The Latest in Lymphedema
Graham Schwarz, MD, FACS, Director of the Cleveland Clinic Microsurgery and Breast Reconstruction Fellowship and Co-Director of the Multidisciplinary Center for Lymphedema Care, joins the Cancer Advances podcast to talk about the latest in lymphedema. Listen as Dr. Schwarz discusses the Multidisciplinary Lymphedema Center and how patients can benefit, along with the big impact microsurgery and supermicrosurgery have made in lymphedema treatment.
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The Latest in Lymphedema
Podcast Transcript
Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest innovative research and 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. Graham Schwarz, Director of Microsurgery and Program Director for the Breast Reconstruction Fellowship, and also Co-director for the Multidisciplinary Lymphedema Center. He's here today to talk to us about lymphedema. So welcome, Graham.
Graham Schwarz, MD: Thanks so much for having me, Dale.
Dale Shepard, MD, PhD: So maybe just start out, give us a little background on what's your role here at Cleveland Clinic?
Graham Schwarz, MD: So I'm a plastic and reconstructive surgeon here at the clinic. I have a specialty in what's called reconstructive microsurgery. In doing so, we really address primarily complex reconstructive problems, much of the time in collaboration with other other specialties. I also have a focus on lymphedema surgery and that involves also both microsurgical, supermicrosurgical and other surgical treatments in order to help improve that condition.
Dale Shepard, MD, PhD: So we have a pretty diverse group that might be listening. Can we maybe start at a very basic level, what is lymphedema?
Graham Schwarz, MD: So lymphedema is really a dysfunction of the lymphatic system. As many of listeners know, the lymphatic system has a primary responsibility in fluid balance and bringing back sort of the interstitial fluid from the body back to the core and into the bloodstream. Additionally, it serves an important immune surveillance function and protects us against infection and cancer. So what happens in lymphedema is that there is either an injury to lymphatic system, or there is a lack of development of the lymphatic system. This can in turn, cause stagnation of that lymph fluid. When then happens, it can be very problematic because that lymph fluid, which has a lot of protein in it, it can tell the body to not only sort of keep the fluid where it is, but it can tell the body to generate scar tissue, so fibrosis, it can activate pathways that tell the body to deposit fat in excess in the region where the lymphatic disfunction is occurring.
So for people experiencing lymphedema, they can start with some swelling and perhaps that can be manageable with certain compression therapies and massage and so forth. But over time, what can happen is that that can turn into a combination of both fluid and solid tissue. In other words, scar tissue and fat tissue. So no matter how much you try to squeeze the fluid out, the limb or the portion of the body may not ever decrease in size. Just to follow up, the reason that this is a problem is because it can cause significant disability. Functionally, it can cause pain. It can really impact on patient's self-image. It can be a financial burden to have to deal with this for four hours a day. It can lead to infections. So it's a real problem and it's not often discussed.
Dale Shepard, MD, PhD: Can you give us an estimate of the number of patients impacted? How many people are we talking that are impacted by lymphedema?
Graham Schwarz, MD: Well, there are millions, millions worldwide. I would say that in Western countries, developed countries, the most common cause of lymphedema is in fact, related to cancer treatments. There are several things that put patients at risk, including removal of lymph nodes and lymph tissue, radiation, certain kinds of chemotherapy. In, let's say, less developed countries, probably the most common cause of lymphedema is parasitic infection actually. We don't see that as much here in the United States. Then again, there can be congenital forms of lymphedema where things just don't develop properly. The rate of lymphedema, at least in Western countries, can vary by cancer type and cancer treatment. So it's highly variable.
Dale Shepard, MD, PhD: And this is primarily surgeries or radiation that are impacting the lymphatics for the extremities, correct?
Graham Schwarz, MD: Well, those are significant risk factors. Certainly, surgery and the more lymphatic tissue in lymph nodes you remove during a cancer surgery, there tends to be a correlation between your risk of development of lymphedema, certainly radiation to sort of nodal areas. Nodal basins definitely increases the risk, but there are certain chemotherapies, taxane based chemotherapies, which are known to be a risk factor as well. Some additional issues with cardiovascular health, weight and body mass index are a known contributor as well.
Dale Shepard, MD, PhD: So tell us a little about the Multidisciplinary Lymphedema Center. What does that entail and what are we doing here at the Cleveland Clinic to tackle lymphedema?
Graham Schwarz, MD: It's actually really exciting because this is a somewhat new venture. We've been working with lymphedema patients for years at the clinic, but I think there is a recognition that oftentimes, it's difficult for patients to sometimes navigate the system. Sometimes they don't even know that they have lymphedema and certainly, they don't have the resources, nor quite frankly, do necessarily their providers have the resources to be able to have experts in the field work with the patients to get them a better outcome. So our goal is really to consolidate care and make it much more easy for patients with lymphedema to navigate the system, see appropriate providers and experts in the field. So what we've done is we've really collaborated with a number of disciplines.
