Learning About Lymphovenous Bypass Surgery

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Hi everybody and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And I'm so happy to have one, a second appearance on Butts & Guts, Dr. Stephanie Valente and two Dr. Julie Lang the Chief of Breast Surgery at Cleveland Clinics Cancer Center. And of course, Stephanie is also a surgeon in the department of breast services at Cleveland Clinic Cancer Center. Ladies, welcome to Butts & Guts.

Dr. Stephanie Valente: Thanks for having us.

Dr. Julie Lang: Great to be here.

Dr. Scott Steele: So, today we're going to talk a little bit about lymphovenous bypass surgery and breast cancer. Something that, obviously, can be extremely debilitating, and not a topic that we cover a whole lot of. So thank you so much for joining us here. And so for both of you, Stephanie, you know we always like to get a little bit of background about each of you, and if you want to... Julie, why don't you lead off and tell us first a little bit about you, where you're from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Julie Lang: I'm originally from Cleveland, Ohio. I grew up in the east side in Mayfield Heights and my medical education brought me to North Carolina, University of North Carolina Chapel Hill, and I completed a seven year surgical residency and postdoctoral research fellowship at the University of California, in San Francisco. Afterwards, I completed a breast surgical oncology fellowship at the MD Anderson Cancer Center. And now I've been in practice for 14 years and returned to my hometown as Chief of Breast Surgery at Cleveland Clinic.

Dr. Scott Steele: Well, welcome back home. And Stephanie, for those who haven't gone back and listened to older episodes, which you should, all the listeners out there, Stephanie, tell us a little bit about yourself.

Dr. Stephanie Valente: I've been in care at the Cleveland Clinic for 10 years. I grew up on the west side of Cleveland and did my training around town. I had the opportunity to also go out to California at University of Southern California and do my fellowship training out there in advanced surgical techniques. So happy to be here today.

Dr. Scott Steele: Well, welcome as well, and both to the west coast and just couldn't wait to get back to beautiful Cleveland, Ohio. So, as many of our listeners may know that October is breast cancer awareness month and next to skin cancers, breast cancer is the most common cancer among women in the United States. And here at the Cleveland Clinic experts such as those joining us today are leading the way in breast cancer screening, treatment, and follow-up care. So we're extremely excited to talk to the both of you today. So, I'll throw this out to either one of you, give me a high level for our listeners. Can you provide just a little bit about breast cancer overview? How does it develop? What are the symptoms? Are their age ranges? What are we talking about here? Set the stage for us.

Dr. Julie Lang: Annually, there are 240,000 patients diagnosed in the United States with breast cancer. And the majority of these are detected on screening mammography. Mammography is very important and it's a life-saving diagnostic tool. So I would encourage all of you, women who are eligible, please go get your mammogram. It's safe to do so, and hospitals are well-protected for you to go and get your mammogram. When we diagnose breast cancer, it is typically done by an image guided core needle biopsy. The radiologist will see something, and then we'll call the patient back, either have an ultrasound or a stereotactic biopsy, which is biopsy aided by use of the mammogram.

So these are how most of the cancers are diagnosed in our country. And about a 25% of breast cancers are node positive breast cancers. And so node positive breast cancers are the subject of our discussion today. These are patients who potentially may need to have something more than a minimally invasive procedure, the minimally invasive procedure being Sentinel node biopsy. Certain patients need a complete axillary lymph node dissection, which removes an average of 15 lymph nodes from the axilla. And this leads to the consequence called lymphedema, which is arm swelling. And arm swelling is a very debilitating condition, it's due to the fact that there's shared lymphatic flow between the breasts and the arm lymph nodes. And this can result in a chronic condition that affects up to 30% of patients who undergo the complete axillary lymph node dissection procedures.

Dr. Scott Steele: So we'll start there and you just mentioned it, and I've seen people that have the sleeves after some sort of either an axillary procedure or breast surgery, something like that. So maybe Stephanie, can you give us, we're going to talk about this lymphovenous bypass surgery. So, can you give a little bit of an overview of lymphedema and this bypass surgery, just to set the stage for this? Is it non-preventable at all to get first of all, to get that lymphedema? Can we do that? Anything about that? Or are you kind of doomed to wearing some sort of a compression device or something long-term after you've had this type of surgery?

