This past year, we had quite a discussion on a newer type of experimental treatment for lymphedema, so I have included two pages of related information,
These two treatments are lymph node transplant and lymph vessel transplant.
In truth, the concept is not new and I found an article first published in 1981 proposing lymph vessel transplantation and subsequently an experiment on dogs.
Obviously, after the passage of twenty six years, if this method were successful, we would have heard more about it and more research information would have been published.
It is my personal opinion, that in the long term, these two methods might well prove more dangerous then beneficial and I would be opposed to their use.
First, one of the biting questions of lymphedema research is “why is it that 60% of breast cancer patients do NOT get lymphedema?”
Research in that area proposes that perhaps those that DO get lymphedema already have a compromised or “at risk” lymph system.
Thus by removing lymph vessels or nodes from one area to re-implant in another simply makes a trade on the location of the at risk area, so what actually is gained or what is the benefit for the patient?
One study following transplant was done eight years after the surgical procedure. However, it is important to realize that lymphedema does not automatically appear immediately after the removal or destruction of either lymphatic vessels, tissue or nodes.
Many times it doesn’t appear for ten or more years. So clearly, more research and study needs to be done on these two techniques. Once it does occur, however, it is at this time a life long condition with no cure..
One more consideration is that the nodes to be transplanted are removed from the inguinal area. Radiological studies have clearly proved that my hereditary lymphedema is caused by the lack of development of numerous nodes in that exact area, both on the right and left sides of my body.
To remove nodes in this critical region is to put the patient at high risk for subsequent development of leg lymphedema. If you trade arm lymphedema for leg lymphedema, have you really helped the patient?
In the meantime, I simply can not recommend it.
Be safe – be well.
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Lymphaticovenular Bypass for Management of Lymphedema in Breast Cancer Patients: A Prospective Analysis
David W. Chang, M.D.; MD Anderson Cancer Center, Houston TX
“Purpose: Lymphedema is a common and debilitating condition following surgical and/or radiation therapy for breast cancer. However, lymphedema is difficult to manage and surgical options have been limited and controversial. The purpose of this prospective study is to provide preliminary analysis of lymphaticovenular bypass for upper limb lymphedema in patients with breast cancer.
Methods: Twenty consecutive patients with lymphedema of upper extremity secondary to treatment of breast cancer who underwent lymphaticovenular bypass using “super-microsurgical” approach from December 2005 to September 2008 were evaluated. Mean age was 54 years. Of 20 patients 16 patients had received preoperative XRT and all patients had received axillary lymph node dissection. All patients presented with stage 2 or 3 lymphedema with mean duration of 4.8 years and the mean volume differential of lymphedema arm compared to unaffected arm of 34%. Evaluation included qualitative assessment and quantitative volumetric analysis prior to surgery, at 1 month, 3 months, 6 months and at 1 year following the procedure. All data were collected prospectively.
Results: Mean number of bypasses performed on each patient was 3.5 and the size of bypasses ranged from 0.3 mm to 0.8 mm. Mean operative time was 3.3 hours (2 to 5 hours). Hospital stay was < 24 hours in all patients. Mean follow up was 18 months. Of 20 patients, 19 patients reported significant clinical improvement following the procedure. Mean volume reduction at 1 month was 29%, at 3 months 36%, at 6 month 39%, and at 1 year was 35% (Fig 1). In 3 patients with clinical improvement, no significant quantitative improvement was noted. There were no postoperative complications or exacerbation of lymphedema.
Conclusion: Lymphaticovenular bypass using “super-microsurgical” approach appear to be effective in improving the severity of lymphedema in patients with breast cancer. Long term analysis is needed.”
Here’s a link to the abstract from American Association of Plastic Surgeons:
Comments by the StepUp-SpeakOut Editorial Board:
Note the small number of patients on whom this technique was performed: 20 women with LE following BC treatment. Of those 20 patients, 19 reported “clinical” improvement (presumably qualitative assessment of some sort) after the bypass surgery. Sixteen of the 19 patients who reported a “clinical” improvement also had a significant “quantitative” improvement (presumably a reduction in arm volume measurement); but the other 3 who had a “clinical” improvement did not have a significant improvement in quantitative measurements. The patients were followed for 18 months after their bypass surgeries, but data are only reported for 1 year post-bypass surgery.
