ó New options to treat lymphedema, a painful buildup of
fluid in the bodyís 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.
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.
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.
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
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.
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
have seen my own patients get lymphedema," she said.
"Their breasts have been rebuilt; Iíve solved their
other problems. Now I wanted to solve this."
lymphedema, she explained, "basically thereís a
blockage to the lymphatic system, it isnít 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 patientís cancer
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. "Thereís a small network of people who do
it, but they are all passionate, like myself," she said,
crediting Dr. Soranís support. "He wants to be able to
offer patients something."
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."
patient is first begun on the traditional comprehensive
treatment, which includes physical therapy, massage,
compression sleeve or stocking and the use of a mechanical
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
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
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."
complication of lymphedema itself can be cellulitis, a serious
bacterial infection of the skin.
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.
advanced-stage lymphedema, liposuction can drain the lymphatic
fluids from the tissues.
Brown, 42, of Lower Burrell, Pa., has recently undergone the
second of two liposuction surgeries to remove fluid from
lymphedema in her leg ó caused by treatment 24 years ago
when she was a teenager diagnosed with non-Hodgkin lymphoma.
nodes were removed from the right groin area to be biopsied.
Her treatment included chemotherapy for six months. Sheís
been in remission since February 1991.
discomfort of lymphedema remained. There were the painful
stares of strangers, too, because of the swelling.
have had to put up with that," she said, "people
treating you like youíre some sort of freak. Even my kids
have had to put up with teasing."
only type of pants Iíve 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.
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
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:
wanted to be able to wear high heels for my wedding in July.
Ö I also was able to fit into a pair of jeans. I hadnít
worn a pair of jeans for 24 years."
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.
have a normal shoe size now," she said.
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
have to wear the stocking the rest of my life," she
added, although right now her leg continues to get smaller and
sheís able to be more active.
can walk up and down the street several blocks without getting
tired; go up steps without it hurting. Iíve gone horseback
riding. There are so many things I can do now."
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.
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."
75 percent of the time, women donít need axillary
dissection. But even among those women, 5 percent to 8 percent
with sentinel node (removal) will get lymphedema."
a methodology to decide which sentinel nodes are taken out,
Dr. Julian said, but even if only three nodes are removed ó
the average number ó 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.
Julian said heís familiar with the new surgical treatments
being tested on lymphedema patients.
trying to re-create the (lymphatic system) channels," he
said, citing plastic surgeons at M.D. Anderson and Memorial
Sloan Kettering cancer centers.
question is, is surgery to re-create channels enough, or does
the patient need physical therapy? Is it a good thing to
added, "We need trials to show itís as good as
lymphedema management. ... There will be different classes of
patients who might benefit from this."