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Lymphland International Lymphedema Online
Reducing Lymphedema -- Research Summary
Reducing Lymphedema
BOSTON, MA (Ivanhoe Newswire) -- Great news! Doctors say cure rates are getting better for breast
cancer, but many women are left with unwanted, sometimes devastating side effects. We’ll show you what’
s making a big difference in the lives of survivors.
When Katie Brophy learned she had breast cancer, she wasn’t surprised.
“I sort of expected it, obviously when you have a lump, you just assume,” Katie Brophy, told Ivanhoe.
A lumpectomy and radiation took care of her cancer, but left her with the risk of lymphedema , a side effect
of treatment that causes fluid build-up in the limbs. as an interior designer, that worried her.
“I’m physical. I paint walls. I wallpaper, refinish wood. The last thing you need to do is have an impaired
arm,” Katie said.
Mayo clinic doctor Andrea Cheville says radiation may destroy arm-draining lymph nodes. Once they’re
damaged, the risk of lymphedema rises and so does the risk of infection.
“It’s unattractive and so I think socially it’s a very difficult condition for people,” Andrea Cheville, M.D.,
MSCE, from the Mayo Clinic physical medicine and rehabilitation, said. “Our best hope is to prevent
people from getting it.”
To do that, she’s testing a new technique that combines CT scans with Spect-imaging. That powerful combo
pinpoints exact locations of critical lymph nodes.
“The physicians who are planning a woman’s radiation can know exactly where those critical nodes are and
avoid them, block them from the radiation field, ”Dr. Cheville said.
Studies show it reduces the number of critical lymph nodes that receive harmful radiation by more than 55
percent.
“We treated 30 women. None of those women have developed lymphedema,” Dr. Cheville said.
Katie was one of those women.
“At the moment, I’m very pleased with the result. Two years have passed. I have no symptoms,” Katie said.
Doctor Cheville says one big advantage of this new approach is many medical centers already have both of
these imaging technologies. Training physicians to fuse the two techniques for this purpose may be all that’s
needed to help women reduce their risk of lymphedema
BACKGROUND: Between 5 percent and 40 percent of women are estimated to experience some form of
lymphedema after breast cancer surgery; however, the condition is often overlooked or misdiagnosed.
Lymphedema occurs when the lymph system is damaged or blocked. It can cause fluid buildup and swelling
and usually affects an arm or a leg, but it can affect other parts of the body. Lymph fluid, tumors, lymph
vessels and lymph nodes all can play a part in lymphedema. (SOURCES: www.breastcancer.org, www.
cancer.gov)
CAUSES AND SYMPTOMS: Lymphedema can be either primary or secondary. Primary lymphedema is
caused by abnormal development and can occur at birth or develop later in life. Secondary lymphedema is
caused by damage to the lymph system due to infection, injury, cancer, scar tissue, or radiation therapy.
People can be at risk of developing lymphedema if they are obese, smoke heavily, have diabetes or have
had a mastectomy or previous surgery to the armpit area. Along with swelling, people with lymphedema may
experience a feeling of heaviness or tightness in the arm or leg. They may also feel aching or discomfort and
possibly hardening of the skin around the affected area.
(SOURCES: www.cancer.gov, www.breastcancer.org and Mayo Clinic)
NEW PREVENTION TECHNIQUES: Using single photon emission computed tomography (SPECT)
along with computerized tomography (CT) scans, doctors may be able to offer substantial protection against
lymphedema. Although a person may have as many as 62 lymph nodes under the arm, only a few are
responsible for the removal of fluids from the arm. The SPECT-CT technique works best for patients who
do not require radiation targeting any remaining lymph nodes. The risk of developing lymphedema may be as
much as 50 percent without taking measures to preserve the function of a person’s lymphatic system.
Because lymphedema can occur years after a surgery, patients will continue to be monitored by their
physicians for signs of lymphedema. Currently, there are two treatment plans for each patient: a standard
plan and one adapted for lymph node sparing based on the SPECT-CT scans. (SOURCE: Mayo Clinic)
Reducing Lymphedema -- In Depth Doctor's Interview
Andrea Cheville, MD, MSCE, from the Mayo Clinic -- Physical Medicine and Rehabilitation, talks about a
new way to potentially prevent lymphedema
Tell me what lymphedema is.
