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Lymphland International Lymphedema Online
| Permission to share this information given by Dr. Mara. Page updated 3/23/09. Dr. Marga is the surgeon who performs this technique. http://www.drmarga.com ------------- SURGICAL TECHNIQUE Postmastectomy Lymphedema Long-term Results Following Microsurgical Lymph Node Transplantation Corinne Becker, MD, Jalal Assouad, MD, Marc Riquet, MD, PhD, and Genevie`ve Hidden, MD Background and Objectives: Lymphedema complicating breast cancer treatment remains a challenging problem. The purpose of this study was to analyze the long-term results following microsurgical lymph node (LN) transplantation. Methods: Twenty-four female patients with lymphedema for more than 5 years underwent LN transplantation. They were treated by physiotherapy and resistant to it. LNs were harvested in the femoral region, transferred to the axillary region, and transplanted by microsurgical procedures. Long-term results were evaluated according to skin elasticity, decrease, or disappearance of lymphedema assessed by measurements, isotopic lymphangiography, and ability to stop physiotherapy. Results: The postoperative period was uneventful; skin infectious diseases disappeared in all patients. Upper limb perimeter returned to normal in 10 cases, decreased in 12 cases, and remained unchanged in 2 cases. Five of 16 (31%) isotopic lymphoscintigraphies demonstrated activity of the transplanted nodes. Physiotherapy was discontinued in 15 patients (62.5%). Ten patients were considered as cured, important improvement was noted in 12 patients, and only 2 patients were not improved. Conclusion: LN transplantation is a safe procedure permitting good long-term results, disappearance, or a noteworthy improvement, in postmastectomy lymphedema, especially in the early stages of the disease. (Ann Surg 2006;243: 313–315) Lymphedema complicating breast cancer treatment remains a challenging problem. Combined physiotherapy is not performed equally in all centers, and many physicians remain skeptical on the overall efficacy of surgical treatments.1 Furthermore, whatever the treatment proposed, the possibility of cure remains questionable. Over the last 12 years, our team has treated limb lymphedema by transplanting lymph nodes.2 The purpose of this study was to analyze the results obtained with this procedure during a minimal 5-year follow-up. PATIENTS AND METHODS We retrospectively reviewed data of 24 female patients suffering from lymphedema following breast cancer treatment who underwent lymph node transplantation by one of us (C.B.) in Cavell Institution in Brussels from 1991 to 1997. Mean age was 58.7 years (range, 37–80 years) with a mean follow-up of 8.3 years (range, 5–11 years). Upper limb lymphedema was right sided in 14 patients and left sided in 10 patients. All the patients were previously seen by their oncologist and considered in breast cancer remission. Breast carcinoma treatment performed was mastectomy (n 3), mastectomy and radiation therapy (n 11), and mastectomy, radiation therapy, and chemotherapy (n 10). Axillary lymphadenectomy had been performed in all cases. In 18 patients, upper limb lymphedema was present for at least 1 year or greater (mean, 5.6 years; range, 1–15 years). In 6 patients, it was present for only a few months (mean, 5 months; range, 3–8 months). Patients complaining of pain and/or presenting with palsy and/or with elephantiasis were excluded from the study. All patients were undergoing physiotherapy and were considered resistant to it. Lymphedema was assessed by measurements, infectious episodes, and isotopic lymphangiography. Measurements were weekly during the preoperative month and were performed before and after physiotherapy. Sites measured were at the wrist, 10 cm above the wrist, at the elbow, and 10 cm above the elbow. Results were then compared with the contralateral limb measurements. The number of previous infectious episodes (erysipela, lymphangitis . . .) and the aspect of the teguments at presentation (elasticity of the skin and infectious disease) were recorded. In case of infectious disease, antibiotic therapy and local treatment was performed. Isotopic lymphangiography was performed in 20 patients. In 15 patients, lymphoscintigraphy demonstrated absence of both lymph nodes and drainage; and in 3 patients, drainage was impaired without clearly demonstrating the absence of nodes. In 2 patients, lymphoscintigraphy was normal. Patients were divided into 2 stages: stage I, early edema with no or less than 2 infectious episodes, skin elasticity preserved, and perimeter not exceeding 30% more than the From Service de Chirurgie