Dr. Stephanie Valente: Those are great questions. So obviously the biggest fear for any woman with breast cancer is recurrence. And the second biggest fear is developing lymphedema as a consequence of her breast surgery. There are a lot of factors that contribute to lymphedema, so minimal surgery, so removing one or two lymph nodes, the risk is about one to 2%. But as Dr. Lang mentioned, some women have advanced breast cancer and the treatment is to remove all of the lymph nodes. In that case, the risk of developing lymphedema over a woman's lifetime is 20 to 30%. And the risk is the highest in the first three years. So 75% chance that if you're going to develop lymphedema, it would be in those first three years. So a lot of things that women can do besides watching weight, is maintaining a healthy body weight, exercise. Some of the chemotherapies that we give women can cause it, and then radiation.

So a lot of women wear the lymphedema sleeve for one of two reasons. One is that they're undergoing treatment, they have developed lymphedema and another one is protective. So some women don't want to develop lymphedema, so they'll wear it when they're doing increased activity, or flying on an airplane, or something like that. We have developed a technique nationally, and we started in our program combined with our plastics and reconstruction surgeons in 2016. Where at the time of surgery, the surgeons identify the lymphatic channels that are draining from the arm, and essentially tag those with clips for the plastic surgeon. We also identify draining veins that drain into the axilla, preserve those at a link. And that gives the opportunity for the plastic surgeons under the microscope to reattach the lymphatic channels directly to the draining veins. It's kind of like driving and hitting a dead end road, which would be the lymphatics traditionally, versus creating a bridge back to the highway. So that's essentially what we're doing is creating a bridge so that the lymphatic flow can drain back into the vena system.

Dr. Scott Steele: So you guys mentioned it, and obviously as somebody who is not as familiar with these type of procedures. Is this something that is kind of a standard of care, is this innovative, is this done anywhere else? How often does this performed?

Dr. Julie Lang: This is a very innovative procedure. And there are a limited number of medical centers around the world performing this procedure because it requires significant expertise. Plastic surgeons who are trained in microvascular anastomosis, or making connections between the blood vessels and the lymphatics, using an operating microscope are required. And they use suture that is finer than a hair. So it really requires a lot of skill and expertise, and it requires preoperative planning for the patient. So Cleveland clinic is a leader in this and has a lot of enthusiasm. And I'm going to let Dr. Valente tell you about a study that she and the group have done previously.

Dr. Stephanie Valente: So we started our program in 2016 and we looked at patients and we followed patients looking at their development of lymphedema. And so it's the same surgeons that were doing this, and we couldn't catch everybody. We couldn't plan on who needed an axillary lymph node dissection. At the time of surgery, we found out they had a positive lymph node and we didn't have plastics on hand to come in and do the procedure.

And so what we found during our short term follow-up is that the risk of getting lymphedema for the same surgeons, doing the procedure without the bypass was around 15%. When we had our plastic surgeons come in and do the bypass, we decreased it to less than 5%, so a 10% improvement. And so now it's really become a standard of care. Anytime we go into surgery and we're going to do an axillary lymph node dissection, we make sure our plastic surgery colleagues are there and they're pretty facile and good with it. So it takes about an extra half hour to an hour to the procedure for a lifetime reduction in developing lymphedema. And so across the country, a lot of patients will fly in just to have the surgery performed.

Dr. Scott Steele: That's absolutely fantastic. And how exciting, so truth or myth, any patient treated for breast cancer is a candidate for the LVB bypass.

Dr. Julie Lang: Well, it's the specific patient population who requires the complete axillary lymph node dissection that would be eligible for considering LVB bypass. Most breast cancer patients are treated with central node biopsy, removing an average of two lymph nodes. And that procedure has very low rates of lymphedema. So most breast cancer patients would not be eligible. But the patients who would be eligible, the ones who are node positive, undergoing planned axillary lymph node dissection, have a chance to benefit. And so the relative benefit is a 10% risk reduction, but the absolute benefit of 30% risk reduction in lymphedema. So we think that that is a significant benefit, and we're actually planning a prospective randomized trial to evaluate this because currently it is not considered standard of care. And we have one of the largest experiences nationwide with this disease. So I'm pleased to report that our multidisciplinary team is currently offering this protocol, and we hope to have this underway in the next year or two.

