Roman Skoracki, MD, a plastic surgeon and medical director of the Stefanie Spielman Comprehensive Breast Center, talks about controlling lymphedema with bypass surgery.
Interview conducted by Ivanhoe Broadcast News in April 2022.
Can you describe what lymphedema is and why the condition starts?
SKORACKI: Lymphedema most of the time in the developed world we see it as a result of treatment of cancer. And it’s usually a direct injury to the lymphatic system, either through removal of lymph nodes or radiation and chemotherapy to the areas. Chemotherapy, probably because there are some tumor cells already. Then the interaction with the chemotherapy agent and the cancer cells causes some damage and that often affects the lymph nodes. It really is a system that evacuates fluid that’s constantly produced throughout the body and brings it to the lymph nodes where it gets dumped back into the bloodstream. Any interruption and any disruption of that system will cause swelling distally, which is lymphedema.
How soon after breast cancer treatment do patients see this develop?
SKORACKI: Relatively quickly after the combination of treatments of removal of lymph nodes and then radiation, usually within six months, we know. The statistics show that anybody who will develop lymphedema will do so within the first two years from over 90 percent of the time. If you haven’t developed lymphedema by one to two years after your treatment, there’s a very, very good chance you never will.
Lymphedema is life threatening in itself?
SKORACKI: Correct.
Does it impact quality of life?
SKORACKI: Unfortunately, it can be a life-threatening condition because it can be associated with infections. However, that is very rare. But it does affect quality of life. The mainstay of treatment for lymphedema remains compression, which means donning of a glove or, you know, a type of hose, depending on which part of the body is affected and then a sleeve, potentially. There’s always need for compression, essentially 24/7. It does affect every part of your daily life. If you imagine, especially now with COVID, we’re constantly washing hands, we’re constantly applying hand sanitizer. When you’re wearing a glove, that’s almost impossible. A compression glove, that is. It makes life much more challenging. There’s absolutely a quality-of-life issues. Then just the heaviness, the tightness that comes along with the swelling, with the lymphedema.
What does the compression sleeve or the compression socks essentially do?
SKORACKI: It’s as if you had a road construction where one of the major highways is taken out and obviously, you’ll get backup of cars behind that site. Usually, cars can still get home if they take side streets, but that’s not a very efficient or effective way. The compression is essentially like calling in a police force and waving people through those side streets more effectively, more efficiently. That’s what the compression does. It forces more fluid through some of the remaining smaller channels that are maybe not quite as effective at clearing the fluid but can do so with a little bit of external help, with literally external force and compression.
Twenty years ago, was there anything really besides compression that could be done?
SKORACKI: There were some things. Manual lymphatic drainage has been around for a long time, which is kind of the ultimate in removing that fluid, which is the same type of idea as the compression, but it’s performed by a therapist that’s trained in that technique. Then it’s used in combination with the compression. But that was about it. In the last 15 to 20 years, there’s been an explosion really, of treatments that come on for patients that go well beyond that.
For patients who’ve had their cancer a while ago and have lymphedema, is it too late for them to seek treatment?
SKORACKI: Usually, it isn’t. Usually, there’s still something we can do. There are really a number of different treatments that we can offer patients as surgeons, and we break them down into kind of physiologic procedures and or what we call ablative procedures. The physiologic ones really aim at rebuilding some of the pathways that clear fluid, whereas the ablative ones focus more on just volume reduction of that limb. Usually, there is still something that can be done in either one of those realms. We obviously have to kind of personalize and individualize that for the patients.
Is a liposuction a fairly new procedure?
