Christopher Reid, MD, Associate Clinical Professor, Plastic and Reconstructive Surgery Division at UCSD Medical Center talks about lymphedema post breast cancer treatment and the options being sought out to potentially prevent it from happening in the first place.
Just overall just tell me what lymphedema is.
Dr. Reid: Lymphedema is in many ways a chronic condition that is most commonly associated with a breast cancer diagnosis. It does happen in the lower extremities, but oftentimes it affects women who have had breast cancer treatment. What it is, is a swelling of the arm that can lead to chronic pain. It can lead to recurrent infections and a lot of big issues for breast cancer survivors.
Why does it happen?
Dr. Reid: Damage to the lymphatics is unfortunately collateral injury during a time of axillary lymph node sampling, which is taking lymph nodes out of the armpit at the time that breast cancer is treated. And as a result of the scarring related to that operation, which is inadvertent or the radiation injury that can happen as part of the extra therapies they get, the lymphatic fluid that is all part of our body can no longer drain the arm and as a result it resides in the arm and causes a lot of swelling.
So what can you do for it?
Dr. Reid: The gold standard of treatment, which is what people have done historically, is you have to wrap the arm. The idea is that you’re keeping all of the fluid from swelling up. This is a big, labor intensive thing that happens for women or they have to wear a compression sleeve which is not very sightly and also very hard to manage. And it wasn’t until probably 10, 15 years ago people started to think about different ways we could treat this disease surgically.
And so now there’s a way to actually prevent it before going in after?
Dr. Reid: Yeah, that’s the exciting thing that we’re offering here at UCSD and there are some other centers in the country that do this as well. It was originally described by an Italian group wherein they thought to themselves when the lymphatics are getting injured at the time of surgery, why not try to fix them with what we call supra micro surgical techniques? And this is actually doing our standard microsurgery repairs, but on a level of smaller than one millimeter.
So what do you do?
Dr. Reid: Essentially we find lymphatics that we think potentially are damaged during the breast cancer surgery, no fault to the breast surgeon doing the operation, and then we drain them into the venous system or the veins in the armpit to allow the arm some way to drain this limb. And as long as it can stay open, hopefully they never go on to develop lymphedema.
Is there are a lot of risk to that?
Dr. Reid: Interestingly other than adding a little bit of time in the operating room, there’s actually probably no risk to the patient to undergo this therapy. I remember when I was interviewing for microsurgery fellowship; I met with one of the biggest proponents in the country who offers this. He said to me this exact thing, there’s no reason why you shouldn’t try it. If I had a family member, a mother, a sister, a friend who was undergoing breast cancer therapy, I would one hundred percent offer this to them because if we can eliminate lymphedema, altogether why not try this?
What’s the percentage of women who will get lymphedema?
Dr. Reid: The numbers are kind of all over the board and that’s probably due to a lot of different studies and a lot of variations because people come in all shapes and sizes. But one quoted statistic is about one in five women who get breast cancer treated with the lymph nodes removed from their axilla, will go on to develop lymphedema at some point in their lifetime. There’s certain things that make it more common, so getting radiation, being larger or obese, those are risk factors that can increase the chances you might go on to develop it.
So could you do this after the fact? Let’s say you get lymphedema. Could you go back in and do this?
Dr. Reid: Typically not. There are other surgical options as we also do offer here at UCSD for this, wherein we either transfer lymph nodes from another part of the body to the axilla to allow the arm to be drained, or we do similar style procedures where we reroute the lymphatic vessels in the arm, but we do it farther down in the arm, not in the axilla.
Can you kind of describe what a lymphatic vessel is? Is it just like a cell?
Dr. Reid: It’s much like the blood vessels in our body that either bring in blood from our heart or back to our heart. The lymphatic vessels are small vessels like this, much smaller, in fact, than our blood vessels, that drain that extra fluid in our body. So it’s actually a network of vessels or little tubes that are very, very tiny. Many people have heard the phrase that we’re almost all made of water, and that’s very true. The reason that this can happen and we can make this work is that we have these small vessels to get that water back to our heart and then have it pump around the rest of our body. We don’t just fill up like a balloon in our arms or legs or wherever.
So when would you do this microsurgery?
Dr. Reid: The lymphatic repair? The time to do it is at the time that the patient is getting a mastectomy or if they’re getting actually a lymph node dissection, sampling the lymph nodes in the armpit, you do it at the same time that the breast surgeon does their surgery.
You could have a double mastectomy and then come back out and look exactly as when you went in?
