Lymph Node Transplant Can Provide Relief from Cancer-Related Lymphedema

By Jim Stallard,

Monday, June 29, 2015

A woman is lying on her back in bed, with her upper arm being examined by a medical professional.
Summary

Lymphedema, an uncomfortable and painful swelling in the arms or legs, is common after treatment for certain cancers. Researchers at Memorial Sloan Kettering are pioneering a better way to bring relief to patients suffering from the condition by devising a safer method for transplanting lymph nodes from other parts of the body.

Highlights
  • Cancer surgery often requires removal of lymph nodes.
  • This can cause lymphedema, painful swelling in the arms or legs.
  • Transplanting lymph nodes from elsewhere in the body can provide relief.
  • A new technique makes it possible to do lymph node transplant safely.

A critical aspect of many cancer surgeries is the removal of nearby lymph nodes, which helps eliminate cancer cells that may have spread from the primary tumor. In some cases, however, removing these lymph nodes causes a debilitating side effect called lymphedema.

Patients with lymphedema suffer tremendously — more than people realize.
Joseph H. Dayan
Joseph H. Dayan Reconstructive surgeon

The lymphatic system is a network of tubes and filters that serves as the body’s waste-disposal system. Removing lymph nodes can create a blockage that prevents fluid waste from draining from the area. This condition involves swelling and stiffness in the arms or legs and causes discomfort, restricts mobility, and can lead to infections requiring hospitalization.

“Patients with lymphedema suffer tremendously — more than people realize,” says Memorial Sloan Kettering reconstructive surgeon Joseph Dayan. “They’ve survived cancer but find themselves stuck with a potentially permanent disability that may get worse over time. Many of these patients can’t wear their usual clothes and even find it difficult to go swimming or be in the sun because a burn can trigger swelling or infection.”

Relieving Discomfort

People with lymphedema can gain some relief through physical therapy or by wrapping their limbs in compression garments, but the condition gravely impairs day-to-day well-being and may never go away. 

A new approach to treating lymphedema involves transplanting lymph nodes from elsewhere in the body to replace those removed as part of treatment. Although this technique has been investigated for years, there is a known risk of lymphedema developing at the site from which the nodes are taken.

Dr. Dayan has helped pioneer a method for selecting lymph nodes for transplant that could minimize this risk.

Reverse lymphatic mapping enables surgeons to ascertain which lymph nodes are appropriate for removal.

“The key was to find some way to identify which lymph nodes primarily drain the trunk — the middle of the body — as opposed to those that mainly drain the arms and legs,” he explains. “Removing lymph nodes that drain the trunk does not generally cause lymphedema. However, no clear guidelines have existed on how to do this operation.”

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Mapping For Safe Removal

The new technique, called reverse lymphatic mapping, enables surgeons to ascertain which lymph nodes are appropriate for removal, reducing risk of lymphedema at the donor site.

“Assume we want to take lymph nodes from the groin and put them under the arm for a patient with breast cancer–related lymphedema,” Dr. Dayan says. “We inject one type of dye into the foot and a different type of dye into the lower abdomen. The first type of dye allows us to trace the location of lymph nodes draining the leg, so we know to avoid them. The second dye reveals the lymph nodes draining the lower abdomen, which can be removed without causing problems.”

Dr. Dayan says it is easy to tell apart the two dyes and the lymph nodes they have infiltrated to see which ones to avoid and which can be safely removed.

The mapping has dramatically increased the safety of transplants.
Joseph H. Dayan
Joseph H. Dayan

“The mapping has dramatically increased the safety of transplants because we can see the drainage pattern,” he says.

A recent study published in Plastic and Reconstructive Surgery by Dr. Dayan and colleagues bears this out. Thirty-five patients were transplanted with no lymphedema from the donor sites, whether the lymph nodes were taken from the groin or from the upper body.

