The Latest Advances in Lymphovenous Bypass Surgery

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest innovative research in clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase I and Sarcoma Programs. Today, I'm happy to be joined by Dr. Stephanie Valente, Medical Director of the Breast Program at Cleveland Clinic Fairview Hospital, in the western region. She is here today to talk to us about lymphaticovenous bypass surgery and breast cancer. So, welcome.

Stephanie Valente, DO: Thank you for having me, Dr. Shepard.

Dale Shepard, MD, PhD: Absolutely. Maybe just start, give us a little bit of a background. What's your role at Cleveland Clinic?

Stephanie Valente, DO: Sure. I'm a breast surgical oncologist. So I see in consultation, and surgically treat, women with a diagnosis of breast cancer.

Dale Shepard, MD, PhD: Excellent. Today we're going to talk about lymphedema and this thing called lymphaticovenous bypass surgery. So tell us a little bit, what is that? Stephanie Valente, DO: Sure. In a woman who's diagnosed with breast cancer, part of their surgical procedure to remove their breast cancer is also removing a few, if not more, of her lymph nodes in her axillary area to stage breast cancer, and in some instances, remove breast cancer that's spread to the lymph nodes.

If we're just checking lymph nodes, the risk of getting permanent swelling in her arm after surgery is about two to 5%. And that's over her lifetime. If we need to remove more lymph nodes, the risk goes up to about 30%. So, for these women who undergo surgical resection of their breast cancer, one of the biggest fears that they have besides cancer coming back is developing lymphedema. Lymphedema is chronic swelling of the arm. Even though they can undergo therapy and procedures, it really is a chronic debilitating morbidity as a result of breast cancer care.

Dale Shepard, MD, PhD: And you said something about two to 5% lifetime risks. Is this something that most women would have early or late, or can people think they're kind of out of the woods and then it develops? What does that look like?

Stephanie Valente, DO: Yeah, that's a great question. Studies have shown that the risk of lymphedema is the greatest in the first three years after surgery. And it's a combination of factors. It's how many lymph nodes are removed, what type of surgery is done, whether or not that woman needs radiation afterwards. And so, after three years, about 25% of patients will have that lifetime risk.

Dale Shepard, MD, PhD: We're going to talk about some things that you can work on surgically, and procedures and things like that, but is there anything patients can do to either minimize their risk, or what are the types of things they can do to make their situation better?

Stephanie Valente, DO: Right. Maintaining an overall healthy body weight is very important. Upper body. Back in the day, there used to be these myths about lymphedema. You can't carry a purse on that side, you can't get blood pressure on that side, because those things would increase a woman's risk of getting lymphedema. What we find out is that, actually, the more women use that arm, as far as physical activity, the more it's actually helping prevent that. So we encourage early mobilization of that arm, maintaining a healthy body weight, and just kind of getting back to normal, and then screening for it.

So I think that's really important. After a woman undergoes surgery, and before then, we get a baseline of kind of where the patient is. And at the Cleveland Clinic, we do a few things. We use circumferential arm measurements, which kind of measure the at-risk arm to the normal arm, and then follow that. And then, we also use bio impedance spectroscopy, which measures the extracellular fluid balance in the affected arm.

And so that way, it's kind of like screening for a mammogram. Sometimes you can't feel the breast cancer, but you see it developing in the mammogram beforehand. And that's similar with lymphedema. Maybe you don't see it or feel it, but able to detect it in its earlier stages, where we can send a woman through what we call breast rehab, and help prevent it from starting.

Dale Shepard, MD, PhD: Who takes lead on follow up? Is this part of our breast program in the breast center?

Stephanie Valente, DO: Yeah. How it works, is that anybody who's diagnosed with breast cancer, when they come in to see the surgeon, they actually get a baseline measurement. Obviously, if they've had their lymph nodes removed, they're at a higher risk, and we follow them a little bit more frequently. But yeah, follow up continues throughout survivorship.

There are techniques that we do in the operating room when we know that we're going to be removing a lot more lymph nodes. So, an axillary lymph node dissection, that we have teamed up with our plastic surgery colleagues to prevent, hopefully, the development of lymphedema.

Dale Shepard, MD, PhD: And actually, there's a previous episode of our Cancer Advances podcast, where we talked to Dr. Schwartz about lymphedema. So if people want to go back and listen to that, they can get some information as well. But when we talk about procedural sorts of things, tell us a little bit about what those procedures might be, and when those occur.

Stephanie Valente, DO: Again, the goal for breast surgery is to remove the cancer, but also prevent, obviously, this morbidity of lymphedema. And so, we do what's called lymphedema prevention surgery, and that's at the time of surgery. This is where we know that a woman's going to need an axillary lymph node dissection. And so, the breast surgeon will inject a blue dye into the upper extremity of the woman's arm before we start surgery. That blue dye travels to the lymphatic channels that are draining the arm.

So, when I'm doing the axillary lymph node dissection, I'm able to identify those blue draining lymphatics. And during the lymph node dissection, I cut across those lymphatics, because that's how I'm removing those lymph nodes. I identify those blue lymph nodes. If they're not in any area where I need to transect them, then I don't. But if I do, I clip them and cut them, and I mark those for the plastic surgeon.

