|
|
Alternatives to Standard
Treatment of Lymphedema--Other
Un-Proven Modalities
| Other
Unproven Modalities |
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.
Pat
top of page
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:
http://www.aaps1921.org/abstracts/2009/12.cgi
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:
top of page
 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
http://www.lymphedema.com/surgery.htm
Acknowledgment
Peninsula Medical, Dr. Reid's Corner
http://www.lymphedema.com/
top of page
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).
top of page
Page Last Modified
09/29/2015
All medical information
presented on this page is the opinion of our Editorial Board and
Experts. See our "About
us"
and
"Resources"
pages.
|
