Managing Patients With Secondary Lymphodema After Cancer Treatment
In an interview with Targeted Oncology, Jay W. Granzow, MD, discussed the diagnosis and early detection of patients with cancer-related secondary lymphedema.
Jay W. Granzow, MD
The risk of developing congenital or secondary lymphedema, a disorder of the lymphatic system, is increased for patients with cancer as they may develop the disease following treatment.
Patients with cancerous tumors that are large enough to block the lymphatic system may be at an even higher risk of developing lymphedema. If a patient receives surgery to remove the cancer, lymph nodes or vessels that carry the lymph fluid may also be removed, leading to a buildup of fluid and secondary lymphedema.
During the 8th International Congress on Cancer Metastasis, experts, including Jay W. Granzow, MD, discussed various aspects of secondary lymphedema following cancer treatment, including the importance of continuing therapy after surgery.
“What's important is that patients tend to need some amount of therapy after surgery to maintain everything. Surgery is not a magic bullet. You can't just perform a microsurgery and make everything go away. But we are able to produce fantastic improvements in patient outcomes,” stated Granzow, lymphedema specialized plastic and reconstructive surgeon, director of the Granzow Lymphedema and Lipedema Center in Jacksonville, Florida, in an interview with Targeted OncologyTM.
In the interview, Granzow, discussed the diagnosis and early detection of patients with cancer-related secondary lymphedema.
Targeted Oncology: Can you discuss lymphedema and the difference between congenital and secondary lymphedema?
Granzow: Lymphedema is something that in medical school, we get very little training in. It's a very under educated and not well understood disease, but it's quite prevalent. Prevalence is anywhere from 5%-40% for breast cancers, gynecologic cancers, prostate cancers, or others, as a consequent of the necessary treatment that was used to treat cancer. Sometimes this is unavoidable, even in the best of hands and best surgeons treating patients. We're also seeing more patients with congenital lymphedema come out as well.
Initially, 5%-8% of our patients may have had congenital lymphedema, meaning that they were born with an inherent defect that didn't require a cancer surgery or something else to become evident as they grow older. Now, we're seeing that number has risen to about 20% of our patients. I think we see more patients and a higher prevalence because there's more education out there and more people understanding that leg swelling could be lymphedema. Lymphedema is a problem of the lymphatic system, which is part of the immune system, and involves the circulation of lymphatic fluid. It cleans bacteria cells, other invaders, pathogens, cancer cells, etc. That's why cancer cells can spread to lymph nodes, which are little filters along the way in the lymphatic system. When these filters are removed or when the synthetic system is damaged, that drainage can be interrupted, and lymphatic drainage can be blocked.
Stage I lymphedema is when the patient feels what's going on. They have swelling in an arm or leg and a backup of fluid at first. On their best day, that fluid can be brought down with conservative treatment, elevation of the leg, compression garments, bandaging, lymphedema therapy, and other modalities. What we haven't been taught before is that that lymphatic fluid is extremely toxic. It damages all the surrounding structures, including the natural lymphatic drainage system. Your lymphatic system pulls that lymphatic fluid out of your arm or leg and drains it out. In a human, those vessels are hollow and with time will swell up as well and constrict and fail with additional lymphatic fluid buildup because of the inflammation that's caused by that fluid. That toxic fluid causes inflammation, damage to the surrounding tissues, including the lymphatic drainage system. As that gets further damaged, there's more build up, less drainage, and you have this vicious cycle that occurs. The skin will get thicker, and the vessels, the arteries, the veins, and the surrounding soft tissues get worse.
Eventually, there's an additional deposit of fat and protein, which is permanent. Fluid drains to the venous system to be processed by the body. If we remove that fluid that's been building up, everything will be fine. But as that stays there longer, there's going to be fat and protein that is builds up. When that sets up, you have stage II lymphedema. Because of that, the arm or leg never gets down to the same size as the opposite, uninvolved side, or a normal arm or leg, and you have further problems because that fat and protein act like a heavy sponge and soak up fluid further. In a stage II patient, it's going to hold on to additional lymphatic inflammation and lymphatic fluid that will cause more inflammation and damage. Understanding that process is important to understanding the treatments of this disease.
Can you discuss the prevalence and incidence of cancer-related lymphedema?
It can be anywhere from 5%-40% of patients that have had cancer and the treatments for cancer who then develop lymphedema after those treatments. Now, my postulate really is that these patients are predisposed to some extent to getting lymphedema. If they're extremely predisposed, they don't even need the cancer surgery to get it and those are the ones that we call congenital or primary. But some patients have more robust lymphatic systems that really need a cancer surgery to knock it out. However, that means that probably 60% or more of people have an even more robust lymphatic system that even with cancer, surgery, radiation, and other treatments don't see a clinical lymphedema.
What did your research on various aspects of secondary lymphedema following cancer treatment examine?
We perform evidence-based medicine, we look at our data, and we use that data to make what we do better. Since I'm a surgeon, I do clinical research, which means we're going to take what we do, look at the results and the outcomes of the procedures that are performed and the treatments that we've given the patients, and then modify what we have to make that better. Typically, our outcomes that we're seeing, and we've seen for a long time is that I can take an affected arm or leg, whether it is stage I or stage II lymphedema, even the ones that are relatively big and heavy, and we're able to bring that down and normalize the size of that arm or leg. With the second set of procedures, we are able to reduce the amount of compression therapy that's needed to keep that down.