Dr. Cheville: Lymphedema is a potentially devastating condition that’s characterized by enlargement of a
body part because of the build-up of protein rich fluid. And it’s unfortunate for many reasons it places
patients at risk of bad medical events, recurrent infections, un-healing wounds. But beyond that it changes
the way they look, it distorts them, you know you have a very big head or a very big arm. It’s unattractive
and so I think socially it’s a very difficult condition for people. It’s also uncomfortable and currently we
cannot cure it. We can control it through a collection of burdensome and very time-consuming self
management activities. Which are wrapping and wearing compression garments which patients never like it’s
always difficult for them. So right now and our best hope is really to prevent people from getting it.
Once you get it are you always going to have it?
Dr. Cheville: Yes.
So even if you can control it you still have it and you have to keep doing the control?
Dr. Cheville: The way I explain it to patients sometimes is if you have a little town that gets bigger and you
don’t expand its sewage system and so every time you have a heavy rain it has a potential to flood. So you
just have more production than the system can handle and so you always have the potential for overload.
We have lots of therapeutic tricks we do to even that out so that patients can handle, can remove the
amount of swelling, fluid that their body brings to their tissue. But again it’s not easy for them. There’s no pill,
there’s no surgical procedure that can make this go away.
And why does it occur?
Dr. Cheville: Well, so we have two sets of pipes, you can kind of think of it as plumbing, that the arteries
bring lots of fluid, an astounding amount of fluid into your body tissues every minute of the day. And the way
that fluid gets out most of it is through the veins but there’s a second set of pipes that most of us don’t know
about until you get lymphedema and when they stop working. But what the lymphatics are responsible for
doing is removing about five percent of the fluid that comes in to tissue during the day but they’re really,
really good at carrying out large solid waste. That is what they are uniquely designed to do so bacteria, large
fats, large proteins that’s really the specialty of the lymphatic system. And when patients undergo cancer
treatment, in fact in the developed world certainly in the United States that’s the number one cause of
lymphedema. We injure the system by removing lymph nodes or irradiating lymph nodes in order to stage a
cancer or to treat a cancer.
So women with breast cancer are prime candidates to get this right?
Dr. Cheville: Absolutely.
Is that because of where you’re treating because if you have pancreatic cancer you’re not near the lymph
nodes in the arms, is it the area that you’re treating?
Dr. Cheville: Yeah, that’s a part of it. So you ask the great question of why once you take out those lymph
nodes you’ve damaged the system, you’ve interrupted the pipe, the plumbing so in essence it’s a plumbing
issue. But we do we focus on the fluid but what we really worry about is all that big waste material that it can
build up in the tissue and cause a lot of problems. And so with breast cancer treatment is changing so we are
less aggressive with our treatment. We used to always take every last lymph node out of a woman’s armpit.
Now we don’t we do a special technique to try and identify the nodes that might have cancer. We take
those out first see if they have any tumor cells and if they don’t we leave the rest of the nodes. So some of
the good news is that there’s less lymphedema now in women with breast cancer. But for those women who
do have all the nodes in their armpit taken out they are at high risk of developing lymphedema in the arm on
the same side but also in their trunk the front and back of their upper trunk as well as their breast if they’ve
elected for conservative treatment.
Are there some lymph nodes that are more critical for draining fluids than other?
Dr. Cheville: They all drain fluid. There’s a lot that we don’t understand about the lymphatic system. There
are lots of layers, eventually lymph is going to be dumped back in to the bloodstream and as I said some of
that solid material that the body picked up is bacteria and the last thing the body wants to do is put bacteria
in the bloodstream. So what happens to the lymph is it gets purified time and time again in lymph nodes and
certain lymph nodes are kind of responsible for certain drainage territories. So you have certain nodes that
drain the breast and certain nodes that drain the arm. And from what we’ve found they’re usually one to at
most three nodes that are kind of the first order that receive most of the lymph from the breast. Other lymph
nodes are going to get that lymph later to purify it again and again to make absolutely sure that we don’t
introduce something harmful into the blood stream.
So people get this because you’re removing the nodes or irradiating the area, you’re not exactly meaning to
irradiate those lymph nodes?
Dr. Cheville: Exactly. Well sometime we do. If we think that a woman is at very high risk of the cancer
coming back then we have to. The priority is saving her life and avoiding a breast cancer related death. So
we absolutely have to irradiate the nodes in her armpit and often we irradiate the nodes at the base of her
neck as well to sterilize the field of any tumors cells. But for women who we don’t think they need radiation
to their lymph nodes we did what’s called a sentinel node biopsy, we took a few nodes we looked at them
we don’t think she has any cancer in her lymph nodes then we want to spare them by all means. Because
that reduces her risk of ultimately of developing incurable lymphedema. What we found in our research was
that women who were just receiving radiation to the breast, they’ve decided to keep their breast and not
have the mastectomy so there we’re irradiating the breast to get rid of any tumor cells. What we found is
about forty percent of the time even though we’re not targeting them the nodes that drain the arm are
receiving potentially harmful doses of radiation.
