Ask the Doctor: Lymphedema and Lymph Node Transfer

<alt="3 pink roses"/>This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your question.

QUESTION: I’ve had breast cancer and developed lymphedema after my mastectomy.  I recently heard about Lymph Node Transfer surgery.  Does it work?  I’m scheduled for a DIEP breast reconstruction, can it be done at the same time?

ANSWER: Lymphedema is a very difficult problem that results when a patient has had breast cancer and has to undergo surgical removal of the lymph nodes under the arm as part of their surgical treatment for breast cancer. There are other causes of lymphedema but our specific interest has been in patients who have had breast cancer.

Lymphedema can be a very debilitating process; it remains a terrible problem worldwide, for all types of reasons. There is still much to be learned about why some people develop lymphedema and others do not. It appears that lymphedema is directly related to several factors in our breast cancer patients. It is directly related to having the lymph nodes removed from under the arm and seems to develop from the scarring that occurs under the arm following mastectomy and / or axillary dissection.

Undergoing radiation of the arm or axilla increases this risk. However, there are many people who undergo removal of the lymph nodes and radiation that do not develop lymphedema. There are also people who have mastectomy, have lymph nodes removed followed by radiation, and don’t develop lymphedema until many years after their surgery. That is the main reason that patients are warned to pay particular attention to their arm if they have had removal of any lymph nodes.

It is also possible that someone could get lymphedema even after simply having a sentinel node removed. A sentinel node procedure (lymphadenectomy) is a way to examine the lymph node without having to remove more than one or two. The whole idea of examining only the sentinel node is to lower the risk for lymphedema, but even with the sentinel node procedure, there is still a chance of developing lymphedema. Our practice became interested in options to help breast cancer patients with lymphedema as we see many who are suffering from the symptoms of this process while undergoing breast reconstruction.

Our practice specializes in microsurgical free flap breast reconstruction utilizing skin, underlying tissue, and microscopic blood vessels that transport life-giving blood to the reconstructed breast. This procedure is commonly referred to as the DIEP if using the abdomen or a GAP if using the buttock tissue. The muscles of the abdominal wall are left intact as it is the removal of the muscles of the abdominal wall that can lead to problems in the donor area, like hernias and bulging, as well as a more involved extended recovery. The lower tummy wall is the most common area that we transfer and it’s also an area where lymph nodes are present. Therefore, over the first decade this surgery was being done, we would encounter lymph nodes in the area of the blood vessels, as well as fatty tissue.

It became obvious that we could transfer lymph nodes on the blood vessels as we refine our technique for microsurgery. Due to the lack of effective treatment for lymphedema, for years surgeons doing perforator flaps have taken on this challenge and are trying to come up with ideas and techniques to treat it. We began doing an extensive amount of research, spanning the globe, looking for information on procedures that may help these patients. In 2005, we formed a group known as the Group for the Advancement of Breast Reconstruction, known as GABRs, and we included members throughout the world who had had a unique experience with our type of breast reconstruction.

We encountered one individual who had 15-years of experience with what is now known as “vascularized lymph node transfer” for the treatment of lymphedema. Initially, Dr. Robert Allen had attempted lymph node transfer during breast reconstruction and the biggest concern was how to transfer lymph nodes from one area of the body to treat lymphedema but not to create lymphedema in the donor area. In 2006, the GABRs met in Beijing, China and invited Corrine Becker, a surgeon from France who had a long history of experience with vascularized lymph node transfer.

She presented her work and through communication and travel to Paris to work with her, members of the GABRs group began to gain experience and learn more of her technique. The biggest hurdle that we were able to overcome was learning how to select the lymph nodes that could be removed as the donor lymph nodes and use those for breast reconstruction without causing lymphedema of the leg. We spent an extensive amount of time discussing her techniques and reviewing her results, as well as her publications.

We then made arrangements for her to travel to South Carolina and actually performed surgery on our own patients with her as an assistant surgeon. Since that time we have been very encouraged by the results with vascularized lymph node transfer as an effective treatment for reduction of the symptoms of lymphedema. We feel very excited but yet are very cautious about all results. It is important that patients realize that this procedure is still evolving and that there are risks involved, but to date we have had very good results and no serious complications.

