The lymphatic system in your body is a network of channels which run parallel to your arteries and veins and performs a number of functions. Excess fluid in your tissue (interstitial fluid) is carried by lymphatic channels to your lymph nodes, which act as filters and present bacteria and foreign particles to white blood cells. This is a key step in your immune system and allows your body to monitor and fight infections. Unfortunately, lymphatic channels can also be a pathway for cancer to travel (metastasize) to lymph nodes and other areas of the body. Another major function of the lymphatic system is to remove the interstitial fluid from your tissue and return it to veins in your body.
When the lymphatic channels are severed or disrupted, excess interstitial fluid may build up, resulting in swelling known as lymphedema. Stagnant interstitial fluid contains proteins and cell debris which cause inflammation and scarring in your tissue, further damaging and overwhelming the lymphatic system, resulting in worsening lymphedema.
In the United States, secondary lymphedema is the most common form and is usually related to the treatment of cancer. The upper extremities of breast cancer patients are affected the most due to the removal or radiation of axillary lymph nodes. The lower extremities can also be affected in patients that have their pelvic or inguinal lymph nodes removed, usually from a gynecologic malignancy or melanoma of the lower extremity. Primary lymphedema occurs less commonly and is usually an inherited abnormality that can present at birth or later in life.
Diagnosis of Lymphedema
Lymphedema can be difficult to diagnose because many conditions can lead to limb swelling, but only lymphedema is caused by an abnormality in the lymphatic system. In order to properly treat the swelling, the correct diagnosis must be made. Diagnosing lymphedema relies heavily on the patient’s history and physical exam. Details such as previous surgeries, the time interval between surgery and symptom onset, a family history of lymphedema, previous infections, and current medical problems including a medication list may aid in the diagnosis.
Circumferential measurements along the affected and unaffected extremity along with volumetric measurements are obtained as part of the diagnostic process. These baseline measurements can then be compared to future measurements to assess the efficacy of treatment.
A number of imaging modalities, including lymphoangiography, lymphoscintigraphy and near infra-red florescence imaging can be used to look for interruption of the lymphatic channels.
Treatement of Lymphedema
The goals of any lymphedema treatment are to:
- Improve lymphatic drainage and decrease swelling
- Prevent recurrent skin infections
- Improve the health of the patient’s skin
- Improve the patient’s functional status and quality of life.
The treatment of lymphedema begins with non-invasive methods such as Complete Decongestive Therapy (CDT). CDT is a safe and effective treatment program that includes manual lymph drainage (MLD), lymphatic exercise, multi-layered compression garment therapy and skin/nail care. CDT is provided by physical therapists that have completed additional lymphatic therapy training.
Unfortunately, CDT is not sufficient for all patients. Some patients are unable to control their lymphedema with non-invasive methods and continue to suffer from repeated bouts of infection and functionally limiting lymphedema. For this patient group, surgery may be indicated. Initial surgical treatments consisted of excising large amounts of edematous tissue and then closing or extensively skin grafting the affected extremity. Thanks to modern microsurgical techniques, procedures designed to restore the lymphatic flow have been developed.
Lymphaticovenular bypass is performed using supermicrosurgical techniques by suturing a lymphatic channel to a small vein just below the skin, called a venule. This allows the interstitial fluid to be diverted directly into the venous system, decompressing the lymphatic channels in that limb and preventing the collection of fluid in the tissue. On average, 2 to 5 lymphaticovenular bypasses are performed on the affected limb. Most patients are discharged home the day after surgery.
Vascularized Lymph Node Transfers move a small group of lymph nodes with their associated artery and vein, and transplant them into the site where the lymphatic channels have been disrupted. For breast cancer patients, the lymph nodes are most commonly taken from the neck or groin and transplanted into the axilla or arm pit area. The artery and vein associated with the lymph nodes are then connected to an artery and vein in the axilla so that the lymph nodes are able to survive and sprout new lymphatic channels, a process known as lymphangiogenesis. The new lymphatic channels allow for increased drainage in the extremity and improve the symptoms of lymphedema. Most patients are discharged 2-3 days after surgery so that the transplanted lymph nodes can be properly monitored for the first couple of days.
Following lymphatic surgery, all patients will initially return to Complete Decongestive Therapy. This is why it is essential to find a treatment team that consists of a surgeon with training in lymphatic and microsurgery, a physician that understand the specific issues of patients with lymphedema, as well as a physical therapist with lymphatic therapy experience. Modern lymphatic treatment is a multi-disciplinary approach that requires the members of your team to properly diagnose and coordinate your treatment.
You are an ideal candidate for lymphatic surgery if you:
- have tried non-invasive treatment but still suffer from:
- recurrent infections
- limited daily function due to lymphedema
- are unable to participate in non-invasive treatments such as CDT
You are not an ideal candidate for lymphatic surgery if you:
- have not been properly diagnosed with lymhedema
- have not attempted non-invasive treatments such as CDT