Thoracique, Hoˆpital Europe´en Georges Pompidou, Paris, France. Reprints: Marc Riquet, MD, PhD, Service de Chirurgie Thoracique, Hoˆpital Europe´en Georges Pompidou, 20-40 rue Leblanc, 75015 Paris Cedex, France. E-mail: marc.riquet@hop.egp.ap.ap-hop-paris.fr. Copyright © 2006 by Lippincott Williams & Wilkins ISSN: 0003-4932/06/24303-0313 DOI: 10.1097/01.sla.0000201258.10304.16 Annals of Surgery • Volume 243, Number 3, March 2006 313 contralateral arm (n 6); stage II, older edema, most often of more than 1 year duration, more than 2 infectious episodes, impaired skin elasticity, and perimeter measured between 30 and 50% more than the contralateral arm (n 18). Surgical approach of the axillary region of the lymphedematous limb was performed in search of receiving vessels: fibrotic muscular and burned tissue were dissected and adhesions released. Axillary vessels were dissected and the periscapular pedicle was isolated. The circumflex posterior branches were individualized and prepared for microanastomoses. An incision was then performed in the inguinal region. The dissection began by visualizing the superficialis circumflex iliac vein. At that level are located lymph nodes irrigated by the circumflex iliac vessels and without direct connection with the lymphatic drainage of the inferior limb. These nodes were dissected, freed, and elevated external to internal at the level of the muscular aponeurosis. The nodes were then harvested with an abundant amount of surrounding fat tissue. Lymph nodes were then transplanted in the axillary receiving site. Artery and vein were anastomosed with the vessels previously prepared, using microsurgical techniques. Both axillary and inguinal approaches were closed on suction drainage. In 7 cases, because of an incomplete result at the level of the forearm, a second procedure was performed. Lymph nodes were harvested in the same manner at the contralateral inguinal site and were transplanted at the level of the elbow. Following surgery, manual drainage (physiotherapy) was performed on the first postoperative day and daily during the first 3 months. Manual drainage was then performed twice a week during the following 3 months and discontinued. No elastic compression dressing was applied following surgery to avoid compression on the transplanted lymph nodes and on the microsurgical anastomosis. Antisludge treatment mainly acetylsalicylates were administrated during the postoperative period. Long-term results were evaluated according to skin elasticity and existence of infectious disease, decrease or disappearance of the lymphedema assessed by measurements, effects observed on isotopic lymphangiography, and ability to stop or to discontinue physiotherapy after 6 months. Longterm results were also evaluated according to the duration of the lymphedema before surgery and occurrence of downstaging after surgery. RESULTS The postoperative period was uneventful except for the appearance of lymphorrhea in 8 patients, which resolved over a few days. Infectious disease disappeared totally in 17 patients; and in the remaining 7 patients, only one episode of skin infectious disease was recorded. Upper limb perimeter returned to normal in 10 cases, remained unchanged in 2 cases, and decreased more than 50% of its value in 6 patients and less than 50% of its value in 6 other patients. Control isotopic lymphangiography was performed in 16 patients. In 11 patients, lymph nodes and lymph drainage were initially absent: in 4 patients, the transplanted lymph nodes were visualized and new lymph drainage pathways appeared. In 3 patients, lymph drainage was impaired without clearly demonstrating lymph nodes: in 1 of these patients, lymph node was visualized. In 2 patients with normal isotopic lymphangiography, results were unchanged. So, 5 of 16 (31%) lymphoscintigraphies demonstrated the effectiveness of lymph node transplantation. Physiotherapy was discontinued after 6 months in 14 patients and after 12 months in 1 patient. In the 9 other patients, physiotherapy remained necessary and was performed once weekly in 7 patients. Physiotherapy was thus discontinued in 15 patients (62.5%). Ten patients were considered cured (good results) (stage I, n 4; stage II, n 6). Two patients were not at all improved, lymphedema remaining unchanged (stage I, n 1; stage II, n 1). Downstaging (from stage II to stage I) was observed in 12 patients. Duration of the lymphedema before surgery was: a few months (n 5) and 1 to 4 years, mean 2.4 years (n 5) in case of good results, 3 and 4 years in case of bad results (n 2), 8 months and 1 to 15 years, mean 7.4 years (n 11) in case of downstaging. In 1 patient with downstaging, the result