Lymph Node Transfers
I have personally checked with Dr. Massey's office
and obtained confirmation that she does perform inguinal
lymph node transfers to treat lower limb lymphedema patients upon careful examination. Her web site makes
more references to upper limb lymphedema.
If you
intend to contact Dr. Massey, I would appreciate that you mention where you got
her contact
information.
Good health to you all,
Pierre
MERCIER, BSc MA, Lymphedema Therapist, Gatineau, Quebec, Canada
PS The
original information I received contained a couple of medical articles on this
topic in PDF format that
I would be happy to
share.
_________________________________________________________________________________
_________________
LYMPHEDEMA PATIENTS
Reverse The Signs
And Symptoms Of Lymphedema
We are proud to announce the creation of a
new ground-breaking surgical procedure to improve the
symptoms
associated with lymphedema.
Dr. Marga F. Massey is a board-certified
plastic surgeon with specialty training in microsurgery. Beginning
January 2009 at Chicago 's Advocate Trinity Hospital , Dr. Massey began
offering a new innovation in
microsurgery leading to an improved
quality of life for lymphedema patients the world over.
If you are
experiencing lymphedema, in any of it's various forms, you may be a candidate
for vascularized
lymph node transplantation, a simple procedure that
can reverse the symptoms associated with lymphedema
and improve
your overall quality of life.
We are very excited about being able to
offer this innovative, life-changing procedure in Chicago , Illinois .
To learn more about Dr. Massey and the lymphedema microsurgery, please
visit us online at www.drmarga.
com . If you would like to schedule
a consultation in our office, please call us
at:
1-312-725-4322
Vascularized lymph node transplantation is a
safe procedure permitting good long-term results and the
disappearance, or significant improvement, of lymphedema symptoms most
in patients who undergo the
procedure
******Keep in mind the
above is an experimental treatment and is NOT endorsed by lymphland.
*It is the opinion of myself, Tina, the practice is not safe due to the
debate of whether or not there
really is a secondary lymphedema. Studies
are emerging that suggest that all lymphedema might be primary
and
caused by secondary triggers. In that case, surgery to remove nodes from one
area to
put in another could cause lymphedema to settle in the area of
removal.
----------------------------------------------------------------------------------------------------
There
are some options for genital edema, though none are easy. For females, you can
get a long line panty
shaper (which was formerly called a girdle)
and then sew another crotch within the crotch to form a pocket.
In this you can place either foam, or a heavy kotex (maternity) which will provide pressure against the labia.
Not terribly comfortable, but can be
effective. There is also genital pads from Solaris (male and female)
which
are then held in place by a long leg panty or underarmor for men. The male
genitalia can be bandaged
and then supported with a scrotal
support. The scrotum and penis will reduce, it is more of a challenge for
female genital edema. Hope this helps Renee Romero RN, CLT-LANA of
Bandages Plus
----------------------------------------------------
Permission
to share this information given by Dr. Mara. Page updated 3/23/09. Dr. Marga
is the surgeon
who performs this technique.
http://www.drmarga.com
-------------
SURGICAL
TECHNIQUE
Postmastectomy Lymphedema
Long-term Results Following
Microsurgical Lymph Node
Transplantation
Corinne Becker, MD, Jalal
Assouad, MD, Marc Riquet, MD, PhD, and Genevie`ve Hidden, MD
Background and
Objectives: Lymphedema complicating breast
cancer treatment remains a
challenging problem. The purpose of this
study was to analyze the long-term
results following microsurgical
lymph node (LN) transplantation.
Methods:
Twenty-four female patients with lymphedema for more
than 5 years underwent
LN transplantation. They were treated by
physiotherapy and resistant to it.
LNs were harvested in the femoral
region, transferred to the axillary
region, and transplanted by microsurgical
procedures. Long-term results were
evaluated according
to skin elasticity, decrease, or disappearance of
lymphedema assessed
by measurements, isotopic lymphangiography, and ability
to
stop physiotherapy.
Results: The postoperative period was uneventful;
skin infectious
diseases disappeared in all patients. Upper limb perimeter
returned
to normal in 10 cases, decreased in 12 cases, and remained
unchanged
in 2 cases. Five of 16 (31%) isotopic
lymphoscintigraphies
demonstrated activity of the transplanted nodes.
Physiotherapy was
discontinued in 15 patients (62.5%). Ten patients were
considered as
cured, important improvement was noted in 12 patients, and
only 2
patients were not improved.
Conclusion: LN transplantation is a
safe procedure permitting good
long-term results, disappearance, or a
noteworthy improvement, in
postmastectomy lymphedema, especially in the
early stages of the
disease.
(Ann Surg 2006;243: 313–315)
Lymphedema
complicating breast cancer treatment remains
a challenging problem. Combined
physiotherapy is not
performed equally in all centers, and many physicians
remain
skeptical on the overall efficacy of surgical
treatments.1
Furthermore, whatever the treatment proposed, the
possibility
of cure remains questionable. Over the last 12 years, our
team
has treated limb lymphedema by transplanting lymph nodes.2
The
purpose of this study was to analyze the results obtained
with this
procedure during a minimal 5-year follow-up.
PATIENTS AND METHODS
We
retrospectively reviewed data of 24 female patients
suffering from
lymphedema following breast cancer treatment
who underwent lymph node
transplantation by one of us (C.B.)
in Cavell Institution in Brussels from
1991 to 1997. Mean age
was 58.7 years (range, 37–80 years) with a mean
follow-up of
8.3 years (range, 5–11 years). Upper limb lymphedema
was
right sided in 14 patients and left sided in 10 patients. All
the
patients were previously seen by their oncologist and considered
in
breast cancer remission. Breast carcinoma treatment
performed was mastectomy
(n 3), mastectomy and radiation
therapy (n 11), and mastectomy,
radiation therapy, and
chemotherapy (n 10). Axillary lymphadenectomy had
been
performed in all cases. In 18 patients, upper limb lymphedema
was
present for at least 1 year or greater (mean, 5.6
years; range, 1–15 years).
In 6 patients, it was present for
only a few months (mean, 5 months; range,
3–8 months).
Patients complaining of pain and/or presenting with
palsy
and/or with elephantiasis were excluded from the study.
All
patients were undergoing physiotherapy and were considered
resistant
to it.
Lymphedema was assessed by measurements, infectious
episodes, and
isotopic lymphangiography.
Measurements were weekly during the
preoperative
month and were performed before and after
physiotherapy.
Sites measured were at the wrist, 10 cm above the
wrist,
at the elbow, and 10 cm above the elbow. Results were
then
compared with the contralateral limb measurements.
The number of
previous infectious episodes (erysipela,
lymphangitis . . .) and the aspect
of the teguments at presentation
(elasticity of the skin and infectious
disease) were
recorded. In case of infectious disease, antibiotic therapy
and
local treatment was performed.
Isotopic lymphangiography was
performed in 20 patients.
In 15 patients, lymphoscintigraphy demonstrated
absence of
both lymph nodes and drainage; and in 3 patients, drainage
was
impaired without clearly demonstrating the absence of nodes. In
2
patients, lymphoscintigraphy was normal.
Patients were divided into 2
stages: stage I, early edema
with no or less than 2 infectious episodes,
skin elasticity
preserved, and perimeter not exceeding 30% more than
the
From Service de Chirurgie Thoracique, Hoˆpital Europe´en Georges
Pompidou,
Paris, France.
Reprints: Marc Riquet, MD, PhD, Service de
Chirurgie Thoracique, Hoˆpital
Europe´en Georges Pompidou, 20-40 rue
Leblanc, 75015 Paris Cedex,
France. E-mail:
[email protected].
Copyright © 2006 by Lippincott
Williams & Wilkins
ISSN: 0003-4932/06/24303-0313
DOI:
10.1097/01.sla.0000201258.10304.16
Annals of Surgery • Volume 243, Number 3,
March 2006 313
contralateral arm (n 6); stage II, older edema, most often
of
more than 1 year duration, more than 2 infectious episodes,
impaired
skin elasticity, and perimeter measured between 30
and 50% more than the
contralateral arm (n 18).
Surgical approach of the axillary region of the
lymphedematous
limb was performed in search of receiving
vessels:
fibrotic muscular and burned tissue were dissected and
adhesions
released. Axillary vessels were dissected and the
periscapular
pedicle was isolated. The circumflex posterior
branches were individualized
and prepared for microanastomoses.
An incision was then performed in the
inguinal region.