Dr. Scott Steele: So you mentioned a little bit about the advantages of getting this procedure done, but are there any disadvantages of it, or is there something... Obviously you said it takes a little bit longer maybe under anesthesia or anything, but what are the potential disadvantages of having this?

Dr. Stephanie Valente: So that's a great question that we actually published a few years ago on, is time. OR time, time is money, right? So when you first start anything new, you have to say, what's the benefit to the patient. It's longer operating, time under anesthesia, it's longer OR time, you do have to have surgeons that are trained in this technique. Which training does take a little bit of time and then operating times. And so you're not just doing one bypass. Sometimes you're doing up to four bypasses. And so it does take time. And so we looked at our trends over time and as the surgeons became comfortable with each other and comfortable with the procedure, we were able to significantly reduce our time. When we first started, we gave ourselves two hours, we're into about 45 minutes right now.

And so then we say what's the value. And so 45 minutes extra in surgery to give somebody a lifetime value is definitely worth it. And so it is longer operative time. The other thing is we don't really understand what radiation does to our anastomosis. So we're using 12-0 suture, to do these anastomoses. It's tiny. And so, are these channels able to recannulate after radiation, or does radiation scar those down? So again, it's another area of research. We do all this work and what does it look like after?

Dr. Scott Steele: So let's talk a little bit more about lymphedema itself. So Truth or Myth: lymphedema can appear in people years after their breast cancer treatment ends.

Dr. Julie Lang: That's actually true. Oftentimes there's an inciting factor, such as infection. So if someone had a history of an axillary lymph node dissection, and then got a horrible infection in their hand, that is a predisposing factor that may lead them to a diagnosis of lymphedema. So these patients should be advised to wear gloves. The proper protection of their hands is really critical if someone has a history of an axillary lymph node dissection.

Dr. Scott Steele: So what is the long-term consequences of lymphedema? I mean, obviously there's the swelling and it's probably an uncomfortable or something, but is there any other dangers to lymphedema?

Dr. Stephanie Valente: So one of the big dangers of lymphedema, which is rare, is lymphangiosarcoma. And this is sarcoma of the arm from chronic lymphedema that develops and goes untreated, obviously that's worst case scenario, but for anybody who lives with lymphedema, that's bad enough. I mean, you can't wear a shirt that fits your arm, your arms as big as your leg. So just trying to find proper fitting clothes, they really can't even hold pencils, wear their rings, wear their watches, use their hand, especially if it's their dominant hand. So it does become functionally very disabling for these patients, with the fear that if it doesn't get treated, they could go on to develop angiosarcoma.

Dr. Scott Steele: So if I understand it right, you're doing this at the time of the actual axillary lymph node dissection. But what about people who may have lymphedema? Can you take them for this bypass procedure and, how quickly could they potentially see results?

Dr. Julie Lang: Yeah, so that would be considered a therapeutic lymphovascular bypass rather than a prophylactic lymphovascular bypass. And so this is an evolving field. Initially, there were a lot of different operations that were studied, and a lot of this has come to fruition in the recent five, 10 years. So we don't have long-term outcomes data for a lot of these procedures yet, but they do seem to be quite promising and of the available options, lymphovascular bypass is the preferred technique here at Cleveland Clinic.

Dr. Stephanie Valente: Let me just add to that. We also do some techniques that have shown to work are, liposuction of the arm, so you could do that. You could do lymph node transfer, sometimes actually just going into the axillary area and clearing up some of that scar that's been created from surgery and radiation is helpful. And so we actually do have a huge lymphedema management program. Maybe just getting into comprehensive decongestant therapy with physical therapy is helpful. So there are a lot of other techniques once lymphedema develops, it's not like it's an end all be all. There are some other options that are out there, but as Dr. Lang mentioned our goal is, if we prevent it, we don't have to treat it.

