A New Treatment for Lymphedema at Penn Medicine {Video}

Christine Wilson, cancer survivor, shares her experiences from the Abramson Cancer Center’s 2013- Focus Melanoma and CAN Prevent Skin Cancer Conferences. In this blog, she discusses new treatments for lymphedema.

Melanoma patients who undergo lymph node dissection have a 20 to 30 percent chance of developing lymphedema—a condition in which damaged or missing lymph nodes can no longer move fluid through the tissue. The fluid backs up and causes swelling, pain, decreased movement and increases the risk of infection and cellulitis. While many patients have their lymphedema managed effectively with physical therapy and appropriate pressure garments, others do not respond to these interventions and can suffer from significant functional and cosmetic problems.

Suhail Kanchwala, MD, described an innovative procedure developed in Europe that involves taking lymph nodes from areas of the patient’s own body, such as the groin or abdomen, and transferring them to the damaged area. The team identifies lymph nodes that are surrounded by a blood supply—an artery or vein and then transplants them as a unit to the patient.

The best candidates for this procedure are patients who have:

• No evidence of any cancer
• Whose lymphedema was caused by surgery
• Who have failed other, more conservative treatment for their lymphedema
• Who have had multiple episodes of cellulitis and severe lymphedema

The technique can be used for both upper and lower extremity lymphedema, and has proven an effective treatment for patients with breast cancer as well as melanoma.

Watch this interview with Dr. Kanchwaala, plastic surgeon and director of the Surgical Lymphedema Program at Penn Medicine, discuss an innovative new surgical treatment for lymphedema after cancer care.

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Exercise and Lymphedema--Clearing Up the Misconceptions

Christine Wilson, cancer survivor, shares her experiences from the Abramson Cancer Center’s 2012 Focus On Melanoma Conference In this blog, she recaps the conference. You can view the conference in its entirety, including presentations here.

In 2010, Katie Schmitz, PhD, FACSM, associate professor of medicine at the Perelman School of Medicine, and a group of her colleagues published a study that changed how patients and doctors think about exercise and lymphedema in cancer patients.

Dr. Schmitz's Physical Activity and Lymphedema (PAL) study demonstrated that a slow, gradual, supervised program of weight lifting not only didn't make lymphedema worse in women who either had the condition or were at risk for it following treatment for breast cancer, it actually had measurable benefits.

These benefits were measured in terms of the ability of patients to function and their overall quality of life. For patients with lymphedema, the risk of flare-ups for patients on the exercise program was reduced by 50%, and for those patients at highest risk for developing lymphedema (those who had five or more nodes removed from their axilla), the expected incidence of lymphedema was 90% less than expected.

Until Dr. Schmitz's data was published, it was standard procedure to tell patients at risk of lymphedema to rest and avoid any kind of activity with the affected arm.

Dr. Schmitz doesn't mince her words. Exercise is important for everyone, including cancer patients. For cancer patients, to be safe and effective, it needs to be done in what she calls a "rehab" mode, meaning that it tailored to the individual needs and abilities and aimed at rebuilding or regaining lost conditioning.

Now, Dr. Schmitz is extending to her work to patients with other types of cancer and those at risk for lower extremity lymphedema, which often occurs in melanoma patients. Her LEG-UP Pilot study is recruiting patients to assess whether the same kind of exercise program is safe and effective for this group. Preliminary results demonstrate that this program works for lower extremity lymphedema as well, with participants experiencing increased strength, increased capacity to walk and no worsening of their condition.

Conditioning and deconditioning are the keys to treatment. When we have cancer and undergo treatment, it is normal to lose some level of strength and flexibility. The disease and its treatment, along with the emotional challenges that are part of the experience, can all lead to a body that is weaker, less able to respond to stress or resist infection and inflammation. The right kind of exercise rebuilds that strength, restores function and enhances overall health and the sense of well being.

Dr. Schmitz's advice to cancer patients, including those who are at risk for or have lymphedema: Find a supervised exercise program that works for you. Go slowly and gradually. Be evaluated on a regular basis by a physical therapist who is knowledgeable about cancer, and keep moving.

If you are concerned about lymphedema following cancer treatment, watch our new video,
"Cancer-related Lymphedema: What You Need to Know.” This video guide features experts from the Abramson Cancer Center and Good Shepherd Penn Partners, recognized as one of the nation's best and most comprehensive lymphedema treatment programs.

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Treatment for Lymphedema

The current standard for managing lymphedema is complete decongestive therapy (CDT). CDT is a multifactorial approach combining manual lymphatic drainage, multilayer compression bandaging, exercise to increase the muscle pump to help move fluid from the limb and meticulous skin care.

This “intensive phase” provided three to five times per week can lead to a reduction in the volume of swelling and a softening and improvement in the skin quality. When the swelling has reduced sufficiently, patients are fitted with elastic compression garments (a stocking), which are worn during the day, and replaced by compression bandaging for sleep during what is called the “maintenance phase.” This conservative approach is highly effective in reducing the swelling and daily self-care with garment use, exercise and meticulous skin care maintain the reduction achieved during treatment.

Unfortunately, the underlying damage to the lymphatic system is not able to be repaired and patients must develop good habits to maintain the limb reduction.

Other treatments for lymphedema are currently being investigated, but it is important to consider the long-term implications of any treatment chosen. Treatments such as pneumatic compression pumps, microsurgical procedures and lymph node transfers have yet to show long-term, lasting benefit to their use, and most of these treatments still require the use of compression garments for adequate maintenance of the reduction in the size of the arm/leg after daily use or surgery.