The dissection began by visualizing the superficialis
circumflex
iliac vein. At that level are located lymph nodes irrigated
by
the circumflex iliac vessels and without direct connection
with the
lymphatic drainage of the inferior limb. These nodes
were dissected, freed,
and elevated external to internal at the
level of the muscular aponeurosis.
The nodes were then
harvested with an abundant amount of surrounding fat
tissue.
Lymph nodes were then transplanted in the axillary
receiving
site. Artery and vein were anastomosed with the
vessels previously prepared,
using microsurgical techniques.
Both axillary and inguinal approaches were
closed on suction
drainage.
In 7 cases, because of an incomplete result
at the level
of the forearm, a second procedure was performed.
Lymph
nodes were harvested in the same manner at the
contralateral
inguinal site and were transplanted at the level of the
elbow.
Following surgery, manual drainage (physiotherapy)
was performed
on the first postoperative day and daily during
the first 3 months. Manual
drainage was then performed twice
a week during the following 3 months and
discontinued. No
elastic compression dressing was applied following
surgery
to avoid compression on the transplanted lymph nodes and on
the
microsurgical anastomosis. Antisludge treatment mainly
acetylsalicylates
were administrated during the postoperative
period.
Long-term results
were evaluated according to skin
elasticity and existence of infectious
disease, decrease or
disappearance of the lymphedema assessed by
measurements,
effects observed on isotopic lymphangiography, and ability
to
stop or to discontinue physiotherapy after 6 months. Longterm
results
were also evaluated according to the duration of
the lymphedema before
surgery and occurrence of downstaging
after surgery.
RESULTS
The
postoperative period was uneventful except for the
appearance of lymphorrhea
in 8 patients, which resolved over
a few days. Infectious disease
disappeared totally in 17
patients; and in the remaining 7 patients, only
one episode of
skin infectious disease was recorded.
Upper limb perimeter
returned to normal in 10 cases,
remained unchanged in 2 cases, and decreased
more than
50% of its value in 6 patients and less than 50% of its
value
in 6 other patients.
Control isotopic lymphangiography was
performed in 16
patients. In 11 patients, lymph nodes and lymph drainage
were
initially absent: in 4 patients, the transplanted lymph nodes
were
visualized and new lymph drainage pathways appeared. In 3
patients,
lymph drainage was impaired without clearly demonstrating
lymph nodes: in 1
of these patients, lymph node
was visualized. In 2 patients with normal
isotopic lymphangiography,
results were unchanged. So, 5 of 16
(31%)
lymphoscintigraphies demonstrated the effectiveness of
lymph node
transplantation.
Physiotherapy was discontinued after 6 months in
14
patients and after 12 months in 1 patient. In the 9 other
patients,
physiotherapy remained necessary and was performed
once weekly in 7
patients. Physiotherapy was thus
discontinued in 15 patients (62.5%).
Ten
patients were considered cured (good results)
(stage I, n 4; stage II, n
6). Two patients were not at all
improved, lymphedema remaining unchanged
(stage I, n 1;
stage II, n 1). Downstaging (from stage II to stage I)
was
observed in 12 patients.
Duration of the lymphedema before surgery
was: a few
months (n 5) and 1 to 4 years, mean 2.4 years (n 5)
in
case of good results, 3 and 4 years in case of bad results (n
2), 8
months and 1 to 15 years, mean 7.4 years (n 11) in
case of downstaging. In
1 patient with downstaging, the result
was considered as good (normalized)
following elective liposuction.
During long-term follow-up, no breast cancer
recurrence
was observed.
DISCUSSION
Autologous lymph node
transplantation permits lymphedema
improvement with long-term downstaging
commonly
obtained (except 2 patients), and physiotherapy discontinued
in
62.3% of patients. Lymphedema was considered cured in
42% of patients and
fixating lymph nodes were detected in
31% of patients controlled by
lymphoscintigraphy. Good
results were obtained more regularly when the
duration of
lymphedema was the shortest before lymph nodes
transplantation.
Effectiveness of the procedure was always
durably
demonstrated with respect to skin infectious diseases.
Autologous
lymph node transplantation for lymphedema
treatment is a recent
microsurgical technique,3 the results
of which have yet to be fully
evaluated.4 Results of the
transplantation of lymph nodes in the rat5,6 and
in the dog7
prove very attractive. In humans, the major concern is to
find
a fatty flap containing lymph nodes with their own
vascularization,
the procurement of which should be performed
without
injury. Our technique uses inguinal lymph node free flap2
made of
the more superior external superficial lymph nodes:
an anatomic study based
on the dissection of 50 inguinal
regions of fresh cadavers demonstrated that
they mainly
received lymph from the abdominal wall and that
their
procurement did not impair lymph drainage of the lower
limb.6 This
procurement site is the only one used in this
report; however, lymph node
transplantation may be used to
treat limb lymphedema with other procurement
sites such as
cervical2 or axillary8 being possible.
No current gold
standard for evaluation of lymphedema
exists;9 hence, evaluating results of
treatments remains difficult
Becker et al Annals of Surgery • Volume 243,
Number 3, March 2006
314 © 2006 Lippincott Williams & Wilkins
and
appears controversial. Fluid displacement data, which would
have been a more
objective methodology, was not available
because it was not routinely
performed. Despite this, and
although circumferential data appear subjective
and difficult
to interpret, results on lymphedema measurements were
satisfactory
in this series, and many patients were able to
discontinue
physiotherapy treatments.
Trevidic and Pecking9 have underlined the role
lymphoscintigraphy
may have to objectively assess results obtained
and to
select patients for surgery. However, in our
series, results obtained on
reappearance of lymph drainage
are difficult to interpret meaningfully, and
colloidal uptake by
transplanted lymph nodes was detected in only 31%
of
patients. Appearance of lymphatic pathways toward the graft
site,
which was sometimes also present, could suggest a
“lymphangiogenetic” effect
of these grafts. These results,
also observed in experimental studies,5–7
would be of paramount
interest if confirmed by other series.
Transplanted
lymph node colloidal uptake was all the
more frequent than the duration of
lymphedema was shorter.
Shesol et al5 also observed, in a study in the rat,
that radioactivity
appeared in 4 of 5 transplanted lymph nodes
when
transplantation was immediately following lymphedema onset,
whereas
it appeared in only 1 of 5 cases when transplantation
was delayed. This
could suggest that it would be
perhaps better not to delay the indication
for lymph node
transplantation.
Effect on skin infectious diseases was
the most obvious.
A role by the transplanted lymph nodes immune
effect
may be possible. Experimental studies have demonstrated
that
autotransplanted lymph nodes rapidly recovered a normal
architecture.10 No
study is available to validate our observations,
but Egawa et al11 reported
reduction of lymphedema
after intraarterial injection of autologous
lymphocytes probably
due to changes in blood protein components.
Lymphoid
tissue present in transplanted lymph nodes may prevent
infection
but may also reduce arm swelling by similar mechanism
of
changes in protein components: this also may explain
partial benefits
obtained when lymphatic pathways are
not
restored.
CONCLUSION
Autologous lymph node transplantation appears
to have a
favorable and persistent effect on postmastectomy
lymphedema.
It is a safe procedure that may be advocated when
discussing
surgical treatments, especially in early stages of the
disease.
REFERENCES
1. Fo¨ldi M. Treatment of lymphoedema. Lymphology.
1994;27:1–5.
2. Becker C, Hidden G, Godart S, et al. Free lymphatic
transplant. Eur J
Lymphol Rel Prob. 1991;6:25–77.
3. Bernars MJ, Witte
CL, Witte MH, et al. The diagnosis and treatment of
peripheral lymphedema:
draft revision of the 1995 consensus document
of the International Society
of Lymphology Executive Committee for
Discussion at the September 3–7, 2001
XVIII International Congress of
Lymphology in Genoa, Italy. Lymphology.
2001;34:84 –91.
4. Campisi C. Surgery for the treatment of lymphedema. Eur J
Lymph Rel
Prob. 2002;10:24 –27.
5. Shesol BF, Nakashima R, Alavi A, et al.
Successful lymph node transplantation
in rats, with restoration of lymphatic
function. Plast Recontr Surg.
1979;63:817–823.
6. Becker C, Hidden G.
Transfert de lambeaux lymphatiques libres. Microchirurgie
et e´tude
anatomique. J Mal Vascul. 1988;13:199 –122.
