Together awareness and innovation are reducing lymphedema risk and improving management for patients who develop the condition.
Emmie Cheses has been in the very fortunate position of being able to take preventive action against lymphedema. When Emmie, of Columbus, Ohio, was diagnosed with breast cancer with lymph node involvement at age 45, she was able to undergo prophylactic surgery with an innovative technique known as lymphovenous bypass to significantly reduce the risk of lymphedema.
The procedure is one of two current innovations in lymphedema treatment—the other being vascularized lymph node transfer. Both approaches stand to revolutionize outlooks for both patients at risk of the condition and those looking for effective treatment.
“Lymphedema is an imbalance of production of lymphatic fluid and the clearing of that fluid,” explains Roman Skoracki, MD, professor of plastic surgery and division chief of reconstructive oncological plastic surgery at The Ohio State University Comprehensive Cancer Center–Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC–James). “In other words, lymphedema makes it so the lymphatic system cannot clear lymphatic fluid at the same rate at which it is produced.”
The lymphatic system is a major part of the body’s immune system—a network of organs, nodes, ducts, and vessels that make and move lymphatic fluid from tissues to the bloodstream. Lymph nodes are found, among other areas, under the arm (axillary), in the neck, and in the groin.
As a result of this imbalance of fluid production and clearing, the fluid—which carries blood cells (mostly blood cells called lymphocytes)—accumulates in the affected area of the body and causes that area to swell. This swelling, or lymphedema, usually occurs in the extremities (arms and legs).
“I liken the lymphatic system to a French drain for a home,” says Dr. Skoracki. These drains, placed outside of houses, are trenches filled with gravel or rock that contain a perforated pipe to redirect surface and groundwater away from an area. “The lymphatic system,” he explains, “is composed of leaky vessels that allow fluid and large protein molecules to come in and also has a pump mechanism (muscles and valves) to move fluid through.” When the lymphatic system is functioning properly, it pushes fluid to the lymph nodes to filter and recycle in the bloodstream.
When this process is interrupted due to lymph node damage or removal, however, the fluid doesn’t get pumped through and instead accumulates to cause the swelling associated with lymphedema. Damage, says Dr. Skoracki, in the industrialized world is often the result of interventions during cancer treatment but can also be caused by other health issues, such as infection and inherited conditions.
“The majority of lymphedema cases are due to disruption of the lymph system during cancer treatment,” he explains. Specifically, lymph nodes are at risk when cancer has spread to them, and they need to be removed—such as in breast cancer that spreads to the axillary nodes. Radiation therapy around the lymph nodes can also damage them, as can tumors that have a direct impact on the nodes.
A Patient Takes Charge
Even though lymphedema management and care is a growing therapeutic area, Emmie decided she wanted to do everything possible to prevent the side effect from developing in the first place. As an active mother, she felt she could not accept the risk of any loss of function.
“I was concerned that lymphedema would change my life,” Emmie says. Not only do her responsibilities as a mom demand the mobility and use of her arms, she’s also a tennis player and loves outdoor pursuits.
Emmie quickly learned that she had considerable risk of lymphedema with the diagnosis of breast cancer with lymph node involvement and its prescribed treatment. In addition to surgery to remove the cancer, she would undergo axillary node dissection (removal of these nodes) with chemotherapy and radiation.
“I did a lot of reading,” she says, “and I learned that with my treatment plan, my risk of lymphedema was higher than with fewer modalities.” Armed with this information, she planned prophylactic lymphovenous bypass surgery with Dr. Skoracki.
Emmie was able to combine the lymphovenous bypass procedure with the breast cancer surgery. This greatly minimized the impact of the additional intervention, as Dr. Skoracki used the same incision to perform the bypass procedure and to remove the cancerous axillary nodes.
How Innovations In Lymphedema Treatment Work
The surgery that Emmie had—lymphovenous bypass—is a relatively new treatment that has been used for about 10 to 15 years, according to Dr. Skoracki. He explains that it involves creating a shunt, or detour, for the lymphatic fluid when its usual course is blocked—another vessel in which the fluid can travel. He likens it to building an on-ramp to link traffic from a congested road to an open road. “The bypass creates a connection to carry away excess fluid,” he says. During the procedure, he creates two to seven bypasses.
