New outpatient surgery helps patients with fluid buildup in tissue
New options to treat lymphedema, a painful buildup of fluid in the body’s soft tissue, are now available to patients who have the condition, which is a common complication for many cancer patients because of the removal of lymph nodes and radiation involved in their treatment.
PITTSBURGH — New options to treat lymphedema, a painful buildup of fluid in the body's soft tissue, are now available to patients who have the condition, which is a common complication for many cancer patients because of the removal of lymph nodes and radiation involved in their treatment.
The treatment, two types of surgery done on an outpatient basis, is the most recent part of the comprehensive lymphedema program at Magee-Womens Hospital of University of Pittsburgh Medical Center first begun in 2005.
Up to about 50 percent of breast cancer patients are affected by the painful swelling, often in the arms. Lymphedema in the legs also affects up to 30 percent of patients treated for gynecologic cancer or prostate cancer.
After adding laser surgery as a lymphedema treatment in 2007, the Magee program then started its early detection and treatment program for lymphedema in 2010 and has continued that focus, according to Atilla Soran, surgical oncologist and director of Magee's program.
The first new surgical treatment is lymphaticovenular bypass, microscopic surgery involving tiny incisions in the arm or leg to drain lymph fluid through small veins. The second is lymph-node transfer, in which surgeons remove lymph nodes from another part of the body and transfer them to the affected body location, where they naturally drain the fluid.
Carolyn De La Cruz, who specializes in breast reconstruction surgery at Magee, has been doing lymphedema surgery for at least six months, treating about six men and women. She was motivated to learn the techniques to help them with this condition that has no cure.
"I have seen my own patients get lymphedema," she said. "Their breasts have been rebuilt; I've solved their other problems. Now I wanted to solve this."
In lymphedema, she explained, "basically there's a blockage to the lymphatic system, it isn't draining properly (into nearby small veins). After surgery, it drains into the venous system." She said recovery, which includes letting the extremity rest, can take several weeks. Insurance does pay for the treatment, she said, as part of a patient's cancer care coverage.
To learn more about the microscopic surgery techniques, Dr. De La Cruz traveled to China and to medical centers in the United States, including the University of Chicago and the University of Pennsylvania. "There's a small network of people who do it, but they are all passionate, like myself," she said, crediting Dr. Soran's support. "He wants to be able to offer patients something."
Dr. Soran explained the surgical treatment was first practiced in Europe and Asia. "It should be offered very early," he said, "during stage 1 lymphedema, which means the extremity is 2 centimeters bigger than normal."
Each patient is first begun on the traditional comprehensive treatment, which includes physical therapy, massage, compression sleeve or stocking and the use of a mechanical pump.
"I follow them for six months, and see how they are doing in the comprehensive lymphedema program. If it is not too advanced, they can get the surgery, then continue the comprehensive program."
Dr. De La Cruz said patients treated for melanoma, sarcoma and other cancers can have lymphedema in an arm and leg, as well. For all the patients, she said, the outcomes are "very promising."
"The goals are reducing infections, reducing the size of the extremity, to give patients relief from the feeling of numbness and fullness and to restore functionality, reducing the burden of using a pump, wearing compression garments. Those are the outcomes we look for."
A complication of lymphedema itself can be cellulitis, a serious bacterial infection of the skin.
Dr. Soran said with a surgical lymphedema treatment, both the rate of infection and amount of swelling goes down. If the patient has cellulitis, it must be treated with antibiotics first before the patient can have surgery.
For very advanced-stage lymphedema, liposuction can drain the lymphatic fluids from the tissues.
Lisa Brown, 42, of Lower Burrell, Pa., has recently undergone the second of two liposuction surgeries to remove fluid from lymphedema in her leg — caused by treatment 24 years ago when she was a teenager diagnosed with non-Hodgkin lymphoma.
Lymph nodes were removed from the right groin area to be biopsied. Her treatment included chemotherapy for six months. She's been in remission since February 1991.
But the discomfort of lymphedema remained. There were the painful stares of strangers, too, because of the swelling.
"I have had to put up with that," she said, "people treating you like you're some sort of freak. Even my kids have had to put up with teasing."
"The only type of pants I've been able to wear, till last year, were stretch cotton pants. I would have to buy shoes that were a size bigger, or half-size bigger." She was told by her family doctor there was nothing they could do. Then three years ago, Brown found Dr. Soran.
He put her through the comprehensive treatment, including sessions with a laser aimed at breaking up damaged tissue. By early 2013 she noticed her leg, once hard and swollen, was feeling softer.
Dr. De La Cruz then did the liposuction in her lower leg in April 2013. She lost about 2 liters of fluid. "The pain was very very bad; like burning," she said. She returned to work after seven weeks and had a dream come true:
"I wanted to be able to wear high heels for my wedding in July. … I also was able to fit into a pair of jeans. I hadn't worn a pair of jeans for 24 years."
She had liposuction on the top of her leg in July this year and reports it was less painful, the recovery was faster and 4 liters of fluid were removed.
"I have a normal shoe size now," she said.
She continues to use a compression pump at home, wrapping her leg and abdomen once a day. Insurance covers the cost of the pump, but Brown says her coverage for physical therapy has recently run out. She expects to have two more surgeries next year with Dr. De La Cruz: more liposuction and surgery to remove excess skin.
"I have to wear the stocking the rest of my life," she added, although right now her leg continues to get smaller and she's able to be more active.
"I can walk up and down the street several blocks without getting tired; go up steps without it hurting. I've gone horseback riding. There are so many things I can do now."
Advances in breast cancer treatment allow many patients to have only a few "sentinel" lymph nodes removed to measure the spread of the cancer. However, a leading breast cancer researcher, Thomas Julian, head of breast surgical oncology for Allegheny Health Network, said many women still need the removal of all the nearby underarm lymph nodes, known as axillary lymph node dissection.
In the National Surgical Adjuvant Breast and Bowel Project, Dr. Julian said, "there was an extraordinarily high level of lymphedema in women who had dissection vs. those who had sentinel node (removal). That was consistent."
"Over 75 percent of the time, women don't need axillary dissection. But even among those women, 5 percent to 8 percent with sentinel node (removal) will get lymphedema."
There's a methodology to decide which sentinel nodes are taken out, Dr. Julian said, but even if only three nodes are removed — the average number — it still disrupts the lymphatic system. He said there is research going on to see if a sentinel node biopsy can help determine who is most at risk of lymphedema.
Dr. Julian said he's familiar with the new surgical treatments being tested on lymphedema patients.
"They're trying to re-create the (lymphatic system) channels," he said, citing plastic surgeons at M.D. Anderson and Memorial Sloan Kettering cancer centers.
"The question is, is surgery to re-create channels enough, or does the patient need physical therapy? Is it a good thing to pursue? Absolutely."
He added, "We need trials to show it's as good as lymphedema management. ... There will be different classes of patients who might benefit from this."
— Jill Daly
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