Improvement of symptoms with vascularized lymph node transfer can occur immediately; however, they also may take up to 2 years to be appreciated. In most of our patients, the indicators of success are different. For the majority, the goal was to improve the edema, lessen the need to wear compression garments on a regular basis, and to eliminate the risk for frequent infections, which are the typical problems that those affected by lymphedema experience.

In order to lower the risk for complications and to closely study our results in conjunction with other colleagues who perform this procedure, we prefer to perform vascularized lymph node transfer as an isolated procedure. It can be done at the time of breast reconstruction; however, there is a chance that some people with mild lymphedema who undergo breast reconstruction may have improvement without lymph node transfer. Therefore, in order to closely study our results, we perform the breast reconstruction first followed by vascularized lymph node transfer as the second step. When the results are complete, we can determine whether it was the reconstruction or the transferred lymph nodes that gave the end result. It is important again to reemphasize that the main risk for of the surgery is that the transfer may not work. It is possible that if the transfer did not work resulting in more scar, the lymphedema could worsen.

Thankfully, to date, we have not experienced this complication. Other complications are damage to the blood vessels under the arm or the nerves under the arm. Therefore, our preference is to have an oncologic surgeon, who performs axillary dissection, release the scar under arm.  At the same surgical setting, after the scar is released, we perform the transfer by removing very specialized lymph nodes from the outer and lower abdominal wall or outer upper leg. We preserve the lymph nodes of the inside leg. These are the ones that drain the lower extremity and therefore, we feel that the risk for lymphedema of the donor area is reduced.

At this point, we have received some very exciting results along with some mixed results and continue to follow our patients very closely. We have had no patients with any serious complications and no patients at this point with lymphedema of the donor site. We are hopeful that the future holds vascularized lymph node transfer as an effective option for people with lymphedema following breast cancer surgery.

We plan to continue to devote and focus our energies on a surgical solution while simultaneously not exposing people to excess risk of additional problems. Once again, we do have to admit that the surgery, although giving some promising results, is  still evolving at this point and we choose to proceed with caution in the best interest of our patients.

— James Craigie, M.D.

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Complications From Vascularized Lymph Node Transfer

The below question is answered by Richard M. Kline Jr., M.Dof The Center for Natural Breast Reconstruction.

I am recovering from a DIEP flap reconstruction and lymph node transfer. I had breast cancer when I was very young and have had lymphedema for 25 years. I was so happy to hear that there was a surgery that possibly could correct the swelling in my arm that I jumped on it with out really researching. I am two weeks into my recovery and I have noticed swelling in my leg and groin. The groin I think is normal for a surgery site. However, the swelling in my leg Im afraid is the onset of lymphedema. I would appreciate any information you could share with me on this .

Hello,

Sorry you are having problems.

As your surgeon probably explained to you prior to surgery, vascularized lymph node transfer is experimental surgery, and no one really knows how often it works, if at all, and what the complication rates are.

As your surgeon also probably explained, lower extremity lymphedema is a potential risk of the node harvest. We strictly limit our node dissection to the area lateral to the superficial inferior epigastric vein and superior to the inguinal ligament, and have thus far had no problems with lower extremity lymphedema developing after the procedure. You may wish to consult with your surgeon about having bioimpedance analysis of your affected lower extremity performed to determine whether early lymphedema is actually present. If it is, then prompt institution of treatment may be advisable.

Richard Kline

Center for Natural Breast Reconstruction

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Will An SGAP Procedure Help With My Lymphedema?

sgapThe following submission below is answered by Dr. Richard M. Kline Jr., MD, of The Center for Natural Breast Reconstruction.

Will a SGAP help with lymphedema?

There is some indication that patients with lymphedema may benefit from having an autogenous reconstruction, and this is one reason why we have elected in our practice not to perform vascularized lymph node transfer at the same time as breast reconstruction.

