Wednesday, December 29, 2010

Surgical Treatments for Breast Cancer-Related Lymphedema

Upper extremity lymphedema for breast cancer survivors can be a major source of morbidity. Historically, the reported incidence in breast cancer survivors after axillary lymph node dissection has ranged from 9 to 41%. Even with sentinel node biopsy, the reported incidence of upper limb lymphedema remains at 4 to 10%.

Lymphedema after surgery may occur immediately but most often appears after a latent period of weeks or months. Common lymphedema symptoms are increased volume and weight of the limb and increased skin tension.

Conservative therapy (complex decongestive treatment) should be the initial treatment when lymphedema is suspected or present. This includes skin care, compression garments, exercise therapy, and manual lymph drainage.

An article in the December issue of the Plastic and Reconstructive Surgery Journal reviews the surgical treatments.

Charles published the first reported surgical procedure of lymphedema of the scrotum in 1912 and described its application to lower limb lymphedema briefly in the same article. Since then, a variety of surgical techniques have been attempted as cures for lymphedema.

These operative strategies can be classified into two categories: ablative operations and physiologic operations in which new channels are created to increase the capacity to transport lymph fluid.

The article goes through a review of the surgical procedures for lymphedema (in general) beginning with the Charles’ operation for elephantiasis. It was an aggressive operation which resected the overlying skin and soft tissue above the deep fascia in the lymphedematous area. The raw surface was covered by a skin graft harvested from the opposite thigh or the resected specimen.

The article presents the authors preliminary experience using lymphaticovenular bypass, an approach to upper limb lymphedema in which healthy lymphatic vessels from the medial thigh area are used as a composite graft.

The senior author (D.W.C.) evaluated 20 consecutive patients with stage 2 or 3 upper extremity lymphedema (clinical staging of lymphedema by Campisi et al) secondary to treatment of breast cancer who underwent lymphaticovenular bypasses ranging from 0.3 to 0.8 mm. Mean operative time was 3.3 hours (range, 2 to 5 hours). Hospital stay was less than 24 hours in all patients.

Of 20 patients, 19 reported significant clinical improvement following the procedure. Mean volume reduction at 1 month was 29 percent; at 3 months, it was 36 percent; at 6 months, it was 39 percent; and at 1 year, it was 35 percent. There were no postoperative complications or exacerbation of lymphedema.

This youtube video from one of the article’s authors, Dr. David Chang ( MDAnderson) explains the procedure:

Resources for more information on lymphedema:

BreastCancer.org – Arm Lymphedema (last updated Dec 2009)

MayoClinic.com – Lymphedema (general info, not breast cancer specific)

National Lymphedema Network

 

REFERENCE

Overview of Surgical Treatments for Breast Cancer–Related Lymphedema; Suami, Hiroo; Chang, David W.; Plastic & Reconstructive Surgery. 126(6):1853-1863, December 2010; doi: 10.1097/PRS.0b013e3181f44658

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