7. Chen HC, O’Brien MC, Roger
IW, et al. Lymph node transfer for the
treatment of obstructive lymphoedema
in the canine model. Br J Plast
Surg. 1990;43:578 –586.
8. Trevidic P,
Cormier JM. Free axillary lymph node transfer. In: Cluzan
RV, ed. Progress
in Lymphology, vol. XIII. Excerpta Medica Paris.
1992:415– 420.
9.
Trevidic P, Pecking AP. Limb radionuclide lymphoscintigraphy prior
and after
a lymphatic bypass using an axillary flap. Lymphology. 1998;
31(suppl):605–
608.
10. Rabson JA, Geyer SJ, Levine G, et al. Tumor immunity in rat
lymph
nodes following transplantation. Ann Surg. 1982;196:92–99.
11.
Egawa Y, Sato A, Katoh I, et al. Reduction in arm swelling and changes
in
protein components of lymphoedema fluid after intra arterial injection
of
autologous lymphocytes. Lymphology. 1993;26:169 –176.
Annals of Surgery •
Volume 243, Number 3, March 2006 Postmastectomy Lymphedema
© 2006 Lippincott
Williams & Wilkins
315
------------------------------
Original
article
Postmastectomy neuropathic pain: Results of microsurgical
lymph
nodes transplantation
Corinne Becker, Duc Nhat Minh Pham, Jalal Assouad,
Alain Badia,
Christophe Foucault, Marc Riquet*
Service de Chirurgie
Thoracique, Hoˆ pital Europe´en Georges Pompidou, 20-40 rue Leblanc, 75015
Paris Cedex, France
Received 2 October 2007; received in revised form
13 November 2007; accepted 19 December 2007
Abstract
Postmastectomy
chronic pain may be divided into widespread and regional pain. Almost half
patients with
regional pain, which is more likely
related to
neuropathic phenomena, do not benefit any pain relief from medication. Our
purpose was to
report results on pain relief obtained by
axillary
lymph nodes autotransplantation.
Methods: Six patients presented with
chronic regional neuropathic pains and upper limb lymphedema after
breast cancer surgery and radiation
therapy. Despite medication,
pain was intolerable and daily activity dramatically reduced. Lymph nodes
were harvested in the femoral region,
transferred to the axillary
region and transplanted by microsurgical procedures.
Results: Lymphedema
resolved in 5 out of 6 patients. Pain was relieved in all, permitting return to
work
and daily activity; analgesic medication
was
discontinued.
Conclusion: This procedure proved efficient and may be
advocated in case of neuropathic pain when
discussing lymphedema
management.
2008 Elsevier Ltd. All rights reserved.
Keywords: Breast
cancer; Lymphedema; Chronic pain; Lymph node; Neuroma;
Autotransplantation
Chronic pain following breast cancer surgery is now a
common
and well-recognized problem with prevalence rates as
high as 42.9%
(175/408) and 46% (59/85) in retrospective
studies,1,2 such rates being also
observed in prospective study
(48.4%, 46/95).3 Chronic pain is defined by
the International
Association for the Study of Pain as that persisting
beyond
the normal healing time of 3 months (IASP, 1986). Little is
known
about its long-term outcome, but chronic pain can resolve
with time.
MacDonald and Coll1 reported a cumulative
prevalence of 43% at 3 years
(mean) postoperatively and of
17% at 9 years (mean). The exact cause of
chronic pain is unclear
and various aetiological theories have been
postulated,
the main 1 being neuropathic origin. Chronic pain
following
breast cancer surgery has been divided into widespread
and
regional pain.4 Widespread pain, which is diffuse, persistent
pain
mainly due to other factors than neuropathic, may induce
significantly more
severity of pain, pain impact and lower
physical health status than regional
pain. However, in case
of widespread pain, medication is rated as at least
somewhat
effective for relieving this pain. On the contrary, only 56%
of
patients with regional pain will benefit any pain relief
from medication.4
Regional pain which is chronic pain
related to neuropathic phenomena,1 so
remains a therapeutic
challenging problem.
Other major problem following
breast cancer treatment is
lymphedema. Whatever the treatment proposed, the
possibility
of curing lymphedema remains questionable. Over the last
13
years, our team has treated limb lymphedema by transplanting
lymph
nodes.5 Results obtained with this procedure proved
satisfactory
demonstrating disappearance or a noteworthy
improvement in postmastectomy
lymphedema, especially in
the early stages of the disease.6
*
Corresponding author.
E-mail address: [email protected] (M.
Riquet).
0960-9776/$ - see front matter 2008 Elsevier Ltd. All rights
reserved.
doi:10.1016/j.breast.2007.12.007
Available online at
www.sciencedirect.com
The Breast 17
(2008) 472e476
www.elsevier.com/locate/breast
-----------------------------------
---------------------------------------------
Minimally
invasive robotic surgery Saint Joseph's Hospital in
Atlanta.
http://www.physorg.com/news157040271.html
Super
micro-surgery offers new hope for breast cancer patients with
lymphedema
March 23rd, 2009 Breast cancer patients with lymphedema in their
upper arm experienced reduced fluid
in the swollen arm by up to 39
percent after undergoing a super-microsurgical technique known as
lymphaticovenular bypass, report researchers at The University of Texas
M. D. Anderson Cancer Center.
Lymphedema treatment -
www.lympha-press.com
Lympha Press is the #1 physician recommended lymphedema
therapy
Prostate Cancer Treatment -
www.ProstRcision.com
Groundbreaking Techniques for the Highest Known Cure
Rates Worldwide.
The results from the prospective analysis,
presented today at the 88th Annual Meeting of the American
Association of Plastic Surgeons, suggest another option for breast
cancer patients considering ways to
manage lymphedema, a common and
debilitating condition following surgery and/or radiation therapy for
breast
cancer.
Lymphedema results when the lymph nodes are removed or blocked
due to treatment and lymph fluid
accumulates causing chronic
swelling in the upper arm. Currently, there is no cure or preventive measure
for lymphedema and it is difficult to manage; the use of
compression bandages, massage and other forms
of lymphatic therapy
are commonly recommended options for patients. According to the National Cancer
Institute, 25 to 30 percent of women who have breast cancer surgery
with lymph node removal and
radiation therapy develop
lymphedema.
Researchers evaluated 20 breast cancer patients with stage
II and III treatment-related lymphedema of the
upper arm who
underwent a lymphaticovenular bypass at M. D. Anderson from December 2005 to
September 2008. Due to lymphedema, the patients' affected arm was
an average of 34 percent larger
compared to the unaffected arm prior to the surgery. Of these 20 patients, 19 reported initial significant
clinical improvement following the procedure. In those patients with
postoperative volumetric analysis
measurements, total mean
reduction in the volume differential at one month was 29 percent, at three
months 33 percent, at six months 39 percent and 25 percent at one
year.
"Patients often resort to lymphatic therapy because other options
brought forward to reduce lymphedema
haven't proved effective,"
said lead author on the study David W. Chang, M.D., professor in the
Department
of Plastic Surgery and Director of the Plastic Surgery Clinic at M. D.
Anderson. "Surgical
techniques, in particular, have been limited
and therefore have been met with skepticism by surgeons,
making it
extremely important to determine which new techniques promise to bring real
benefits to
patients."
In lymphaticovenular bypass surgery,
surgeons use tiny microsurgical tools to make two to three small
incisions measuring an inch or less in the patient's arm. Lymphatic
fluid is then redirected to microscopic
vessels - approximately 0.3
- 0.8 millimeters in diameter - to promote drainage and alleviate lymphedema.
The procedure is minimally invasive and is generally completed in
less than four hours under general
anesthesia, allowing patients to
return home from the hospital within 24 hours. M. D. Anderson is among a
few institutions in the United States to offer this technically complex
surgery.
"Lymphedema is like a massive traffic jam with no exit," Chang
said. "This procedure does a lot to help
relieve lymphedema by
giving the fluid a way out. While it does not totally eliminate the condition,
there is
very little downside for the patient and we may see
significant improvement in its severity."
Chang notes that while most
effective when completed in earlier stages before the affected arm is fibrotic,
almost any breast cancer patient suffering from lymphedema stage I,
II or III is a candidate. Though breast
cancer was the focus of
this study, the surgery can also be performed on patients who have lymphedema
in the leg resulting from cancers involving pelvic
regions.
