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Friday, September 28, 2012

ONLINE FIRST: Lymphedema: Should Surgery Be an Option?




DALLAS -- Is surgery appropriate for breast cancer patients who develop lymphedema after treatment? Is it effective, not to mention safe?


Lymphedema remains a challenging problem. Breast cancer survivors are at a lifetime risk of developing lymphedema, at least one third develop it within 18 months, and it has generally been considered incurable.


But surgical procedures are available that can reduce symptoms, and possibly even relieve the condition permanently.


The safety and efficacy of lymphedema surgery were discussed by two breast surgeons in a point-counterpoint session on lymphedema surgery here at the National Lymphedema Network Conference. The meeting, jointly sponsored by the National Lymphedema Network and the University of Chicago Pritzker School of Medicine, was attended by about 750 Network members and guests, primarily certified lymphedema therapists.


The procedures discussed were liposuction, vascularized lymph node transfer, and lymphovenous anastomosis.


Both debaters agreed that surgery is not for every patient.

 Jay W. Granzow, MD, Associate Clinical Professor of Surgery in the Division of Plastic and Reconstructive Surgery at the David Geffen School of Medicine at UCLA, stressed the safety of these procedures in his remarks, but also described the great relief from symptoms he has seen in his patients.

 But Sarah McLaughlin, MD, Assistant Professor of Surgery at the Mayo Clinic in Jacksonville, Florida, urged caution in selecting patients, and selecting the right surgeon, because training is highly specialized and there is very little in the literature on outcomes.


‘Data Limited, There Are Concerns’

“Surgery offers the potential to actually cure lymphedema, and after years of patients suffering with a chronic condition we now have a glimpse into what might be,” McLaughlin said.


Despite that optimistic opening, though, she was the counterpoint speaker, and she said her problem with surgery is the paucity of data in the literature. The studies that exist are small, she said, and most are anecdotal.


“We do not have data linking these procedures with improved quality of life or functional aspects, and the right timing is not known. There are nuances in these procedures that have to be sorted out. At this point we don’t have enough data to say we haven’t done any harm.”


There are years of experience with conservative management -- typically with compression stockings or bandages, mechanical pumps, or manual lymphatic drainage with therapeutic massage -- and rigorous data showing such treatment is safe and effective and offers successful control.


McLaughlin said compression and decongestive therapy can lead to a reduction in lymphedema volume of 50 to 60 percent, depending on patient commitment and the aggressiveness of the therapist and the measures used.


There has to be significant commitment for conservative treatment to work -- not only from the patient but also from the caregiver in terms of time, patience, and expense. “Conservative management means daily care,” she said. “And obviously, it is for maintenance, not for cure.”


‘Only for the Dedicated’

Liposuction can reduce lymphedema, but it is for the dedicated patient who will strictly adhere to compression therapy postoperatively to keep the lymphedema from returning. McLaughlin said there’s no doubt liposuction is effective, and that it meets its goal of reducing bulk, returning the limb to 100 percent of the original volume.


And it is better at that than conservative measures, according to a Swedish published in 2006, with quality-of-life data on 35 patients who had liposuction and controlled compression therapy for lymphedema compared with 14 controls who had controlled compression therapy alone. Combined therapy removed the arm lymphedema completely at one year whereas compression therapy reduced it by only half.


“Liposuction reduced pain and anxiety,” she said. “But it did not [comparatively] change range of motion, hand swelling, overall quality of life, psychological well-being, or depression.”


And this was the only lymphedema quality-of-life study in the literature, again demonstrating the lack of data, she said. “We have to document these benefits to justify doing these procedures.”


Possible to Correct Underlying Pathophysiology?

Reductive liposuction can relieve symptoms but it does not correct the underlying pathophysiology, she continued. But the two reconstructive procedures, lymphovenous anastomosis and autologous lymph node transplantation, do hold that promise.


“Will [microvascular] surgery correct the underlying pathophysiology? What makes reconstructive surgery enticing is that the answer is supposed to be yes.”


McLaughlin said that for lymphovenous anastomosis to be successful in the long term, the patient must have a proximal obstruction and patent, functional distal vessels. These patients typically have mild to moderate disease.

There has been concern about a possible pressure differential between the venous and the lymphatic systems where there may be some venous backflow causing a thrombosis of the anastomosis.


“This risk is probably less so with microvascular anastomosis than it was with large veins and lymphatics, but it’s still something to consider,” she said.


Lymph Node Transfers Carry Risks

In theory, a transplanted healthy lymph node fosters lymphatic collateral growth and spontaneous lympho-lymphatic anastomoses in the affected nodal basin reversing the physiologic process. This has been demonstrated in animal models, McLaughlin said.


The risk she sees is in donor site morbidity: “Are we trading one problem for another? We know in breast cancer patients who have sentinel node biopsy, the risk of lymphedema is not zero,” she said, estimating the risk at five to seven percent.