Lymphovenous bypass is considered minimally invasive because the lymph vessels are located right under the skin. Dr. Skoracki adds that he sees results quickly, and patients can generally go home after spending one night in the hospital for antibiotics.
The other innovative lymphedema treatment, vascularized lymph node transfer, is the newer of the two procedures. It was pioneered in Taiwan and Europe about eight years ago, says Dr. Skoracki. In vascularized lymph node transfer, the surgeon takes a group of healthy lymph nodes—or a “cluster,” as he explains—from a donor site and places them in the area with lymph node damage.
“The transferred lymph nodes,” says Dr. Skoracki, “sprout channels to reconnect to surrounding lymphatic channels. So, once transplanted, these nodes establish themselves and become part of the lymphatic system in their new location.
Results with lymph node transfer are not as quick as with the bypass procedure. The nodes have to make their own connections, which takes about three months. Transfer is also the more invasive of the two, as it requires two incisions: the donor and transfer sites. Dr. Skoracki says that patients stay in the hospital for a few days after surgery to make sure the transfer worked.
With these two options in lymphedema procedures, doctors are able to choose which approach is best for each patient. According to Dr. Skoracki, the outcomes with lymph node bypass and transfer are similar, but because bypass is less invasive it’s his first-line preference for eligible patients.
“The bypass is generally my first choice,” he explains. “I reserve the lymph node transfer for those patients who are not candidates for the bypass or received insufficient relief from the bypass procedure.” In general, patients for whom bypass is not appropriate have had lymphedema for a while and have developed so much scarring that the superficial lymphatic channels (the ones accessed just under the skin) are no longer usable, making bypass ineffective.
A Bright Future
Almost two years after breast cancer treatment and lymphovenous bypass, Emmie’s outcome is looking positive. “As of now I’m doing well,” she says. She is, however, still vigilant in her lymphedema prevention, ever conscious of the fact that treatment reduced the risk of lymphedema but didn’t completely eliminate it.
“I’m very careful with my right [affected] arm,” Emmie says, explaining that she basically takes the same precautions she would if she had lymphedema. This includes no blood pressure cuffs or needle sticks on her right arm, and she wears a compression sleeve when she flies. Emmie says that she will also do the prescribed stretches and physical therapy indefinitely to keep risk at bay.
What These Innovations Mean On A Larger Scale
Emmie was fortunate that she had, in Dr. Skoracki, convenient access to a surgeon who is performing both lymphovenous bypass and vascularized lymph node transfer, but not all patients have the same opportunity. There are currently few surgeons performing either procedure in the United States, and each requires a specialized microsurgery facility.
Dr. Skoracki is hopeful, however, that by contacting facilities that are known for performing the procedures, such as The OSUCCC— James (cancer.osu.edu), patients can find accessible centers and physicians who are doing the techniques. He also says that the innovations bring attention to lymphedema treatment overall: “It’s an exciting time. There’s so much interest in lymphedema on so many levels, which is good news for advances in awareness, therapies, and surgery.”
Lymphedema and Gynecologic Cancers
With advances in the treatment of gynecologic cancers (cervical, uterine, ovarian, and vulvar) and subsequent improvements in survival, the important issues of survivorship and quality of life have been gaining much needed attention among healthcare providers and oncologists. While treatments may be effective in eradicating cancer, the long-term side effects associated with these interventions—particularly those related to surgery and radiation—may result in chronic conditions that have a significant impact on a woman’s ability to enjoy her day-to-day life.
Lymphedema is one of these chronic conditions that can present a problem if not managed correctly. A condition of acute or chronic swelling associated with a disruption of the lymphatic system, lymphedema can occur in any part of the body but most frequently affects the upper or lower limbs. Extracellular fluid composed of water, protein, fats, bacteria, and cellular waste products, lymph is normally channeled into the lymphatic vessels, transported to lymph nodes, and eventually returned to the bloodstream. But a dysfunctional lymphatic system can lead to persistent swelling; a feeling of fullness, heaviness, and discomfort in the affected limb; and tightness of clothing or shoes.