Primarily, we have our physical therapists and occupational therapists, many of whom are specialists in lymphedema therapy. We have our vascular medicine specialists who can deal with all modes of cardiovascular problems and have worked with these patients a lot in the past. We have folks like me who are plastic surgeons, and there are certainly new surgical treatments that have been developed over the last, let's say, decade or so and become more mature that can help. But there are so many other people were important in these patients' sort of journeys. Not only is their oncology team important, so they're key players, but we have folks who are involved in weight loss, our endocrine and bariatric weight lost colleagues and several other disciplines really important to be able to give the entire spectrum of care to these folks.
Dale Shepard, MD, PhD: Now, how much of this is focused on main campus? How much of this extends out to the region?
Graham Schwarz, MD: So it can be both. Currently, we're in a format where we're trying to just make access as easy as possible for patients. So we have developed several care pathways that will allow for patients to come in from the region. Even quite frankly, folks come to us from international and across the country, and we have ways to navigate the patients to our various multidisciplinary team members on a single day or within a couple of days to get most of their testing and assessments and management plan underway.
Dale Shepard, MD, PhD: All right. You're a plastic surgeon. Let's shift to something fun. Microsurgery, supermicrosurgery certainly has made a big impact in lymphedema. Tell us about that. What is it and what can be done?
Graham Schwarz, MD: So microsurgery has made a big impact. What microsurgery effectively is, is a set of techniques where we're operating on structures that are in the millimeter to few millimeter range. That's something that's been around since the eighties and nineties and so forth. We can use those types of techniques to transfer tissue from one area of the body to a different area of the body; so effectively, performing a transplantation, an auto transplant patient. As it relates to lymphedema, what we can offer in the appropriate patients is the transfer of lymphatic tissue or lymph nodes from one region of the body to another region of the body. This has been shown to improve lymphedema for a variety of reasons, which we can talk about. Supermicrosurgery is an evolution, so of speak, of a microsurgical technique. In these cases, we're dealing with structures that are less than 0.8 millimeters in size. So the technical nuance of doing these types of surgeries is a little higher. We require even more specialized instrumentation and a specialized skillset, but thankfully, we're able to offer all options to our patients here at the Cleveland Clinic.
Dale Shepard, MD, PhD: So give us a comparison to something. 0.8 millimeter, that's pretty small. What would that be equivalent to?
Graham Schwarz, MD: So that's almost less than a human hair. So we have fortunately, access to the microscopy and instruments and suture to be able to actually connect structures that are that small. So when we talk about lymphedema, one of the surgical procedures that we use, and it's especially impactful in folks with earlier stages of lymphedema, is something called lymphovenous bypass or lymphaticovenous anastomosis. What we do in this type of a procedure is we locate, through a certain mapping procedure, we locate lymphatic channels and we actually connect them into very, very tiny veins in an effort to get some of that protein laid in lymph fluid out of the extremity or out of the area, effectively providing a detour for that lymphatic fluid to get back into the bloodstream, into the core and decongest the area that is at issue.
Dale Shepard, MD, PhD: So that's essentially, as it says, a bypass. That's just sort of rerouting the fluid. You had just recently mentioned auto transplant. That's that sounds like it's more reconstructing the system?
Graham Schwarz, MD: In essence, that's correct. What we believe to be the mechanism, and it's still yet to be fully elucidated, but there's some good data to support this both in human and animal models, is that when we transfer this lymphatic tissue, lymph nodes, for example, if they have a blood supply, they can act as almost a pump where they can transfer fluid a little bit more efficiently from the interstitium into the bloodstream. So we're not at the level of the lymphatic vessel, we're at a slightly larger, more macro level. So between that, and oftentimes we'll transfer some skin, which also contains some lymphatic tissue and lymphatic collectors, that can bring some of this fluid through the vein that we connect at the site where we do the transplantations. We'll bring that fluid, that lymphatic and interstitial fluid back into the bloodstream. Now, in addition, what it's thought to do is to provide an immunologic center to the area so that in folks who are, let's say, devoid of lymph nodes or lymphatic function, you have these new transplanted immune centers in the areas that are at risk for infection.
Dale Shepard, MD, PhD: So some of the older therapies, the massage therapies you mentioned, they could be time-consuming, they're chronic. Patients that have surgery for their lymphedema, are they likely to still need some of those modalities? Or is this something that can really make them not need those therapies?
Graham Schwarz, MD: So I think it depends a lot on where their starting point is. Our approach here is that we really believe that both surgery and therapy are effective means of managing lymphedema. We will often times use them in tandem. I think it's really important, for folks who are or thinking about and are surgical candidates, it's important for them to be optimized with physical therapies prior to any surgery and continue to work through therapy and use compression after surgery. Now, at some time after surgery, there may be the opportunity to completely eliminate compression and therapy, but many times there is not.
That doesn't mean that it's not impactful, surgery that is, it means that we may be able to create a situation where therapy is much more effective. So for example, using surgery, perhaps a patient was not before, able to get any of the fluid out of their arm or leg or what have you. But now with surgery, there is a pathway to allow a better decongestion of the area. So maybe they don't have to spend as much time during the day, or maybe they don't have to do these compression maneuvers, or massage or pumping every day. Maybe they can really diminish the amount of time they spend taking care of their lymphedema. So it really can be a synergy. Some folks are very lucky. They get rid of all compression. Some patients still may need to use it, but experience a great improvement in their quality of life and time spent dealing with lymphedema.