She cited a retrospective study published last year in the journal Vascular (2011;19:195-205) comparing lymphovenous anastomosis with node transfer: “This paper scares me -- 16 of 19 patient having anatomosis surgery had poor results, nine were worse off than at baseline, and there was an increase in infection episodes,” she said. “I’m not saying we shouldn’t consider this, but we have to be really careful about the risks because they’re not zero.”


Lymphedema surgery is one element in care, McLaughlin concluded, but it should be performed in referral centers by specialized teams, and by surgeons specially trained in all three procedures. “This training is not gleaned through standard plastic surgery, vascular surgery, or orthopedic microsurgery training.”


‘It’s Safe and Effective’

In his presentation, Granzow, who is also Assistant Chief of Plastic Surgery at Harbor UCLA Medical Center and board certified in Plastic Surgery and Otolaryngology-Head and Neck Surgery and a specialist in aesthetic surgery, perforator flap breast reconstruction, and lymphedema surgery, included a discussion of actual cases -- to “put a face” on surgery outcomes, he said. “Simply looking at photos does not demonstrate the relief patients can feel after surgery.”


Granzow said quality-of-life improvements after surgery are seen quickly and are dramatic: “The limb is not tight any more, it is not stiff, the compression garment doesn’t have to be worn every day. And we’ve seen cases where patients are out of the sleeve permanently and don’t ever need to use it again. You can’t get that with conservative therapy, or very rarely, and that’s what’s so exciting.”


He acknowledged McLaughlin’s concern about there being only few, small clinical studies in the literature -- “but whenever you have a new procedure, you’re going to have small numbers. We’re at the point today where breast cancer reconstruction was 10 years ago; this is just starting to bud and to get bigger.”


He emphasized the safety aspects, noting that before he considers patients for surgery they undergo a thorough workup to rule out venous insufficiency, deep vein thrombosis, or tumor blockage, which he said can be missed by primary care physicians, who may mistakenly diagnose these problems as lymphedema. The next step is for patients to be treated by a trained lymphedema therapist, who removes as much fluid as possible from the affected extremity until response plateaus.


At that point surgery may be avoided, he said. If not, the first surgical procedure considered is volume reduction with lymphatic liposuction, which Granzow said is extremely effective and safe in reducing the solid component of lymphedema and can lower the incidence of cellulitis.


“Liposuction for volume reduction is totally different from cosmetic liposuction, and patients should choose a plastic surgeon experienced in the care of lymphedema patients,” he said.


He noted that the economy has “hit plastic surgery hard -- especially surgeons who do primarily cosmetic surgery. Some practices are down 60 to 80 percent, and many surgeons who do cosmetic plastic surgery are now offering lymphedema treatment.”


Lymphedema liposuction uses low suction settings, is an in-patient procedure, and is much more labor intensive -- “This puts you to work,” he said.


With liposuction for arms, he expects a 100 to 110 percent reduction in the lymphedema, so that compared with the opposite arm the treated arm might actually be smaller after the procedure. For legs the goal is 80 to 90 percent reduction, so the affected leg will be close in size to the opposite leg.


“We want to improve mobility, for clothes to fit better, and to simplify activities of daily life,” he said.


Volume reduction after liposuction is quick, with most volume gone at six months, Granzow said. But maintenance therapy and compression garments are usually required lifelong.


Microsurgical lymph node transfer or lymphovenous anastomosis, the other surgical options, can be done after liposuction to optimize results.


Lymphovenous anastomosis is aimed at bridging or bypassing the obstruction. Granzow said that results in early studies are not relevant today because the technique has evolved: Whereas once it meant finding the largest lymphatic and anatomosing that to the largest vein, it is now done in the site of the lymphedema.


The standard surgical risk applies for all three procedures, with risk comparable to that of other surgical procedures of similar length -- “These are very low risks in the scale of surgical options, and we know of no patients who have had lymphedema become worse.”


Lymph Nodes Transferred

Vascularized lymph node transfer would ideally be done soon after diagnosis when vessels have not had a chance to dilate and become sclerotic, Granzow said. Nodes are taken from the superficial, lateral groin lymph node basin, leaving intact the sentinel groin node lymph and deep pelvic lymph nodes.


The procedure can be performed independently or together with a deep inferior epigastric perforator (DIEP) procedure for breast reconstruction. The goal is to reduce the need for a compression garment and also to reduce symptoms.


“No cases have been seen in which vascularized lymph node transfer harvest has caused lymphedema,” he said.


He said the studies McLaughlin cited about risk with sentinel lymph node dissection cannot fairly be compared with lymph node transfer for lymphedema because the two use different harvest sites. He cited a study (Plast Reconstr Surg 2009;123:1265-1275) in which vascularized groin lymph nodes nourished by the superficial circumflex iliac vessels were harvested and transferred to the dorsal wrist of the lymphedematous limb in 13 post-mastectomy patients who had not responded to conservative management.


The researchers, from Chang Gung Memorial Hospital in Taiwan, reported that the incidence of cellulitis was decreased in 11 patients, and that postoperative lymphoscintigraphy showed improved lymph drainage of the affected arm, decreased lymph stasis, and rapid lymphatic clearance.