was considered as good (normalized) following elective liposuction. During long-term follow-up, no breast cancer recurrence was observed. DISCUSSION Autologous lymph node transplantation permits lymphedema improvement with long-term downstaging commonly obtained (except 2 patients), and physiotherapy discontinued in 62.3% of patients. Lymphedema was considered cured in 42% of patients and fixating lymph nodes were detected in 31% of patients controlled by lymphoscintigraphy. Good results were obtained more regularly when the duration of lymphedema was the shortest before lymph nodes transplantation. Effectiveness of the procedure was always durably demonstrated with respect to skin infectious diseases. Autologous lymph node transplantation for lymphedema treatment is a recent microsurgical technique,3 the results of which have yet to be fully evaluated.4 Results of the transplantation of lymph nodes in the rat5,6 and in the dog7 prove very attractive. In humans, the major concern is to find a fatty flap containing lymph nodes with their own vascularization, the procurement of which should be performed without injury. Our technique uses inguinal lymph node free flap2 made of the more superior external superficial lymph nodes: an anatomic study based on the dissection of 50 inguinal regions of fresh cadavers demonstrated that they mainly received lymph from the abdominal wall and that their procurement did not impair lymph drainage of the lower limb.6 This procurement site is the only one used in this report; however, lymph node transplantation may be used to treat limb lymphedema with other procurement sites such as cervical2 or axillary8 being possible. No current gold standard for evaluation of lymphedema exists;9 hence, evaluating results of treatments remains difficult Becker et al Annals of Surgery • Volume 243, Number 3, March 2006 314 © 2006 Lippincott Williams & Wilkins and appears controversial. Fluid displacement data, which would have been a more objective methodology, was not available because it was not routinely performed. Despite this, and although circumferential data appear subjective and difficult to interpret, results on lymphedema measurements were satisfactory in this series, and many patients were able to discontinue physiotherapy treatments. Trevidic and Pecking9 have underlined the role lymphoscintigraphy may have to objectively assess results obtained and to select patients for surgery. However, in our series, results obtained on reappearance of lymph drainage are difficult to interpret meaningfully, and colloidal uptake by transplanted lymph nodes was detected in only 31% of patients. Appearance of lymphatic pathways toward the graft site, which was sometimes also present, could suggest a “lymphangiogenetic” effect of these grafts. These results, also observed in experimental studies,5–7 would be of paramount interest if confirmed by other series. Transplanted lymph node colloidal uptake was all the more frequent than the duration of lymphedema was shorter. Shesol et al5 also observed, in a study in the rat, that radioactivity appeared in 4 of 5 transplanted lymph nodes when transplantation was immediately following lymphedema onset, whereas it appeared in only 1 of 5 cases when transplantation was delayed. This could suggest that it would be perhaps better not to delay the indication for lymph node transplantation. Effect on skin infectious diseases was the most obvious. A role by the transplanted lymph nodes immune effect may be possible. Experimental studies have demonstrated that autotransplanted lymph nodes rapidly recovered a normal architecture.10 No study is available to validate our observations, but Egawa et al11 reported reduction of lymphedema after intraarterial injection of autologous lymphocytes probably due to changes in blood protein components. Lymphoid tissue present in transplanted lymph nodes may prevent infection but may also reduce arm swelling by similar mechanism of changes in protein components: this also may explain partial benefits obtained when lymphatic pathways are not restored. CONCLUSION Autologous lymph node transplantation appears to have a favorable and persistent effect on postmastectomy lymphedema. It is a safe procedure that may be advocated when discussing surgical treatments, especially in early stages of the disease. REFERENCES 1. Fo¨ldi M. Treatment of lymphoedema. Lymphology. 1994;27:1–5. 2. Becker C, Hidden G, Godart S, et al. Free lymphatic transplant. Eur J Lymphol Rel Prob. 1991;6:25–77. 3. Bernars MJ, Witte CL, Witte MH, et al. The diagnosis and treatment of peripheral lymphedema: draft revision of the 1995 consensus document of the International Society of Lymphology Executive Committee for Discussion at the September 3–7, 2001 XVIII International Congress of Lymphology in Genoa, Italy. Lymphology. 