SKORACKI: The liposuction has been around for a long time, but we haven’t applied it to lymphedema. There’s a colleague of ours in Sweden that really championed this. He has now just published 20-year follow-up data showing that it is a sustained effect and a sustained volume reduction. Really what it focuses on, that’s kind of on the ablative side that I was talking about. What we do with that is see, rather, in lymphedema is that we have the fluid fluctuation that I talked about earlier. Unfortunately, that also produces extra fat, or the fat globules in the affected limb grow larger. It’s a kind of a double whammy. You get extra volume both from the fat hypertrophy, from the extra growth of fat, as well as the fluid. Now, the liposuction addresses that fat component and removes the fat and removes it permanently. Especially for patients where we’ve controlled the fluid fluctuation well, but we haven’t yet addressed the extra volume of the fat, it can be incredibly powerful and incredibly helpful.
Is it a one-time procedure?
SKORACKI: It tends to be a one-time procedure because those fat cells that we remove with liposuction, they don’t regrow. Now, the remaining fat cells, and we always leave a few behind, can still grow larger. The ones that we’ve removed do not regrow. Generally, it’s sustained even up to 20 years after that procedure, sustained volume reduction.
Could you describe what you’re doing. Is it a needle or how are you removing the fat?
SKORACKI: For the liposuction, there’s small, tiny little stab incisions that are essentially a quarter of an inch or so in length. We then usually inject some fluid into the arm. That injection of fluid is really designed to minimize bleeding from that operation. And then we use standard liposuction techniques to remove the fat. We spend a lot of time, and we have some specialized techniques to try to avoid damage to any remaining lymphatic channels. More or less, we remove the fat that’s underneath the skin with our cannulas and then just put one little stitch into those little sites that we have through which we were able to evacuate the fat and then place the patient in pretty significant compression after the surgery. That is very important.
Could you speak to the cellulitis infection?
SKORACKI: Yes. Thankfully, not everybody experiences these infections that manifest themselves usually as redness that spreads very quickly. Most commonly patients are systemically affected. They have this immediate sense of kind of a flu-like illness coming on very quickly with high fevers. And so that, A, it does more damage. Each time there is an infection it does more damage to the lymphatic system. Also, it can be life-threatening in some cases. We take that very seriously. Patients do need to be on antibiotics again. Thankfully, only a few patients usually experience that complication. If they do, it’s something that can recur and that needs to be treated.
Can you tell me about Pandora’s case?
SKORACKI: Pandora is an incredible woman. She had a lymphedema of her upper extremity related to her breast cancer treatment. She’s been through a couple of rounds of breast cancer treatment. She’s particularly unique because her livelihood depends on the use of her upper extremity. She’s an organist, a professional organist. For her, it was just a struggle to have to play the instrument with compression on, really, at most times. With Pandora, she went through a number of different procedures. Most of them were physiologic, but we also added the liposuction at the end, as well. The physiologic ones, we transplanted lymph nodes from one part of her body into two different areas of her upper extremity to reintroduce kind of the idea that the lymph nodes can dump fluid, can take that lymphatic fluid, and dump it back into the bloodstream. That’s been very helpful. We also performed a lymphovenous bypass procedure on her where we can – we make a direct connection between the lymphatic channels and the little blood vessel. The same kind of idea that we allow the lymphatic system that wants to pump that fluid out of the arm an egress, an area to kind of dump the fluid into.
How long ago was her procedure?
SKORACKI: It’s been at least three or four years since Pandora went through her surgeries.
Is Pandora one of those patients where two years ago, there would have been nothing?
SKORACKI: That is correct.
You have to just deal with it?
SKORACKI: Yes. Yes, she would have been. I mean, compression would have been the mainstay of her treatment and that would have been it.
Would she had been able to continue play with the swelling?
SKORACKI: Probably not nearly as well as she does now. I think it would have been a struggle and I think it was a struggle for her for a few years. I think we, thankfully, we’ve been able to make a significant difference. Now, I do want to mention, I think, that most of these surgeries that we perform are an adjunct, that we still rely heavily on compression. We still rely very heavily on our physical therapists that are specifically trained for lymphedema because they help in the day-to-day. They’re very helpful with range of motion, with compression, with teaching some of the manual lymphatic drainage techniques that the patients may go through and may continue at home. We can certainly, with the surgical interventions that we have now, we’re able to really improve that, too often reduce the volume very significantly beyond what can be done with the compression. We do work in unison. It’s still very much a team sport.