Cancer treatment is not the only cause of lymphedema. Primary
lymphedema can develop from
developmental causes at birth, the onset
of puberty or in adulthood. Secondary lymphedema can develop
as a
result of surgery, radiation, infection or trauma. In developing countries, a
form of lymphedema
caused by a parasite called Filariasis affects as
many as 200 million people worldwide. "As we begin to
refine our
technique and learn more about the efficacy of this surgery, we have the
potential to impact a
large number of people," Chang
said.
Long-term follow-up with patients who have received
lymphaticovenular bypass surgery is necessary to
determine if the
procedure continues to promote drainage after one year. Chang and his team of
surgeons
at M. D. Anderson believe that the fluid volume will keep
decreasing over time and suggest that the
surgery could possibly be
used as a preventive measure for lymphedema in the future. "Working toward a
definitive technique to cure this encumbering side effect of cancer
and improve a patient's quality of life as
a cancer survivor is a
priority for those of us in this field."
Source: University of Texas M.
D. Anderson Cancer Center (news :
web)
---------------------------------------
http://www.freep.com/article/20090323/FEATURES08/903230314
Node
transplant may help lymphedema's painful swelling
BY PATRICIA ANSTETT • FREE
PRESS MEDICAL WRITER • March 23, 2009
Two years after her mastectomy,
Susan Cochrane spent the day in her Tecumseh yard planting flowers.
She got a mild sunburn on her arms, though she had been careful to wear
sunscreen and gloves.
That night, her left arm looked a little
swollen and red. Within three days, the arm had thickened and
gotten painful.
"That started the whole cascade," said Cochrane,
54, describing a four-year struggle with lymphedema, a
painful
swollen limb condition that can be a complication of surgery for breast
cancer.
About 8% of breast cancer patients alone develop the problem,
which can occur, as Cochrane found,
several years after
surgery.
In January 2008, Cochrane developed her worst flare-up, a
painful case of cellulitis, an infection triggered
by her
lymphedema. It caused "a fiery redness of the skin that completely encircled my
forearm." A
massage therapist, "I was afraid my career was over,"
Cochrane said.
Fortunately for Cochrane, the plastic surgeons she works
with in Ann Arbor knew a colleague, Dr.
Rebecca Studinger at St.
John Providence Park Hospital, who had begun offering patients with
lymphedema an option called a lymph node transplant.
Studinger,
a plastic surgeon specializing in breast cancer reconstruction, is one of only
a handful of U.S.
doctors performing the technique. It was
developed over the last 20 years by a French physician, Dr.
Corinne
Becker, but only recently has been offered in the United States. Becker has
published a few
articles on small groups of patients, but the
technique is not well studied.
Studinger spent a week in France with
Becker learning the operation. "When I first heard about it, I said,
'I've
got to go learn it,' " she said.
While not a cure for everyone, one in
four of Becker's patients who had lymphedema for no more than
three
years had a 50% reduction in arm swelling after a transplant, she said.
Studinger has performed
about 20 of the procedures in the last
year. The transplant sometimes brings relief while a patient remains
hospitalized.
Cochrane's
arm felt better within hours of the transplant and now, a year later, "I pretty
much don't have
any limitations," she said.
(2 of
2)
She has developed a pamphlet for breast cancer patients she works
with at the Center for Reconstructive
Surgery in Ann Arbor, which
has incorporated massage therapy as part of the post-operative care patients
receive. Massage after breast cancer surgery can help prevent
lymphedema from occurring.
Another of Studinger's patients,
Kathryn Lay, 35, a mother of four from Farmington Hills, underwent a
lymph
node transplant at the same time Studinger performed her breast reconstruction
procedure. A
longtime bowler, Lay developed lymphedema 10 months
after she had a double mastectomy and removal
of 14 underarm lymph
nodes in January 2008. She had been diagnosed with breast cancer the year
before, at age 33.
"The swelling went down almost immediately"
after the transplant, Lay said. She's easing back into
bowling
every other week at Country Lanes in Farmington Hills.
Given all that has gone on in her life, Lay said she tries not to complain about her arm pain. She is grateful
to her husband, Ralph, "my deep-rooted solid oak
tree" who has "picked up the slack" during breast
cancer and
lymphedema treatment.
"I was diagnosed at 33, and I have a long life to
live," she said. "I want to focus on that."
Contact PATRICIA ANSTETT at
313-222-5021 or [email protected].
-----------------------
AAPS:
Surgery Effectively Reduces Lymphedema
By Crystal Phend, Staff Writer,
MedPage Today
Published: March 24, 2009
Reviewed by Zalman S. Agus, MD;
Emeritus Professor
University of Pennsylvania School of Medicine. Earn
CME/CE credit
for reading medical news
RANCHO MIRAGE, Calif.,
March 24 -- For breast cancer patients with lymphedema, surgery can
improve lymphatic drainage, researchers said, but whether the benefits
last long term remains to be seen.
Action Points
--------------------------------------------------------------------------------
Explain
to interested patients that lymphedema occurs when lymph nodes to the arm are
removed or
damaged, leading to a buildup of fluid and
swelling.
Note that this study was published as an abstract and
presented orally at a conference. These data and
conclusions should
be considered to be preliminary until published in a peer-reviewed
journal.
Lymphaticovenular bypass "microsurgery" on the upper arm reduced
arm volume by up to 39% in these
patients, David W. Chang, M.D., of
the University of Texas M.D. Anderson Cancer Center in Houston,
and
colleagues found.
The effects in a prospective, single center study
appeared durable through one year, although longer-term
follow-up
is needed, Dr. Chang reported here at the American Association of Plastic
Surgeons meeting.
Compression garments, massage, and other
conservative medical treatment remain the first line of defense
for
the 25% to 40% of breast cancer patients who develop lymphedema after
chemotherapy or radiation
therapy.
Although a wide
variety of palliative surgical techniques have been pioneered in Europe and
Asia, these
options have been controversial and limited, Dr. Chang
said.
At M.D. Anderson, he said, surgeons use lymphaticovenular
bypass. This minimally-invasive technique
involves two or three
1-inch or smaller incisions in the arm to insert microsurgical tools used to
redirect
lymphatic fluid to veins 0.3 to 0.8 mm in
diameter.
"For the most part, lymphedema in the U.S. has not been
treated surgically," Dr. Chang said. "The reason
it hasn't gained
popularity is that it's technically challenging and doesn't cure the
lymphedema."
Given this skepticism, his group monitored outcomes of
20 consecutive patients who had
lymphaticovenular bypass at their
institution from December 2005 through September 2008.
All of the
women had stage 2 or 3 lymphedema for a mean duration of 4.8 years before the
surgery. Their
breast cancer therapy had included axillary lymph
node dissection in all cases, with preoperative radiation
therapy
as well in 16 cases.
Surgery lasted an average of 3.3 hours and
patients were discharged within 24 hours afterward. The
procedure
included a mean of 3.5 lymphaticovenular bypasses per patient.
After
surgery, patients resumed nonsurgical strategies, including compression
garments.
Prospective follow-up over the next 18 months revealed
significant postoperative clinical improvement in
19 of the 20
women.
Three patients reported clinical lymphedema reduction without
a corresponding significant quantitative
volume
reduction.
The researchers found that, whereas before surgery, the
affected arm was an average of 34% larger than
the unaffected arm
on quantitative volumetric analysis, the mean volume reduction afterward
was:
29% at one month
33% at three months
39% at six
months
25% at 12 months
Dr. Chang cautioned against over-interpreting
the dip in the results at one year. Based on a series from
researchers in Asia and Europe, limb volume plateaus at some point
after surgery but yields durable results.
He also noted that arm
volume didn't capture other qualitative benefits that may be more important for
patient quality of life. "Patients feel the arm is softer and
lighter than before."
The researchers reported no postoperative
complications or lymphedema exacerbations.
"Lymphaticovenular bypass
using a 'super-microsurgical' approach appears to be effective in improving
the severity of lymphedema in patients with breast cancer," they
concluded.
Dr. Chang said his team believes that these results will
improve over time with continued fluid volume
reductions. However,
he acknowledged the small sample size and the need for long-term follow
up.
The researchers reported no conflicts of
interest.
Primary source: American Association of Plastic
Surgeons
Source reference:
Chang DW, et al "Lymphaticovenular bypass for
management of lymphedema in breast cancer patients: A
prospective
analysis" AAPS 2009.