About Our Procedures

Microsurgery has come a long way since its invention by vascular surgeons in the 1960s. The term refers to any surgery involving a surgical microscope. And it has found one of its best applications in breast reconstruction. Through microsurgery, our skilled surgeons are able to harvest healthy tissue from one part of a womans body and reattach it to the breast area. Through the careful process of attaching blood vessels, microsurgery allows patients to have natural looking breasts made from their own, living tissue. Another benefit is the minimized impact and injury to muscles, allowing patients to enjoy a faster, fuller recovery.

View an animation of our procedures here.

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Your Question about Reconstruction Surgery and Lymph Node Transfers Answered

breast questionThe below question is answered by Charleston breast surgeon, Dr. Richard M. Kline, Jr., MD of The Center for Natural Breast Reconstruction:

Can a one-sided microsurgical reconstruction be done in conjunction (same surgery) with lymph node transfer?

Lymph nodes can be “piggy-backed” on a DIEP flap, but our impression is that that precludes the ideal positioning of eitherthe nodes or the flap. Additionally, we have concerns that the nodes may not be as well vascularized (have as good a blood supply) that way (rather than doing them as their own separate flap), although extra small blood vessels can sometimes be hooked up to the nodes themselves.

Our preference is to just do the autogenous (your own tissue, no implant) reconstruction first, as some patients with lymphedema will improve with this alone. If they don’t improve, we’ve found that a vascularized lymph node transfer fits in very well with the second stage of the breast reconstruction. Of course, it is possible to do a DIEP or GAP with a separate vascularized lymph node transfer in one setting, but that makes a long procedure about 2 hours longer, so we haven’t pursued it.

-Dr. Richard M. Kline, Jr., MD
Center for Natural  Breast Reconstruction

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What Are My Options If I Develop Lymphedema?

I’ve had breast cancer and developed lymphedema after my mastectomy.  I recently heard about Lymph Node Transfer surgery.  Does it work?  I’m scheduled for a DIEP breast reconstruction, can it be done at the same time?

Question answered by Dr. James Craigie:

Lymphedema is a very difficult problem that results when a patient has had breast cancer and has to undergo surgical removal of the lymph nodes under the arm as part of their surgical treatment for breast cancer. There are other causes of lymphedema but our specific interest has been in patients who have had breast cancer.

Lymphedema can be a very debilitating process; it remains a terrible problem worldwide, for all types of reasons. There is still much to be learned about why some people develop lymphedema and others do not. It appears that lymphedema is directly related to several factors in our breast cancer patients. It is directly related to having the lymph nodes removed from under the arm and seems to develop from the scarring that occurs under the arm following mastectomy and / or axillary dissection.

Undergoing radiation of the arm or axilla increases this risk. However, there are many people who undergo removal of the lymph nodes and radiation that do not develop lymphedema. There are also people who have mastectomy, have lymph nodes removed followed by radiation, and don’t develop lymphedema until many years after their surgery. That is the main reason that patients are warned to pay particular attention to their arm if they have had removal of any lymph nodes.

It is also possible that someone could get lymphedema even after simply having a sentinel node removed. A sentinel node procedure (lymphadenectomy) is a way to examine the lymph node without having to remove more than one or two. The whole idea of examining only the sentinel node is to lower the risk for lymphedema, but even with the sentinel node procedure, there is still a chance of developing lymphedema. Our practice became interested in options to help breast cancer patients with lymphedema as we see many who are suffering from the symptoms of this process while undergoing breast reconstruction.

Our practice specializes in microsurgical free flap breast reconstruction utilizing skin, underlying tissue, and microscopic blood vessels that transport life-giving blood to the reconstructed breast. This procedure is commonly referred to as the DIEP if using the abdomen or a GAP if using the buttock tissue. The muscles of the abdominal wall are left intact as it is the removal of the muscles of the abdominal wall that can lead to problems in the donor area, like hernias and bulging, as well as a more involved extended recovery. The lower tummy wall is the most common area that we transfer and it’s also an area where lymph nodes are present. Therefore, over the first decade this surgery was being done, we would encounter lymph nodes in the area of the blood vessels, as well as fatty tissue.