2001;34:84 –91. 4. Campisi C. Surgery for the treatment of lymphedema. Eur J Lymph Rel Prob. 2002;10:24 –27. 5. Shesol BF, Nakashima R, Alavi A, et al. Successful lymph node transplantation in rats, with restoration of lymphatic function. Plast Recontr Surg. 1979;63:817–823. 6. Becker C, Hidden G. Transfert de lambeaux lymphatiques libres. Microchirurgie et e´tude anatomique. J Mal Vascul. 1988;13:199 –122. 7. Chen HC, O’Brien MC, Roger IW, et al. Lymph node transfer for the treatment of obstructive lymphoedema in the canine model. Br J Plast Surg. 1990;43:578 –586. 8. Trevidic P, Cormier JM. Free axillary lymph node transfer. In: Cluzan RV, ed. Progress in Lymphology, vol. XIII. Excerpta Medica Paris. 1992:415– 420. 9. Trevidic P, Pecking AP. Limb radionuclide lymphoscintigraphy prior and after a lymphatic bypass using an axillary flap. Lymphology. 1998; 31(suppl):605– 608. 10. Rabson JA, Geyer SJ, Levine G, et al. Tumor immunity in rat lymph nodes following transplantation. Ann Surg. 1982;196:92–99. 11. Egawa Y, Sato A, Katoh I, et al. Reduction in arm swelling and changes in protein components of lymphoedema fluid after intra arterial injection of autologous lymphocytes. Lymphology. 1993;26:169 –176. Annals of Surgery • Volume 243, Number 3, March 2006 Postmastectomy Lymphedema © 2006 Lippincott Williams & Wilkins 315 ------------------------------ Original article Postmastectomy neuropathic pain: Results of microsurgical lymph nodes transplantation Corinne Becker, Duc Nhat Minh Pham, Jalal Assouad, Alain Badia, Christophe Foucault, Marc Riquet* Service de Chirurgie Thoracique, Hoˆ pital Europe´en Georges Pompidou, 20-40 rue Leblanc, 75015 Paris Cedex, France Received 2 October 2007; received in revised form 13 November 2007; accepted 19 December 2007 Abstract Postmastectomy chronic pain may be divided into widespread and regional pain. Almost half patients with regional pain, which is more likely related to neuropathic phenomena, do not benefit any pain relief from medication. Our purpose was to report results on pain relief obtained by axillary lymph nodes autotransplantation. Methods: Six patients presented with chronic regional neuropathic pains and upper limb lymphedema after breast cancer surgery and radiation therapy. Despite medication, pain was intolerable and daily activity dramatically reduced. Lymph nodes were harvested in the femoral region, transferred to the axillary region and transplanted by microsurgical procedures. Results: Lymphedema resolved in 5 out of 6 patients. Pain was relieved in all, permitting return to work and daily activity; analgesic medication was discontinued. Conclusion: This procedure proved efficient and may be advocated in case of neuropathic pain when discussing lymphedema management. 2008 Elsevier Ltd. All rights reserved. Keywords: Breast cancer; Lymphedema; Chronic pain; Lymph node; Neuroma; Autotransplantation Chronic pain following breast cancer surgery is now a common and well-recognized problem with prevalence rates as high as 42.9% (175/408) and 46% (59/85) in retrospective studies,1,2 such rates being also observed in prospective study (48.4%, 46/95).3 Chronic pain is defined by the International Association for the Study of Pain as that persisting beyond the normal healing time of 3 months (IASP, 1986). Little is known about its long-term outcome, but chronic pain can resolve with time. MacDonald and Coll1 reported a cumulative prevalence of 43% at 3 years (mean) postoperatively and of 17% at 9 years (mean). The exact cause of chronic pain is unclear and various aetiological theories have been postulated, the main 1 being neuropathic origin. Chronic pain following breast cancer surgery has been divided into widespread and regional pain.4 Widespread pain, which is diffuse, persistent pain mainly due to other factors than neuropathic, may induce significantly more severity of pain, pain impact and lower physical health status than regional pain. However, in case of widespread pain, medication is rated as at least somewhat effective for relieving this pain. On the contrary, only 56% of patients with regional pain will benefit any pain relief from medication.4 Regional pain which is chronic pain related to neuropathic phenomena,1 so remains a therapeutic challenging problem. Other major problem following breast cancer treatment is lymphedema. Whatever the treatment proposed, the possibility of curing lymphedema remains questionable. Over the last 13 years, our team has treated limb lymphedema by transplanting lymph nodes.5 Results obtained with this procedure proved satisfactory demonstrating disappearance or a noteworthy improvement in postmastectomy lymphedema, especially in the early stages of the disease.6 * Corresponding author. E-mail address: marc.riquet@egp.aphp.fr (M. Riquet). 