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April 2017 : Advances in Surgical Management of Lymphedema
Advances in Surgical Management of Lymphedema
New options reduce edema in limbs, improve quality of life for cancer patients with lymphedema
The affected left arm of a patient with lymphedema resulting from breast
cancer treatment is seen before (left) and after liposuction debulking
of the left arm. The procedure yielded a 1,600-mL reduction in limb
volume. Images courtesy of Dr. Mark Schaverien.
Lymphedema in the arms or legs can be a debilitating effect of oncologic surgery or radiation therapy. Approaches to managing the condition vary according to its severity and may include surgery. Surgeons at The University of Texas MD Anderson Cancer Center have several techniques that reduce limb volume and restore function in cancer survivors with moderate to severe lymphedema.
“The combination of radiation and surgical removal of the lymph nodes is the most common cause of lymphedema in cancer patients,” said Matthew Hanasono, M.D., a professor in the Department of Plastic Surgery. Lymphedema of an upper extremity is seen most often in breast cancer patients who have undergone axillary lymph node dissection and radiation therapy to the axillary nodal basin. Lymphedema of a lower extremity is seen most frequently in patients with bladder, prostate, or gynecological cancers who have undergone pelvic lymph node dissection and radiation therapy to the pelvic nodal basin.
Lymphedema is typically managed by manual lymphatic drainage (i.e., massage), exercise, and compression garments. However, these techniques are time consuming and do not restore function for all patients.
In the past decade, Dr. Hanasono and his colleagues have shown that lymphovenous bypass and vascularized lymph node transfer are effective surgical treatments for lymphedema. Building on this experience, MD Anderson surgeons are refining treatment for severe lymphedema to reduce limb swelling and improve patients’ quality of life by combining these two procedures or using liposuction debulking.
Combining procedures
Lymphovenous bypass and vascularized lymph node transfer
Lymphovenous bypass surgery, in which the obstructed lymphatic vessels are anastomosed to small adjacent veins, often provides an immediate benefit by improving lymphatic drainage. In many patients, especially those with early-stage lymphedema, lymphovenous bypass can provide a long-lasting benefit. However, in some patients, the effectiveness begins to decrease around 12 months after surgery. In contrast, vascularized lymph node transfer—in which healthy lymph nodes from an unaffected region are transplanted as a vascularized flap—can provide permanent new lymphatic drainage, but these new lymphatic channels do not begin functioning until 6–9 months after surgery.
MD Anderson surgeons have found that performing lymphovenous bypass and vascularized lymph node transfer during the same operation can overcome the limitations of each procedure. “We’ve found that combining these two surgeries can provide both immediate and lasting relief,” said Mark Schaverien, M.D., an assistant professor in the Department of Plastic Surgery. “This can be a very powerful treatment for patients with lymphedema.”
Almost all patients who undergo the combined procedure see improvements such as reduction in the size, tightness, or heaviness of the limb and a reduced frequency of infections in the limb. Total cure, although achieved in some patients, is rare. Patients typically continue to wear compression garments and perform manual drainage after surgery; however, the need for both of these is reduced in most patients.
“After these surgeries, we’ve seen a significant reduction in the amount of time patients have to spend on massage and compression garments to remove fluid from their limbs,” said Edward Chang, M.D., an associate professor in the Department of Plastic Surgery. “Moreover, I’ve had patients who had multiple infections in their affected limb before surgery who do not get infections anymore after surgery.”
Associated with lymph node transfer is the risk of donor site lymphedema. To minimize this risk, reverse mapping of the donor site lymph nodes—a procedure similar to sentinel lymph node mapping, in which a contrast agent is injected and used to find the draining lymph nodes—is performed before surgery to make sure the nodes that drain the nearby extremity are left intact. “With that technique, we’ve had no issues at all,” Dr. Schaverien said. “Donor site lymph node mapping is mandatory here and is being increasingly used elsewhere.”
Lymphovenous bypass and vascularized lymph node transfer with breast reconstruction
The lateral chest wall is the most common donor site for lymph node transfer to treat lymphedema of the leg, and the lymph nodes from the lateral chest wall on the unaffected side can also be used to treat lymphedema of the arm in breast cancer survivors who do not require breast reconstruction. But when a patient requires both lymphedema treatment and breast reconstruction, lymphatics can be transferred and anastomosed to the affected region along with the transverse rectus abdominis (TRAM) or deep inferior epigastric perforator (DIEP) flap used for breast reconstruction. “The combined lymphovenous bypass and vascularized lymph node transfer surgeries we do are the same whether the lymphedema is in the arm or the leg,” Dr. Hanasono said. “But for the arm, we can combine them with breast reconstruction.”
