New techniques and technologies are easing the pain and debilitation of lymphedema
BY BOB HECKER
An estimated 40 percent or more of patients who undergo lymph node dissection for cancer treatment will develop secondary lymphedema, but two innovative microvascular surgeries are helping patients control or even prevent this permanent and often debilitating condition.
These specialized procedures reroute lymphatic channels to allow proper fluid drainage after cancer surgery, and they are available only at The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC – James) and a few other institutions in the United States.
The procedures are called lymphatic venous anastomosis (LVA), or lymphatic bypass, and vascularized lymph node transfer (VLNT), and some of these were pioneered by surgeons at the OSUCCC – James.
“Cancer surgery often involves the removal of lymph nodes that are used to help determine whether the cancer has spread,” says Roman Skoracki, MD, professor and director of the Division of Reconstructive Oncological Plastic Surgery at Ohio State. He is also a member of the OSUCCC – James Cancer Control Program.
In the developed world, secondary lymphedema usually stems from oncologic therapy and is the most common type of lymphedema. Less common is primary or congenital lymphedema, which is caused by genetic defects and can occur at different times of life. “Worldwide,” Skoracki says, “the most common reason for lymphedema is a parasitic infection called filariasis that is transmitted by mosquitoes, but we very rarely see it in the developed world.”
Morbid obesity, he adds, is another etiological factor in lymphedema. “Patients with a body mass index greater than 40 or even 50 can develop significant dysfunction of their lymphatic system.”
In the United States, Skoracki says, most lymphedema stems from lymph node dissection in the treatment of cancer, particularly cancers that frequently metastasize to lymph nodes, such as breast cancer, gynecologic and urologic cancers, melanomas and other skin cancers. Lymph node removal in the head and neck region can also cause swelling, but to a much lesser degree.
Skoracki says the risk of lymphedema is significantly higher among patients whose treatment requires full lymph node removal—or removal of an entire lymphatic basin—rather than just sentinel node removal for a biopsy sampling. Full lymph-node removal carries varying degrees of risk.
“For example,” he says, “if all lymph nodes are removed from the axilla during surgery for breast cancer, there is a 40-percent risk of lymphedema in the arm near the affected breast. In the lower extremities, removing the superficial and deep inguinal lymph nodes probably presents a 60 percent chance of developing lymphedema.”
Until recently, most patients could hope to control their swelling only by using compression garments, massage and physical therapy, but that is changing thanks to the gradually expanding availability of LVA and VLNT surgeries.
“With their expertise as microvascular plastic surgeons, Dr. Skoracki and his colleagues offer hope and relief for patients suffering from lymphedema,” says Michael Miller, MD, professor and chair of the Department of Plastic Surgery at Ohio State. “They’re among only a few surgeons nationwide performing these microvascular procedures, which relieve lymphedema’s painful symptoms.”
Besides Skoracki, surgeons who perform LVA and VLNT at the OSUCCC – James include David Cabiling, MD, and Albert Chao, MD. Both worked with Skoracki at The University of Texas MD Anderson Cancer Center before coming to Ohio State.
LVA and VLNT
Skoracki notes that the LVA and VLNT procedures are very different.
“LVA attempts to recreate connections that naturally exist between the lymphatic system and the bloodstream in areas where they have been disrupted by lymph node removal,” he says. “We utilize a super-microsurgical technique to create tiny shunts between lymphatic channels and blood vessels that carry fluid around the blocked areas. The rerouted fluid is then dumped into the bloodstream, which has the capacity to take on a significantly greater amount of fluid than it usually carries.”
Skoracki was part of a 2013 study published in the journal Plastic and Reconstructive Surgery that involved 100 patients who underwent LVA. “We saw symptom improvement in 96 percent of patients,” he says. “This technique proved especially effective for those who had already developed early-stage
lymphedema in their arms and hands.”
Importantly, he adds, “We now offer this same approach prophylactically to high-risk breast cancer patients to minimize their risk of developing lymphedema. By performing this procedure at the time of a lumpectomy or mastectomy, we can lower a woman’s risk of developing lymphedema by 90 percent.
“We may offer something similar prophylactically for lower extremity patients as well, including those with urologic and gynecologic cancers, but that’s still in its infancy.”
LVA is not an option for patients who, according to fluorescent imaging techniques, have no functioning lymphatic channels to connect to in the affected region. Those patients may be candidates for the newer VLNT procedure, which reintroduces lymph nodes into an area where they have been removed.
“We transplant lymph nodes from an unaffected area of the body and attach them to a blood supply in the affected area,” the microsurgeon says. “Then the lymph nodes themselves sprout connections and release vascular endothelial growth factor C (VEGF-C), which attracts the growth of lymphatic channels toward them as well. So this procedure essentially recreates a functioning lymphatic system by replacing what’s been lost.”
In one approach to VLNT, Skoracki says, the OSUCCC – James surgeons are true pioneers. They were the first team to harvest and transplant lymph nodes from the body’s mesentery, a fan-shaped tissue that tethers the blood vessels that come to the bowel.