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Preventing Lymphedema

The best strategy for treating lymphedema after cancer treatment is prevention education.

In particular, patients should learn how to care for and protect the skin to reduce the risk of infection. The lymphatic system is compromised by treatment, making patients more susceptible to infection in the region of the body close to the damaged lymph nodes. For most patients with gynecologic or colorectal cancer, this includes both legs and the lower abdomen and genital region. For patients treated for melanoma on one leg, that leg and the lower abdomen on that side are at risk for swelling.

Keeping the skin meticulously clean, free of injury and healthy with moisturizing and protection can reduce the risk of cellulitis which, for some patients, may be trigger swelling or increase swelling.

The signs and symptoms of cellulitis include a hot, red, painful, swollen area of skin in the “at risk” region. Many patients developing cellulitis also have a fever or feeling that they are becoming ill. These symptoms require emergency treatment as cellulitis can spread rapidly, causing significant illness and swelling of the limb.

The best advice is to seek medical attention immediately.

While lymphedema cannot be prevented as doctors are unable to predict with certainty who will develop lymphedema after cancer treatment, the best approach is for patients to be well educated about its signs and symptoms, practice risk reduction and find effective treatment early if symptoms of lymphedema appear.

Research at Penn Medicine in breast cancer-related lymphedema has shown that a healthy lifestyle emphasizing weight management and progressive exercise can be beneficial for patients at risk for lymphedema and those who have been diagnosed with lymphedema.

More research is required to determine if these same guidelines can be proven for patients with leg lymphedema.

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How to Find a Lymphedema Specialist

The Cancer Rehabilitation Program at the Abramson Cancer Center and at the Joan Karnell Cancer Center along with the lymphedema program at Good Shepherd Penn Partners help patients prevent or treat lymphedema.

Therapists at Good Shepherd Penn Partners are certified lymphedema therapists (CLT) who have attended programs recognized as the most advanced training available. Many of Penn’s therapists have further certification through the Lymphology Association of North America (LANA).

Penn is also home to groundbreaking research on lymphedema caused by treatment for breast cancer, specifically the Physical Activity and Lymphedema (PAL) Trial. This study found that lifting weights may prevent, or relieve, lymphedema.

The National Lymphedema Network is a well-known patient advocacy group for individuals with lymphedema. Its website is a valuable source of accurate information and for locating treatment professionals

The American Physical Therapy Association lists specialists in many areas, including lymphedema, through its ‘Find a PT’ service.

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Diagnosing and Staging Lymphedema

Cancer-related lymphedema is characterized as secondary lymphedema since it is ‘secondary to’ known damage to the lymphatic system due to surgery and/or radiation associated with the treatment of cancer.

There are very few medical tests that are valuable in the diagnosis of lymphedema. The diagnosis is made primarily based on an extensive and accurate medical history and physical examination.

Lymphoscinitgraphy is one diagnostic test that may be performed. In this test, radioactive labeled protein is injected beneath the surface of the skin, and the uptake and transport of the labeled protein is observed over several hours. This test can characterize the impairment of the lymphatic system’s ability to transport proteins and fluid, but is rarely necessary to plan and provide appropriate treatment.

Stages of Lymphedema

The stage of lymphedema is determined as part of the diagnosis. Lymphedema can be successfully treated in all stages, but the best and most rapid results occur when the lymphedema is identified and treated early.

• Stage 0: Achiness, heaviness, increased warmth, sensation of fullness
• Stage 1: Visible swelling that is soft and ‘pits’ if pressed and may disappear with elevation or overnight in bed
• Stage 2: Swelling that doesn’t go away with elevation. Often the tissue is becoming more firm and less likely to be indented or ‘pit’ with pressure
• Stage 3: Hard swelling associated with other changes in the skin- callus formations or small mushroom-like growths called papillomas.

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Treating Lymphedema in Lower Extremities

Lymphedema is a possible complication of cancer treatment. While it is a well known complication after breast cancer treatment with swelling in the arm or chest wall, lymphedema can also occur in the lower half of the body after treatment for cancers in abdomen and pelvis.

 

 

What is lymphedema?

The body’s lymphatic system performs several important functions.

• Drains protein and excessive fluid from the tissues
• Helps to digest fat
• Works as part of the immune system to protect against infection and cancer

Lymphedema is the accumulation of protein-rich fluid causing swelling, or edema, in the soft tissues. This edema irritates the tissues causing inflammation that can lead to thickening and hardening of the tissue. Lymph node sampling (removal) or radiation therapy, as part of treatment for cancer, are two known risk factors for the developing lymphedema after cancer.

Early signs and symptoms of lymphedema include:

• Achiness
• Heaviness
• Increased warmth
• Swelling
• Unusual sensation in the limb

Swelling in the region of surgery is normal after a surgical procedure, but swelling that persists for extended periods of time may be cause for concern.

Lymphedema in Lower Extremities

Cardiac disease, nutritional abnormalities or blood clots (deep vein thrombosis or DVT) are all conditions that can cause swelling in the legs. It’s important to have any swelling evaluated by a physician to determine the cause.

If it is determined that the swelling is caused by lymphedema it’s important to be evaluated by a health professional with expertise in lymphedema management. Only a few physicians in the United States have expertise in lymphedema diagnosis and management, but many specialists in oncology or physical medicine and rehabilitation recognize this condition and make referrals to specialists in lymphedema management.

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