Tell me what you’re studying because prevention is what you’re going for there is no cure.
Dr. Cheville: Our hope is to do everything we can while a woman goes through primary breast cancer
treatment to reduce her risk of ever developing lymphedema. We’ve earned the luxury in cancer treatment
now about worrying about patients quality of life. We’ve gotten very good at curing people particularly
patients with early stage breast cancer and now we’re able to broaden our focus and start to refine our
treatments so that they do the least damage possible to normal tissues. And that’s really the theme of my
research. We know that as I said surgically removing the lymph nodes and radiating the lymph nodes is what
injures the system and increases a woman’s likelihood of developing lymphedema. The surgeons have done
a fabulous job of steadily reducing the unnecessary surgical damage but we haven’t done much to reduce a
woman’s radiation exposure. So we’ve developed a technique where we identify the lymph nodes. We go
for arm drainage because that’s where most women will develop bad lymphedema. We worry about the
breast, the trunk but it turns out that the body is very good at developing other pathways to drain the lymph
but they can’t do that in the arm because it’s all got to get out of the arm. So our work is focused on
protecting that are the first order recipients of lymph from the arm.
So how many of the lymph nodes in the arm area are you removing or are you trying to protect all of them?
Are there critical ones that you don’t want to remove?
Dr. Cheville: The way we identify these lymph nodes is we inject a very small amount of radioactive tracer in
the back of the hand and the inner part just inside the elbow. And it’s very safe this is a very routine
procedure, it’s something we do thousands of times a day in the United States. But we’re using this
technique in a slightly different way. We introduce the tracer just below the skin that causes a bee sting that
goes away quickly and then that tracer because it’s linked to a big molecule, a big solid material so the
lymphatics take that up and they transport it back to the critical nodes that are draining the arm. And usually
we find that’s about one to three and those are the nodes we want to spare. And almost always there’s one
node that takes up a lot more tracer than the other.
So is there an average in a woman, ten nodes or three nodes?
Dr. Cheville: If a woman has only undergone what we call a sentinel lymph node biopsy, and to identify the
nodes that are draining the breast we use exactly the same technique, we put the same radiolabel tracer in
her breast and we identify the nodes that are draining the breast, look at those for cancer cells and as I
mentioned if they’re clean we leave the rest of the nodes. So in a woman who has only undergone that
procedure her sentinel node, which is the name of the nodes that light up when we inject the breast, if the
sentinel node is negative and we inject the arm usually we see on average two point four nodes. However if
a woman has undergone what we call a completion axillary dissection, that’s when the sentinel node was
positive, so we have to take most of the remaining nodes in her armpit and we inject her arm we see from
between five and seven lymph nodes. And what that reflects is that the lymph is trying to get back. It’s trying
very hard to make its way back through the system but the big channel is gone because the nodes that
usually are the first recipients of the lymph have been surgically removed. So that lymph is going to all kinds
of different nodes trying to work its way back and forge new drainage pathways.
So what is the imaging technique called that you’re using?
Dr. Cheville: SPECT.
Can you tell me what it stands for?
Dr. Cheville: Single photonic emission computed tomography.
So is it called the SPECT CT?
Dr. Cheville: Yeah, SPECT stands for single photon emission computed tomography and it combines two
techniques. We have what are called Gama cameras that pick up radioactivity so they do a fabulous job of
identifying where that tracer that we injected into a woman’s arm where that goes and which nodes now
have the tracer. But it doesn’t tell us, if we have a picture we just see black dots which isn’t very
informative. A CAT scan gives us a lot of anatomic detail and when we put those two scans together we can
see exactly where those critical nodes are located in the body.
Is the imaging technique new or is using it in this way new?
Dr. Cheville: Using it in this way is new.
So hospitals across the country use this technique in other imaging needs?
Dr. Cheville: That’s one of the strengths of this technique is that the technology is widely available in most
medical centers.
So it’s really the combining of the two that’s this new approach, is it something that people would have to go
through training or could most labs do it?
Dr. Cheville: Most labs, the tricky thing it turns out is not acquiring the images. What we do, the goal of the
research is to take the SPECT CT and to fuse it with the CAT scans that are used in radiation planning. And
so we merge those images and that way the physicians that are planning a woman’s radiation can know
exactly where those critical nodes are and avoid them, block them from the radiation field.
