on their quality of life, their daily function, and it just makes it hard to use that arm in a normal fashion moving forward.

It's also a problem because patients with lymphedema often encounter frequent infections and recurring infections in that extremity for, in some cases, the remainder of their life. So, it becomes a recurring, never-ending chronic medical problem.

There are many causes of lymphedema worldwide. In the United States, the most common cause of lymphedema is an operation, usually for some sort of malignancy. In our world of breast cancer treatment, the majority of patients who acquire lymphedema after treatment do so because they've either had a complete axillary node harvest, meaning all the lymph nodes in their axillary or armpit region were removed as treatment of the breast cancer, or they underwent radiation as part of their treatment. Those cause a local disruption in lymphatic channels that drain not only the breast, but also drain the arm on the affected side, and that can lead to an accumulation of fluid and the development of lymphedema.

What is the current treatment for lymphedema?

Right now, in the majority of the United States, the standard treatments are still the first-line conservative, symptomatic treatments. So a patient who is starting to develop lymphedema and is seen by a treatment provider [usually will] undergo treatments aimed at reducing the swelling of the limb … on a daily basis with compression devices — wraps and external manual dressing that firmly compress the arm and reduce some of that localized swelling. Or, they can undergo physical therapy treatments. Also in that realm of conservative therapy is massage or lymphatic massage. Manually, physical therapists will compress patients’ arms through multiple sessions a week to try to drain some fluids out of their arms. Some patients with recurrent infections undergo chronic oral antibiotic suppression.

What are some new options for treating lymphedema?

We've got some really new operative options that have been developed in the last few years aimed at surgically recreating lymphatic channels in the affected limb.

So. what we can do in a patient with lymphedema is, down in the forearm area of that swollen, affected limb, we have the ability now, in the operating room, to isolate out lymphatic channels that have been disrupted. Under operative magnification, because we're talking about really very small, less than a millimeter diameter channels, we find these lymphatic channels, isolate them out, and reconnect them before the point of disruption —not to other lymphatic channels, necessarily, but even to veins in the arm. We're finding paths for those lymphatic channels that are collecting lymphatic fluid but no longer can drain into the armpit area, reconnecting them down the lines to veins or other ways that they can then shunt their fluid into the systemic circulation, rather than have it build up in the arm.

It's what we call lymphaticovenous bypass, finding ways to surgically recreate those channels that have been disrupted.

The other thing we're doing is what we call vascularized lymph node transfer. [These are] operations where, if a patient has had their lymph nodes removed from their axillary region due to breast cancer treatment, we can find groups of lymph nodes from other parts of the body, whether it's the groin, the neck area, or the intra-abdominal area, and harvest those lymph nodes, and essentially transplant them to the axillary region where the lymph nodes are missing. That can also, as a secondary surgical procedure, help to further reduce the severity and reverse some of the effects of the lymphedema in that patient.

What research has recently come out that confirms the validity of these procedures?

The research around the outcomes of both lymphaticovenous bypass and vascularized lymph node transfer has centered in 2 areas. Number 1, there's been a lot of clinical-based outcomes research [assessing] the improvement when patients have these operations in lymphedema: How much can we reduce arm circumference by doing these operations, reversing the lymphedema by recreating channels or restoring lymph node basins, and how much can we reduce the risk of future symptoms, such as chronic infections, when they have previously occurred in a patient?

When it comes to these operations, it looks like, based on clinical outcomes research, that whether it's lymphaticovenous bypass or vascularized lymph node transfer, when you follow the patients 1, 2, or 3 years out from these operations, arm circumference in the affected limb can be reduced as much to 50% to 70%. So, there's a really drastic correction in the affected limb that's experienced lymphedema.

The other type of research that's been done is looking at it on a more molecular, basic science biologic level, [considering] how lymph node transplants to the axilla actually function. When we take a group of lymph nodes and transplant them into the armpit or axillary area, how does that packet of lymph nodes actually work and function to reduce the future progression and reverse some of the effects of lymphedema? It looks like, [due to] local molecular signaling through cytokines released from that transplanted lymph node basin, it's actually able to trigger the biologic regrowth and growth of new lymphatic channels to replace the ones that were surgically removed.

There’s a lot of exciting research both in the clinical setting and the basic science setting looking into the outcomes of these procedures.