0960-9776/$ - see front matter 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2007.12.007 Available online at www.sciencedirect.com The Breast 17 (2008) 472e476 www.elsevier.com/locate/breast ----------------------------------- --------------------------------------------- Minimally invasive robotic surgery Saint Joseph's Hospital in Atlanta. http://www.physorg.com/news157040271.html Super micro-surgery offers new hope for breast cancer patients with lymphedema March 23rd, 2009 Breast cancer patients with lymphedema in their upper arm experienced reduced fluid in the swollen arm by up to 39 percent after undergoing a super-microsurgical technique known as lymphaticovenular bypass, report researchers at The University of Texas M. D. Anderson Cancer Center. Lymphedema treatment - www.lympha-press.com Lympha Press is the #1 physician recommended lymphedema therapy Prostate Cancer Treatment - www.ProstRcision.com Groundbreaking Techniques for the Highest Known Cure Rates Worldwide. The results from the prospective analysis, presented today at the 88th Annual Meeting of the American Association of Plastic Surgeons, suggest another option for breast cancer patients considering ways to manage lymphedema, a common and debilitating condition following surgery and/or radiation therapy for breast cancer. Lymphedema results when the lymph nodes are removed or blocked due to treatment and lymph fluid accumulates causing chronic swelling in the upper arm. Currently, there is no cure or preventive measure for lymphedema and it is difficult to manage; the use of compression bandages, massage and other forms of lymphatic therapy are commonly recommended options for patients. According to the National Cancer Institute, 25 to 30 percent of women who have breast cancer surgery with lymph node removal and radiation therapy develop lymphedema. Researchers evaluated 20 breast cancer patients with stage II and III treatment-related lymphedema of the upper arm who underwent a lymphaticovenular bypass at M. D. Anderson from December 2005 to September 2008. Due to lymphedema, the patients' affected arm was an average of 34 percent larger compared to the unaffected arm prior to the surgery. Of these 20 patients, 19 reported initial significant clinical improvement following the procedure. In those patients with postoperative volumetric analysis measurements, total mean reduction in the volume differential at one month was 29 percent, at three months 33 percent, at six months 39 percent and 25 percent at one year. "Patients often resort to lymphatic therapy because other options brought forward to reduce lymphedema haven't proved effective," said lead author on the study David W. Chang, M.D., professor in the Department of Plastic Surgery and Director of the Plastic Surgery Clinic at M. D. Anderson. "Surgical techniques, in particular, have been limited and therefore have been met with skepticism by surgeons, making it extremely important to determine which new techniques promise to bring real benefits to patients." In lymphaticovenular bypass surgery, surgeons use tiny microsurgical tools to make two to three small incisions measuring an inch or less in the patient's arm. Lymphatic fluid is then redirected to microscopic vessels - approximately 0.3 - 0.8 millimeters in diameter - to promote drainage and alleviate lymphedema. The procedure is minimally invasive and is generally completed in less than four hours under general anesthesia, allowing patients to return home from the hospital within 24 hours. M. D. Anderson is among a few institutions in the United States to offer this technically complex surgery. "Lymphedema is like a massive traffic jam with no exit," Chang said. "This procedure does a lot to help relieve lymphedema by giving the fluid a way out. While it does not totally eliminate the condition, there is very little downside for the patient and we may see significant improvement in its severity." Chang notes that while most effective when completed in earlier stages before the affected arm is fibrotic, almost any breast cancer patient suffering from lymphedema stage I, II or III is a candidate. Though breast cancer was the focus of this study, the surgery can also be performed on patients who have lymphedema in the leg resulting from cancers involving pelvic regions. Cancer treatment is not the only cause of lymphedema. Primary lymphedema can develop from