In addition to lymph node transplant, there are other possible approaches to treating lymphedema. For example, MSK reconstructive surgeon Babak Mehrara is investigating drugs that could alleviate or reverse the condition.

“I don’t think we’re going to solve lymphedema by surgery alone,” Dr. Dayan says. “It’s going to take a lot of different minds and different perspectives.”

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Comments

Dr. Mehrara is my surgeon, and he is amazingly smart and in my opinion a great doctor who truly cares about his patients. I have faith that his research will help many people. God willing I will not need those meds but I'm confident that if I do need them, a very competent doctor did all the right research.

Is MSK doing this procedure?

Can this still be done several years after the lymph nodes were removed?

Thank you.

Thank you for reaching out. Yes, Memorial Sloan Kettering surgeons are doing lymph node transplantation. If you are interested in an appointment or finding out if you are a good candidate, you can call 212-639-8095.

1. Are there guidelines as to how severely you are swollen before considering the surgery?
2. Is the surgery generally paid for with most insurance companies?
3. Are there other side effects or risk?
Thanks!

Thank you for your comment. We sent your questions on to Dr. Dayan, who responds:

1. The degree of swelling alone does not determine whether or not you are a candidate for surgery. We perform a thorough workup of your limb that evaluates the fluid content versus the fat/scar overgrowth that occurs with longstanding lymphedema, which may impact what kind of surgery is most appropriate or how much of an improvement you may expect to see. We also perform studies on the function and anatomy of your lymphatic system. These tests give us a clearer picture of the state of your particular lymphedema. We have operated on patients with very early stage lymphedema (only 6 months out of surgery) as well as patients who have had lymphedema for many years with a lot of swelling.

2. Most insurance companies do cover surgery.

3. Thank you for asking about risks of surgery as knowing the risk of any procedure is important in making an informed decision. The most common risks are minor, such as a temporary fluid collection from the area we take lymph nodes from called a seroma, or infection which can occur from any surgery. There is a risk that the lymph node transfer will not improve lymphedema or even worsen it, although this is rare. There have been reports of causing lymphedema in the arm or leg by harvesting lymph nodes from the groin or neck, but these surgeries were not performed using the technique of reverse lymphatic mapping, which reduces this risk. In our series of over 75 cases over the past 5 years, we have not observed any lymphedema caused by harvesting lymph nodes using reverse lymphatic mapping. There are other sources of lymph nodes such as the omentum, which is a carpet of fat and lymphatic tissue inside the abdominal cavity which can be used and does not have a risk of lymphedema in the limbs, but has other potential risks seen with abdominal surgery such as hernia or bowel obstruction.

I have lymphedema in my lower legs and now I am on disability I lost my job last year in October and I barely make 1200$ a month to take care of my wife and myself. I am very interested in this procedure so I can get back to a normal life style and work and provide for my family. please feel free to contact me about finding out if I can have this procedure done. thank you

Mike, thank you for reaching out.

To find out more about whether this procedure is right for you, contact the office of Dr. Joseph Dayan at:

212-639-8095

Good morning,
I am a doctor with recent diagnosis of primary lymphoedema, my right leg, expecially the foot is affected, this situation is having bad impact on all of my life (job, family etc), and, would ask if, considering my situation is in an initial state, could I be a candidate for LN transplant?
Many thanks and kind regards

Ligeia, thank you for reaching out.

To find out more about whether this procedure is right for you, contact the office of Dr. Joseph Dayan at:

212-639-8095

This is such great news! Can i be a candidate please. Every time i ask about surgery/ln transplant dr's say not enough known about it. I was just diagnosed in feb 2015 with arm lymphedema and the whole wrappings and garments is making me so upset and unable to function completely.... Please advise

Mimi, thank you for your comment. To clarify, the lymph node transplantation offered by our doctors is for cancer-related lymphedema (as opposed to primary lymphedema). If your condition is cancer-related, you may be a good candidate and can contact the office of Dr. Joseph Dayan at:

