John F. Turner, MD, FACS, breast surgeon at Evangelical Community Hospital in Lewisburg, PA, talks about how to lower the chances of having lymphedema after surgery.
Could you tell me what Lymphedema is and what it’s doing to a patient?
TURNER: Lymphedema is swelling of a body part related to damage to the draining lymphatics of the lymph system, the system that clears impurities out of our body fluids. So, arteries deliver blood to the arm, for instance, and in the arm, those lead to capillaries and the capillaries then deliver nutrients. Well, what’s left over after those nutrients are delivered is the fluid that we often refer to as serum. If you’ve ever mashed your finger or injured your extremity and you have a little bit of that yellowish fluid leaking out, that’s what that is. Well, that has to get back into the venous system, so it’s collected by lymph vessels, which are different from the arteries and veins, but they carry lymph fluid back to the venous system. When they reach certain points along the way, that fluid is filtered by lymph nodes. The lymph nodes take the impurities out – whether it be bacteria or foreign substances out of that. Then, when that fluid then empties into the vein in the neck, that fluid has been, essentially, purified. Well, if cancer cells are in that fluid, those cancer cells can block the lymph nodes. Or if you do surgery to the lymph nodes, in the case of breast cancer, with a lymph node biopsy or lymph node removal, you can cause scarring in the lymph nodes or just the absence of the lymph nodes, and then there’s a resistance to the emptying of that fluid from the extremity or the breast itself or – in the leg it would be the leg. That swelling can be very miserable for the patient. The extremity is heavy, it’s difficult to use, is susceptible to infection and other complications, ulceration, especially in the lower extremities. To me, it is the worst complication that can occur after breast cancer surgery, second only to breast cancer recurrence.
How frequent is it that a woman after she has breast cancer surgery will have lymphedema?
TURNER: Well, it really depends on what was done to the lymph nodes. In the old days, when we removed the entire group of lymph nodes in the underarm called an axillary lymph node dissection, the incidence was around 30%. Even today, if you have to do a full dissection, which does happen sometimes, the incidence is about 30%. If you add radiation to that, the incidence can more than double. For a sentinel lymph node biopsy, which is just removal of the first lymph node to get any drainage from the breast, the incidence is about 7% depending on whose data you look at.
What’s the treatment once patients have these?
TURNER: Well, the treatment is compression of varying types, most often the use of a compression sleeve. So, if the problem is that the pressure inside of the venous or the lymphatic system is greater than the pressure in the tissues of the extremity, you can reverse that process sometimes by increasing the pressure in the tissue of the extremity by applying a pressure garment to the extremity. You’re much better off preventing, though than treating.
How can you tell if a patient is going to be at risk? Is it only if they’ve had these lymph nodes impacted during surgery or is it even possible to tell?
TURNER: You should assume that every patient that’s had any procedure done to their lymph nodes is at risk, and then it becomes a matter of assessing that risk and assessing whether there’s any early signs of lymphedema.
Treatment, for the most part, traditionally, has been after the fact, after you determine that somebody has lymphedema. Talk to me a little bit about is there a way to be upfront, a preventative measure for this?
TURNER: Well, there are practical preventative measures, such as avoiding even the carrying of a pocketbook strap over the shoulder on the side of the surgery. Patients are allowed to do work in their garden, but they should wear gloves. If they do get a nick on their finger, for instance, they should apply some antibiotic ointment, make sure it stays clean. If it starts to look red like it could be getting infected, they should be treated before that becomes a problem with the lymphatic system. There are other ways of lowering the risk. Even after that, you’re still left with the 7% risk. The only way that can really be addressed is to assess the amount of fluid in their extremity with a test called LDEX, which is a short phrase that refers to what’s really called bio-impedance spectroscopy, which is I guess a good way to describe it would be like an EKG of your arms which gives is an indirect measurement of how much fluid is in the extremity. So, what that device is measuring is the conductivity of electricity in the extremity. It turns out that the more fluid that is present in the extremity, the lower the resistance to electrical conductivity. So, what it’s really looking at is does the resistance to electrical flow decrease? So, we’re not electrocuting the patient, but we’re giving a small current of electricity and then measuring what the resistance is. So, we get a baseline. So, for instance, today we did a cancer consult on a patient who we just diagnosed with biopsy, and one of the first things we did after she arrived was check an LDEX test on her with the Sozo device. That’s our baseline. When she comes back one month after surgery, we will check it again. Then when she comes back every three months for the first three years, we’ll check it. And then every six months out to the 10th year. If we see an upward deflection in the LDEX number of 10 points or more, that’s a sign that we’re beginning to see increased fluid in the extremity and that patient is at a significant risk of developing chronic lymphedema. The important thing is that, at that point, you still can’t see lymphedema, you can’t feel it, the patient isn’t aware that anything’s wrong. We also know from research that, if we place those patients in a compression sleeve for a period of a month, that 97% of the time we can avoid chronic lymphedema. So, it is a way of preventing chronic lymphedema from occurring.