“The mesentery also has a great number of lymph nodes embedded in it,” he says, “and we can harvest small clusters of nodes from it without causing lymphedema at the site from which we take them.
“Most of the lymph nodes that surgeons traditionally transfer put the harvest site at risk for lymphedema. This is why we remove them from the mesenteryand also the omentum (another fold of the peritoneum). We think it’s a great option for patients that minimizes potential complications.”
Skoracki says the OSUCCC – James microsurgeons “essentially invented” the mesentery approach and adds that, as of now, it is available nowhere else in the nation.
Skoracki attributes the emergence of LVA and VNLT in part to the evolution of technology. In a September 2016 review article that he coauthored in the journal Plastic and Reconstructive Surgery, Skoracki and his colleagues explain that improvements in microsurgical equipment allowed the development of these supermicrosurgery techniques.
“LVAs are indicated when thepatient still has functionality of the lymphatic system,” they write, “which may be assessed and documented using ICG lymphography as defined as linear channels propelling dye from the distal extremity toward the trunk…
“ICG lymphangiography and MRL (a specialized magnetic resonance imaging technique of the lymphatic system) enable the surgeons to locate the most functional lymphatic channels, which they then join to small blood vessels after marking the channels on the patient’s skin before surgery.”
Other critical advances include improvements in operating microscopes that enable surgeons to perform bypasses that were impossible to do earlier because the magnification didn’t exist. New infrared cameras allow surgeons
to visualize lymphatic channels and obstructions through the skin before making an incision. This equipment is available in the clinic, as well as in the operating room, Skoracki says, so physicians can preoperatively determine the stage of a patient’s lymphedema and optimal surgical options.
Not All Qualify
LVA and VLNT cannot be applied to all lymphedema patients.
“For patients who are morbidly obese, the primary intervention is weight loss, and unfortunately there is no proven method of weight loss for this population other than bariatric surgery,” Skoracki says. “If residual lymphedema is a problem after they lose weight, then we can offer our surgical procedures.”
Others who may not qualify are patients with late-stage lymphedema. Late-stage disease is characterized by little remaining fluid and much fibrosis. Most of the swelling is due to fat overgrowth, a side effect of lymphedema.
“Sometimes we can offer liposuction to remove the fatty layer and reduce the limb size, but that doesn’t address the fluid component of the problem, which we need to address first,” Skoracki says.
Patients with end-stage lymphedema can present with elephantiasis and verrucous (wartlike) skin changes, he says. “Affected limbs are extremely large and very disfigured. They are difficult to wrap or compress, and they sometimes contain skin breakdown and wounds.
“We offer an excisional procedure to these patients in which we remove the affected tissue and place skin grafts on the muscle underneath. It’s not the most esthetically appealing outcome, but it can improve their quality of life because these patients tend to be extremely debilitated.
“Beyond these exceptions,” he says, “we have microsurgical interventions to offer most patients with lymphedema.”
Skoracki and his colleagues are pleased that LVA and VLNT are becoming more widely available. “Younger microsurgery clinicians are being trained and starting programs elsewhere,” Skoracki says. “Lymphedema is a condition that calls for a multidisciplinary, individualized approach. You need to look at it from several angles, including surgical, medical, imaging and certified lymphedema therapy.”
The OSUCCC – James team includes all of those components, Skoracki says. The team includes vascular internists such as Steven Dean, DO; certified lymphedema therapists such as Karen Hock, MS, who leads an oncology rehab team of physical therapists; and Daniel Eiferman, MD, a general surgeon “who has significant experience and expertise in lymphedema.”
In addition, “We’re seeing a huge uptick in lymphedema research around the country, including some exciting clinical trials that we are participating in here at Ohio State. One is a pharmaceutical trial for an anti-inflammatory agent that’s showing effectiveness in the body’s intrinsic repair mechanism for injuries to the lymphatic system,” he says, pointing out that the medication is not yet available in the United States outside of a study protocol.
“We still have no ‘gold standard of care for lymphedema,’” he says, “but research will provide more insight and better options for patients as we learn more about the pathophysiology and progression of this condition.”
Skoracki believes this should be encouraging for physicians and their patients.
“We’re seeing a blooming of treatment options, and the immediate translation from research into the clinic of things that we didn’t know about five or 10 years ago, at least not to the extent that we do now,” he says. “And patient access to lymphedema teams is becoming more widespread. Rather than just two or three pockets where these options are available, patients have more choices of getting help nearby.”
The Lymphatic System and Lymphedema
The lymphatic system returns fluid and protein molecules from the tissues to the circulatory system via the lymph nodes and plays an important role in the body’s immune defenses. It is composed of a network of thin-walled vessels, the lymph nodes, spleen, tonsils, adenoids and diffuse lymphoid tissue in the digestive and respiratory systems.
Removal of lymph nodes during cancer surgery can impair fluid drainage from the affected area, resulting in lymphedema. The condition is characterized by chronic and painful swelling (usually in the extremities), tightness and heaviness in the affected area, a heightened risk of infection, limited range of motion, and impaired ability to engage in activities of daily living and to wear normal clothes.