212-639-8095

My Mom had a mastectomy 30 years ago. Her arm is terribly disfigured and huge she's only 4"10" so very heavy to carry around. Would like to know if there are any doc ties in Southern California that are doing this. We found one but he won't take insurance and the min surgery is $100.000.00. Please let us know. Ty

Dr. Ketan Patel at USC in Los Angeles, Ca. Is doing this surgery and they take insurance.

i have Lymphedema in both legs. I have had many abdominal surgeries in past years including an Esophagectomy in 02. My doctor wants to do a needle biopsy bilateral. I'm afraid it will just cause a flare up again. What good can come from this & should I allow it? He isn't a Lymphedema specialist by his admission.

Dear Mollie, if you are interested in learning more about the lymph node transplant at MSK, you can call 212-639-8095 ET during regular business hours. In general, our best recommendation for people suffering from lymphedema is to see a board-certififed physiatrist (a rehab doctor) practicing at an NCI-designated cancer center or another academic medical center. If you're interested in seeing a physiatrist at MSK, you can call 646-888-1900. Thanks so much for your question!

I have lymphedema in both legs, I have been hospitalized for cellulitis multiple times over the years. My condition developed after back surgery. I have tried so many things. Is something like this an option for me? Does insurance cover the procedure? Thank you in advance.

Dear Charlotte, thanks so much for your question. The procedure in question is for cancer-related lymphedema. If you look through the comments on the blog, there are a few other surgeons mentioned who might do similar procedures. Thanks so much for reaching out to us!

Where is this doc located? my mothers arm is so bad and right now she has an opened wound because of it we live in Erie Pennsylvania. She had breast cancer 5 years ago a year after that the took 16 lymph nods out under her arm. She has had the open wound for about 9 months

Dear Lisa, Dr. Dayan practices at Memorial Sloan Kettering in New York City. If you'd like to contact his office to see if your mom might be a good candidate, you can call 212-639-8095. Thanks so much for reaching out.

I was diagnosed with Lymphedema in both legs 10 years ago, not connected with cancer. Last year I was put on 30mg of Cymbalta for an unrelated pain problem. Two weeks later my Lymphedema was relieved 80-90% and I have had the best year since I've been diagnosed. The best part is the constant pain has been mostly relieved and I don't wear my compression stockings unless I'm standing or sitting for extended periods. Cymbalta has changed my life and I hope one day there will be some research so it can potentially help others!

I had a mastectomy and radiation last year and have recently developed lymphedema. I'm considering tram flap reconstruction later this year. Can this procedure be done before or after reconstruction? Thank you.

Diane, we sent your question to Dr. Dayan, who replied, "Lymph node transfer can usually be done in patients either before or after TRAM or DIEP flap reconstruction. An imaging test called an MRA is performed on all of my patients prior to surgery to evaluate the number, quality, and location of the lymph nodes to be transferred." Thank you for your comment.

Hi -- im so excited about this news. I have breast cancer related lymphedema in my left arm following the removal of 16 lymph nodes and radiation. What is the recovery time for the transplant surgery?

Thank you for your question. We reached out to Dr. Dayan, and he responds: The recovery time depends on where the lymph nodes are harvested from, but for upper extremity lymphedema, recovery typically takes about 2-3 weeks until you feel well. In the early post-operative period, you will need to be in the close care of a certified lymphedema therapist to minimize swelling, which will provide the best environment for new lymphatic vessels to grow and find their way to the transplanted lymph nodes. Most patients experience significant improvement in their lymphedema but still require continued compression. In some cases, patients require less compression than they did before surgery, and we have also have some patients who no longer require any compression on long-term follow-up.

All of the lymph nodes in my left armpit were removed at MSK in 1986 along with a lumpectomy. I developed lymphedema 18 years later in 2004, and it has become progressively worse. At 81 years of age, would I be a candidate, and is this procedure covered by Medicare?