Dr. Reid: In a nutshell. It’s not always that cut and dry, but yeah that’s the goal. We’re able to sometimes make it so it’s almost scarless on the breast because we bring in some skin and fat from the belly to rebuild the breast that was removed. So there are some great options. Sadly some people I think don’t offer it to women who they think are too big or too small because they think they’re not candidates. Or don’t offer it at all because it requires specialized training. Recent papers have been published by people that I know who are very well regarded micro surgeons, saying that the best operation you can offer an obese or a large woman is using the abdominal tissue or their own tissue from another part of their body because you can’t make an implant big enough. The biggest implants that we have won’t be big enough for some women. In addition there’s very skinny women that don’t get offered to use their own tissue because people just don’t think they have enough; and that’s just frankly not true. There is a big paper out of Memorial Sloan Kettering in New York, which is one of the nationally recognized cancer centers showing that those patients actually have better outcomes when they look at their patient satisfaction long term when you use their own tissue.
Is it safer?
Dr. Reid: There’s not necessarily a big safety difference between the two of them. There’s probably more hiccups along the road because you’re adding an extra surgery, but you don’t have to take them back to the operating room for complications as frequently.
Any other risk or anything we should know about it? What about recovery time? Is it the same?
Dr. Reid: That’s the thing I think that catches people off guard sometimes is because you are operating on another part of the body, there’s a scar somewhere else and there’s a new place that can have pain. There’s always a risk they do get weak in the belly for some reason because you do need to take some muscle or otherwise to make it work, but when a tissue expander implant patient is discharged, that’s often on the first or second day. We’d like to keep our patients for three or four days so it’s a little bit more time in the hospital. It’s a much longer operation which is not really anything unsafe for the patient. It just means that I have to work a lot harder, which I’m happy to do. And then they probably have maybe another week or two of recovery at home more than what a standard patient with the implant reconstruction.
Anything else?
Dr. Reid: With regard to one of the things I think women hate the most about breast reconstruction, and I unfortunately have to do this a lot of my other patients too, regardless of what you have done, you almost always have drains, which are the tubes that hang out of your body. And these women undergo a big operation and it does create some discomfort and almost invariably every one of them tells me that the drains are the worst part. In some ways if that’s the worst part, then that’s the best part because it’s a small part; but it’s very annoying. I do have an app that I use actually where they’re able to send me their drain outputs every day and I can review them so we can get them out early.
There is an interesting area of breast reconstruction using patients own tissue that’s exciting, but is probably not ready for the mainstream where there are nerves that go to the skin and the fat that we bring up from the abdomen. There are other parts of the body we rebuild with their own tissue too, but specifically for the abdomen, groups have started to investigate connecting the nerves in the patient’s chest to the nerves that came out of the abdomen and trying to give them a breast that has sensation. I think it’s an exciting area, and in the future it’s probably something we’ll be doing more frequently. But at least at this point, it’s not quite something that’s ready for the mainstream or the results are quite there yet.
Have you done any yet?
Dr. Reid: I have not offered that to my patients mostly because it does add some time, doesn’t necessarily add risk to the case, but there isn’t convincing techniques of exactly how we can make it work. But in many ways that’s how a lot of these operations started, people just had to come up with an idea and then refine it.
Let’s say you don’t have a breast reconstruction right away. Can you go back and do this surgery later?
Dr. Reid: Yeah, one of the other big advantages of having what we call a free flap based breast reconstruction, using their own tissue; is that in the event that a woman is just not ready to have reconstruction because they’re overwhelmed with a diagnosis or they’re gonna have to have radiation or otherwise, sadly some women just don’t even get offered this. We’re always available to offer free flap breast reconstruction. There is a group of patients that is at least a sizable portion of my practice, which is salvaging other people’s results that try to do implants that just don’t work where eventually when they do fail, we’re available for them. So the nice part about using their own tissue is that yes, as long as they don’t go and get their own tummy tuck, we can use it.
Right. I think it would be a deterrent because my daughter in law had breast cancer and she didn’t want to have reconstructive surgery because she had to have radiation and then that meant going back in again, and it was just a lot to process and that probably deters women right?
Dr. Reid: Yes it’s a lot. And not that I’ve been through it, but I’m very sympathetic to how challenging this is. I start the conversation with telling them, listen, I just want to give you the information and whatever you choose, I can help you. Doesn’t matter if it’s now or later. I’ll always be there and be available to offer this because I can offer these advanced techniques.
Like reconstruction with implants, if you get radiation, does it make the surgery a little harder because of that tissue?
Dr. Reid: Yeah. One of the challenging aspects of treating breast cancer is that radiation is a big part of it. I think that our radiation oncologists do a great job and want to take really good care of the patients, but it does alter the tissue. So it’s very hard to do tissue expander based reconstruction when you know that there’s radiation and get a good result. It does increase the risk that it fails. I try not to radiate the flaps that we use when we use the patient’s belly tissue. A lot of times we’ll wait to do the reconstruction till after radiation. And it’s definitely more challenging, but in those situations the best reconstruction they can get is the reconstruction using their own tissue once radiation effects have set in.
END OF INTERVIEW
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