Is this something that you can see in real time what’s going on?
TURNER: So, the patient has to remove their shoes and socks. The device has metal plates on the bottom, and so they stand on those metal plates. Then there are metal plates on the top that they place their hands on, and that’s how the electrical current is delivered. You can use it to check any extremity, it’s just that here we’re looking at the upper extremity.
You said increments of 10, can you explain to me what a baseline number would be, what a good number is?
TURNER: There is no good or bad baseline number. It is whatever it is. So that’s that patient’s baseline level of conductivity. So, for instance, I think the patient we had earlier had a baseline of negative 13. That’s where she started. So, when she comes in next time, she may have negative eight, which is fine. It’s not going to remain the same, so you’re going to see deviations up and down in that. We see that you see a curve as you’re moving forward. So, when we get there is a tablet that sits on top of the device and that has stored within it or in the cloud all of their measurements throughout history. So, you can see from the beginning, the first time you ever checked an LDEX, and then every three months LDEX are plotted on a graph, which you can see in a little bit. So, you can follow what their direction has been. So, what you don’t want to see is this steady upward curve that now reaches into the red zone that we would call it, where they’ve gone more than 10 points above what their baseline was. Let’s say they start at minus 13. They might be minus eight and then minus 15, then minus three, then plus two, and then the next time they come so now it’s plus 13, now you’ve got a problem. So at that point, we would refer the patient to our lymphedema specialist, who’s one of our physical therapists, and they would fit the patient for a sleeve, talk to them about some exercises and put them in a sleeve for one month. At the end of that month, I would see them back and do another LDEX. The vast majority of the time the LDEX has returned to normal at that point. At that point, they can stop wearing the sleeve.
What’s the benefit for the patient here and how long have you been able to extend this window into what’s going on?
TURNER: Well, the benefit is the avoidance of long-term use of a compression sleeve and long-term suffering from lymphedema. Chronic lymphedema is absolutely miserable. If you’re familiar with the actress Kathy Bates, she had bilateral mastectomy and developed bilateral lymphedema. She is a great resource for what symptomatic lymphedema does to the patient and lectures the worldwide on that. It is an absolute miserable situation. So, the benefit is the avoidance of that. So if that patient, the same patient, never had an LDEX checked and we did not have that early warning that their numbers had deflected upward, they would never be placed in a prophylactic sleeve for a month. They would’ve come in for one of their future visits and had clinically significant lymphedema where they’ve got swelling that you can see, they’re symptomatic with it. At that point, the great majority of the time, they are going to live with that for the rest of their life. They can have some improvement with compression, whether it be the compression sleeve or wrapping or massaging and wrapping or pneumatic compression devices, and sometimes it’s all of the above. At most you can give them improvement, but you’re not going to give them a resolution or healing of that lymphedema.
And how long has this been a tool?
TURNER: Well, we’ve been using it for about five years now. It’s been around for a little longer than that. Like everything else, when something first comes out, you’re a little skeptical about whether it really works. So, we watched it for a while, and then the data really came out that showed, again, 97% prevention of chronic lymphedema. That became something that you just couldn’t avoid paying attention to. So, the management of lymphedema in the world of surgery has really advanced gradually over the past 20 years, and it was just 20 or 25 years ago that the standard of care was to remove the entire group of lymph nodes in the underarm with that 30% incidence of lymphedema and we just accepted it. We thought that was it. The first thing that came to help that was the principle of sentinel lymph node biopsy as opposed to full lymph node dissection. The sentinel lymph node is the first lymph node to get any drainage from the breast. The principle is, if you identify it and biopsy it and it has no tumor in it, then the others can be considered free of tumor and you can avoid the full lymph node dissection. The second big advancement was the development of the LDEX device.
Is there anything I didn’t ask you, doctor, that you’d want to make sure that viewers at home knew?
TURNER: I think the big thing is to be aware of this, whether it be yourself or a relative. And if you’re not someplace where this can be followed and you can have preventative measures done, then you really ought to seek some place that you can have these numbers followed and try to avoid lymphedema.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
DEANNA HOLLENBACH
DEANNA.HOLLENBACH@EVANHOSPITAL.COM
(570) 490-3110
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