How are they blocked?
Dr. Cheville: It’s actually very simple. They are able, now it’s computerized so they’re able to change the
field a little bit.
It’s so precise that they can just move it over, nothing has to be laid over or anything like that?
Dr. Cheville: No really it’s done on a computer.
What are the results of your study, what have you seen?
Dr. Cheville: What we found and it exceeded our wildest hopes we’ve been able to reduce the amount of
incidental radiation. This is radiation that’s not therapeutic it’s not needed to reduce a woman’s risk of
cancer, it’s the nodes are getting radiation they don’t need. We’ve been able to reduce the number of nodes
getting damaging doses by about fifty percent.
What were you thinking when you saw the results?
Dr. Cheville: I was really delighted. It’s not a huge deal for a woman to go through this, you know this scan.
It’s a one-time deal and it may protect her for the rest. If we can incorporate this technique it could protect
her from developing an incurable and very, very difficult condition.
Reducing the incidental level of radiation how does that translate in to the number of causes you’ve seen of
women with lymphedema? Have you see a drop in cases here?
Dr. Cheville: We treated thirty women none of those women have developed lymphedema. We did not have
a control group in this study so that’s the next step is to get an estimate of lymphedema. Because protecting
the nodes is nice but what we really want to do is eliminate lymphedema and so the next step is a
randomized controlled trial.
Is that something you’re working on now?
Dr. Cheville: I’m working on getting funding.
This is something that could be adopted by hospitals across the country even though they could start doing
this now or you need to do the randomized control trial to make sure this is worth it and really meaningful?
Dr. Cheville: What really supports what we do in Western medicine is the strength of the evidence that
supports it. And so we do a lot of things that don’t have a strong evidence base I feel very passionately that
we have good evidence. And so my colleagues and co-investigators want very much to just offer this to
women, It’s kind of a why would you not. Why would you not there’s no harm, really SPECT is a very safe
technique we’ve never had any adverse events from the injection so their question is why would you not. If
we have the opportunity to even spare one patient from lymphedema it’s not prohibitively expensive, it’s not
challenging for patients. But as a scientist I feel we really do have to do this right.
Let’s say you have this randomized study and what you see then is what you see now what would this do for
women, what kind of impact would this have?
Dr. Cheville: That’s a tricky question to answer because in my clinical work and I treat lymphedema but I
became passionate about this because I experience firsthand how frustrated women become trying to
control this condition indefinitely. And so over time my research interest came to focus on prevention
because I think that’s our best shot at really helping them. So in my clinical work I divide women in to,
breast cancer survivors, into three categories. Those who have had a sentinel lymph node biopsy only and
their risk of lymphedema is relatively low, it’s about seven to ten percent. Numbers have been published up
to seventeen percent and in part it reflects that we haven’t followed these women prospectively a long time.
So actually if in ten years we may find a higher incidence of lymphedema in the group but they are at the
least risk. Then you take women who are in the middle group they have had all of their or most of their
lymph nodes in their armpits removed but they didn’t need radiation to the armpit. I think those are the
women who will really benefit from this technique because their risk may approach forty percent, their
lifetime risk of developing lymphedema. And I think that’s the group that we can really help with this. Then
the third group is those women who present with later stage disease and we simply have to treat them very
aggressively. We have to radiate all the nodes to protect them from recurrent cancer. And there are other
strategies that we’re looking at for that group of women. But it’s really that middle group.
And so for that group how would this affect their lives, how would this change their future if this works?
Dr. Cheville: I think in two important ways, one there’s a lot of peace of mind of not being at risk for
lymphedema. Because lymphedema is harmful not just having it, that’s a kind of indefinite burden that
plagues women. It affects their work performance, their psychological well being, their familial rolls, it really
undermines every quality of life domain. So avoiding it is critical but even knowing that you’re at risk is very
distressing for women. They are frightened, we don’t always do a great job of educating them in the means
that they can reduce their risk. So I think giving women peace of mind even if they never develop
lymphedema that their risk has been substantially reduced is a very valuable contribution.
People that do radiation must hear that a lot, that I’m scared of getting lymphedema because people have
had friends or family that had it.
Dr. Cheville: The internet, the internet is a blessing and a curse but you can certainly very quickly call up
some gruesome pictures of lymphedema with a brief search. And it frightens women terribly.