Lymphedema also predisposes women to cellulitis, lymphangitis, and a compromised immune system. Both surgery and radiation—common treatments among women with gynecologic cancers—are risk factors for developing lymphedema. Lymph nodes are often surgically removed to evaluate for the presence or spread of cancer or because they are obviously involved with cancer. Radiation treatment can also interrupt lymphatic flow.The onset of lymphedema is variable and can occur within weeks of surgery or treatment or may occur years later. Once present, lymphedema requires lifelong attention; if left untreated, it can become an irreversible condition.The first step in the treatment of lymphedema is recognition and diagnosis.
Although there has been increasing awareness of the need to identify women with lymphedema, particularly those with breast cancer who have undergone the removal of axillary lymph nodes, the issue has been considerably under appreciated and underreported in cases of gynecologic cancers. Incidence rates ranging from 3 to 64 percent have been reported, depending on the type of cancer and the surgery or treatment utilized.Treatment involves several components, such as manual lymphatic drainage, compression wrapping, exercises, and education about skin care and integrity.
Manual lymphatic drainage (MLD) is similar to massage but uses lighter pressure to move lymph fluid from a poorly functioning lymphatic pathway to an adjacent functioning one; this is often performed by a licensed lymphedema specialist. During the initial phase of treatment, the therapist performs MLD daily; following this therapy, the patient is taught to perform MLD herself, and she periodically returns to a therapist for maintenance. Compression wrapping or hosiery is specially fitted to help prevent lymph reaccumulation, and it is particularly important during air travel. Compression garments are fitted after daily MLD has achieved its desired effect. Elastic taping may also be used to affect lymphatic flow. Exercise enhances lymphatic flow, mobility, and protein absorption. Maintaining skin integrity is also vital to long-term lymphedema management.
Success in managing lymphedema comes from early detection, prompt intervention, and knowledge of the risk factors that predispose a patient to this condition. Although lymphedema has historically received minimal attention, it is gaining recognition because of its profound impact on a woman’s self-image and quality of life. Medicare, for example, now recognizes and covers compression garments used in the treatment of lymphedema.
Additionally, the Gynecologic Oncology Group—a National Cancer Institute–funded cooperative research group committed to improving cancer care for women with gynecologic malignancies—continues to participate in research aimed at reducing lower-extremity lymphedema by studying less radical forms of surgery, such as sentinel lymph node biopsy for vulvar and cervical cancers, and evaluating the effectiveness of different treatment strategies for lymphedema.Women who have survived the perils of a cancer diagnosis should be able to enjoy the hard-fought life they are now living, and it is only through continued thoughtful and effective research that we healthcare providers will be able to fully define the scope of lymphedema and evaluate interventions directed at its prevention and treatment. If you are facing surgery or other treatment that may affect your lymphatic system, speak with your healthcare provider about lymphedema education and prevention.
Lymphedema and Exercise
Studies are increasingly indicating that exercise can help combat many of side effects of treatment. During chemotherapy, exercise may increase fitness and energy levels, improve mood, and help patients better tolerate cancer treatments. After treatment is concluded, exercise can increase strength and aerobic capacity, improve joint flexibility, elevate mood, and help patients resume regular activities and work demands. In addition, exercise has been shown to decrease the risk of onset or recurrence of many types of cancer. It is essential that cancer survivors communicate with their healthcare team and engage in exercise that is appropriate for their unique needs and stage of treatment or recovery.
Recent studies have demonstrated that regular exercise, including strength training, may decrease the risk of lymphedema or diminish symptoms of the condition if it is already present.
We hope that by providing information about how to perform exercises safely and use good technique to improve flexibility, strength, and function, we can help survivors who are experiencing lymphedema enjoy the many physical and psychological benefits of exercise.
The lymphatic system relies on the movement of muscles to circulate the lymph fluid throughout the body. You can think of the lymphatic system as a road system. When one or more roads are blocked due to lymph node removal, the system does not flow smoothly. The “traffic congestion” can cause swelling known as lymphedema.Even if you have only had a few lymph nodes removed, you should still understand the lymphedema precautions. Lymphedema can occur right after surgery or years later.
Decreasing the Risk of Lymphedema One of the most important things you can do to decrease your risk of lymphedema is to maintain a healthy weight. It is also important to learn proper nutrition and the appropriate exercise routines for your specific needs.The following are additional steps one should take to decrease the chance of developing lymphedema:
- Try to avoid extreme temperatures, and avoid sunburns.
