Lymphedema

Lymphedema is a relatively common side effect following cancer treatment. Up to 56 percent of the patients may develop lymphedema after breast cancer treatment. According to the National Cancer Institute (NCI), lymphedema may occur following treatments for other cancers as well. Basically, lymphedema is possible whenever the lymph system is disrupted.

Lymphedema is unpredictable. It has been reported to occur within days of surgery to up to 30 years after an injury to the lymph system. However, majority of lymphedema cases (80%) occur within the first three years after surgery. Lymphedema occurs when the lymph system no longer effectively removes fluid and proteins that circulate under the skin, causing limbs to swell and eventually become hard, heavy, inflexible, and painful.

Lymphedema can be either congenital or acquired. Congenital lymphedema occurs in patients born with insufficiently developed lymph system. The condition develops when the lymph production overwhelms the lymph system's ability to drain. In contrast to the congenital lymphedema, the drainage insufficiency in the acquired lymphedema happens as a result of traumatic injury or surgery. The acquired lymphedema happens more frequently than the congenital lymphedema in developed countries such as the United States.

Lymphedema Diagnosis

  • Lymphedema is most frequently a clinical diagnosis. An experienced physician can arrive at the diagnosis thorough a physical examination.
  • Radiographic (x-ray) imaging is frequently necessary to further increase the diagnostic precision and reliability.
  • Commonly performed imaging studies include computed tomography (CT) scan, radionuclide lymphoscintigraphy, and fluorescent indocyanine green (ICG) lymphography.
    • Lymphoscintigraphy and ICG lymphography
      • Both involve injection of contrast into the skin
      • Allows the lymphatic system to pick up the contrast and visualization of the lymphatic system
      • Lymphoscintigraphy uses a radioactive contrast and can visualize deep lymphatic tissues
      • ICG lymphography relies on a non-radioactive fluorescent contrast and can only visualize superficial lymphatic tissues

Lymphedema Staging

  • Many staging systems exist for lymphedema severity staging as there is no consensus in the medical field as of yet.
  • We adopt the Campisi Staging System to determine the disease severity based on reversibility of the limb swelling:
    • Completely reversible swelling indicates early-stage disease
    • Irreversible, persistent swelling is consistent with intermediate disease
    • Presence of thick, hardened skin indicates late disease

Campisi Staging System

1A:   No overt swelling despite impaired lymph drainage
1B:   Reversible swelling that subsides with limb elevation
2:   Limb elevation only partially reduces swelling
3:   Persistent edema; recurrent lymphangitis
4:   Fibrotic lymphedema with column-limb
5:   Elephantiasis with limb deformation including widespread lymphostatic warts
 

Non-Surgical Treatment Options

First-line treatment of lymphedema is complete decongestive therapy (CDT) consisting of manual lymph drainage, compression bandaging, exercises to enhance lymphatic pumping, meticulous skin care, and persistent use of a pressure garment to maintain the volume reduction achieved through treatment. Many patients can be successfully treated and maintained with CDT. However, surgery may be the appropriate next step when the non-surgical treatment does not yield satisfactory improvement.

Surgical Treatment Options

At University of Iowa Hospitals & Clinics, we offer the full spectrum of lymphedema surgical treatments including the debulking procedure, the LVA, and the VLNT.

Two Categories of Surgical Treatments for Lymphedema

  1. Debulking procedure
    • Remove lymphedema-affected tissues
    • Achieve symptomatic relief
    • Procedure of choice for patients with the most severe form of lymphedema
  2. Physiologic procedure
    • Aimed at restoring or augmenting the compromised lymph drainage

Two Physiologic Procedures Offered

  • Lymphaticovenular Anastomosis (LVA)
    • Most effective in patients with early disease
    • Can still be offered selectively in those with more advanced disease
  • Vascularized Lymph Node Transfer (VLNT)
    • Usually the procedure of choice for those with a severely damaged lymph system

 

Lymphaticovenular Anastomosis (LVA)

Lymphatic Channel ScaleLVA is an advanced, minimally-invasive procedure. Using an ultra high-power microscope and supermicrosurgical technique, lymphatic channels in the range of 0.2 to 0.5 mm are connected to nearby veins. The sutures used in the LVA are nearly invisible to the naked eye. Successfully constructed LVAs allow lymphatic fluid to flow into the bloodstream, reducing symptoms in the affected limb.

Read more about how Dr. Wei Chen used this innovative super-microsurgery technique to treat lymphedema.

IVA

 

Vascularized Lymph Node Transfer (VLNT)

VLNT is a novel microsurgical modality that involves transferring healthy, functioning lymph nodes from another part of the body to the affected limb to treat lymphedema. Using sophisticated microsurgery techniques, the lymph nodes are transplanted while preserving their delicate blood supply, thereby preserving the function of the lymph nodes. It has proven effective in late-stage lymphedema.

Lymphedema

Care Team