Can you repeat for me again the two procedures that you did and what was the timing between the two.
SKORACKI: With Pandora, we actually performed three procedures. We did the physiologic procedures first, and those focused on trying to get the fluid fluctuation under control. One of them was just the lymphovenous bypass, where we literally connect the plumbing, we connect lymphatic channels to a venual to give it a site of egress. In addition to that, with Pandora, and the reason we had to add something to that procedure, was because Pandora didn’t have that many remaining channels left. There was so much damage to our lymphatic system already. We added the transplant of lymph nodes to that. We took lymph nodes from another part of her body with their blood supply and transplanted them into the forearm as well as into our armpit, in order to reestablish new pathways that the lymphatics would reconnect to and give it a site of egress through lymph nodes. It would have been in the in the original setting before the lymph nodes were removed. Once we had the fluid under control, then we added the liposuction to reduce the volume, the fat volume of the extremity, as well.
When you see her play the organ, what goes through your mind?
SKORACKI: She is such an incredible character to begin with. It is always a pleasure and a joy to see her. It is extremely rewarding. To see her and to be able to witness her practice her craft at such a high level, it’s extremely rewarding. It is wonderful to see her be able to do the things that she loves to do.
Is there anything I did not ask you, Doctor, that you want people to know about lymphedema or about treatment?
SKORACKI: A couple of things. There is one procedure that we actually perform kind of prophylactically or immediately at the time of lymph node removal, and I’m very excited about that because it allows us to harness the power of the lymphatic system. It allows us to have the intact lymphatic system continue to work without any damage. What we do there is at the time when we know a patient will have a lymph node clearance, removal of all of the lymph nodes in a given region, we can actually perform a bypass right at that time in the area of the lymph node removal and thereby minimize the risk of ever developing lymphedema. We reduce the risk by about five- to 10-fold, which is incredibly significant. That is one of the most exciting areas for us right now is to intervene early before lymphedema ever develops and avoid its development. Beyond that, what is very important is it is just that whoever is thinking about seeking any types of these treatments is just to seek out a center where the treatment is very individualized. Everybody is quite different and there are so many different treatments and treatment combinations that it is very important to find a center that works as a multidisciplinary center where every patient is assessed very carefully, and their treatment can be individualized.
Is the preventive surgery that you do immediately after a standard at a lot of places, or is it only at an academic center like yours?
SKORACKI: I do not think, I hope that it will become standard of care, but it is not. I think at this stage it is only in some of the major cancer centers that it’s being offered. I is a handful of centers around the United States at this stage that I’m aware of that is offering this type of a procedure.
And what do you call that procedure?
SKORACKI: It is either called immediate or prophylactic lymphovenous bypass. Creating a bypass right at the time of the initial lymph node removal.
How much time is that with any kind of resection or cancer removal?
SKORACKI: It would be done exactly at the time when the cancer is removed, and the lymph nodes are removed as part of that treatment.
Does your team come in after the doctors are done?
SKORACKI: Absolutely. It would be done immediately at the same time.
How much time does that add to the procedure?
SKORACKI: Depending on how many. Often, we find more than one channel. In fact, usually the average is somewhere between two and seven or so channels that we bypass. I would say it adds about an hour and a half to two hours to the procedure. Thankfully, aside from the added time, there are very few other potential complications that can occur with this procedure. We use the same types of incisions that our ablative surgeons have made, and we operate in the same field. There is little in terms of complications or potential morbidity that we would add, aside from the extra time.
Do patients feel it is time well spent?
SKORACKI: They do, absolutely.
Is there anything you can, or you would normally check in a checkup with her arm?
SKORACKI: We would just examine the entire upper extremity. We feel around and I will ask her. She is usually very good.
END OF INTERVIEW
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