- Avoid restricting your lymph circulation. Examples of this would be taking blood samples from or blood pressure on the affected arm, carrying a heavy bag on your arm, or wearing tight clothing and jewelry.
- Check regularly for infection, and call your doctor immediately if an infection occurs. Insect bites, scratches, skin punctures, and bites can cause infections.
- Wash the affected area frequently and apply moisturizer to avoid cracks in the skin.
The National Lymphedema Network’s website (lymphnet.org) is a terrific resource. You should also speak with your therapist for a complete list of lymphedema precautions.
Lymphedema Therapist Learn the first signs of lymphedema; it is easier to manage if treated early. Your lymphedema specialist will teach you complex decongestive therapy, consisting of skin care, manual lymph drainage, and exercise. If you meet with your lymphedema specialist at the first signs of swelling, pitting, redness, or heaviness, lymphedema can be kept under control. The specialist will also make sure that your exercise plan is compatible with the treatment and will clear you to exercise if your lymphedema is under control.Additionally, if baseline measurements have not already been taken at the hospital, it is recommended that you obtain a baseline girth measurement by a lymphedema specialist. The limbs that are at risk for lymphedema should be periodically measured to make sure they have not changed in size. Symptoms can be managed more easily if dealt with as soon as they appear.A compression garment or sleeve, which supports the muscles and helps bring the lymphatic fluid to the heart, can be worn while exercising and at other times. These garments need to be professionally fitted and monitored by a lymphedema specialist.
Exercise and Lymphedema Your body will work better if you are engaged in regular physical activity. Moreover, exercise is very helpful for lymphedema control, but it must be done in a safe manner if lymph nodes have been removed or radiated. If you have lymphedema, you should begin to exercise under professional guidance after receiving medical clearance. It is important to learn the right exercises for your particular situation and how to perform them properly and with good form. Exercise needs to progress slowly, using a properly fitted garment. Our goal is to promote physical activity without incurring pain or injury, which can make lymphedema worse.All the exercises should incorporate abdominal breathing and relaxation breathing. These breathing techniques are beneficial because they do the following:
- Stimulate lymph flow and lymphatic drainage
- Act as a lymphatic system pump, moving the sluggish lymph fluid
- Enable oxygen to get to the tissues
- Reduce stress, a common cancer side effect
It is also helpful to incorporate Pilates into your exercise routine because of the deep breathing used with each movement. When you begin Pilates exercises, perform just a few repetitions and use no weights or use the lightest machine tension. After you are able to exercise for several sessions without flare-ups, you can use resistance bands, light weights, and modified body-weight exercises.You can develop a good fitness level without triggering lymphedema. Swimming is a very good exercise for those with lymphedema. The water creates compression. Because repetitive motions are risky, try to vary your swimming strokes. The water should not be hot, and the pool area should be clean to help you to avoid infection. When you leave the water, follow proper skin care precautions. Moisturize to prevent dry skin, which can lead to cracks in the skin and infection.Yoga poses can cause flare-ups. Do not perform the following poses: downward-facing dog, upward-facing dog, plank, and side plank. Avoid hot yoga.
Exercise helps the lymphatic fluid move throughout the body. Muscles pump and push the lymph fluid and can help move the lymph away from the affected area. Strength training may help pump the lymph fluid away from the affected limb, but it does not necessarily prevent lymphedema. Slow progression of exercise will allow you to monitor fullness or aching, which can indicate stress to the lymphatic system. You should stop if you feel tired or if your limb aches or feels heavy.
When you consider, as Dr. Skoracki notes, that lymphedema has had (and still has, to some extent) a reputation for being incurable, effective treatment in the form of lymphovenous bypass and vascularized lymph node transfer is incredibly impressive progress. And with improvements in management with drainage, physical therapy, and compression, this is most certainly a very promising time for anyone affected by or at risk of lymphedema.
If you have already undergone treatment, discuss evaluation and treatment for lymphedema. Help is available.To learn more about lymphedema, contact or visit:American Cancer Society (800) ACS-2345 [800-227-2345] www.cancer.org National Lymphedema Network (800) 541-3259 www.lymphnet.org