Dale Shepard, MD, PhD: What are some of the factors that go into deciding what therapy is best for any particular patient?
Graham Schwarz, MD: There are a number of things. I think that we get a sense of where they are in terms of their lymphedema and sort of what, "stage," they're at. Some people have just noticed a new swelling. Some folks have been dealing with this for years and years and years, and really never had the opportunity to have any kind of care. So physical exam obviously plays still an extremely important role, as does their history. One thing that we do specifically when we evaluate patients for surgery is we perform a test called ICG lymphography, and what ICG lymphography is, it's a fluorescence guided imaging technique where we inject a fluorescent dye into somebody's limb or area that we're concerned about and we actually can map out the lymphatic drainage pathways. We can also see if there is evidence of backup into the skin of the lymph fluid. Depending on their physical exam and their other comorbidities in this type of a test, it can help us to determine what's the right treatment for them.
For example, if somebody has an early presentation of swelling and let's say, therapy has not resolved it and they're walking through their therapy, they're very compliant, but things are just not working out, we can assess them, we can do a test like this, and we can see are there still functioning lymphatic vessels? If there are functioning emphatic vessels, that provides us the opportunity to perform a bypass procedure like we talked about. The bypass procedure has many advantages in the sense that it's quite minimally invasive. We're operating just below the skin's surface. It's a same day surgery and maybe a few hours to do because it's technically involved, but it's a same day surgery with very little pain and we can often make an impact. Now, in patients who have a pattern of lymphatic disfunction where they have too much backup of the lymph fluid into their skin, into their dermis, that may indicate that the lymphatic vessels are just are too scarred and too sclerotic to be able to perform these super microsurgery procedures.
So in those cases, that's where we might use a lymphatic tissue transfer type of a procedure. Now, lastly, there are procedures that don't involve microsurgery and supermicrosurgery, and those are actually tissue removal procedures. So for those folks who have a lot of scar tissue and have a lot of fatty tissue, maybe even that they have a lot of extra skin, we need to use procedures to remove some of that because that's not going to go away with diversion of the fluid. That's actually solid tissue that needs to be removed. So liposuction works really great for that. Sometimes we need to excise some tissue as well through skin excisional procedures. So we take sort of a stage approach to folks with lymphedema when we're dealing with surgery. Oftentimes, we'll do one procedure to address a fluid component. We'll do another procedure to address the solid components. Some patients have both.
Dale Shepard, MD, PhD: When we think about physicians that might be listening in realizing that maybe there's some resources that are available here at the Cleveland Clinic that might be useful, who are the best patients to have referred here to the lymphedema center?
Graham Schwarz, MD: Well, any patient with suspected lymphedema we will be glad to help evaluate and figure out what are the best treatments. So if there's a patient with limb swelling, for example, it may be lymphedema. It may not. It may be a problem with their veins, venous insufficiency, or maybe a combination of both. So when providers have the ability to just refer to a common sort of front door, we can help figure out what exactly is going on with that patient. If they do have lymphedema, we will get them involved with our therapy teams and our vascular medicine doctors, and if appropriate, surgical team for evaluation.
Dale Shepard, MD, PhD: That's great. Well, thank you very much for your insight today, Graham. Do you have any additional comments?
Graham Schwarz, MD: Well, I just want to say thanks, Dale, for having me. I do want to just make mention of another exciting endeavor that we've been involved in, in the last number of years. One important thing for patients, especially cancer patients, is certainly preventing lymphedema because once you have it, unfortunately, lymphedema isn't known to be curable at this time. Now, that may change in the next few years. But what I just want to highlight is that over the last number of years, we have really focused on trying to identify at risk patients. When the opportunity presents itself, especially in patients who have, let's say, breast cancer who require removal of many of their lymph nodes or all their Lynch nodes, there are some surgical procedures that we have developed to be performed at the time of that kind of cancer treatment.
For example, a person has breast cancer, they have their lymph nodes removed, the breast oncology team is able to map out some of the lymph channels that are draining the extremity, draining the arm and occasionally, they're able to even preserve of the lymph channels. Now, if not, if that's not an oncologically safe thing to do and they have to transect some of the lymph channels, because we've marked them and we've kind of illuminated them with some tracer, that means that we can now find them, we can visualize them and we can actually reconnect them, and we can perform one of these lymphatic venous bypasses in the immediate setting before, in fact, anybody ever developed lymphedema.
Using this collaborative approach, we've really been able to reduce lymphedema rates by up to half, by up to 50% in some of these high risk patients. So we're excited about that and we're excited about the sort of monitoring paradigm that we've developed at the clinic with our breast cancer colleagues. I think that this is a paradigm that other cancer specialties are interested in as well. So I'm really excited about seeing this develop across cancer specialties here at the clinic.
Dale Shepard, MD, PhD: Wow. It's fascinating work in a really important area. So thank you very much for being with us today.
Graham Schwarz, MD: I really appreciate you 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. 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.