developmental causes at birth, the onset of puberty or in adulthood. Secondary lymphedema can develop as a result of surgery, radiation, infection or trauma. In developing countries, a form of lymphedema caused by a parasite called Filariasis affects as many as 200 million people worldwide. "As we begin to refine our technique and learn more about the efficacy of this surgery, we have the potential to impact a large number of people," Chang said. Long-term follow-up with patients who have received lymphaticovenular bypass surgery is necessary to determine if the procedure continues to promote drainage after one year. Chang and his team of surgeons at M. D. Anderson believe that the fluid volume will keep decreasing over time and suggest that the surgery could possibly be used as a preventive measure for lymphedema in the future. "Working toward a definitive technique to cure this encumbering side effect of cancer and improve a patient's quality of life as a cancer survivor is a priority for those of us in this field." Source: University of Texas M. D. Anderson Cancer Center (news : web) --------------------------------------- http://www.freep.com/article/20090323/FEATURES08/903230314 Node transplant may help lymphedema's painful swelling BY PATRICIA ANSTETT • FREE PRESS MEDICAL WRITER • March 23, 2009 Two years after her mastectomy, Susan Cochrane spent the day in her Tecumseh yard planting flowers. She got a mild sunburn on her arms, though she had been careful to wear sunscreen and gloves. That night, her left arm looked a little swollen and red. Within three days, the arm had thickened and gotten painful. "That started the whole cascade," said Cochrane, 54, describing a four-year struggle with lymphedema, a painful swollen limb condition that can be a complication of surgery for breast cancer. About 8% of breast cancer patients alone develop the problem, which can occur, as Cochrane found, several years after surgery. In January 2008, Cochrane developed her worst flare-up, a painful case of cellulitis, an infection triggered by her lymphedema. It caused "a fiery redness of the skin that completely encircled my forearm." A massage therapist, "I was afraid my career was over," Cochrane said. Fortunately for Cochrane, the plastic surgeons she works with in Ann Arbor knew a colleague, Dr. Rebecca Studinger at St. John Providence Park Hospital, who had begun offering patients with lymphedema an option called a lymph node transplant. Studinger, a plastic surgeon specializing in breast cancer reconstruction, is one of only a handful of U.S. doctors performing the technique. It was developed over the last 20 years by a French physician, Dr. Corinne Becker, but only recently has been offered in the United States. Becker has published a few articles on small groups of patients, but the technique is not well studied. Studinger spent a week in France with Becker learning the operation. "When I first heard about it, I said, 'I've got to go learn it,' " she said. While not a cure for everyone, one in four of Becker's patients who had lymphedema for no more than three years had a 50% reduction in arm swelling after a transplant, she said. Studinger has performed about 20 of the procedures in the last year. The transplant sometimes brings relief while a patient remains hospitalized. Cochrane's arm felt better within hours of the transplant and now, a year later, "I pretty much don't have any limitations," she said. (2 of 2) She has developed a pamphlet for breast cancer patients she works with at the Center for Reconstructive Surgery in Ann Arbor, which has incorporated massage therapy as part of the post-operative care patients receive. Massage after breast cancer surgery can help prevent lymphedema from occurring. Another of Studinger's patients, Kathryn Lay, 35, a mother of four from Farmington Hills, underwent a lymph node transplant at the same time Studinger performed her breast reconstruction procedure. A longtime bowler, Lay developed lymphedema 10 months after she had a double mastectomy and removal of 14 underarm lymph nodes in January 2008. She had been diagnosed with breast cancer the year before, at age 33. "The swelling went down almost immediately" after the transplant, Lay said. She's easing back into bowling every other week at Country Lanes in Farmington Hills. Given all that has gone on in her life, Lay said she tries not to complain about her arm pain. She is grateful to her husband, Ralph, "my deep-rooted solid oak tree" who has "picked up the slack" during breast cancer and lymphedema treatment. "I was diagnosed at 33, and I have a long life to live," she said. "I want to focus on that." Contact PATRICIA ANSTETT at 