Lymphedema is swelling of the arm, hand, or chest wall caused by a build-up of lymph fluid in those tissues after breast cancer surgery. Radiation therapy and chemotherapy can add to the risk of lymphedema.
An uncommon type of surgery, called lymphaticovenular bypass, sometimes is done to treat lymphedema. The very small study reviewed here found that lymphaticovenular bypass can ease lymphedema in some women, but it's unclear how long the benefits last. Besides the uncertainty about how long the results last, lymphaticonvenular bypass is controversial because it may make lymphedema worse if not done by a specially trained, very experienced surgeon.
As blood flows through the body's tissues, a small amount of clear fluid -- lymph fluid -- naturally forms and bathes the tissues. Lymph fluid moves through tissues via a network of channels called lymphatic vessels. Normal muscle action helps keep lymph fluid levels balanced by moving the fluid through the lymphatic vessels and back into the bloodstream so fluid doesn't build up and cause swelling. Lymph nodes, such as the ones in your armpit, act like relay stations in the lymphatic vessel network.
During surgery to remove breast cancer, some of the lymphatic vessels in the chest wall and armpit area may have to be cut. (Lymphatic vessels are more likely to be cut if lymph nodes are removed.) If some lymph vessels are cut, there may be fewer channels to drain the lymph fluid from nearby tissues. Lymph fluid then can build up in the arm, hand, or chest wall area.
About 40% of women develop some degree of lymphedema after breast cancer surgery. Lymphedema can improve slowly or even go away over time. Still, lymphedema is more likely to be a problem for women who've had more extensive surgery and had lymph nodes removed. A number of non-surgical techniques can help reduce the risk of lymphedema, including compression garments and massage.
In this very small study, researchers looked at the results of 20 women who chose to have lymphaticovenular bypass surgery to treat lymphedema that had lasted for an average of about 5 years after breast cancer surgery. The surgery was done at the M.D. Anderson Cancer Center in Houston. During lymphaticovenular bypass, which is considered microsurgery, three or four lymphatic vessels in the arm are connected directly to veins (blood vessels that move blood to the heart). The goal of this rerouting is to increase the flow of lymphatic fluid out of the arm and ease the lymphedema. This surgical treatment for lymphedema is rare, but is more common in Asia and Europe than it is in the United States.
Researchers assessed lymphedema improvement by measuring the size (volume) of the affected arm before and after lymphaticovenular bypass. They also asked the women how the arm felt -- whether it felt lighter or softer, for example.
After lymphaticovenular bypass, the women's arms were smaller, but by the end of the first year after surgery, some of the benefits seemed to be lost. Affected arm size decreased:
Many of the women reported that their arms felt lighter and softer after the microsurgery and none of the women had significant complications or had the lymphedema get worse.
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.
If you have severe lymphedema and non-surgical treatments haven't helped, you may be considering lymphaticovenular bypass surgery. Make sure that the surgeon doing the surgery (usually a plastic surgeon) has a lot of experience and has had good success with the procedure.
You can learn more about lymphedema and the non-surgical steps you can take to avoid, minimize, and manage it in the Breastcancer.org Arm Lymphedema section.
RANCHO MIRAGE, Calif., March 24 (MedPage Today) -- For breast cancer patients with lymphedema, surgery can improve lymphatic drainage, researchers said, but whether the benefits last long term remains to be seen.
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:
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.
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