Related Article(s):
ASCO Breast: Upper-Body
Breast Cancer Surgery Aftermath Often Lingers
SABCS: Air Travel Holds
Little Lymphedema Risk for Breast Cancer Survivors
http://www.medpagetoday.com/Surgery/PlasticSurgery/13404
I have personally checked with Dr. Massey's office
and obtained confirmation that she does perform inguinal
lymph node transfers to treat lower limb lymphedema patients upon careful examination. Her web site makes
more references to upper limb lymphedema.
If you
intend to contact Dr. Massey, I would appreciate that you mention where you got
her contact
information.
Good health to you all,
Pierre
MERCIER, BSc MA, Lymphedema Therapist, Gatineau, Quebec, Canada
PS The
original information I received contained a couple of medical articles on this
topic in PDF format that
I would be happy to
share.
_________________________________________________________________________________
_________________
LYMPHEDEMA PATIENTS
Reverse The Signs
And Symptoms Of Lymphedema
We are proud to announce the creation of a
new ground-breaking surgical procedure to improve the
symptoms
associated with lymphedema.
Dr. Marga F. Massey is a board-certified
plastic surgeon with specialty training in microsurgery. Beginning
January 2009 at Chicago 's Advocate Trinity Hospital , Dr. Massey began
offering a new innovation in
microsurgery leading to an improved
quality of life for lymphedema patients the world over.
If you are
experiencing lymphedema, in any of it's various forms, you may be a candidate
for vascularized
lymph node transplantation, a simple procedure that
can reverse the symptoms associated with lymphedema
and improve
your overall quality of life.
We are very excited about being able to
offer this innovative, life-changing procedure in Chicago , Illinois .
To learn more about Dr. Massey and the lymphedema microsurgery, please
visit us online at www.drmarga.
com . If you would like to schedule
a consultation in our office, please call us
at:
1-312-725-4322
Vascularized lymph node transplantation is a
safe procedure permitting good long-term results and the
disappearance, or significant improvement, of lymphedema symptoms most
in patients who undergo the
procedure
******Keep in mind the
above is an experimental treatment and is NOT endorsed by lymphland.
*It is the opinion of myself, Tina, the practice is not safe due to the
debate of whether or not there
really is a secondary lymphedema. Studies
are emerging that suggest that all lymphedema might be primary
and
caused by secondary triggers. In that case, surgery to remove nodes from one
area to
put in another could cause lymphedema to settle in the area of
removal.
----------------------------------------------------------------------------------------------------
There
are some options for genital edema, though none are easy. For females, you can
get a long line panty
shaper (which was formerly called a girdle)
and then sew another crotch within the crotch to form a pocket.
In this you can place either foam, or a heavy kotex (maternity) which will provide pressure against the labia.
Not terribly comfortable, but can be
effective. There is also genital pads from Solaris (male and female)
which
are then held in place by a long leg panty or underarmor for men. The male
genitalia can be bandaged
and then supported with a scrotal
support. The scrotum and penis will reduce, it is more of a challenge for
female genital edema. Hope this helps Renee Romero RN, CLT-LANA of
Bandages Plus
----------------------------------------------------
Permission
to share this information given by Dr. Mara. Page updated 3/23/09. Dr. Marga
is the surgeon
who performs this technique.
http://www.drmarga.com
-------------
SURGICAL
TECHNIQUE
Postmastectomy Lymphedema
Long-term Results Following
Microsurgical Lymph Node
Transplantation
Corinne Becker, MD, Jalal
Assouad, MD, Marc Riquet, MD, PhD, and Genevie`ve Hidden, MD
Background and
Objectives: Lymphedema complicating breast
cancer treatment remains a
challenging problem. The purpose of this
study was to analyze the long-term
results following microsurgical
lymph node (LN) transplantation.
Methods:
Twenty-four female patients with lymphedema for more
than 5 years underwent
LN transplantation. They were treated by
physiotherapy and resistant to it.
LNs were harvested in the femoral
region, transferred to the axillary
region, and transplanted by microsurgical
procedures. Long-term results were
evaluated according
to skin elasticity, decrease, or disappearance of
lymphedema assessed
by measurements, isotopic lymphangiography, and ability
to
stop physiotherapy.
Results: The postoperative period was uneventful;
skin infectious
diseases disappeared in all patients. Upper limb perimeter
returned
to normal in 10 cases, decreased in 12 cases, and remained
unchanged
in 2 cases. Five of 16 (31%) isotopic
lymphoscintigraphies
demonstrated activity of the transplanted nodes.
Physiotherapy was
discontinued in 15 patients (62.5%). Ten patients were
considered as
cured, important improvement was noted in 12 patients, and
only 2
patients were not improved.
Conclusion: LN transplantation is a
safe procedure permitting good
long-term results, disappearance, or a
noteworthy improvement, in
postmastectomy lymphedema, especially in the
early stages of the
disease.
(Ann Surg 2006;243: 313–315)
Lymphedema
complicating breast cancer treatment remains
a challenging problem. Combined
physiotherapy is not
performed equally in all centers, and many physicians
remain
skeptical on the overall efficacy of surgical
treatments.1
Furthermore, whatever the treatment proposed, the
possibility
of cure remains questionable. Over the last 12 years, our
team
has treated limb lymphedema by transplanting lymph nodes.2
The
purpose of this study was to analyze the results obtained
with this
procedure during a minimal 5-year follow-up.
PATIENTS AND METHODS
We
retrospectively reviewed data of 24 female patients
suffering from
lymphedema following breast cancer treatment
who underwent lymph node
transplantation by one of us (C.B.)
in Cavell Institution in Brussels from
1991 to 1997. Mean age
was 58.7 years (range, 37–80 years) with a mean
follow-up of
8.3 years (range, 5–11 years). Upper limb lymphedema
was
right sided in 14 patients and left sided in 10 patients. All
the
patients were previously seen by their oncologist and considered
in
breast cancer remission. Breast carcinoma treatment
performed was mastectomy
(n 3), mastectomy and radiation
therapy (n 11), and mastectomy,
radiation therapy, and
chemotherapy (n 10). Axillary lymphadenectomy had
been
performed in all cases. In 18 patients, upper limb lymphedema
was
present for at least 1 year or greater (mean, 5.6
years; range, 1–15 years).
In 6 patients, it was present for
only a few months (mean, 5 months; range,
3–8 months).
Patients complaining of pain and/or presenting with
palsy
and/or with elephantiasis were excluded from the study.
All
patients were undergoing physiotherapy and were considered
resistant
to it.
Lymphedema was assessed by measurements, infectious
episodes, and
isotopic lymphangiography.
Measurements were weekly during the
preoperative
month and were performed before and after
physiotherapy.
Sites measured were at the wrist, 10 cm above the
wrist,
at the elbow, and 10 cm above the elbow. Results were
then
compared with the contralateral limb measurements.
The number of
previous infectious episodes (erysipela,
lymphangitis . . .) and the aspect
of the teguments at presentation
(elasticity of the skin and infectious
disease) were
recorded. In case of infectious disease, antibiotic therapy
and
local treatment was performed.
Isotopic lymphangiography was
performed in 20 patients.
In 15 patients, lymphoscintigraphy demonstrated
absence of
both lymph nodes and drainage; and in 3 patients, drainage
was
impaired without clearly demonstrating the absence of nodes. In
2
patients, lymphoscintigraphy was normal.
Patients were divided into 2
stages: stage I, early edema
with no or less than 2 infectious episodes,
skin elasticity
preserved, and perimeter not exceeding 30% more than
the
From Service de Chirurgie Thoracique, Hoˆpital Europe´en Georges
Pompidou,
Paris, France.
Reprints: Marc Riquet, MD, PhD, Service de
Chirurgie Thoracique, Hoˆpital
Europe´en Georges Pompidou, 20-40 rue
Leblanc, 75015 Paris Cedex,
France. E-mail:
[email protected].
Copyright © 2006 by Lippincott
Williams & Wilkins
ISSN: 0003-4932/06/24303-0313
DOI:
10.1097/01.sla.0000201258.10304.16
Annals of Surgery • Volume 243, Number 3,
March 2006 313
contralateral arm (n 6); stage II, older edema, most often
of
more than 1 year duration, more than 2 infectious episodes,
impaired
skin elasticity, and perimeter measured between 30
and 50% more than the
contralateral arm (n 18).
Surgical approach of the axillary region of the
lymphedematous
limb was performed in search of receiving
vessels:
fibrotic muscular and burned tissue were dissected and
adhesions
released. Axillary vessels were dissected and the
periscapular
pedicle was isolated. The circumflex posterior
branches were individualized
and prepared for microanastomoses.
