Lymphoedema is a chronic condition where patients experience potentially lifelong swelling of arms or legs. In the UK, most patients develop it after lymph node removal for cancer surgery, such as in breast cancer, although other patients can be born with it. However, a UK medical first is set to reduce breast cancer related lymphoedema by 4% to 8% worldwide with preventative treatment.
Two new UK studies both recently presented to the British Association of Plastic, Reconstructive and Aesthetic Surgeons’ (BAPRAS – www.bapras.org.uk) Scientific Meeting are set to relieve the pain and misery for many of the estimated 450,000 people living with lymphoedema in the UK today1 with an estimated 250 million sufferers worldwide.2
Lymphoedema is a chronic condition where patients experience potentially lifelong swelling of arms or legs. It can affect patients of any age and is incredibly common, more than the combined number of people with Multiple Sclerosis, Motor Neurone Disease, HIV and Parkinson’s Disease.3
Of the many causes of secondary lymphoedema (that develops as an adult), the most common cause in the UK is after any surgery or treatment (such as radiotherapy) that removes a large number of lymph nodes to treat cancer. This may include cancers of the breast, pelvis, skin cancers, head, and neck cancers to name just a few.
One in five women treated for breast cancer are affected by lymphoedema.4 This usually occurs because cancer cells have travelled from the breast to lymph nodes in the armpit and need to be removed. Because the same lymph nodes drain the arm, around 20-30% of these patients may develop lymphoedema after because fluid cannot drain from the arm. Treatment for established lymphoedema may involve a combination of physio, surgery (with mixed results) and garment use which can be lifelong.
Two new studies address the importance of prevention of lymphoedema where possible, to reduce the number of patients going on to develop this debilitating condition. So-called immediate lymphatic reconstruction uses a super-microsurgery technique to join arm lymphatics (which are often less than 0.5MM) to veins (lymphovenous anastomosis or LVA) straight after lymph node removal, using very fine instruments and a microscope.
The first new study, ‘Immediate Lymphatic Reconstruction (ILR) after Axillary Lymph Node Dissection with no additional donor site morbidity in patients undergoing immediate breast reconstruction with DIEP flap’ was carried out in St Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex.
Patients undergoing mastectomy and lymph node removal from the armpit, were offered simultaneous breast reconstruction and immediate lymphatic reconstruction. To bridge the gap between these cut arm lymphatics, a vein graft was used from the abdomen (which was also being used for the breast reconstruction) to join the very small lymphatics in the arm back to veins in the body.
Mr Kavan Johal, Consultant Plastic surgeon, runs the lymphoedema service at St Andrew’s with his Consultant colleague Mr Mat Griffiths. For this new study, Mr Johal said: “This work is preventative and is key to stop lymphoedema developing. Traditionally, breast cancer travels to the armpits and if lymph nodes are removed this treats the cancer but prevents drainage from the arm and so fluid starts to build up.
“We have now carried out immediate lymphatic reconstruction (ILR) on a large number of patients in our unit, however sometimes the lymphatics in the arm can be far from the veins in the body. Here we used a new but difficult technique where we essentially take a length of vein often from the abdomen and use the graft to connect it directly to the lymphatic and then to a vein in the body, allowing restoration of drainage.
"We believe that preventative or prophylactic lymphatic reconstruction at this point in the patient’s journey could reduce breast cancer related lymphoedema down to 4% to 8% (from 20-30%) based on current data worldwide.”
As lymphoedema is difficult to treat it may worsen with age which means more treatments and more of a drain on public health resources.
In fact, according to Ms Laura Puscas, Consultant Plastic Surgeon and co-author of the study, statistics show that the problem is becoming more acute each year. She explains: “In general, we are seeing younger people, sometimes patients in their 20’s to 30’s presenting with breast cancer. At this age range, the cancer is more aggressive.
“Lymphoedema patients face enormous physical, psychological and socioeconomic consequences. The condition can be not only painful, but disfiguring and lead to a loss of mobility, independence, reduced productivity, and depression. With no cure, treatment for the condition is largely palliative and requires meticulous daily management.”
The second study, ‘Outcomes of Axillary Surgery-Related Lymphoedema: Identifying Predictors for Exclusion from Prophylactic Lymphatic-Venous Anastomosis,’ set out to identify those patients most likely to benefit from additional treatment following axillary lymph node dissection (ALND) based around age, BMI, smoking status, tumour characteristics, and radiotherapy.
According to co-study author, Joanna Ochogwu from Cambridge University Hospital; “Lymphoedema is a life-long condition but ‘nipping it in the bud’ and making the right decisions earlier at treatment stage means that it is much more likely that individuals will be able to manage their own condition with minimal intervention or dependence on health care professionals.
"Our study identified, by limb volume increase, that after ALND the highest rates of lymphoedema were observed in smokers, those with class 2 obesity, patients over 70 and those receiving radiotherapy. With this precise knowledge we are now able to inform regarding best treatment policy to improve long-term outcomes.”
According to consultant plastic surgeon and BAPRAS President Paul McArthur; “It is always encouraging to see the latest advances being presented to the surgical community at our Scientific Meetings. For too long lymphoedema treatment has been difficult to access once it develops, with very few options and a post-code lottery for whether surgery is even available. The option for prophylactic treatment before or during node removal is promising to prevent patients from future unnecessary suffering.”
References
2. https://www.bbc.com/future/article/20241216-lymphoedema-the-hidden-pandemic-affecting-250-million
3. https://www.thebls.com/pages/what-is-lymphoedema
4. https://acsjournals.onlinelibrary.wiley.com/doi/10.1002/cncr.34489