Patients always come to us, and we prescribe a course of therapy. Treatment therapy is important and that therapy doesn't increase with our treatment. That means that they start with that baseline therapy they need to be taken care of lifelong. Our goal is then to reduce the volume and decrease that amount of therapy that's needed to give the patient a better outcome, and to give the therapist a better result when they treat and take care of patients.
What were the findings reported from the session held during the 8th International Congress on Cancer Metastasis?
Nothing in surgery is a guarantee, but we have a very good range of outcomes. My expectation in our office is that we achieve an arm or leg that is about the same size as a normal arm or leg. As another part of that treatment, we can reduce the amount of effort and therapy needed to both keep that arm or leg normal sized, and to decrease the amount of therapy vs what the patient came in with or required at the beginning. We decrease the amount of effort it takes to take care of that patient and get them back to a normal size, meaning that can they wear jeans, boots, etc. Those things are expectations that we have. Patients who are congenital patients maybe started with lymphedema at age 14, haven't been able to wear jeans and now, 20 years later, they can get back into jeans after surgery and treatment. Those are things that we can typically achieve, which is fantastic.
What's important is that patients tend to need some amount of therapy after surgery to maintain everything. Surgery is not a magic bullet. You can't just perform a microsurgery and make everything go away. But we are able to produce fantastic improvements in patient outcomes.
What advice do you have regarding early detection for lymphedema?
For secondary patients, because they are going to be at the highest risk, patients want to be vigilant and should get an appointment the lymphedema therapist or certified lymphedema therapist. Those are therapists that can hopefully be found in their area, whether it's at their hospital, or at least in a driving distance from them. Those therapists are highly trained to spot early signs of lymphedema. They're also going to be able to educate the patients as to what to do as high-risk factors.
There will be a lot of education that goes on. That's going to be early identification too because those therapists can be trained to spot swelling that occurs that the patients might not be aware of. There are additional modalities and machines that can be specially programmed to perform special studies to have an early detection. There is imaging that we can perform as well. That depends on having someone who is going to be trained enough with those specific techniques to be able to perform early detection also.
What detection methods are currently available for these patients?
Early detection methods are going to be the clinical diagnosis, which I think are the most important early detection methods. There are methods like the SOZO machine which uses the dielectric constant. This is an easier thing to interpret because you don't need the background experience to be able to run that machine. If you have a really well-trained clinician or therapist, they're going to have a good idea of what goes on as well. There are other modalities, such as indocyanine green imaging, and although that requires an injection, they can pick up even early lymphedema. We also use a lymphoscintigraphy study which is done in the hospital and shows the deep movement or transport of that lymph node in arms or legs that will show us the functional state of the lymphatic system and be able to show if there is something going on that we can't clinically see otherwise.
Can you explain the rehabilitation process of patients with cancer-related secondary lymphedema?
Almost everything centers around that lymphedema therapist. The therapist is the most important first step. For me, I won't see the patient if they haven't had a good therapy workup before as we aren't able to integrate that into their treatment plan. That way the patient is taken care of properly at home. Most almost all my patients come and fly long distances inside the United States or overseas, so want to make sure that they are cared for properly with therapy first.
What that therapy also is going to do is reduce the fluid that's present and decrease that amount of toxic fluid that's inflammatory and damaging to that system. This will allow them to start on their healing path. Then, we evaluate them in the office, and we can add additional surgeries. If the patient comes with advanced stage II lymphedema, we need to remove those solids first and get them down to a stage I that can be treated better with therapy or even microsurgery later. We use a procedure called a suction assisted protein lipectomy where I use cannulas to suction out that material through very small incisions. Then, we carefully bandage that patient, we get them in the compression garments, and with the therapist over the next year, we get them to compress down, and that is what normalizes the size of the arm or leg.
Now, their therapy that's required is usually less at this point, the volume is much less, the inflammation is less, and those vessels are able to start healing. That lymphatic system starts to recover to some extent in many of the patients, not all the patients, but many of the patients. We can start draining better too. The vessels, arteries, and the veins start to recover. Then I can go back and I can add microsurgery, so I can do something called a lymphaticovenous anastomosis surgery, where I take the lymphatics and connect them directly to veins, shunts, or outflows into that venous system. I can find those tiny lymphatic channels, disconnect them, and connect them to tiny, appropriately-sized veins with little 1-way valves. That way, whenever there's movement with the patient's body, that lymphatic system will pump, push that extra little lymph into that venous system, and it will eventually drain that arm or leg much better, and it will significantly reduce the amount of garment compression therapy that you need afterwards.
I can also borrow lymph nodes from another part of the body in a safe way. There's a way called reverse mapping that we use and have been using for a long time. We move those over into the affected arm or leg and we can improve the drainage with those as well. Then what we'll do is we'll allow that patient to heal. Over time, they will continue to get better typically. As inflammation goes down and as a drainage improves from not only the first surgery, but also the second surgery, they will have improvements that they wouldn't otherwise see, even if it is years after surgery.
What unmet needs still exist in the space?
One is education. I wish we had more education at the medical school level and at the physician training level about lymphedema, what can be done. There is hope out there. We want that education to be better, and that's why we want to have interviews, do videos, publish medical literature, and find what we can do to make it better. There is hope and there's a lot we can do to treat lymphedema. There's a lot we can do to make the patients better. Second is educating the insurance companies. For us, it's a fight for almost all our patients. The vast majority that come through and get surgeries with us are covered by their insurance company. That's not well known for many of the insurances. We must educate or fight with the insurances quite consistently to make sure that they get the appropriate coverages. That's been a frustration with everyone and it's slowly improving, but I'd say that, that that's still a big deficiency that we'd like to improve upon.