An incision was then performed in the
inguinal region.
The dissection began by visualizing the superficialis
circumflex
iliac vein. At that level are located lymph nodes irrigated
by
the circumflex iliac vessels and without direct connection
with the
lymphatic drainage of the inferior limb. These nodes
were dissected, freed,
and elevated external to internal at the
level of the muscular aponeurosis.
The nodes were then
harvested with an abundant amount of surrounding fat
tissue.
Lymph nodes were then transplanted in the axillary
receiving
site. Artery and vein were anastomosed with the
vessels previously prepared,
using microsurgical techniques.
Both axillary and inguinal approaches were
closed on suction
drainage.
In 7 cases, because of an incomplete result
at the level
of the forearm, a second procedure was performed.
Lymph
nodes were harvested in the same manner at the
contralateral
inguinal site and were transplanted at the level of the
elbow.
Following surgery, manual drainage (physiotherapy)
was performed
on the first postoperative day and daily during
the first 3 months. Manual
drainage was then performed twice
a week during the following 3 months and
discontinued. No
elastic compression dressing was applied following
surgery
to avoid compression on the transplanted lymph nodes and on
the
microsurgical anastomosis. Antisludge treatment mainly
acetylsalicylates
were administrated during the postoperative
period.
Long-term results
were evaluated according to skin
elasticity and existence of infectious
disease, decrease or
disappearance of the lymphedema assessed by
measurements,
effects observed on isotopic lymphangiography, and ability
to
stop or to discontinue physiotherapy after 6 months. Longterm
results
were also evaluated according to the duration of
the lymphedema before
surgery and occurrence of downstaging
after surgery.
RESULTS
The
postoperative period was uneventful except for the
appearance of lymphorrhea
in 8 patients, which resolved over
a few days. Infectious disease
disappeared totally in 17
patients; and in the remaining 7 patients, only
one episode of
skin infectious disease was recorded.
Upper limb perimeter
returned to normal in 10 cases,
remained unchanged in 2 cases, and decreased
more than
50% of its value in 6 patients and less than 50% of its
value
in 6 other patients.
Control isotopic lymphangiography was
performed in 16
patients. In 11 patients, lymph nodes and lymph drainage
were
initially absent: in 4 patients, the transplanted lymph nodes
were
visualized and new lymph drainage pathways appeared. In 3
patients,
lymph drainage was impaired without clearly demonstrating
lymph nodes: in 1
of these patients, lymph node
was visualized. In 2 patients with normal
isotopic lymphangiography,
results were unchanged. So, 5 of 16
(31%)
lymphoscintigraphies demonstrated the effectiveness of
lymph node
transplantation.
Physiotherapy was discontinued after 6 months in
14
patients and after 12 months in 1 patient. In the 9 other
patients,
physiotherapy remained necessary and was performed
once weekly in 7
patients. Physiotherapy was thus
discontinued in 15 patients (62.5%).
Ten
patients were considered cured (good results)
(stage I, n 4; stage II, n
6). Two patients were not at all
improved, lymphedema remaining unchanged
(stage I, n 1;
stage II, n 1). Downstaging (from stage II to stage I)
was
observed in 12 patients.
Duration of the lymphedema before surgery
was: a few
months (n 5) and 1 to 4 years, mean 2.4 years (n 5)
in
case of good results, 3 and 4 years in case of bad results (n
2), 8
months and 1 to 15 years, mean 7.4 years (n 11) in
case of downstaging. In
1 patient with downstaging, the result
was considered as good (normalized)
following elective liposuction.
During long-term follow-up, no breast cancer
recurrence
was observed.
DISCUSSION
Autologous lymph node
transplantation permits lymphedema
improvement with long-term downstaging
commonly
obtained (except 2 patients), and physiotherapy discontinued
in
62.3% of patients. Lymphedema was considered cured in
42% of patients and
fixating lymph nodes were detected in
31% of patients controlled by
lymphoscintigraphy. Good
results were obtained more regularly when the
duration of
lymphedema was the shortest before lymph nodes
transplantation.
Effectiveness of the procedure was always
durably
demonstrated with respect to skin infectious diseases.
Autologous
lymph node transplantation for lymphedema
treatment is a recent
microsurgical technique,3 the results
of which have yet to be fully
evaluated.4 Results of the
transplantation of lymph nodes in the rat5,6 and
in the dog7
prove very attractive. In humans, the major concern is to
find
a fatty flap containing lymph nodes with their own
vascularization,
the procurement of which should be performed
without
injury. Our technique uses inguinal lymph node free flap2
made of
the more superior external superficial lymph nodes:
an anatomic study based
on the dissection of 50 inguinal
regions of fresh cadavers demonstrated that
they mainly
received lymph from the abdominal wall and that
their
procurement did not impair lymph drainage of the lower
limb.6 This
procurement site is the only one used in this
report; however, lymph node
transplantation may be used to
treat limb lymphedema with other procurement
sites such as
cervical2 or axillary8 being possible.
No current gold
standard for evaluation of lymphedema
exists;9 hence, evaluating results of
treatments remains difficult
Becker et al Annals of Surgery • Volume 243,
Number 3, March 2006
314 © 2006 Lippincott Williams & Wilkins
and
appears controversial. Fluid displacement data, which would
have been a more
objective methodology, was not available
because it was not routinely
performed. Despite this, and
although circumferential data appear subjective
and difficult
to interpret, results on lymphedema measurements were
satisfactory
in this series, and many patients were able to
discontinue
physiotherapy treatments.
Trevidic and Pecking9 have underlined the role
lymphoscintigraphy
may have to objectively assess results obtained
and to
select patients for surgery. However, in our
series, results obtained on
reappearance of lymph drainage
are difficult to interpret meaningfully, and
colloidal uptake by
transplanted lymph nodes was detected in only 31%
of
patients. Appearance of lymphatic pathways toward the graft
site,
which was sometimes also present, could suggest a
“lymphangiogenetic” effect
of these grafts. These results,
also observed in experimental studies,5–7
would be of paramount
interest if confirmed by other series.
Transplanted
lymph node colloidal uptake was all the
more frequent than the duration of
lymphedema was shorter.
Shesol et al5 also observed, in a study in the rat,
that radioactivity
appeared in 4 of 5 transplanted lymph nodes
when
transplantation was immediately following lymphedema onset,
whereas
it appeared in only 1 of 5 cases when transplantation
was delayed. This
could suggest that it would be
perhaps better not to delay the indication
for lymph node
transplantation.
Effect on skin infectious diseases was
the most obvious.
A role by the transplanted lymph nodes immune
effect
may be possible. Experimental studies have demonstrated
that
autotransplanted lymph nodes rapidly recovered a normal
architecture.10 No
study is available to validate our observations,
but Egawa et al11 reported
reduction of lymphedema
after intraarterial injection of autologous
lymphocytes probably
due to changes in blood protein components.
Lymphoid
tissue present in transplanted lymph nodes may prevent
infection
but may also reduce arm swelling by similar mechanism
of
changes in protein components: this also may explain
partial benefits
obtained when lymphatic pathways are
not
restored.
CONCLUSION
Autologous lymph node transplantation appears
to have a
favorable and persistent effect on postmastectomy
lymphedema.
It is a safe procedure that may be advocated when
discussing
surgical treatments, especially in early stages of the
disease.
REFERENCES
1. Fo¨ldi M. Treatment of lymphoedema. Lymphology.
1994;27:1–5.
2. Becker C, Hidden G, Godart S, et al. Free lymphatic
transplant. Eur J
Lymphol Rel Prob. 1991;6:25–77.
3. Bernars MJ, Witte
CL, Witte MH, et al. The diagnosis and treatment of
peripheral lymphedema:
draft revision of the 1995 consensus document
of the International Society
of Lymphology Executive Committee for
Discussion at the September 3–7, 2001
XVIII International Congress of
Lymphology in Genoa, Italy. Lymphology.
2001;34:84 –91.
4. Campisi C. Surgery for the treatment of lymphedema. Eur J
Lymph Rel
Prob. 2002;10:24 –27.
5. Shesol BF, Nakashima R, Alavi A, et al.
Successful lymph node transplantation
in rats, with restoration of lymphatic
function. Plast Recontr Surg.
1979;63:817–823.
6. Becker C, Hidden G.
Transfert de lambeaux lymphatiques libres. Microchirurgie
et e´tude
anatomique. J Mal Vascul. 1988;13:199 –122.