Dana Wirth Sparks
Mayo Clinic Department of Public Affairs
(507) 538-0844
Sparks.dana@mayo.edu
http://www.mayoclinic.org/medical-edge/
http://newsblog.mayoclinic.org
http://socialmedia.mayoclinic.org/
Reducing Lymphedema
BOSTON, MA (Ivanhoe Newswire) -- Great news! Doctors say cure rates are getting better for breast
cancer, but many women are left with unwanted, sometimes devastating side effects. We’ll show you what’
s making a big difference in the lives of survivors.
When Katie Brophy learned she had breast cancer, she wasn’t surprised.
“I sort of expected it, obviously when you have a lump, you just assume,” Katie Brophy, told Ivanhoe.
A lumpectomy and radiation took care of her cancer, but left her with the risk of lymphedema , a side effect
of treatment that causes fluid build-up in the limbs. as an interior designer, that worried her.
“I’m physical. I paint walls. I wallpaper, refinish wood. The last thing you need to do is have an impaired
arm,” Katie said.
Mayo clinic doctor Andrea Cheville says radiation may destroy arm-draining lymph nodes. Once they’re
damaged, the risk of lymphedema rises and so does the risk of infection.
“It’s unattractive and so I think socially it’s a very difficult condition for people,” Andrea Cheville, M.D.,
MSCE, from the Mayo Clinic physical medicine and rehabilitation, said. “Our best hope is to prevent
people from getting it.”
To do that, she’s testing a new technique that combines CT scans with Spect-imaging. That powerful combo
pinpoints exact locations of critical lymph nodes.
“The physicians who are planning a woman’s radiation can know exactly where those critical nodes are and
avoid them, block them from the radiation field, ”Dr. Cheville said.
Studies show it reduces the number of critical lymph nodes that receive harmful radiation by more than 55
percent.
“We treated 30 women. None of those women have developed lymphedema,” Dr. Cheville said.
Katie was one of those women.
“At the moment, I’m very pleased with the result. Two years have passed. I have no symptoms,” Katie said.
Doctor Cheville says one big advantage of this new approach is many medical centers already have both of
these imaging technologies. Training physicians to fuse the two techniques for this purpose may be all that’s
needed to help women reduce their risk of lymphedema
BACKGROUND: Between 5 percent and 40 percent of women are estimated to experience some form of
lymphedema after breast cancer surgery; however, the condition is often overlooked or misdiagnosed.
Lymphedema occurs when the lymph system is damaged or blocked. It can cause fluid buildup and swelling
and usually affects an arm or a leg, but it can affect other parts of the body. Lymph fluid, tumors, lymph
vessels and lymph nodes all can play a part in lymphedema. (SOURCES: www.breastcancer.org, www.
cancer.gov)
CAUSES AND SYMPTOMS: Lymphedema can be either primary or secondary. Primary lymphedema is
caused by abnormal development and can occur at birth or develop later in life. Secondary lymphedema is
caused by damage to the lymph system due to infection, injury, cancer, scar tissue, or radiation therapy.
People can be at risk of developing lymphedema if they are obese, smoke heavily, have diabetes or have
had a mastectomy or previous surgery to the armpit area. Along with swelling, people with lymphedema may
experience a feeling of heaviness or tightness in the arm or leg. They may also feel aching or discomfort and
possibly hardening of the skin around the affected area.
(SOURCES: www.cancer.gov, www.breastcancer.org and Mayo Clinic)
NEW PREVENTION TECHNIQUES: Using single photon emission computed tomography (SPECT)
along with computerized tomography (CT) scans, doctors may be able to offer substantial protection against
lymphedema. Although a person may have as many as 62 lymph nodes under the arm, only a few are
responsible for the removal of fluids from the arm. The SPECT-CT technique works best for patients who
do not require radiation targeting any remaining lymph nodes. The risk of developing lymphedema may be as
much as 50 percent without taking measures to preserve the function of a person’s lymphatic system.
Because lymphedema can occur years after a surgery, patients will continue to be monitored by their
physicians for signs of lymphedema. Currently, there are two treatment plans for each patient: a standard
plan and one adapted for lymph node sparing based on the SPECT-CT scans. (SOURCE: Mayo Clinic)
Reducing Lymphedema -- In Depth Doctor's Interview
Andrea Cheville, MD, MSCE, from the Mayo Clinic -- Physical Medicine and Rehabilitation, talks about a
new way to potentially prevent lymphedema
Tell me what lymphedema is.
