Vascularized Lymph Node Transfer Improves Arm Lymphedema after Breast Cancer Surgery
By: Dr. Steven Pisano
Arm lymphedema (permanent arm swelling) after surgery for breast cancer is a common problem, occurring in 7% of women undergoing sentinel lymph node biopsy and up to about 45% of women undergoing a traditional axillary node dissection. Post-surgical radiation therapy increases the likelihood of upper extremity lymphedema further.
Lymphedema of the upper extremity is characterized by an increase in the circumference of the arm and forearm, pitting (soft) edema (swelling), loss of range of motion at the shoulder and/or elbow, and discomfort. In advance cases the tissues can become markedly swollen, hard, discolored (so called "brawny edema"), and even painful.
Treatment of lymphedema can be divided into non-surgical and surgical options.
The non-surgical treatment includes: range of motion exercises, elevation, “lymphatic” massage, compression garments, intermittent pneumatic compression devices, and multi-layered banding. Non-surgical treatment can be effective in mild to moderate cases. The advantage of non-surgical treatment is that it avoids surgery. The disadvantage is that it may not be definitive in mild to moderate cases and may not be sufficiently effective in advanced cases. Non-surgical methods may be also cumbersome and are usually time-consuming.
Several surgical treatments for arm lymphedema have been described including: lymphatic-to-vascular anastomosis (“LVA” hook-up), liposuction, direct soft tissue excision from the upper extremity, transfer or transplant of autologous (from the patient) tissue to the axilla, and more recently vascularized lymph node transfer.
Vascularized lymph node transfer can be performed a couple of ways: lymph nodes can be transplanted at the same time as breast reconstruction with a DIEP flap, or as a stand-alone block of tissue. Both methods can significantly improve lymphedema and recent reports show a high success rate.
Lymph nodes transplanted with a DIEP flap are typically found along the superficial epigastric vein. Groundbreaking work performed at PRMA has also identified nodes along the Deep Inferior Epigastric blood vessels (the same blood vessels that are used in the DIEP flap procedure). Lymph nodes transferred as a stand-alone block of tissue can be harvested from different parts of the body but are most commonly taken from the superficial groin area, using great care to preserve the nodes that drain the leg. Lymph node groups are found along the circumflex iliac vessels or branches off the femoral vessels. The lymph node group is transplanted to the arm. The blood supply to the transplanted lymph nodes is connected to blood vessels in either the wrist, antecubital area (inner elbow), or more commonly the axilla (underarm).
At PRMA we offer the complete spectrum of upper extremity lymphedema treatment. Microsurgery is part of our daily practice and we are proud to offer our patients state-of-the-art reconstructive procedures including the vascularized lymph node transfer and LVA.