Myrna, thank you for reaching out. We consulted with Dr. Dayan, who responds: "Lymphedema can be especially difficult as you age, particularly if you have arthritis, in terms of putting on compression garments. If you are in good health, your age alone would not necessarily prevent you from having an operation, although safety is absolutely a priority. For us to feel comfortable to proceed with surgery, you would not only have to have a very thorough pre-operative medical evaluation, but the lymphedema must be such a burden on you that it makes sense to offer you a lymph node transfer when weighing the risks of surgery. Medical problems such as heart failure, stroke, emphysema/COPD would put you at high risk, and this surgery would not be appropriate. This question would be best discussed with your surgeon who could fully evaluate not only your lymphedema but the big picture in terms of health risk as well. I cannot comment on Medicare coverage but our financial services department may be able to help."

For the Medicare question, you might contact one of our Insurance Specialists by calling 646-497-9176 to discuss your situation.

I live in Denmark. I wonder if you have any contacts here for that kind of surgery? It sounds very interesting.

Birgitte, thank you for reaching out. We passed your question on to Dr. Dayan, who responds: "I personally do not know lymph node transfer surgeons in Denmark, but I would recommend reaching out to the plastic surgery department at the major hospitals in your area and ask them. The closest contact I know personally who performs lymph node transfer would be in Germany, Dr. Holger Engel."

I had a VLNT done last August and I am seeing positive changes. I have hope! If you have secondary LE, please consider talking to a specialist in this field!

I am currently experiencing secondary lymph edema in my right leg, caused by a full groin direction ten years ago…I will contact your office but am more curious as to whether you know of any Boston based doctors following these procedures/ surgeries/ and meds? Thank you. This could be a whole new life for many of us…

My husband had all right leg lymph nodes removed 5 years ago. Severe lymphedema has developed. Survivor of stage 4 Melanoma (5 yrs), his groin area very inflamed, can he qualify for this procedure? He is afraid the area where new lymph nodes are taken might also develop lymphedema.

We are sorry to hear about your husband's condition. Because everyone's circumstances are unique, it's best that he consult with a reconstructive surgeon who is experienced in doing this procedure to see if it would be helpful for him. If he would like to make an appointment with one of our surgeons, please call our Physician Referral Service at 800-225-2225. Thank you for reaching out to us.

I have secondary lymphedema in my left arm after having a sarcoma tumor removed in my left armpit area, along with most of my lymph nodes. The remaining lymph nodes then proceeded to stop working after I had radiation.
I've been hospitalized for cellulitis I believe 6-7 times now! Each time it seems like I am in the hospital longer than the previous time. I live in Indiana, near Fort Wayne. Is there anyone in my state that offers this procedure? I'd love to have this surgery! The side effects you've mentioned are all ones that I've experienced, and it is really annoying and difficult. I almost wasn't able to be in my best friend's wedding due to my left arm being so large; the tuxedo jacket wouldn't fit on my arm.
Thanks in advance for any information you have for me!

Nick, thank you for reaching out. Unfortunately, Memorial Sloan Kettering cannot make recommendations about surgeons because this procedure is still very new for most surgeons and few, if any, use the reverse lymphatic mapping technique described in this story. To set up an appointment or to find out if you are good candidate for lymph node transplantation due to cancer-related lymphedema, we suggest you contact the office of Joseph Dayan at:

212-639-8095

https://www.mskcc.org/cancer-care/doctors/joseph-dayan

I am so excited to learn of this. My brother has been 5 yrs cancer free now. However his left arm is so huge and painful. He frequently gets cellulitis and is hospitalized. Is there anyone in Indianapolis, In that performs the procedure?