7. Chen HC, O’Brien MC, Roger
IW, et al. Lymph node transfer for the
treatment of obstructive lymphoedema
in the canine model. Br J Plast
Surg. 1990;43:578 –586.
8. Trevidic P,
Cormier JM. Free axillary lymph node transfer. In: Cluzan
RV, ed. Progress
in Lymphology, vol. XIII. Excerpta Medica Paris.
1992:415– 420.
9.
Trevidic P, Pecking AP. Limb radionuclide lymphoscintigraphy prior
and after
a lymphatic bypass using an axillary flap. Lymphology. 1998;
31(suppl):605–
608.
10. Rabson JA, Geyer SJ, Levine G, et al. Tumor immunity in rat
lymph
nodes following transplantation. Ann Surg. 1982;196:92–99.
11.
Egawa Y, Sato A, Katoh I, et al. Reduction in arm swelling and changes
in
protein components of lymphoedema fluid after intra arterial injection
of
autologous lymphocytes. Lymphology. 1993;26:169 –176.
Annals of Surgery •
Volume 243, Number 3, March 2006 Postmastectomy Lymphedema
© 2006 Lippincott
Williams & Wilkins
315
------------------------------
Original
article
Postmastectomy neuropathic pain: Results of microsurgical
lymph
nodes transplantation
Corinne Becker, Duc Nhat Minh Pham, Jalal Assouad,
Alain Badia,
Christophe Foucault, Marc Riquet*
Service de Chirurgie
Thoracique, Hoˆ pital Europe´en Georges Pompidou, 20-40 rue Leblanc, 75015
Paris Cedex, France
Received 2 October 2007; received in revised form
13 November 2007; accepted 19 December 2007
Abstract
Postmastectomy
chronic pain may be divided into widespread and regional pain. Almost half
patients with
regional pain, which is more likely
related to
neuropathic phenomena, do not benefit any pain relief from medication. Our
purpose was to
report results on pain relief obtained by
axillary
lymph nodes autotransplantation.
Methods: Six patients presented with
chronic regional neuropathic pains and upper limb lymphedema after
breast cancer surgery and radiation
therapy. Despite medication,
pain was intolerable and daily activity dramatically reduced. Lymph nodes
were harvested in the femoral region,
transferred to the axillary
region and transplanted by microsurgical procedures.
Results: Lymphedema
resolved in 5 out of 6 patients. Pain was relieved in all, permitting return to
work
and daily activity; analgesic medication
was
discontinued.
Conclusion: This procedure proved efficient and may be
advocated in case of neuropathic pain when
discussing lymphedema
management.
2008 Elsevier Ltd. All rights reserved.
Keywords: Breast
cancer; Lymphedema; Chronic pain; Lymph node; Neuroma;
Autotransplantation
Chronic pain following breast cancer surgery is now a
common
and well-recognized problem with prevalence rates as
high as 42.9%
(175/408) and 46% (59/85) in retrospective
studies,1,2 such rates being also
observed in prospective study
(48.4%, 46/95).3 Chronic pain is defined by
the International
Association for the Study of Pain as that persisting
beyond
the normal healing time of 3 months (IASP, 1986). Little is
known
about its long-term outcome, but chronic pain can resolve
with time.
MacDonald and Coll1 reported a cumulative
prevalence of 43% at 3 years
(mean) postoperatively and of
17% at 9 years (mean). The exact cause of
chronic pain is unclear
and various aetiological theories have been
postulated,
the main 1 being neuropathic origin. Chronic pain
following
breast cancer surgery has been divided into widespread
and
regional pain.4 Widespread pain, which is diffuse, persistent
pain
mainly due to other factors than neuropathic, may induce
significantly more
severity of pain, pain impact and lower
physical health status than regional
pain. However, in case
of widespread pain, medication is rated as at least
somewhat
effective for relieving this pain. On the contrary, only 56%
of
patients with regional pain will benefit any pain relief
from medication.4
Regional pain which is chronic pain
related to neuropathic phenomena,1 so
remains a therapeutic
challenging problem.
Other major problem following
breast cancer treatment is
lymphedema. Whatever the treatment proposed, the
possibility
of curing lymphedema remains questionable. Over the last
13
years, our team has treated limb lymphedema by transplanting
lymph
nodes.5 Results obtained with this procedure proved
satisfactory
demonstrating disappearance or a noteworthy
improvement in postmastectomy
lymphedema, especially in
the early stages of the disease.6
*
Corresponding author.
E-mail address: [email protected] (M.
Riquet).
0960-9776/$ - see front matter 2008 Elsevier Ltd. All rights
reserved.
doi:10.1016/j.breast.2007.12.007
Available online at
www.sciencedirect.com
The Breast 17
(2008) 472e476
www.elsevier.com/locate/breast
-----------------------------------
---------------------------------------------
Minimally
invasive robotic surgery Saint Joseph's Hospital in
Atlanta.
http://www.physorg.com/news157040271.html
Super
micro-surgery offers new hope for breast cancer patients with
lymphedema
March 23rd, 2009 Breast cancer patients with lymphedema in their
upper arm experienced reduced fluid
in the swollen arm by up to 39
percent after undergoing a super-microsurgical technique known as
lymphaticovenular bypass, report researchers at The University of Texas
M. D. Anderson Cancer Center.
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Rates Worldwide.
The results from the prospective analysis,
presented today at the 88th Annual Meeting of the American
Association of Plastic Surgeons, suggest another option for breast
cancer patients considering ways to
manage lymphedema, a common and
debilitating condition following surgery and/or radiation therapy for
breast
cancer.
Lymphedema results when the lymph nodes are removed or blocked
due to treatment and lymph fluid
accumulates causing chronic
swelling in the upper arm. Currently, there is no cure or preventive measure
for lymphedema and it is difficult to manage; the use of
compression bandages, massage and other forms
of lymphatic therapy
are commonly recommended options for patients. According to the National Cancer
Institute, 25 to 30 percent of women who have breast cancer surgery
with lymph node removal and
radiation therapy develop
lymphedema.
Researchers evaluated 20 breast cancer patients with stage
II and III treatment-related lymphedema of the
upper arm who
underwent a lymphaticovenular bypass at M. D. Anderson from December 2005 to
September 2008. Due to lymphedema, the patients' affected arm was
an average of 34 percent larger
compared to the unaffected arm prior to the surgery. Of these 20 patients, 19 reported initial significant
clinical improvement following the procedure. In those patients with
postoperative volumetric analysis
measurements, total mean
reduction in the volume differential at one month was 29 percent, at three
months 33 percent, at six months 39 percent and 25 percent at one
year.
"Patients often resort to lymphatic therapy because other options
brought forward to reduce lymphedema
haven't proved effective,"
said lead author on the study David W. Chang, M.D., professor in the
Department
of Plastic Surgery and Director of the Plastic Surgery Clinic at M. D.
Anderson. "Surgical
techniques, in particular, have been limited
and therefore have been met with skepticism by surgeons,
making it
extremely important to determine which new techniques promise to bring real
benefits to
patients."
In lymphaticovenular bypass surgery,
surgeons use tiny microsurgical tools to make two to three small
incisions measuring an inch or less in the patient's arm. Lymphatic
fluid is then redirected to microscopic
vessels - approximately 0.3
- 0.8 millimeters in diameter - to promote drainage and alleviate lymphedema.
The procedure is minimally invasive and is generally completed in
less than four hours under general
anesthesia, allowing patients to
return home from the hospital within 24 hours. M. D. Anderson is among a
few institutions in the United States to offer this technically complex
surgery.
"Lymphedema is like a massive traffic jam with no exit," Chang
said. "This procedure does a lot to help
relieve lymphedema by
giving the fluid a way out. While it does not totally eliminate the condition,
there is
very little downside for the patient and we may see
significant improvement in its severity."
Chang notes that while most
effective when completed in earlier stages before the affected arm is fibrotic,
almost any breast cancer patient suffering from lymphedema stage I,
II or III is a candidate. Though breast
cancer was the focus of
this study, the surgery can also be performed on patients who have lymphedema
in the leg resulting from cancers involving pelvic
regions.
Cancer treatment is not the only cause of lymphedema. Primary
lymphedema can develop from
developmental causes at birth, the onset
of puberty or in adulthood. Secondary lymphedema can develop
as a
result of surgery, radiation, infection or trauma. In developing countries, a
form of lymphedema
caused by a parasite called Filariasis affects as
many as 200 million people worldwide. "As we begin to
refine our
technique and learn more about the efficacy of this surgery, we have the
potential to impact a
large number of people," Chang
said.