It’s an interesting but preliminary study. They need greater numbers of patients and more follow-up time (and perhaps a more comprehensive assessment) to see if this really works. Also, there is no mention whether other, conventional LE therapy was provided to those women while they were recovering from their bypass surgery. For a fuller explanation, see the analysis of an article about this procedure at BreastCancer.org from which we quote:
“Lymphaticovenular bypass surgery is difficult to do and requires special surgical training. This may be one reason why it’s not a common lymphedema treatment. While the women in this study did receive some benefit from the surgery, the decrease in arm size didn’t last and none of the women were considered cured of lymphedema. More, larger studies are needed to see if the results last over time, as well to figure out if the surgery works for a variety of women. ” [Emphasis supplied]
We have written to Dr. Chang and he was quick to respond and interested in conveying information. This is what we learned:
They measure by volume displacement;
The surgery is not curative;
The surgery is currently considered experimental and not covered by Medicare or insurance;
Dr. Chang is committed to helping women with LE:
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Surgical Management of Lymphedema
by Tony Reid MD PhD
There have been several questions on our Lymphedema forum asking about the surgical treatment options for lymphedema so I decided to provide a general discussion of the surgical management of lymphedema. There are several different surgical approaches to the treatment of lymphedema. For the sake of simplicity, most of the techniques involve the formation of an anastamosis between the lymphatic system and the venous system. An anastamosis is essentially a bridge or conduit from the lymphatic system to the venous system. The goal of these microvascular surgeries is to form a channel between the pooled and blocked lymphatic system and the venous system so that the venous system can remove the accumulated lymphatic fluid.
A brief review the physiology of the lymphatic system is in order to help understand these surgical techniques. Arterial, or oxygenated blood is pumped from the heart to the various tissues. The oxygen is removed from the blood by the cells and cellular waste products are dumped into the blood from the cells. The deoxygenated blood is the venous blood and it flows back to the heart where it is pumped to the lungs to pick up more oxygen.
All cells are bathed by a small amount of fluid that circulates around the cells and then drains into the lymphatic system. The lymphatic system arises from these tiny spaces between cells. In many ways, the lymphatic and venous system are similar since they both function to remove excess waste from cells. The lymphatic system differs from the venous system because it is a much more delicate system of channels. In addition, the volume of lymphatic flow is less than 10% of the flow of the venous system. The lymphatic system is so delicate that in many places the walls of the lymphatic channels are only a few cells thick. These channels are often difficult to identify under the microscope and it takes a trained eye to identify them. The lymphatic channels converge into larger channels and finally drain into the venous system before entering the heart.
These lymphatic and venous systems, while separate, run in parallel. Therefore, a bridge can be formed between the two systems allowing for the drainage of excess fluid from an obstructed lymphatic system. As you might imagine, such bridges would have to be very small. In addition, once formed, flow could go from the lymphatic system to the venous system, but flow could also go from the venous system to the lymphatic system. Since the lymphatic system is frequently obstructed in cases of lymphedema, the lymphatic system is more likely to be a higher pressure than the venous system and the flow is likely to go from the lymphatic system to the venous system thereby alleviating the condition of lymphedema.
While the concept of forming a surgical channel to remove excess lymphatic fluid is very appealing, forming an effective and stable anastamosis between obstructed lymphatic vessels and the venous system is technically very difficult. The trials that report on these techniques are often very small, the follow-up is often short and there is inadequate information about what happens to the patients in cases where the surgery was ineffective.
A paper entitled, Microsurgical lymphovenous anastomosis for treatment of lymphedema: a critical review(1) was published from the Mayo Clinic several years ago and the authors followed their patients for an average of three years after the surgery. Their trial was also small, involving only 18 patients. The patients were mixed, some had secondary lymphedema, some had filariasis and some had primary lymphedema. 14 patients were evaluated and of these 14, 5 had improvement, 5 were unchanged and 4 had progression of their lymphedema at the time of last follow-up. The authors concluded that there was no objective evidence supporting the value of microsurgical treatment for lymphedema.
One of the main concerns about using surgical approaches to the management of lymphedema is the probability of making the condition significantly worse. Patients with lymphedema have enough problems without making the condition worse with an invasive surgical procedure. One of the critical questions that must be addressed by these studies is the complication rate and the extent of worsening of edema experienced by these patients. There will be discussion of the surgical approach to the treatment of lymphedema at upcoming NLN conferences and I look forward to learning of any new and effective treatments.
One of the more exciting possibilities is the use of growth factors that selectively stimulate the growth of lymphatic vessels. These growth factors have been identified recently and research is ongoing to understand how they work and whether they will be of benefit in the treatment of lymphedema. While this is only in the earliest stages of research, such technology offers the promise of effective therapy in the future.