Vascularized TRAM or DIEP flaps often are the best option for breast reconstruction in patients who do not undergo reconstruction at the time of mastectomy because radiation therapy performed after the cancer surgery often causes tissue damage that makes later reconstruction with implants problematic. “If a patient has had mastectomy and radiation, a tissue flap will probably give us the best result for reconstruction,” Dr. Chang said. “And a patient who has had radiation likely has lymphedema, so we can address this at the same time.”
Combining lymphedema treatment with breast reconstruction allows patients to address both issues without increasing their recovery time or length of hospital stay. It has become a common practice at MD Anderson for plastic surgeons to perform a vascularized TRAM or DIEP flap breast reconstruction, vascularized lymph node transfer, and lymphovenous bypass all in one operation.
Because of the specialized training and equipment necessary to anastomose lymphatic vessels, the combination of breast reconstruction and lymphedema surgery is not widely available. “It’s a fairly specialized surgery, so it needs to be done by people who are trained to do it and do it frequently,” Dr. Chang said. “A lot of plastic surgeons can do flap reconstructions; very few can offer patients the whole package that addresses their lymphedema at the same time.
During a lymphovenous bypass procedure, blue dye shows movement through
a lymphatic vessel (white arrow) into the vein to which it is
anastomosed (red arrow). Image courtesy of Dr. Edward Chang.
Liposuction debulking
Not all patients are candidates for lymphovenous bypass and vascularized lymph node transfer. In particular, patients with advanced lymphedema may have lymphatics that are too severely damaged to allow restored drainage. Liposuction debulking can offer relief to such patients.
“Many patients and even some physicians don’t realize that lymphedema begins with an accumulation of fluid and then becomes a condition of fat whereby the fat grows in response to proteins in the lymphatic fluid,” Dr. Schaverien said. “So compression therapy alone, although it removes the fluid fraction, will never get the limb back to its baseline size because of the fat fraction.”
Liposuction debulking for lymphedema patients is performed much like liposuction for cosmetic purposes. “Traditionally, lymphedema debulking was done with open procedures that were morbid,” Dr. Schaverien said. “Now we do it with liposuction with minimal scarring and minimal morbidity.”
Liposuction debulking can reduce the volume of the affected limb and restore function. Although the patient must continue to wear compression garments for life, the reduced limb size and improved function typically remain stable.
Choosing the right treatment
Ideally, patients with lymphedema are diagnosed and sent to a lymphedema-certified physical therapist for treatment before the condition becomes severe. Some patients who present as soon as their swelling occurs have complete resolution of their lymphedema with compression therapy and manual drainage within 6 months. Those whose lymphedema does not respond to such therapy may be eligible for surgery; and the earlier surgery is performed, the better the outcome.
To determine whether a patient is likely to benefit from surgery and which procedure should be used, an extensive work-up is performed. “The clinical signs and symptoms and even the duration of the lymphedema are poorly predictive of the actual condition of the lymphatic vessels,” Dr. Schaverien said. “So we do an extensive work-up to determine which surgical treatment is best suited for the patient.” Duplex ultrasonography is performed to rule out venous thrombosis as the cause of the swelling, and lymphoscintigraphy determines whether the patient’s lymphatics are amenable to lymphovenous bypass and lymph node transfer.
Dr. Chang and colleagues devised a lymphedema staging system to help select the appropriate management strategy for each patient. The staging system is based on the degree of dermal backflow and the patency and contractility of lymphatic vessels on indocyanine green lymphangiography. Stage I lymphedema is characterized by minimal dermal backflow, several patent vessels, and slightly impaired contractility; stages II, III, and IV are characterized by increased dermal backflow and reduced vessel patency and contractility; and stage V is characterized by no dye movement at all.
“We individualize the treatment algorithm to the patients,” Dr. Schaverien said. “Patients often have a combination of procedures during the course of their treatment.”
In addition to the patient’s lymphedema stage, financial concerns may affect whether a patient can undergo surgical treatment for lymphedema. Dr. Schaverien said, “Liposuction is very uncommonly performed for lymphedema treatment in the U.S., mainly due to the lack of insurance coverage. However, we’ve been very successful in getting the operation approved once we explain how it benefits the patient.”
Many insurance companies also consider the combined lymph node transfer and lymphovenous bypass procedure experimental and are reluctant to cover it, according to Dr. Chang. “The combined procedure is relatively new,” Dr. Chang said, “but it’s not experimental in our opinion because we’ve had more than a year of follow-up in some patients, and we’re showing that the surgery benefits patients with lymphedema.”
For more information, contact Dr. Edward Chang, Dr. Matthew Hanasono, or Dr. Mark Schaverien at 713-794-1247.
FURTHER READING
Nguyen AT, Chang EI, Suami H, et al. An algorithmic approach to simultaneous vascularized lymph node transfer with microvascular breast reconstruction. Ann Surg Oncol. 2015;22:2919–2924.
OncoLog, April 2017, Volume 62, Issue 4
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