Long-term follow-up with patients who have received
lymphaticovenular bypass surgery is necessary to
determine if the
procedure continues to promote drainage after one year. Chang and his team of
surgeons
at M. D. Anderson believe that the fluid volume will keep
decreasing over time and suggest that the
surgery could possibly be
used as a preventive measure for lymphedema in the future. "Working toward a
definitive technique to cure this encumbering side effect of cancer
and improve a patient's quality of life as
a cancer survivor is a
priority for those of us in this field."
Source: University of Texas M.
D. Anderson Cancer Center (news :
web)
---------------------------------------
http://www.freep.com/article/20090323/FEATURES08/903230314
Node
transplant may help lymphedema's painful swelling
BY PATRICIA ANSTETT • FREE
PRESS MEDICAL WRITER • March 23, 2009
Two years after her mastectomy,
Susan Cochrane spent the day in her Tecumseh yard planting flowers.
She got a mild sunburn on her arms, though she had been careful to wear
sunscreen and gloves.
That night, her left arm looked a little
swollen and red. Within three days, the arm had thickened and
gotten painful.
"That started the whole cascade," said Cochrane,
54, describing a four-year struggle with lymphedema, a
painful
swollen limb condition that can be a complication of surgery for breast
cancer.
About 8% of breast cancer patients alone develop the problem,
which can occur, as Cochrane found,
several years after
surgery.
In January 2008, Cochrane developed her worst flare-up, a
painful case of cellulitis, an infection triggered
by her
lymphedema. It caused "a fiery redness of the skin that completely encircled my
forearm." A
massage therapist, "I was afraid my career was over,"
Cochrane said.
Fortunately for Cochrane, the plastic surgeons she works
with in Ann Arbor knew a colleague, Dr.
Rebecca Studinger at St.
John Providence Park Hospital, who had begun offering patients with
lymphedema an option called a lymph node transplant.
Studinger,
a plastic surgeon specializing in breast cancer reconstruction, is one of only
a handful of U.S.
doctors performing the technique. It was
developed over the last 20 years by a French physician, Dr.
Corinne
Becker, but only recently has been offered in the United States. Becker has
published a few
articles on small groups of patients, but the
technique is not well studied.
Studinger spent a week in France with
Becker learning the operation. "When I first heard about it, I said,
'I've
got to go learn it,' " she said.
While not a cure for everyone, one in
four of Becker's patients who had lymphedema for no more than
three
years had a 50% reduction in arm swelling after a transplant, she said.
Studinger has performed
about 20 of the procedures in the last
year. The transplant sometimes brings relief while a patient remains
hospitalized.
Cochrane's
arm felt better within hours of the transplant and now, a year later, "I pretty
much don't have
any limitations," she said.
(2 of
2)
She has developed a pamphlet for breast cancer patients she works
with at the Center for Reconstructive
Surgery in Ann Arbor, which
has incorporated massage therapy as part of the post-operative care patients
receive. Massage after breast cancer surgery can help prevent
lymphedema from occurring.
Another of Studinger's patients,
Kathryn Lay, 35, a mother of four from Farmington Hills, underwent a
lymph
node transplant at the same time Studinger performed her breast reconstruction
procedure. A
longtime bowler, Lay developed lymphedema 10 months
after she had a double mastectomy and removal
of 14 underarm lymph
nodes in January 2008. She had been diagnosed with breast cancer the year
before, at age 33.
"The swelling went down almost immediately"
after the transplant, Lay said. She's easing back into
bowling
every other week at Country Lanes in Farmington Hills.
Given all that has gone on in her life, Lay said she tries not to complain about her arm pain. She is grateful
to her husband, Ralph, "my deep-rooted solid oak
tree" who has "picked up the slack" during breast
cancer and
lymphedema treatment.
"I was diagnosed at 33, and I have a long life to
live," she said. "I want to focus on that."
Contact PATRICIA ANSTETT at
313-222-5021 or [email protected].
-----------------------
AAPS:
Surgery Effectively Reduces Lymphedema
By Crystal Phend, Staff Writer,
MedPage Today
Published: March 24, 2009
Reviewed by Zalman S. Agus, MD;
Emeritus Professor
University of Pennsylvania School of Medicine. Earn
CME/CE credit
for reading medical news
RANCHO MIRAGE, Calif.,
March 24 -- For breast cancer patients with lymphedema, surgery can
improve lymphatic drainage, researchers said, but whether the benefits
last long term remains to be seen.
Action Points
--------------------------------------------------------------------------------
Explain
to interested patients that lymphedema occurs when lymph nodes to the arm are
removed or
damaged, leading to a buildup of fluid and
swelling.
Note that this study was published as an abstract and
presented orally at a conference. These data and
conclusions should
be considered to be preliminary until published in a peer-reviewed
journal.
Lymphaticovenular bypass "microsurgery" on the upper arm reduced
arm volume by up to 39% in these
patients, David W. Chang, M.D., of
the University of Texas M.D. Anderson Cancer Center in Houston,
and
colleagues found.
The effects in a prospective, single center study
appeared durable through one year, although longer-term
follow-up
is needed, Dr. Chang reported here at the American Association of Plastic
Surgeons meeting.
Compression garments, massage, and other
conservative medical treatment remain the first line of defense
for
the 25% to 40% of breast cancer patients who develop lymphedema after
chemotherapy or radiation
therapy.
Although a wide
variety of palliative surgical techniques have been pioneered in Europe and
Asia, these
options have been controversial and limited, Dr. Chang
said.
At M.D. Anderson, he said, surgeons use lymphaticovenular
bypass. This minimally-invasive technique
involves two or three
1-inch or smaller incisions in the arm to insert microsurgical tools used to
redirect
lymphatic fluid to veins 0.3 to 0.8 mm in
diameter.
"For the most part, lymphedema in the U.S. has not been
treated surgically," Dr. Chang said. "The reason
it hasn't gained
popularity is that it's technically challenging and doesn't cure the
lymphedema."
Given this skepticism, his group monitored outcomes of
20 consecutive patients who had
lymphaticovenular bypass at their
institution from December 2005 through September 2008.
All of the
women had stage 2 or 3 lymphedema for a mean duration of 4.8 years before the
surgery. Their
breast cancer therapy had included axillary lymph
node dissection in all cases, with preoperative radiation
therapy
as well in 16 cases.
Surgery lasted an average of 3.3 hours and
patients were discharged within 24 hours afterward. The
procedure
included a mean of 3.5 lymphaticovenular bypasses per patient.
After
surgery, patients resumed nonsurgical strategies, including compression
garments.
Prospective follow-up over the next 18 months revealed
significant postoperative clinical improvement in
19 of the 20
women.
Three patients reported clinical lymphedema reduction without
a corresponding significant quantitative
volume
reduction.
The researchers found that, whereas before surgery, the
affected arm was an average of 34% larger than
the unaffected arm
on quantitative volumetric analysis, the mean volume reduction afterward
was:
29% at one month
33% at three months
39% at six
months
25% at 12 months
Dr. Chang cautioned against over-interpreting
the dip in the results at one year. Based on a series from
researchers in Asia and Europe, limb volume plateaus at some point
after surgery but yields durable results.
He also noted that arm
volume didn't capture other qualitative benefits that may be more important for
patient quality of life. "Patients feel the arm is softer and
lighter than before."
The researchers reported no postoperative
complications or lymphedema exacerbations.
"Lymphaticovenular bypass
using a 'super-microsurgical' approach appears to be effective in improving
the severity of lymphedema in patients with breast cancer," they
concluded.
Dr. Chang said his team believes that these results will
improve over time with continued fluid volume
reductions. However,
he acknowledged the small sample size and the need for long-term follow
up.
The researchers reported no conflicts of
interest.
Primary source: American Association of Plastic
Surgeons
Source reference:
Chang DW, et al "Lymphaticovenular bypass for
management of lymphedema in breast cancer patients: A
prospective
analysis" AAPS 2009.
Related Article(s):
ASCO Breast: Upper-Body
Breast Cancer Surgery Aftermath Often Lingers
SABCS: Air Travel Holds
Little Lymphedema Risk for Breast Cancer Survivors
http://www.medpagetoday.com/Surgery/PlasticSurgery/13404