Becki, thank you for your question. Unfortunately, Memorial Sloan Kettering cannot make recommendations about surgeons in certain regions because this procedure is still very new for most surgeons. To set up an appointment or to find out if you are good candidate for lymph node transplantation due to cancer-related lymphedema, we suggest you contact the office of Joseph Dayan at:

212-639-8095

https://www.mskcc.org/cancer-care/doctors/joseph-dayan

My 25 year old daughter had 18 lymph nodes removed from her right groin after melanoma surgery on her right buttock. The SNL node was positive for micromatisis. Her leg has been swollen since about the 4th week after surgery. She is on her 41st week of interferon treatment out of 52 weeks. When would she be able to do this surgery? Are there qualified surgeons doing this in the chicago or Denver area also? She's so young to have to deal with this the rest of her life!

Luanne, thank you for reaching out. Unfortunately, Memorial Sloan Kettering cannot make recommendations about surgeons because this procedure is still very new for most surgeons. To set up an appointment or to find out if you are good candidate for lymph node transplantation due to cancer-related lymphedema, we suggest you contact the office of Joseph Dayan at:

212-639-8095

https://www.mskcc.org/cancer-care/doctors/joseph-dayan

I had both breasts removed. The Cancer was in the left side.This was done in 2008. I also had the radiation.The swelling didn't start right away. I just want to know if I can talk to your doctors about this Lymphedema.The swelling is on my left side.My fingers,my entire arm is swollen. Its very heavy. I live in Indianapolis,Indiana. I would appreciate any information. Thank you.

Sheila, thank you for your question. If you are interested in learning more about the lymph node transplantation at MSK, you can call the office of Joseph Dayan at 212-639-8095 ET during regular business hours. In general, our best recommendation for people suffering from lymphedema is to see a board-certififed physiatrist (a rehab doctor) practicing at an NCI-designated cancer center or another academic medical center. If you're interested in seeing a physiatrist at MSK, you can call 646-888-1900.

Hi , I was treated for breast cancer and had a complete axillary clearance from under my right arm resulting in lymphedema of the arm.
I had a diep flap reconstruction. My question is
Can the diep flap surgery cause leg lymphedema ? My left leg aches , measures bigger than the right and I have groin pain. It feels as if the leg is struggling to drain into the groin.

kind regards,
Vidula

Dear Vidula, we are sorry to hear about your symptoms. It's best to have a physician examine your leg and evaluate your symptoms to better understand the possible cause and suggest appropriate treatment options. Thank you for reaching out to us.

Hi,

Is this surgery suitable for primary as well as secondary lymphoedema? Is anyone performing the surgery in the UK?

Thanks

Ben

Ben, thank you for reaching out. Unfortunately, Memorial Sloan Kettering cannot make recommendations about surgeons in other countries because this procedure is still very new for most surgeons.

If you are interested in coming to Memorial Sloan­Kettering or having records reviewed, you can contact our International Center by calling 1­212­639­4900 or going to http://www.mskcc.org/cancer­care/international­patients. The email address is international@mskcc.org.

I am a 56 year old male located in Australia who 5 years ago had stage 3 melanoma in my right groin.
I had 16 lymph nodes removed & have developed serious lymphedema in my right leg requiring full compression at all times.
Are there any surgeons doing mapping or similar work in Australia or would i be required to travel to the US for this surgery? Also what costs/medical insurance would be applicable.

Wayne thank you for your question. Unfortunately, Memorial Sloan Kettering cannot make recommendations about surgeons in other countries because this procedure is still very new for most surgeons.

If you are interested in coming to Memorial Sloan­Kettering or having records reviewed, you can contact our International Center by calling 1­212­639­4900 or going to http://www.mskcc.org/cancer­care/international­patients. The email address is international@mskcc.org. They will be able to help answer questions about traveling to the US, costs and medical insurance.

My lumpectomy was in Feb 2015 and developed lymphedema in March. It is particularly bothersome in the wrist and hand as well as the arm. I understand it is difficult to get the fluid out of the hand. Has the surgery been successful involving the hand? Thank you

Lymph edema for 20 years following a mastectomy and tram flap surgery for reconstruction. Would there be a problem finding viable lymph nodes to harvest?

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