So then, when I'm done with my part of the surgery, I always tell patients, the goal of surgery is when you wake up, you're cancer free. So, I do what I need to do to get them cancer free. And then the plastic surgeon will come in, and they'll take those small little lymphatic channels, and they'll reanastomose those at the time of surgery to some of the small veins that I've left behind as well.

I always tell patients, it's kind of like you're driving down the road and you hit a dead end street. That's kind of like those lymphatic channels, just hitting against that clip in that lymphatic channel, whereas, the bypass actually is kind of a bridge back to the highway. So it's going to redirect that lymphatic flow so that it goes directly back into the vein, so that those women have a pathway for the lymphatic channels to flow, and hopefully decrease the chance that they develop lymphedema.

Dale Shepard, MD, PhD: So this is essentially a part of the initial surgery. This is something that's all done at the same time?

Stephanie Valente, DO: Correct.

Dale Shepard, MD, PhD: Patient wakes up from the surgery, and hopefully won't have problems because of that.

Stephanie Valente, DO: Yeah. It adds about an extra hour onto their surgery. But studies here that we've done at the Cleveland Clinic shows that it decreases their risk of developing lymphedema by about 10%, which is a lot.

Dale Shepard, MD, PhD: That is quite a bit. How common place are these procedures? Are these things that are being done on a widespread basis, or are types of procedures we're doing a little bit differently here?

Stephanie Valente, DO: Yeah. We've been doing the lymphedema prevention surgery here at the Cleveland Clinic since 2016. Nationally, the American Society of Breast Surgeons has recognized lymphedema as a significant problem in survivorship. And so, really focusing efforts more recently on training surgeons about recognizing lymphedema, understanding its importance in survivorship, and then actually teaching surgeons this technique, because it is not something that you learn in general surgery residency, except for if you're a general surgery resident here.

But there are a few places across the country, because it is an advanced surgical technique that is a specialized training to learn how to look for the lymphatic channels. And then in our case, we do use our microvascular surgeons to help with anastomosis. So it is a team approach.

Dale Shepard, MD, PhD: You mentioned things that were factors, like the number of lymph nodes that need to remove things like that. Who would be an ideal candidate? Give us an idea. So if someone might be listening, saying, "Hey, I have a patient that, maybe, I need to make sure they have a procedure like this," who would that be?

Stephanie Valente, DO: Yeah. And we do have patients who come specifically for this procedure. This is somebody who's diagnosed with breast cancer, who it is known at the time of their diagnosis of breast cancer that they have breast cancer that's metastasized to their lymph nodes. And so that procedure, the axillary lymph node dissection procedure, has been discussed with that patient already.

Sometimes patients get chemotherapy before surgery, with the hopes of shrinking the lymph nodes or killing the cancer from the lymph nodes, so that they might not need such an aggressive axillary surgery. And if that's the case, we would just remove a few of the lymph nodes after chemotherapy. But because we do this so frequently at the Cleveland Clinic, if there is cancer that's in the lymph nodes after chemotherapy, we're able to add this surgery on. So say, if we need to do the lymph node dissection, if we need to do more aggressive axillary surgery at the time of their surgery, then we're able to do this procedure, because it is pretty common here.

Dale Shepard, MD, PhD: What are the gaps? What are we missing at this point, in terms of our ability to surgically minimize risk?

Stephanie Valente, DO: The question is, and in the research you say, "Gosh, do we need to remove all these lymph nodes? Do we need to continue doing such a morbid surgery? Can radiation alone help this? Are removing all the lymph nodes, like the modified radical mastectomy is removing the chest wall, do we need to do this?" Those are questions that are actually being answered right now in national research clinical trials. And so, we don't have the answer to that.

And so right now, there are many reasons that axillary lymph node dissection is indicated. And so, as long as we're doing that procedure, we should be doing a preventative surgery along with it to help decrease the chance. But I could see in the future, maybe not needing to do that, but we're not quite there yet.

Dale Shepard, MD, PhD: So this is more of a trying to prevent a problem from developing procedure. What's available for a patient who may have missed out on an opportunity to have a procedure like this, and they're two or three or five years out from their surgery, and they have problems with their arm, are there things that are being worked on, or things available now, that are similar that can help these patients?

Stephanie Valente, DO: Yeah. And that might have been what you and Dr. Schwartz talked upon before, but lymphedema prevention surgery, again, decreases their risk by about 10%. Obviously, there are some women who still ultimately develop lymphedema. And so, we're studying, why do certain women develop lymphedema, and some women don't? Is there a way that their lymphatic channels are made up? Is it their anatomy? Is it the dissection? Is it the treatment that they receive?

And so, we're continuing to study those things, but if a woman does develop lymphedema, then they would go on to meet with our plastic lymphedema surgeons. And they actually assess these patients, and they study their lymphatic channels, and they study their flow, and they say, is there anything that they can offer from a surgical standpoint that would help reduce lymphedema? And so, they do lymphovenous anastomosis in the forearm, maybe taking it out of the axilla if there's a lot of scar tissue in that area. So they have a lot of different techniques that they can do.