Dr. Cheville: Lymphedema is a potentially devastating condition that’s characterized by enlargement of a
body part because of the build-up of protein rich fluid. And it’s unfortunate for many reasons it places
patients at risk of bad medical events, recurrent infections, un-healing wounds. But beyond that it changes
the way they look, it distorts them, you know you have a very big head or a very big arm. It’s unattractive
and so I think socially it’s a very difficult condition for people. It’s also uncomfortable and currently we
cannot cure it. We can control it through a collection of burdensome and very time-consuming self
management activities. Which are wrapping and wearing compression garments which patients never like it’s
always difficult for them. So right now and our best hope is really to prevent people from getting it.
Once you get it are you always going to have it?
Dr. Cheville: Yes.
So even if you can control it you still have it and you have to keep doing the control?
Dr. Cheville: The way I explain it to patients sometimes is if you have a little town that gets bigger and you
don’t expand its sewage system and so every time you have a heavy rain it has a potential to flood. So you
just have more production than the system can handle and so you always have the potential for overload.
We have lots of therapeutic tricks we do to even that out so that patients can handle, can remove the
amount of swelling, fluid that their body brings to their tissue. But again it’s not easy for them. There’s no pill,
there’s no surgical procedure that can make this go away.
And why does it occur?
Dr. Cheville: Well, so we have two sets of pipes, you can kind of think of it as plumbing, that the arteries
bring lots of fluid, an astounding amount of fluid into your body tissues every minute of the day. And the way
that fluid gets out most of it is through the veins but there’s a second set of pipes that most of us don’t know
about until you get lymphedema and when they stop working. But what the lymphatics are responsible for
doing is removing about five percent of the fluid that comes in to tissue during the day but they’re really,
really good at carrying out large solid waste. That is what they are uniquely designed to do so bacteria, large
fats, large proteins that’s really the specialty of the lymphatic system. And when patients undergo cancer
treatment, in fact in the developed world certainly in the United States that’s the number one cause of
lymphedema. We injure the system by removing lymph nodes or irradiating lymph nodes in order to stage a
cancer or to treat a cancer.
So women with breast cancer are prime candidates to get this right?
Dr. Cheville: Absolutely.
Is that because of where you’re treating because if you have pancreatic cancer you’re not near the lymph
nodes in the arms, is it the area that you’re treating?
Dr. Cheville: Yeah, that’s a part of it. So you ask the great question of why once you take out those lymph
nodes you’ve damaged the system, you’ve interrupted the pipe, the plumbing so in essence it’s a plumbing
issue. But we do we focus on the fluid but what we really worry about is all that big waste material that it can
build up in the tissue and cause a lot of problems. And so with breast cancer treatment is changing so we are
less aggressive with our treatment. We used to always take every last lymph node out of a woman’s armpit.
Now we don’t we do a special technique to try and identify the nodes that might have cancer. We take
those out first see if they have any tumor cells and if they don’t we leave the rest of the nodes. So some of
the good news is that there’s less lymphedema now in women with breast cancer. But for those women who
do have all the nodes in their armpit taken out they are at high risk of developing lymphedema in the arm on
the same side but also in their trunk the front and back of their upper trunk as well as their breast if they’ve
elected for conservative treatment.
Are there some lymph nodes that are more critical for draining fluids than other?
Dr. Cheville: They all drain fluid. There’s a lot that we don’t understand about the lymphatic system. There
are lots of layers, eventually lymph is going to be dumped back in to the bloodstream and as I said some of
that solid material that the body picked up is bacteria and the last thing the body wants to do is put bacteria
in the bloodstream. So what happens to the lymph is it gets purified time and time again in lymph nodes and
certain lymph nodes are kind of responsible for certain drainage territories. So you have certain nodes that
drain the breast and certain nodes that drain the arm. And from what we’ve found they’re usually one to at
most three nodes that are kind of the first order that receive most of the lymph from the breast. Other lymph
nodes are going to get that lymph later to purify it again and again to make absolutely sure that we don’t
introduce something harmful into the blood stream.
So people get this because you’re removing the nodes or irradiating the area, you’re not exactly meaning to
irradiate those lymph nodes?
Dr. Cheville: Exactly. Well sometime we do. If we think that a woman is at very high risk of the cancer
coming back then we have to. The priority is saving her life and avoiding a breast cancer related death. So
we absolutely have to irradiate the nodes in her armpit and often we irradiate the nodes at the base of her
neck as well to sterilize the field of any tumors cells. But for women who we don’t think they need radiation
to their lymph nodes we did what’s called a sentinel node biopsy, we took a few nodes we looked at them
we don’t think she has any cancer in her lymph nodes then we want to spare them by all means. Because
that reduces her risk of ultimately of developing incurable lymphedema. What we found in our research was
that women who were just receiving radiation to the breast, they’ve decided to keep their breast and not
have the mastectomy so there we’re irradiating the breast to get rid of any tumor cells. What we found is
about forty percent of the time even though we’re not targeting them the nodes that drain the arm are
receiving potentially harmful doses of radiation.
