An NCI-designated Comprehensive Cancer Center
By Abe Rosenberg | January 28, 2020
Tan-Mark Mark C. Tan, M.D.
In 2009, Karin Moser, a financial planner from South Pasadena, California, needed a bilateral mastectomy after tests detected several cancerous tumors. Months later, just as she thought her medical challenges were behind her, Moser’s left arm, wrist and hand began to swell, causing serious pain, making it impossible to wear her normal clothing and battering her self-esteem.
“It was terrible, the worst,” she recalled. “I’m a size 4 but I couldn’t wear long sleeves. You stare at it 24/7. People are always asking you about it. My little boy’s friends said cruel things to him.
“Sometimes I just fell into a vast wasteland of helplessness.”
The wasteland has a name: lymphedema. It’s a common byproduct of breast cancer surgery (and other procedures) when multiple lymph nodes are removed. The nodes play a critical role in our immune system, filtering out impurities and sending lymph, a fluid containing proteins and fats, through the bloodstream. If lymph nodes are damaged or missing, fluid builds up, typically in the arms and legs.
Lymphedema has no cure, and until recently the only available treatment was complete decongestive therapy (CDT) — massaging the limb and applying compression bandages to force the lymph to move, temporarily alleviating some of the symptoms with the goal of getting into a compression garment for use long term.
Moser struggled for years until she met Mark C. Tan, M.D., associate clinical professor in City of Hope’s Division of Plastic Surgery. Tan employs a pair of relatively new microsurgeries: a lymphovenous bypass that creates a new path for lymphatic flow, and a more elaborate vascularized lymph-node transfer, taking nodes from the abdomen (where they are abundant) and implanting them into the affected area.
For Moser the results were dramatic.
“It’s a complete change. There’s no pain anymore,” she said. “I’m getting my arm back. I’m way less self-conscious. I don’t worry about being in public. People who see me now don’t even know something was wrong unless I tell them. I’m getting back to a normal life!”
Tan specializes in reconstructive surgery for breast cancer patients. During his training, he says “lymphedema was not on the radar.” Slowly, techniques that originated in Japan began to make their way to the U.S. Tan has now performed about 50 such procedures, and while he’s encouraged by the results, he’s careful not to oversell the possibilities.
“We know we can do these procedures,” he said. “But we’re still missing the long-term data, and we don’t experiment on patients. We insist on evidence-based medicine. We are, however, making progress. We’ve figured out the workflow and we have the infrastructure to do this. We need to keep refining the techniques.”
Choosing the right patients for each procedure is part of that refinement. If the lymphedema is in an early stage and the patient’s lymph system is still working, albeit slower, a bypass may improve the flow. But in later stages, when scarring and inflammation have developed and the “pumping” system no longer works at all, transplanting healthy nodes may be the only option.
The ideal patient, Tan says, has exhausted all of the other, more conservative options and is no longer getting enough relief from them. The ideal outcome? Sure, Tan’s gratified when he hears about improved appearance, more freedom of movement, less pain, restored self-esteem. But he places one goal above all:
“I want to improve quality of life.”
Lymphedema compromises the immune system, leaving the patient susceptible to serious, even lethal infections. A simple wound can allow bacteria to enter and spread unchecked. One of the most painful and debilitating infections is cellulitis, a skin condition that can be deadly if it’s left untreated.
“A swollen arm won’t kill you,” Tan said bluntly. “An infection will. This surgery can reduce the risk of infection and, for me, that’s a win.”
It was certainly a win for Nancy Bell, a school administrator from Colorado. She lived with lymphedema in her right arm for 14 years. In addition to the swelling and discomfort, Bell endured dozens of infections, including bouts of cellulitis.
“It seems I was always taking antibiotics, always had to be careful,” she remembered.
Surgeons at other facilities turned her down. But through her daughter (Courtney Bitz, director of Clinical Social Work at City of Hope), Bell found Tan. She had the surgery in 2017.
“I’m doing a lot better now,” she said. “I still can’t do some everyday activities, but I’m almost normal.
“Before, it was all about the arm. I couldn’t go a day without thinking about it. It was like a monkey on my back.
“Now I hardly think about it at all.”
Tan thinks about it all the time. He’s taking this new path methodically, one step at a time. It’s his way.
“I want to build on their progress,” he said. “I won’t promise more than I can deliver.”
His patients are reassured by his conservative, low-key, no promises “We’ll try” approach. They understand that even after surgery they’re not cured and might need to continue conventional CDT.
But they also say Tan delivered plenty, restoring more of their normal life than they thought possible. Including their emotional well-being.
Moser’s “vast wasteland”? It’s a thing of the past.
“The clouds have parted,” she said. “The skies are clear!”
But perhaps the best treatment for lymphedema is never getting it in the first place.  Patients who are at a particularly high risk of developing lymphedema may be candidates for a prophylactic lymphovenous anastomosis (LVA), a procedure that involves identifying the cut ends of the lymphatic channels at the time of lymph node removal and reconnecting them to nearby veins. Evidence suggests prophylactic LVA can reduce the risk of developing lymphedema by as much as 30 percent.
City of Hope has also implemented a lymphedema prevention program utilizing the SOZO, a digital device that is able to detect the earliest signs of edema, scoring patients on an "L-Dex" scale. An L-Dex score increase of 6.5 or more from baseline triggers an intervention. A clinical study showed that subclinical detection using L-Dex combined with early intervention led to a 95% reduction in lymphedema progression.

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