313-222-5021 or panstett@freepress.com. ----------------------- AAPS: Surgery Effectively Reduces Lymphedema By Crystal Phend, Staff Writer, MedPage Today Published: March 24, 2009 Reviewed by Zalman S. Agus, MD; Emeritus Professor University of Pennsylvania School of Medicine. Earn CME/CE credit for reading medical news RANCHO MIRAGE, Calif., March 24 -- For breast cancer patients with lymphedema, surgery can improve lymphatic drainage, researchers said, but whether the benefits last long term remains to be seen. Action Points -------------------------------------------------------------------------------- Explain to interested patients that lymphedema occurs when lymph nodes to the arm are removed or damaged, leading to a buildup of fluid and swelling. Note that this study was published as an abstract and presented orally at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal. Lymphaticovenular bypass "microsurgery" on the upper arm reduced arm volume by up to 39% in these patients, David W. Chang, M.D., of the University of Texas M.D. Anderson Cancer Center in Houston, and colleagues found. The effects in a prospective, single center study appeared durable through one year, although longer-term follow-up is needed, Dr. Chang reported here at the American Association of Plastic Surgeons meeting. Compression garments, massage, and other conservative medical treatment remain the first line of defense for the 25% to 40% of breast cancer patients who develop lymphedema after chemotherapy or radiation therapy. Although a wide variety of palliative surgical techniques have been pioneered in Europe and Asia, these options have been controversial and limited, Dr. Chang said. At M.D. Anderson, he said, surgeons use lymphaticovenular bypass. This minimally-invasive technique involves two or three 1-inch or smaller incisions in the arm to insert microsurgical tools used to redirect lymphatic fluid to veins 0.3 to 0.8 mm in diameter. "For the most part, lymphedema in the U.S. has not been treated surgically," Dr. Chang said. "The reason it hasn't gained popularity is that it's technically challenging and doesn't cure the lymphedema." Given this skepticism, his group monitored outcomes of 20 consecutive patients who had lymphaticovenular bypass at their institution from December 2005 through September 2008. All of the women had stage 2 or 3 lymphedema for a mean duration of 4.8 years before the surgery. Their breast cancer therapy had included axillary lymph node dissection in all cases, with preoperative radiation therapy as well in 16 cases. Surgery lasted an average of 3.3 hours and patients were discharged within 24 hours afterward. The procedure included a mean of 3.5 lymphaticovenular bypasses per patient. After surgery, patients resumed nonsurgical strategies, including compression garments. Prospective follow-up over the next 18 months revealed significant postoperative clinical improvement in 19 of the 20 women. Three patients reported clinical lymphedema reduction without a corresponding significant quantitative volume reduction. The researchers found that, whereas before surgery, the affected arm was an average of 34% larger than the unaffected arm on quantitative volumetric analysis, the mean volume reduction afterward was: 29% at one month 33% at three months 39% at six months 25% at 12 months Dr. Chang cautioned against over-interpreting the dip in the results at one year. Based on a series from researchers in Asia and Europe, limb volume plateaus at some point after surgery but yields durable results. He also noted that arm volume didn't capture other qualitative benefits that may be more important for patient quality of life. "Patients feel the arm is softer and lighter than before." The researchers reported no postoperative complications or lymphedema exacerbations. "Lymphaticovenular bypass using a 'super-microsurgical' approach appears to be effective in improving the severity of lymphedema in patients with breast cancer," they concluded. Dr. Chang said his team believes that these results will improve over time with continued fluid volume reductions. However, he acknowledged the small sample size and the need for long-term follow up. The researchers reported no conflicts of interest. Primary source: American Association of Plastic Surgeons Source reference: Chang DW, et al "Lymphaticovenular bypass for management of lymphedema in breast cancer patients: A prospective analysis" AAPS 2009. Related Article(s): ASCO Breast: Upper-Body Breast Cancer Surgery Aftermath Often Lingers SABCS: Air Travel Holds Little Lymphedema Risk for Breast Cancer Survivors http://www.medpagetoday.com/Surgery/PlasticSurgery/13404 |