It became obvious that we could transfer lymph nodes on the blood vessels as we refine our technique for microsurgery. Due to the lack of effective treatment for lymphedema, for years surgeons doing perforator flaps have taken on this challenge and are trying to come up with ideas and techniques to treat it. We began doing an extensive amount of research, spanning the globe, looking for information on procedures that may help these patients. In 2005, we formed a group known as the Group for the Advancement of Breast Reconstruction, known as GABRs, and we included members throughout the world who had had a unique experience with our type of breast reconstruction.

We encountered one individual who had 15-years of experience with what is now known as “vascularized lymph node transfer” for the treatment of lymphedema. Initially, Dr. Robert Allen had attempted lymph node transfer during breast reconstruction and the biggest concern was how to transfer lymph nodes from one area of the body to treat lymphedema but not to create lymphedema in the donor area. In 2006, the GABRs met in Beijing, China and invited Corrine Becker, a surgeon from France who had a long history of experience with vascularized lymph node transfer.

She presented her work and through communication and travel to Paris to work with her, members of the GABRs group began to gain experience and learn more of her technique. The biggest hurdle that we were able to overcome was learning how to select the lymph nodes that could be removed as the donor lymph nodes and use those for breast reconstruction without causing lymphedema of the leg. We spent an extensive amount of time discussing her techniques and reviewing her results, as well as her publications.

We then made arrangements for her to travel to South Carolina and actually performed surgery on our own patients with her as an assistant surgeon. Since that time we have been very encouraged by the results with vascularized lymph node transfer as an effective treatment for reduction of the symptoms of lymphedema. We feel very excited but yet are very cautious about all results. It is important that patients realize that this procedure is still evolving and that there are risks involved, but to date we have had very good results and no serious complications.

Improvement of symptoms with vascularized lymph node transfer can occur immediately; however, they also may take up to 2 years to be appreciated. In most of our patients, the indicators of success are different. For the majority, the goal was to improve the edema, lessen the need to wear compression garments on a regular basis, and to eliminate the risk for frequent infections, which are the typical problems that those affected by lymphedema experience.

In order to lower the risk for complications and to closely study our results in conjunction with other colleagues who perform this procedure, we prefer to perform vascularized lymph node transfer as an isolated procedure. It can be done at the time of breast reconstruction; however, there is a chance that some people with mild lymphedema who undergo breast reconstruction may have improvement without lymph node transfer. Therefore, in order to closely study our results, we perform the breast reconstruction first followed by vascularized lymph node transfer as the second step. When the results are complete, we can determine whether it was the reconstruction or the transferred lymph nodes that gave the end result. It is important again to reemphasize that the main risk for of the surgery is that the transfer may not work. It is possible that if the transfer did not work resulting in more scar, the lymphedema could worsen.

Thankfully, to date, we have not experienced this complication. Other complications are damage to the blood vessels under the arm or the nerves under the arm. Therefore, our preference is to have an oncologic surgeon, who performs axillary dissection, release the scar under arm.  At the same surgical setting, after the scar is released, we perform the transfer by removing very specialized lymph nodes from the outer and lower abdominal wall or outer upper leg. We preserve the lymph nodes of the inside leg. These are the ones that drain the lower extremity and therefore, we feel that the risk for lymphedema of the donor area is reduced.

At this point, we have received some very exciting results along with some mixed results and continue to follow our patients very closely. We have had no patients with any serious complications and no patients at this point with lymphedema of the donor site. We are hopeful that the future holds vascularized lymph node transfer as an effective option for people with lymphedema following breast cancer surgery.

We plan to continue to devote and focus our energies on a surgical solution while simultaneously not exposing people to excess risk of additional problems. Once again, we do have to admit that the surgery, although giving some promising results, is  still evolving at this point and we choose to proceed with caution in the best interest of our patients.

—James Craigie, M.D.

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