Surgical Options for Lymphedema
By Luanne Jorewicz
Lymphedema of the extremities, whether from cancer treatment or other causes, typically is not curable. But advances in surgical techniques are reducing or eliminating symptoms for many patients.
Standard treatments for lymphedema
The goal of standard lymphedema treatment is to manage the symptoms and either reduce swelling or halt its progression. Lymphedema treatment plans are tailored according to each patient’s needs but commonly include compression garments, exercise, manual lymph drainage (a type of massage therapy), or combinations of these therapies. Health care providers also counsel patients who have lymphedema in proper skin care to guard against lacerations and infections.
Over the past century, various surgical techniques have been tried in an attempt to reduce or even cure lymphedema. However, most of these techniques have been abandoned because they are ineffective or the results could not be reproduced by other practitioners. Only recently have advances in microsurgery made the surgical management of lymphedema a viable alternative.
Surgery for lymphedema
Since 2006, surgeons at The University of Texas MD Anderson Cancer Center have been performing microsurgical treatments for lymphedema—lymphovenous bypass and vascularized lymph node transfer—with promising results.
Specialists in Japan have been leading the advances in these procedures, and several surgeons from MD Anderson—including Roman Skoracki, M.D., and Matthew Hanasono, M.D., associate professors in the Department of Plastic Surgery—have spent time in Japan learning these skills. According to Dr. Skoracki, “It’s a treatment that hasn’t been readily accepted until the last 10 years or so, but it is now represented in several academic centers in the United States.” MD Anderson is still one of only about two dozen centers in the world that offer these advanced surgical procedures for lymphedema management, however.
Any patient with lymphedema is a potential candidate for these microsurgical procedures, but the best results—particularly for lymphovenous bypass—are seen in patients with early-stage lymphedema. Active cancer is considered a contraindication to lymphedema surgery for most patients.
Because few institutions offer these procedures, no formal system has been established for selecting patients for the operations, so there are likely many patients who would benefit from one of the procedures who are not being referred to surgical teams for evaluation.
To plan for either of these microsurgical operations, the surgeons first stage the affected limb’s lymphatics by lymphoscintigraphy, in which a radioactive colloid is injected into the lymphatic vessels totrace the flow of lymph and detect lymphatic dysfunction. Intraoperative lymphography is used during either procedure.
In lymphovenous bypass, the surgeon anastomoses obstructed lymphatic vessels, typically 0.1 mm to 0.8 mm in diameter, to small adjacent venules so that lymph is redirected. The procedure, which requires two to five small incisions in the affected arm or leg, is usually performed using general anesthesia. Patients typically recover quickly; the procedure may take no more than a half day from arrival to discharge.
Although lymphovenous bypass can greatly reduce edema in the affected limb, most patients will continue to have some swelling after surgery and will continue standard lymphedema treatment with compression garments and massage therapy.
Lymph node transfer
A more invasive surgery is vascularized lymph node transfer. This procedure involves harvesting healthy lymph nodes from unaffected areas—often the groin for patients with lymphedema of the arm—and microsurgically transplanting them as vascularized flaps to replace damaged or missing lymph nodes.
“These lymph nodes are moved with an intact blood supply, an artery and a vein that can be anastomosed to the recipient site,” Dr. Hanasono said. “The transferred nodes then appear to absorb and collect the lymphatic fluid that was being blocked.”
The transferred lymph nodes are also thought to stimulate lymphangiogenesis, during which new lymphatic vessels grow and connect to the lymphatic channels of the transplanted lymph nodes to create new pathways for lymph drainage.
In some patients who have undergone delayed breast reconstruction with vascularized flaps, the lymph node transfer has been performed at the same time. Performing these two procedures simultaneously is becoming increasingly common, and the transferred lymph nodes may be part of the same flap used for the breast reconstruction.
Because breast reconstruction with autologous flap transfer requires a hospital stay of approximately 5 days and lymph node transfer may require 2–3 days of in-hospital observation, performing the two procedures simultaneously saves the patient an additional trip to the hospital, a second operation under general anesthesia, recovery time, and considerable expense.
Patients typically wear compression garments for several weeks after undergoing lymph node transfer, but many are eventually able to stop using the garments. Infections that are common in patients with lymphedema are less frequent in patients who have undergone lymph node transfer or lymphovenous bypass, owing to the improved lymph drainage.
Exploring uncharted territory
One challenging aspect of lymph node transfer is to discern which nodes can be harvested without damaging the donor region and creating another area of lymphedema. To address this challenge, researchers at MD Anderson are remapping the lymphatic system and its drainage pathways—a field in which little has been done since the 19th century. Alexander Nguyen, M.D., an assistant professor in the Department of Plastic Surgery, is using lymphoscintigraphy and sentinel lymph node mapping to better identify critical lymph nodes that should be left intact.
By injecting dye into the hand, Dr. Nguyen is able to see where the lymphatics stagnate in the arm and to determine whether patients with upper extremity lymphedema would be better candidates for lymphovenous bypass or lymph node transfer. In addition, lymphoscintigraphy shows where the surgeons should be doing the anastomoses. Finding the appropriate lymphatic and an adequate vein used to be like finding a needle in a haystack, according to Dr. Nguyen. Now, he said, “We have a GPS to improve success rates.”
Research led by Hiroo Suami, M.D., Ph.D., an assistant professor in the Department of Plastic Surgery, also is aimed at elucidating the anatomy of the circulatory system. Dr. Suami developed a unique technique using radiopaque media and a surgical microscope to visualize the lymphatic channels and to designate regional skin lymphatic zones called “lymphosomes.” When the lymphatic pathways are better understood, it may be possible to preserve a drainage route for the upper extremity via the clavicular lymph nodes (the Mascagni pathway), bypassing the axillary lymph nodes removed during axillary node dissections.
Also, Dr. Suami said, “The lymphosome concept will provide a template to more accurately interpret lymphoscintigraphy to diagnose cancer spread and define suitable lymph node donor sites for vascularized lymph node transfer.”
A better understanding of the lymphatic system will help surgeons to more effectively perform surgical procedures that reduce or even eliminate the symptoms of lymphedema. But even now, Dr. Nguyen said (paraphrasing the consensus statement of the International Society of Lymphology), “Microsurgery offers the closest chance to a cure for lymphedema that we currently have.”
Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg. 2013;132:1305-1314.
For more information, contact Dr. Matthew Hanasono at 713-794-1247, Dr. Alexander Nguyenat 713-794-1247, Dr. Roman Skoracki at 713-794-1247, or Dr. Hiroo Suami at 713-794-1247.
OncoLog, June 2014, Volume 59, Issue 6