Emerging tools prove effective against lymphedema

City of Hope is on a quest to minimize — and perhaps one day eradicate — lymphedema, a residual effect of cancer that produces swelling ranging from mild to uncomfortable to positively painful.
Leading the charge is Mark C. Tan, M.D., associate clinical professor in the Division of Plastic Surgery and a specialist in breast reconstruction and lymphedema treatment, who collaborates with a committed team of specialists to assess and treat cancer patients with lymphedema.

'The Body's Housekeeper'

The lymphatic system is a network of vessels, organs, lymph nodes and ducts that moves lymph, a fluid containing proteins and fats, from the tissues to the bloodstream. It plays a key role in the body’s immune system.
When functioning properly, the lymphatic system is the body’s housekeeper. The fluid is carried by vessels into the lymph nodes, of which there are hundreds throughout the body. The nodes contain infection-fighting white blood cells that filter out the garbage such as bacteria and cancer cells, and send the rest of the fluid along its way, into the bloodstream. If the lymph nodes have been damaged or removed because of surgery (usually during cancer’s staging phase) or treatment such as radiation therapy, fluid builds up in tissues and causes swelling (edema), typically in the arms and legs.

Not Just Breast Cancer

Most people probably associate lymphedema with breast cancer treatment, a notion that Sherry Hite, an occupational therapist who works with Tan and oversees a team of certified lymphedema therapists, would like to dispel. According to Hite, the prevalence of lymphedema associated with breast cancer, 20 percent, is about the same as in gynecologic cancers. Additionally, other cancers, such as head and neck, can also produce swelling. In any case, medical professionals aim to alleviate the sometimes debilitating discomfort of lymphedema and other accompanying issues (tightness in the affected area, limited range of motion, infection, hardening of the skin).
Mark Tan
Mark C. Tan, M.D.
Currently, lymphedema is incurable, so effective management is critical. “Lymphedema is progressive,” said Tan, “and if left alone, it’s not something that will reverse on its own.”

An Individualized Approach

He emphasizes the importance of approaching patients as individuals: Before treatment, the lymphedema, much like cancer, is staged to determine the severity and type of therapy that will yield the best results. Nonsurgical intervention is the first step, and this is when Hite and a team of lymphedema therapists implement complete decongestive therapy (CDT). This rigorous, two-week approach to reducing lymphedema includes manual lymphatic drainage, exercise and compression bandaging. The compression helps trapped lymph move.
At best, CDT may preclude the need for surgery. If surgery is deemed necessary, CDT prepares patients for optimal outcomes. Determining the ideal time for surgery is a coordinated decision between Tan and the lymphedema therapists.

Surgical Solution

Liposuction, which sucks out extra fat (where lymphatic fluid has a tendency to accumulate), is one surgical option, but it addresses only the symptoms of lymphedema. Surgeries that are more physiologic in nature — that is, aiming to address underlying problems — are Tan’s area of expertise.
Drawing on techniques introduced in Japan in the ’90s and that have been used (although not yet widely) in the United States for about a decade and at City of Hope for two years, Tan performs a procedure called a vascularized lymph-node transfer.
This procedure is reserved, generally, for more advanced stages of lymphedema. Functioning nodes are harvested from areas other than the one with lymphedema and transferred to the affected area. Lymph nodes have growth factors that stimulate the growth of lymphatic vessels, ultimately enabling lymph to find its way to the transplanted node. To minimize the risk of lymphedema development in the area where the node has been removed, Tan tries to transfer nodes from the abdominal area, where there is node redundancy.
“There aren’t a lot of people doing this,” Tan said. “We’re grateful that we have the ability to offer this uncommon surgery and have the resources to treat these patients. Yes, we’ve got the equipment, but more importantly, we’ve got the therapists, surgeons, the residents — this is a team effort.”

Hoping for Relief

Surgery does not guarantee a cure, cautions Tan, but it does offer relief and likely the ability to forego the daily use of a compression garment. Another surgical approach is lymphovenous bypass, in which a microscope is used to sew a lymphatic vessel to a nearby vein, bypassing the blockage and allowing better flow of excess lymph. For a few patients, a combination of bypass and transfer has been used.
Tan points out that these types of surgeries, although not new, are still in their infancy; nonetheless, there are data supporting symptom improvement.
“It’s exciting to offer these surgeries as an option,” Hite said. “The unique relationships on the multidisciplinary team make it all possible.”
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