Less Lymphedema, Thanks to New Procedure

By Joseph H. Dayan, MD and Babak J. Mehrara, MD,

Tuesday, October 13, 2015

New Hope for Patients

Lymphedema is among the most dreaded complications following cancer treatment, resulting in permanent and progressive limb swelling, chronic infections, and limitations in daily activities. Unfortunately, it is fairly common. In fact, women with breast cancer who are undergoing axillary lymph node dissection have a 20 to 50 percent risk of developing lymphedema. Traditionally, the mainstay of treatment has been lifelong compression, and little progress has been made over the years to expand the range of available options — until now.  

At Memorial Sloan Kettering Cancer Center (MSK), plastic and reconstructive surgeons Joseph Dayan and Babak Mehrara are collaborating to provide patients with new options to reduce the effects of lymphedema. Through their groundbreaking work, vascularized lymph node transplant is currently being integrated with the latest developments in lymphatic imaging and targeted therapies to offer patients an improved quality of life.

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 Vascularized Lymph Node Transplant

Vascularized lymph node transplant (VLNT) is a groundbreaking microsurgical procedure that transfers expendable lymph nodes from one part of a patient’s body (typically the neck, abdomen, chest, or groin) to the affected limb — effectively replacing the lymph nodes removed during oncologic surgery. Growth factors in the transplanted lymph nodes stimulate lymphangiogenesis, restoring lymphatic circulation and reducing swelling in the limb.

Dr. Dayan has recently developed a new technique called reverse lymphatic mapping that allows the surgeon to selectively choose expendable lymph nodes from the donor site, thus avoiding potential donor site complications. This breakthrough has increased the safety of VLNT and is now provided to all surgical patients at MSK. The procedure is typically three to four hours in length and requires an overnight hospital stay for patients with upper extremity lymphedema, or a three-day stay for patients with lower limb lymphedema. While VLNT is not a cure, the majority of patients see a marked improvement. 

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 Advances in Imaging

We are now utilizing the latest technologies in lymphatic imaging — including indocyanine green lymphangiography (IGL) — in conjunction with VLNT to improve patient outcomes. This technique allows us to acquire high-resolution images of the lymphatic system in the extremity, thereby improving diagnosis and post-op evaluation. Enhanced visualization is critical, enabling us to accurately stage patients. The use of IGL, as well as several other modalities, allows us to evaluate multiple aspects of a patient’s disease stage with much greater sophistication than traditional staging, which focused solely on a patient’s history and physical exam.

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 Candidates for VLNT

Candidates for VLNT are patients in good health, with a body mass index of less than 30, who have developed upper or lower extremity lymphedema following cancer treatment. Patients with lower extremity lymphedema who also have significant venous insufficiency are not appropriate candidates. At MSK, the majority of patients treated with VLNT have lymphedema related to breast cancer, or lower limb lymphedema following treatment for gynecologic tumors or melanoma.

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Developing Targeted Therapies

In the area of scientific research, Dr. Mehrara’s lab — which is funded by the National Institutes of Health — is devoted to fostering a deeper knowledge of the pathological mechanisms of lymphedema. The team’s efforts to date have greatly increased our understanding of the disease and allowed us to identify targeted approaches for treatment. As an example, the cellular mechanisms that regulate the key pathological changes of lymphedema (e.g., chronic inflammation, fibrosis, and lymphatic dysfunction) are becoming much better understood. These treatments can be applied in a similar manner as they are for other chronic diseases (e.g., plaque psoriasis or rheumatoid arthritis) using well-tolerated immunotherapeutics. Current studies are under evaluation by the Institutional Review Boards and will begin accrual following regulatory filing.  

MSK remains dedicated to developing increasingly stronger options to treat patients with lymphedema.

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