The end of cancer treatment can be an exciting milestone in a patient’s recovery process, so any lingering health issues can be frustrating. A Baylor College of Medicine plastic surgeon discusses lymphedema, a disruption to the lymphatic system often caused by cancer surgery or treatment that leads to swelling, heaviness, increased infection risk and discomfort in the limbs, and the options to treat it.
“Lymphedema can be a constant reminder to a patient of their cancer journey and is a lifestyle-limiting health issue that persists long after they are past the treatment portion of their cancer care,” said Dr. Jessie Yu, assistant professor in the Division of Adult Plastic Surgery in the Michael E. DeBakey Department of Surgery at Baylor.
The role of the lymphatic system
The lymphatic system is part of the body’s natural immune defense system and plays an important role in cancer. Lymphatic channels and lymph nodes are present throughout the body and work to remove excess fluid and ultimately pump it back to the heart. Lymph nodes are found at specific areas, such as the armpits, groin and elbow, where the lymphatic channels converge.
If the lymphatic system is injured or lymph nodes are removed by surgery, this can cause a backup in how lymph fluid drains from the limb. Lymphatic fluid leaks out of damaged lymph channels into the healthy surrounding tissue and can cause tissue edema (swelling), thickening and even scarring (fibrosis). Over time, these changes result in the hallmark signs of lymphedema, including swelling, redness, recurrent infections and limb heaviness.
The most common reason people in the U.S. develop lymphedema is after surgery, particularly if lymph nodes are removed for cancer staging or treatment. This is called “secondary lymphedema.” Radiation therapy also has been associated with lymphedema.
“Interestingly, most patients do not notice signs or symptoms of lymphedema until two to three years after their initial procedure,” Yu said. “Why and how some people get lymphedema and others do not is a huge area of research, but we do know that risk factors for lymphedema include being overweight and undergoing chemotherapy or radiation in that area.”
Treating lymphedema early is best, but matching the right procedure with the right type of lymphedema is key, she said.
Yu said that it’s important to start with noninvasive treatments to achieve limb volume reduction using compression dressings that are customized to the patient. Lymphatic massage or home lymphatic pumps also can be used with compression.
“If the limb volume goes down using these initial steps, it not only tells me that the patient is an excellent candidate for the next step, which is surgery, but also will improve this patient’s ultimate outcome after the surgery,” Yu said.
In patients with early stage lymphedema where they have some functional and some nonfunctional lymphatics, one of the available surgeries is the lymphovenous bypass, where surgeons use a 1 to 2 centimeter incision to create a “bypass” of the blocked lymphatic system that results in a detour for the lymphatic fluid to return to the heart via the venous system.
For more advanced stage lymphedema patients who have non-functioning lymphatic channels, a vascularized lymph node transfer surgery is an option. Surgeons borrow healthy lymph nodes from another part of the body, usually the abdomen or groin, to stimulate new lymphatic growth and pump out the extra fluid in the diseased area. This is a particularly good option for patients who also want to undergo breast reconstruction using their own tissue since lymph nodes and tissue can be transferred in one surgery.
Those with extremely advanced lymphedema who may not be candidates for the other procedures may benefit from surgical debulking surgery or liposuction to decrease limb size.
Continued outpatient lymphedema therapy is required after all of these procedures. Goals of surgery include eliminating or reducing the use of compression garments in patients and improving symptoms, such as feeling less heavy, having less infections, and being more nimble with that limb.
“Lymphedema is a complicated problem and can be difficult to treat,” Yu said. “Our plastic surgeons at Baylor are committed to providing the most cutting edge and comprehensive lymphedema care to our patients. The field of lymphedema research is also actively exploring and developing new treatments and interventions for our patients.”