One of the problems with these by-pass surgeries is that the by-pass tract becomes blocked soon after the surgery. We learned this while studying cardiac by-pass surgeries and surgeries to by-pass obstructed veins in the legs. Since obstruction of the lymphatic by-pass channels also appeared to occur, anastomoses were performed in dogs to determine the rate of blockage of lymphatic venous by-pass surgeries (2). By 8 months, 75% of the anasotmoses were blocked. The authors concluded that the rate of blockage was high; therefore, chances of success were better when several anastomoses were performed in the early stages of lymphedema, before significant tissue fibrosis and complete loss of lymphatic valvular function occurred.
There have been relatively few papers written about these techniques from centers in the United States in recent years. Many of the publications have come from Russia, China and Japan.
In a Russian study, 152 patients were followed for a period of 2 to 6 years after surgery to form an anastomosis between the lymphatic and venous systems (3). Approximately 2/3 of the patients demonstrated improvement; however, 1 of 3 patients did not improve or got worse. Only the abstract is available in English and the authors did not report the percent of overall percent changes in limb volume. In addition, they did not discuss the whether complications of the surgery were observed.
In China, 110 patients with lymphedema of the were treated with microsurgery forming an anastomosis between lymphatics and veins (4). Ninety-eight patients with lymphedema of the extremities were followed-up for 26 months and about 2/3 of the patients demonstrated improvement. In those patients, the average reduction in circumference of the affected limb was 59%. However, there was no discussion of the long-term effects of the surgery or the results or complications among the patients that did not respond to the surgery.
In Australia, 52 patients were treated by microlymphatic surgery (5). Significant improvement was observed in 22 patients (42 percent), with an average reduction of 44 percent of the excess volume. However, long-term results were not available. In addition, the authors concluded that better results can be expected with earlier operations because the patients usually have less lymphatic disruption.
A recent article from Japan, reports the use of microsurgical lymphaticovenous implantation for the treatment of chronic lymphedema (6). This technique involves placing a lymphatic shunt in the area of obstruction. Only 8 patients were treated with this method and larger studies are need to assess the long-term benefit of this technique.
One of the main concerns about using surgical approaches to the management of lymphedema is the probability of making the condition significantly worse. One of the critical questions that must be addressed by these studies is the complication rate and the extent of worsening of edema experienced by these patients. There will be discussion of the surgical approach to the treatment of lymphedema at upcoming NLN conferences and I look forward to learning of any new and effective treatments.
One of the more exciting possibilities is the use of growth factors that selectively stimulate the growth of lymphatic vessels. While this is only in the earliest stages of research, such technology offers the promise of effective therapy in the future.
1. Gloviczki P, J Vasc Surg 1988 May;7(5):647-652. Microsurgical lymphovenous anastomosis for treatment of lymphedema: a critical review.
2. Gloviczki P, J Vasc Surg 1986 Aug;4(2):148-156. The natural history of microsurgical lymphovenous anastomoses: an experimental study.
3. Zolotorevskii, Khirurgiia (Mosk) 1990 May;5:96-101. Late results of lymphovenous anastomoses in lymphedema of the lower extremities.
4. Huang GK Langenbecks Arch Chir 1989;374(4):194-199. Results of microsurgical lymphovenous anastomoses in lymphedema–report of 110 cases.
5. O’Brien BM, Plast Reconstr Surg 1990 Apr;85(4):562-572. Long-term results after microlymphaticovenous anastomoses for the treatment of obstructive lymphedema.
6. Yamamoto Y, Plast Reconstr Surg 1998 Jan;101(1):157-161. Microsurgical lymphaticovenous implantation for the treatment of chronic lymphedema.
Tony Reid MD PhD
Peninsula Medical, Dr. Reid’s Corner
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Comments by The StepUp-Speak Out Editorial Board:
After reading the information on new, unproven treatments for lymphedema, we would like to urge caution in the use of treatments designed to stimulate the growth of lymphatic vessels. What’s troubling about that approach is how inappropriate such treatments would be in most cancer patients. The whole point of the new anti-cancer drug “Avastin” (bevacizumab) is to inhibit angiogenesis, or growth of new blood vessels. By blocking the actions of “vascular endothelial growth factor,” Avastin prevents tumors from promoting the formation of blood vessels, thus keeping them from acquiring the extra oxygen and nutrients they need. It seems that administering a vascular growth factor to promote the growth of lymphatic vessels could fuel the cancer instead. We are not aware of tissue specificity in the recombinant vascular endothelial growth factors (i.e., one that stimulates the endothelial cells of lymphatic vessels but does not stimulate the endothelial cells of arteries and veins).
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