Again, we've also got a robust physical therapy and occupational therapy program here. So those therapists work specifically with our patients who've had this procedure, or who are developing lymphedema, to say, are there exercises that they can do at home? Is there a weight loss program that they need? What can these women actually do to decrease the swelling, and get them back to as normal as they can?

Dale Shepard, MD, PhD: And then, you had just mentioned something about radiation. If as a surgeon, you're there, and you know what you're taking out from a lymph node standpoint, you can try to intervene. Sounds like from a radiation standpoint, that would be difficult, because you might be scarring down lymphatics, and don't have a lot of control. So is there anything that could be done in a more preventive way from a radiation standpoint?

Stephanie Valente, DO: Right. Usually, these women who have... Again, in 2021, if you have lymph nodes that have cancer in them, the recommendation is going to be to receive radiation, to prevent local recurrence. And so, we know going into surgery that most all of these women are going to be recommended to get radiation. And so, the question is, what does radiation do to our little microvascular anastomoses?

And so, studies have shown that they remain patent. And so, whether or not it's connecting these channels, and they're able to stay. But again, it's another good area of research, exactly like how do these stay patent? How many lymphatic anastomoses do we need to do? Is one good enough? Do we need to do three? Kind of what that looks like. But we do know that radiation significantly causes scarring there.

The other thought is, can we build a radiation technique with the dosimetrist and the physicist to design radiation field that actually would exclude the lymphatic channels that have been reanastomosed? And so, we've been looking at that with our radiation oncologist as well.

Dale Shepard, MD, PhD: You mentioned before about patients being concerned about the consequence of surgeries and lymphedema. And I guess the question is, oftentimes, as a medical oncologist, I know people don't come to see me, because they're afraid of chemotherapy and side effects. How do we educate docs that might be sending patients? How do we educate patients about the fact that these techniques are available, and that this may not be as much of a problem for them as they might anticipate? How do we get the word out?

Stephanie Valente, DO: Podcasts such as this.

Dale Shepard, MD, PhD: Oh, that's a good idea.

Stephanie Valente, DO: Great idea. No, but I think it's a national awareness. Recently, the American Society of Breast Surgeons put together a three hour webinar for all of the breast surgeons, to discuss lymphedema, management of lymphedema, the myths of lymphedema, and similar topics like this. Webinars, education, because again, it is really important, and it's not something that we learned in med school to really focus on, but we know that the focus is shifting. And so, there's a strong movement towards looking at this now.

Dale Shepard, MD, PhD: That's great. What other things are coming up? What else should we know about these types of procedures in management of lymphedema?

Stephanie Valente, DO: As we understand lymph nodes, I think that's really important, is understanding the protective effect in the body. Are removing these helping or hurting patients, and is removing them or radiating them better? Which one is it? Are we sclerosing the lymph nodes with radiation, or removing them? And if we can divert pathways.

And again, just figuring out why patients develop lymphedema. Is it the surgery? Is it the anatomy? Is it the surgeon, the radiation? So I think, really kind of looking at all those different angles, and then figuring out how to study. And we don't really have great tests. We use a lot of Indocyanine green, maybe MRI, but the lymphatic channels are very small and have a lot of different pathways that they take.

So as we understand the importance, we always talk about arteries and veins in medical school, and really don't talk too much about the lymphatic channels and pathways, but I think understanding those and how they play a role, especially, you're looking at immunotherapy and stuff, how does that play a role in chemotherapy and in breast cancer care? And again, is keeping or removing lymph nodes and lymphatic channels?

So we actually are putting together... One of our research topics, is doing this procedure, actually, oncologically safe? We've done close to 150 of these procedures, and we've actually had no axillary recurrences. So we know that this procedure is safe.

Dale Shepard, MD, PhD: Well, I appreciate all of your insight today. You're doing some good work. We do a great job controlling tumors, but then these survivorship issues are huge.

Stephanie Valente, DO: For sure.

Dale Shepard, MD, PhD: And so, I appreciate all the work you're putting into that.

Stephanie Valente, DO: Yeah. I would just say, as a physician or a patient, if you have someone who has signs or symptoms of lymphedema... It was interesting, I was at the grocery store one day, and the lady was helping me out, and I couldn't help notice that her arm from her hand to her shoulder was wrapped in an Ace wrap bandage. And I just thought, gosh, how inconvenient that would be for her to continue to wash her hands, especially during COVID, and being wrapped. And so, I couldn't help myself but to ask her how she was getting treated and managed for lymphedema.

And I did even refer the lady at the grocery store to see one of our plastic surgery colleagues, because I feel so strongly that there are options, and that women should understand that they do have options, and that they don't have to continue to live in the state that they're living in.

Dale Shepard, MD, PhD: Well, thank you very much.

Stephanie Valente, DO: You're welcome. Thanks for having me.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget, you can access real time updates from Cleveland Clinic's Cancer Center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.