Tuesday, March 20, 2018

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New Procedure Can Eliminate Lymphedema’s Debilitating Symptoms

Written by  Rich Ellis

Lymph node transfer surgery replaces nodes removed during breast cancer treatment.

Lymph node transfer surgery is a relatively new procedure in the U.S. that is helping breast cancer survivors improve their quality of life by alleviating the painful, debilitating symptoms associated with lymphedema.

According to Matthew G. Stanwix, MD, with Richmond Plastic Surgeons, lymphedema is a swelling of the extremities — primarily the arm in the case of breast cancer — that results after lymph nodes are removed for cancer surveillance or because of the presence of cancer-causing agents.

Lymph nodes process and move lymphatic fluid through lymphatic channels. When those nodes are removed and the channels are damaged from scarring, the fluid can’t be processed well enough to move it through the arm, leading to swelling of the limb.

Lymphedema’s painful symptoms

Symptoms associated with lymphedema can be wide ranging and vary in their severity.

“There could be a size issue where one arm is bigger than the other arm, heavier or with a larger circumference,” Dr. Stanwix explains. “It could be painful because of the swelling or the fluid itself settling and causing discomfort.”

Lymphedema presents an increased risk of infection because the swelling in the arm can lead to breaks in the skin and because the lymph nodes that help fight infection were removed, Dr. Stanwix says. The swelling can also lead to the skin breaking down and taking on a leathery or woody appearance and feel.

“It can be quite debilitating, and some patients have to go to therapy three or four times a week for the rest of their lives,” says Dr. Stanwix. “So it’s a quality of life issue both from the symptoms and from the amount of time spent managing it.”

Christina Wood knows all too well about breast cancer and lymphedema. The 46-year-old North Chesterfield resident was diagnosed with breast cancer in March of 2011, had a bilateral mastectomy in April 2011, and developed lymphedema in the fall of 2012.

“It began as a mild swelling in my left arm,” says Wood. “I had read about it when going through treatment. When they performed the mastectomy, they removed the sentinel lymph node on my left side. That and the radiation treatment made me very likely to have lymphedema.”

Temporary lymphedema treatment options

Treating lymphedema through nonsurgical options focuses on helping to move the lymphatic fluid from the arm, Dr. Stanwix explains. These measures, which provide temporary relief but are not a permanent cure, include wearing a compression sleeve to prevent fluid from settling in the arm, having a physical therapist massage the arm to manually move the fluid, and using pump mechanisms that squeeze periodically to push lymphatic fluid from the arm.

Wood's therapist massaged her arm and wrapped it with bandages that she wore all day for weeks at a time to help push fluid out of the arm. Once her arm reached the desired size, she got a compressive sleeve that she wore all day, switching to a different sleeve at night.

“I also used a Flexitouch machine,” Wood says. “Every morning I’d lie on my bed for 90 minutes while the machine pumped air through the suit I was wearing.”

The Flexitouch System is a pneumatic compression device that simulates the lymphatic system. Wood's system consisted of a sleeve extending from palm to armpit, a vest covering one side of her body, and a third piece wrapped around her midsection. Hoses hooked to the machine help move lymphatic fluid, reducing swelling.

Lymph node transfer surgery as a permanent solution

These treatment options, however, don’t solve the underlying problem that leads to lymphedema. For that, Dr. Stanwix and eligible patients turn to lymph node transfer surgery.

“The surgery has been in existence for a decade or so, but it didn’t begin in the U.S. as we’re more cautious when it comes to newer medical technology and advancements,” Dr. Stanwix says. “It’s grown in the U.S. over the last three years. The risks are very low and the advantages are very high because lymphedema is a huge quality of life issue.”

The goal of lymph node transfer surgery is to restore the movement of lymphatic fluid by replacing the lymph nodes removed during cancer treatment with healthy lymph nodes from another part of the body.

“The good thing about this surgery is that it’s not very invasive,” Dr. Stanwix explains. “Surgery lasts for four to five hours with patients spending one night in the hospital. Pain is minimal with a few 4-inch incisions, and there aren’t too many restrictions on patients afterwards, so they can return to their normal lives in a couple of weeks.”

During the surgery, Dr. Stanwix first removes any scarring in the lymphatic channels that resulted from the lymph nodes being removed previously and establishes a healthy tissue base. He then removes four to 10 nodes from the groin and transfers them to the armpit area, using microscopic surgery to reconnect the nodes with a blood supply. There’s no need to connect or establish new lymphatic channels; they will develop on their own later.

While lymph nodes are also present in the neck, Dr. Stanwix says it’s more common to take them from the leg. “The way you get around drainage problems in the leg is that you don’t remove all the lymph nodes, and you only take the nodes that aren’t draining the leg,” Dr. Stanwix says.

Healing and recovery

After the surgery, it takes months for the new lymphatic channels to develop, and during this time period patients must be aggressive in continuing to perform physical therapy in the same manner as before the node transfer surgery.

The transfer surgery is still in its infancy, and success is often determined by a reduction in or elimination of a patient’s symptoms and the physical therapy they had undergone to manage the lymphedema.

“Not everyone can have the surgery,” Dr. Stanwix says. “We really screen patients, and they must have exhausted their conservative management options over a course of months.”

Patients exhibiting the leathery skin symptoms and those experiencing skin infections caused by lymphedema are not candidates for the surgery.

Wood said her recovery from the surgery was uneventful and progressing well, and she is looking forward to her lymph node transfer surgery being life-changing so she won't have to continue with the intensive treatment needed to manage the disease. While she was cautioned that it could take 12 to 18 months for everything to heal and to see results from the surgery, she has since learned that her cancer has returned. She believes it’s interfering with the lymph node transfer surgery’s expected results and success.

Those who battle lymphedema may also have to battle insurance companies that don’t always want to approve payment for the lymph node transfer surgery.

“The insurance companies are saying, 'this isn’t lifesaving. It’s a quality of life issue, so why should we pay for it?'” says Dr. Stanwix. “My view is just the opposite.”

Unfortunately, lymphedema is somewhat common, and the risk of developing it increases proportionally with the number of lymph nodes removed during cancer treatment. At the same time, lymph node transfer surgery is such a new procedure that many patients and even the physicians involved in cancer treatment aren’t aware it exists. That should change as the surgery becomes better established in the U.S. and awareness grows about its potentially life-changing results.