Tell me what you’re studying because prevention is what you’re going for there is no cure.
Dr. Cheville: Our hope is to do everything we can while a woman goes through primary breast cancer
treatment to reduce her risk of ever developing lymphedema. We’ve earned the luxury in cancer treatment
now about worrying about patients quality of life. We’ve gotten very good at curing people particularly
patients with early stage breast cancer and now we’re able to broaden our focus and start to refine our
treatments so that they do the least damage possible to normal tissues. And that’s really the theme of my
research. We know that as I said surgically removing the lymph nodes and radiating the lymph nodes is what
injures the system and increases a woman’s likelihood of developing lymphedema. The surgeons have done
a fabulous job of steadily reducing the unnecessary surgical damage but we haven’t done much to reduce a
woman’s radiation exposure. So we’ve developed a technique where we identify the lymph nodes. We go
for arm drainage because that’s where most women will develop bad lymphedema. We worry about the
breast, the trunk but it turns out that the body is very good at developing other pathways to drain the lymph
but they can’t do that in the arm because it’s all got to get out of the arm. So our work is focused on
protecting that are the first order recipients of lymph from the arm.
So how many of the lymph nodes in the arm area are you removing or are you trying to protect all of them?
Are there critical ones that you don’t want to remove?
Dr. Cheville: The way we identify these lymph nodes is we inject a very small amount of radioactive tracer in
the back of the hand and the inner part just inside the elbow. And it’s very safe this is a very routine
procedure, it’s something we do thousands of times a day in the United States. But we’re using this
technique in a slightly different way. We introduce the tracer just below the skin that causes a bee sting that
goes away quickly and then that tracer because it’s linked to a big molecule, a big solid material so the
lymphatics take that up and they transport it back to the critical nodes that are draining the arm. And usually
we find that’s about one to three and those are the nodes we want to spare. And almost always there’s one
node that takes up a lot more tracer than the other.
So is there an average in a woman, ten nodes or three nodes?
Dr. Cheville: If a woman has only undergone what we call a sentinel lymph node biopsy, and to identify the
nodes that are draining the breast we use exactly the same technique, we put the same radiolabel tracer in
her breast and we identify the nodes that are draining the breast, look at those for cancer cells and as I
mentioned if they’re clean we leave the rest of the nodes. So in a woman who has only undergone that
procedure her sentinel node, which is the name of the nodes that light up when we inject the breast, if the
sentinel node is negative and we inject the arm usually we see on average two point four nodes. However if
a woman has undergone what we call a completion axillary dissection, that’s when the sentinel node was
positive, so we have to take most of the remaining nodes in her armpit and we inject her arm we see from
between five and seven lymph nodes. And what that reflects is that the lymph is trying to get back. It’s trying
very hard to make its way back through the system but the big channel is gone because the nodes that
usually are the first recipients of the lymph have been surgically removed. So that lymph is going to all kinds
of different nodes trying to work its way back and forge new drainage pathways.
So what is the imaging technique called that you’re using?
Dr. Cheville: SPECT.
Can you tell me what it stands for?
Dr. Cheville: Single photonic emission computed tomography.
So is it called the SPECT CT?
Dr. Cheville: Yeah, SPECT stands for single photon emission computed tomography and it combines two
techniques. We have what are called Gama cameras that pick up radioactivity so they do a fabulous job of
identifying where that tracer that we injected into a woman’s arm where that goes and which nodes now
have the tracer. But it doesn’t tell us, if we have a picture we just see black dots which isn’t very
informative. A CAT scan gives us a lot of anatomic detail and when we put those two scans together we can
see exactly where those critical nodes are located in the body.
Is the imaging technique new or is using it in this way new?
Dr. Cheville: Using it in this way is new.
So hospitals across the country use this technique in other imaging needs?
Dr. Cheville: That’s one of the strengths of this technique is that the technology is widely available in most
medical centers.
So it’s really the combining of the two that’s this new approach, is it something that people would have to go
through training or could most labs do it?
Dr. Cheville: Most labs, the tricky thing it turns out is not acquiring the images. What we do, the goal of the
research is to take the SPECT CT and to fuse it with the CAT scans that are used in radiation planning. And
so we merge those images and that way the physicians that are planning a woman’s radiation can know
exactly where those critical nodes are and avoid them, block them from the radiation field.
