Ohio State surgeon helps pioneer preventive lymphedema-relieving surgery in patients with cancer

An estimated 5 million people in the United States experience chronic lymphedema ― painful and mobility-limiting swelling of arms and legs ― after undergoing lymph node dissection and receiving some form of treatment for their cancer.

However, a new procedure may prevent lymphedema altogether.

Roman Skoracki

Preventive lymphedema-relieving surgery is a fairly new procedure performed in Europe and the United States. Only a handful of surgeons perform the procedure, which is done immediately after axillary lymph node dissection so surgeons can perform two separate procedures with only one incision site.

HemOnc Today asked Roman Skoracki, MD, division chief of oncologic surgery at The Ohio State University Comprehensive Cancer Center and also one of the few surgeons who performs the procedure in the United States, about the unique nature of preventive lymphedema-relieving surgery, how it is performed and the potential benefits for patients.

Question: How did you become involved in the procedure?

Answer: This prophylactic surgery was really the brain child of a group of surgeons in Italy. I have been performing lymphedema surgery for a while and I attend many of the major conferences on this topic. At one of these conferences, I came across the group from Italy about 10 years or so ago and we have been in contact ever since. At a recent meeting, they presented some work that they had shared with me and that was the work of the prophylactic bypass. I had more discussions with them about this and it just made sense to me, so I started performing the surgery, as well.

Q: What makes this procedure different from other treatments for lymphedema?

A: It is not that different in terms of the technical aspects of the procedure, so it is still a rerouting or bypass from the lymphatic system to the venous system, which is something that we do perform for the treatment of lymphedema. The difference here is that it is performed before lymphedema develops. It is done at the same time that the surgical oncologist performs the axillary lymph node dissection. We perform the bypass at this time with the hope that the patient will never develop lymphedema.

Q: Can you describe how the procedure is performed?

A: The nice thing about this procedure is that the downside is relatively minimal in the sense that the surgical oncologist will perform the axillary lymph node dissection on select patients as indicated by the stage of their disease and immediately after the removal of the lymph nodes. We come in and utilize the same incision so there is no new incision. We do inject dye into the arm or hand in order to better visualize any lymphatic channels that may be severed coming from the arms. If we do identify any severed areas, we take those lymphatic channels and we find small blood vessels in the area and we connect the two so that we essentially give the lymphatic channel a new outflow.

Q: What type of feedback have you received from patients who underwent the procedure?

A: We have not performed very many of the procedures yet here in the United States, as the procedure is still in its infancy. However, the patients who have undergone the procedure have been very satisfied, and those who have undergone the procedure have not developed lymphedema. This is also what our colleagues in Italy have found ― the chance of developing lymphedema is not brought to zero, but it is dramatically reduced. If a patient has an axillary lymph node dissection and the patient does require radiation and chemotherapy, then the risk for lymphedema is up to 40%. With this procedure, the risk is reduced to 4%. That is a very drastic decrease in the risk for developing lymphedema.

Q: Are there any major adverse events or challenges associated with the procedure?

A: We have not encountered any adverse events in the patients that we have performed the procedure on because we do not add any significant risks to the patient. The only thing we do is inject the dye, and this is very well tolerated. The difficulty is that it is technically quite challenging, because these channels are very small in diameter and we are usually working in a very deep and tight space. From a technical standpoint, it can be very challenging, but there is very little risk to the patient associated with it.

Q: What advice would you offer the patient who is weary of undergoing the procedure? Is this something that is for everyone?

A: The procedure is not for everyone, but I can think of very few downsides to why one would not consider this. For background, my colleague, Hiroo Suami, MD, PhD, has done a tremendous amount of work in the anatomy of the lymphatic system. The foundation of sentinel lymph node biopsy is based on the fact that there is a drainage pathway from the breast that leads to the axilla that is specific to the breast. This drainage pathway will go initially from one part of the breast to one or a few sentinel nodes, which will be exposed to the fluid. Dr. Swami found that, in the majority of patients, the equivalent lymphatic drainage system that comes from the arm is entirely different or separate from the breast but they both converge in the axilla. At the time of axillary lymph node dissection, some effort has been put into trying to differentiate these two sets of drainage and filtration systems and to separate them. Dr. Suami and colleagues have found that, in about 20% of patients, there is an overlap of the two systems and you may not be able to differentiate. Armed with this knowledge, we can focus on those lymphatic channels arising exclusively from the arm, avoiding any channels that may have been carrying cancer cells from the breast, and focus on re-establishing an outflow or drainage pathway only for the arm lymphatics. The downside is very little. There is no significant bleeding or other major drawbacks associated with the surgery.

Q: What advice would you offer surgeons who hope to learn how to perform this procedure?

A: They should familiarize themselves with lymphatic surgery as a whole, and once they have done that, this procedure becomes the next step. Technically, it is not any more demanding than the surgeries we already perform for lymphedema. I think if they were to familiarize themselves with these other procedures, this is a natural extension of these procedures. It does require close collaboration and coordination with your surgical oncologist, which is something we are very familiar with and practice on a daily basis with our multidisciplinary patient care approach.

Q: Is there anything else you would like to add?

A: It is nice for patients to know that this is an exciting time in lymphedema research and clinical care. There is so much research going on and there are so many strides being made at every level, in education, basic science research, in imaging, in the conservative treatment, and at the prevention and surgical treatment level. Things have improved a great deal in a short time already, and I believe there is a lot of hope and excitement in the field of lymphedema care. I am certain that there will be many changes in the next 5 to 10 years that will improve patients’ lives tremendously. – by Jennifer Southall

For more information:

Roman Skoracki, MD, can be reached at The Ohio State University, Department of Plastic Surgery, 915 Olentangy River Road, Suite 2140, Columbus, OH 43212.

Disclosure: Skoracki reports no relevant financial disclosures.