Dr. Scott Steele: So what's on the horizon as far as additional research. I know you said that you're leading this, you got this awesome trial that's getting underway, but any of the things that our audience should be aware of in terms of the entire breast cancer or with regards to LVB.

Dr. Julie Lang: We're very interested in this LVB program, and I'll add to what has been stated already, is that we're planning to look at certain blood tests that can predict for lymphedema risk or predict for lymphedema response to LVB surgery. So that that scientific component of the study will be built in there as well. And additionally, I recently joined Cleveland Clinic and I'm a physician scientist. So I have a laboratory in the Learner Research Institute, and we're going to be studying liquid biopsy or blood indicators of cancer diagnosis, or prognosis for therapy. So we're excited to be bringing the lab online here to benefit our breast cancer patients.

Dr. Stephanie Valente: And from a clinical standpoint looking at, I had mentioned radiation, can we tailor our radiation to radiate everywhere except for anastomosis? We could look at that. We are also looking at how many lymphovenous bypasses do we need? Is one enough, is four enough? Where do we stop? And what's the maximum benefit for these patients. And then, again, looking at fluorescence imaging to see if our anastomosis are working. And as Dr. Lang mentioned, that all patients are created equal as far as anatomy. So is there certain anatomy that predisposes somebody to getting lymphedema versus someone else.

Dr. Scott Steele: That's exciting times. And so glad you're here to lead the way on that. So for all the listeners who are always with us, you know we like to end with some quick hitters to get to know our guests a little bit better. And Stephanie, since you are a second time, I'm going to change up the questions a little bit. Julie it's your first time, so I will give them both to you. So if you do listen to music in the operating room, what is your choice type of music?

Dr. Stephanie Valente: I don't know if anyone's going to want to come in my operating room, but I love it. I love to listen to Meghan Trainor on Pandora.

Dr. Julie Lang: I love to listen to alternative rock, especially Pearl Jam.

Dr. Scott Steele: Fantastic. And for both of you, what is your favorite food to cook?

Dr. Stephanie Valente: Does cereal count?

Dr. Scott Steele: Absolutely.

Dr. Julie Lang: I like to grill steaks.

Dr. Scott Steele: Fantastic. At what was your first car?

Dr. Julie Lang: My first car was a Saturn Coupe.

Dr. Stephanie Valente: My first car was a stick-shift red Ford Probe.

Dr. Scott Steele: Fantastic. And finally, if you had to have a go-to movie on a rainy Sunday evening, where you're just going to go in and the kids are in bed. What's your go-to movie?

Dr. Stephanie Valente: You can never go wrong with The Goonies.

Dr. Julie Lang: I would watch The Princess Bride.

Dr. Scott Steele: Good choices, good choices, good choices. So to the both of you, give us a final take home message for our listeners out there regarding this important topic.

Dr. Stephanie Valente: I think one of the most important topics for breast cancer is looking at survivorship. And one of the big components of survivorship is how a woman looks and feels after she's completed her breast cancer surgery. And so I think looking at the techniques that we do with surgery and making somebody cancer free, really looking at how we're leaving those patients. And functionally, if we're able to decrease their risk of getting lymphedema, then we're doing them a really good job.

Dr. Julie Lang: And I would add, Cleveland Clinic has an amazing, talented, innovative surgical team. And now we're able to organize some clinical trials and really go in depth and study these research questions of our days so that we can advance the field and lead to better outcomes for breast cancer patients in the future.

Dr. Scott Steele: That's great stuff. And so please remember it's important for you and your family to continue to receive medical care for your empowerment, and your peace of mind. Take the time to schedule a mammogram. Visit ClevelandClinic.org/walkinmammo, that's ClevelandClinic.org/walkin-M-A-M-M-O, to view all of the mammography locations, hours, and phone numbers, including those offering walk-in screening appointments for those women, even with no breast symptoms. And be rest assured here at the Cleveland Clinic, we're taking all the necessary precautions to sterilize our facilities and protect our patients and our caregivers. So Dr. Lang, Dr. Valente, thanks for joining us on Butts & Guts.

Dr. Stephanie Valente: Thanks for having us.

Dr. Julie Lang: Thank you.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.