Zelma Reid had her lymph nodes removed during breast cancer surgery, and for three years escaped lymphedema, a chronic condition that occurs when lymph fluid pools under the skin and causes swelling.
Then she was bitten by a mosquito.
“Within days, I noticed that my left arm was swelling below my elbow,” Reid recalls. “I had been warned: ‘Don't hurt that arm; don't let them take blood from it, because you have no lymph nodes there.’”
Her arm became bright red and painful. Its skin became tight and hot. She developed chills and a fever.
When patients have cancer surgery, nearby lymph nodes usually are removed to check for the spread of cancer.
“Essentially, you have a clog in the pipes that are draining fluid from the arm or leg. So the fluid backs up, like a sink or bathtub overflowing.”
The lymph fluid that collects in the skin and underlying tissues can interfere with wound healing and lead to infections.
“The arm or leg swells and gets heavier, making it difficult for patients to do their regular activities,” Chang says. “Some can't wear their wedding rings anymore.”
Up to 3 million cancer survivors in the United States — and millions more worldwide — develop lymphedema, sometimes years after surgery. Injuries can lead to flareups, so cancer survivors are advised to use razors with care, wear rubber gloves to wash dishes, avoid having cuticles cut during manicures and apply insect repellent, because bites can become infected.
The lymphatic system plays a major role in the immune system, so lymphedema can be painful and even lifethreatening.
“The lymph nodes contain immune cells that help fight infection by attacking and destroying germs and other harmful substances that are carried along in the lymph fluid, before returning that fluid to the circulatory system,” Chang explains. "When you remove the nodes, the fluid can no longer drain, so in breast cancer, the arm may swell and become at high risk for infection.”
Gentle, regular massages to stimulate new pathways for the lymphatic fluid are often prescribed, along with mummy-style compression bandages and custom-made compression garments that are worn on the affected limb.
Chang, who performed Reid’s breast reconstruction, referred her to physical therapy where she tried all these procedures, plus a Flexitouch device that inflates and deflates to pump fluid out of the arm. Reid spent hours each week in therapy for three years, but her lymphedema improved only a little.
Now, nearly pain-free surgery can provide major relief from this troubling condition.
MD Anderson is one of only a few centers in the country with experience in surgery to reduce lymphedema.
A highly effective bypass procedure connects lymph vessels to blood vessels so the fluid can bypass “clogs” and drain from the arm or leg into the bloodstream. The operation takes two or three hours, with patients advised to refrain from strenuous activity for about four weeks.
For those who don't have lymph vessels appropriate for bypass, a more complex lymph node transfer procedure, which takes six to eight hours, is performed. Surgeons take healthy lymph nodes from elsewhere in the body to replace the ones that were removed. Using sutures finer than a human hair and specialized microscopes, the surgeons sew together tiny blood vessels to maintain blood flow and keep the lymph nodes alive. Patients remain in the hospital for about five days and are advised to allow two months for recuperation.
“We're one of the few institutions that are able to offer both operations,” Chang says. “One of the things that we started here at MD Anderson is doing both the transfer and the bypass together, which we think is more synergistic.
Combining the two approaches probably has a better impact than doing either one alone.”
MD Anderson also has pioneered combining breast reconstruction with lymph node transfers. Using tissue from the patient's abdomen to rebuild the breast provides the woman with a tummy tuck at the same time.
“Multiple studies have shown that breast reconstruction improves a patient's psychological health, self-esteem and well-being,” Chang says.
This February, Chang surgically created three bypasses in Reid's arm. The incisions were like paper cuts, she says, so they were practically pain-free. An overnight stay at the hospital allowed time for IV antibiotics before she headed home.
“My left arm and hand had been very red and very tight. Before I went home, my hand already looked almost like my right hand,” Reid says. “In just two months, there's been tremendous progress. It's much softer.”
While Chang recognizes performing surgery to relieve lymphedema is not curing cancer, it's still very beneficial.
“But going through cancer treatment is not an easy journey. If we can do something to help patients' quality of life, I'm hoping we can have a pretty big impact.”