How are they blocked?
Dr. Cheville: It’s actually very simple. They are able, now it’s computerized so they’re able to change the
field a little bit.
It’s so precise that they can just move it over, nothing has to be laid over or anything like that?
Dr. Cheville: No really it’s done on a computer.
What are the results of your study, what have you seen?
Dr. Cheville: What we found and it exceeded our wildest hopes we’ve been able to reduce the amount of
incidental radiation. This is radiation that’s not therapeutic it’s not needed to reduce a woman’s risk of
cancer, it’s the nodes are getting radiation they don’t need. We’ve been able to reduce the number of nodes
getting damaging doses by about fifty percent.
What were you thinking when you saw the results?
Dr. Cheville: I was really delighted. It’s not a huge deal for a woman to go through this, you know this scan.
It’s a one-time deal and it may protect her for the rest. If we can incorporate this technique it could protect
her from developing an incurable and very, very difficult condition.
Reducing the incidental level of radiation how does that translate in to the number of causes you’ve seen of
women with lymphedema? Have you see a drop in cases here?
Dr. Cheville: We treated thirty women none of those women have developed lymphedema. We did not have
a control group in this study so that’s the next step is to get an estimate of lymphedema. Because protecting
the nodes is nice but what we really want to do is eliminate lymphedema and so the next step is a
randomized controlled trial.
Is that something you’re working on now?
Dr. Cheville: I’m working on getting funding.
This is something that could be adopted by hospitals across the country even though they could start doing
this now or you need to do the randomized control trial to make sure this is worth it and really meaningful?
Dr. Cheville: What really supports what we do in Western medicine is the strength of the evidence that
supports it. And so we do a lot of things that don’t have a strong evidence base I feel very passionately that
we have good evidence. And so my colleagues and co-investigators want very much to just offer this to
women, It’s kind of a why would you not. Why would you not there’s no harm, really SPECT is a very safe
technique we’ve never had any adverse events from the injection so their question is why would you not. If
we have the opportunity to even spare one patient from lymphedema it’s not prohibitively expensive, it’s not
challenging for patients. But as a scientist I feel we really do have to do this right.
Let’s say you have this randomized study and what you see then is what you see now what would this do for
women, what kind of impact would this have?
Dr. Cheville: That’s a tricky question to answer because in my clinical work and I treat lymphedema but I
became passionate about this because I experience firsthand how frustrated women become trying to
control this condition indefinitely. And so over time my research interest came to focus on prevention
because I think that’s our best shot at really helping them. So in my clinical work I divide women in to,
breast cancer survivors, into three categories. Those who have had a sentinel lymph node biopsy only and
their risk of lymphedema is relatively low, it’s about seven to ten percent. Numbers have been published up
to seventeen percent and in part it reflects that we haven’t followed these women prospectively a long time.
So actually if in ten years we may find a higher incidence of lymphedema in the group but they are at the
least risk. Then you take women who are in the middle group they have had all of their or most of their
lymph nodes in their armpits removed but they didn’t need radiation to the armpit. I think those are the
women who will really benefit from this technique because their risk may approach forty percent, their
lifetime risk of developing lymphedema. And I think that’s the group that we can really help with this. Then
the third group is those women who present with later stage disease and we simply have to treat them very
aggressively. We have to radiate all the nodes to protect them from recurrent cancer. And there are other
strategies that we’re looking at for that group of women. But it’s really that middle group.
And so for that group how would this affect their lives, how would this change their future if this works?
Dr. Cheville: I think in two important ways, one there’s a lot of peace of mind of not being at risk for
lymphedema. Because lymphedema is harmful not just having it, that’s a kind of indefinite burden that
plagues women. It affects their work performance, their psychological well being, their familial rolls, it really
undermines every quality of life domain. So avoiding it is critical but even knowing that you’re at risk is very
distressing for women. They are frightened, we don’t always do a great job of educating them in the means
that they can reduce their risk. So I think giving women peace of mind even if they never develop
lymphedema that their risk has been substantially reduced is a very valuable contribution.
People that do radiation must hear that a lot, that I’m scared of getting lymphedema because people have
had friends or family that had it.
Dr. Cheville: The internet, the internet is a blessing and a curse but you can certainly very quickly call up
some gruesome pictures of lymphedema with a brief search. And it frightens women terribly.
Dana Wirth Sparks
Mayo Clinic Department of Public Affairs
(507) 538-0844
Sparks.dana@mayo.edu
http://www.mayoclinic.org/medical-edge/
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