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The Lymph Node Transplant

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Zack Smith

on 5 August 2016

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Transcript of The Lymph Node Transplant


Zachary Smith,R.T.(R)(T),MBA
Director - Radiation Oncology/Tumor Registry
Baton Rouge General Pennington Cancer Center
Baton Rouge, Louisiana
Objectives:

Review the purpose and function of the lymphatic system.
Develop an understanding of the causes of lymphedema
Review current methods and their effectiveness in managing lymphedema.
Compare lymph node transplant claims, outcomes, and controversies.
Review of the Lymphatic System

The lymph fluid contains a variety of white blood cells

The fluid is protein-rich and can be clear to yellow-tinged

The system captures microorganisms and destroys them
Lymphedema as a Consequence
of Cancer Surgery
Other types of Surgery
Sentinel Lymph Node Biopsies
Dissections based on histology of primary
Early detection and aggressive management
The Lymph Node Transplant
Theory of the procedure.
Patient Selection
Technique(s)
Reported outcomes
Patients often told:
to 'cope' with lymphedema
it's a normal side effect of breast surgery
Current Management Techniques:

Manual Lymph Drainage Massage
Special Exercises
Compression Bandages,Sleeves,Pumps
Skin Care - Use Caution and protect limbs from cuts
and scratches
Don't carry heavy objects with affected limb*
A New Tool in the Battle of Managing Post-Op Lymphedema: The Lymph Node Transplant
FACT:
Only the Brain and Placenta lack lymphatic vessels.
Peyer' patches
Tonsils and Adenoids
Thymus
Spleen
Nodes
Milroy's Disease is a congenital condition
resulting in Lymphedema
Thank you
Conclusions
24-49% Patients report lymphedema after Mastectomy
4-28% after Lumpectomy
4-17% after Sentinel Node Biopsy and XRT
2-11.5% with Partial Breast XRT
2-35% with Whole Breast XRT
9- 65% if Regional Nodes Irradiated
31-65% with Irradiation of Axilla
Current Techniques to Minimize the Risk
- targeted removal of specific node(s)
- minimizes the trauma to the lymphatic system
- DCIS
- ER/PR positive
Reduction of Trauma to the Patient's Lymphatic System
- - 41% after cervical cancer surgery
- - 5-10% after endometrial cancer
- - 60-67% after vulvar cancer
Key!!
Early Detection and Aggressive Management
Implications of Lymphedema

- Risk of Infection
- Loss of Function
- Lower Quality of Life
Function:
So What is Lymphedema?

Lymphedema is the an abnormal accumulaiton of protein-rich fluid in the interstitium, which leads to limb swelling, chronic inflammation and reactive fibrosis of the affected tissue.
Primary lymphedema is genetic and usually affects the lower limbs.
Secondary lymphedema can result from damage to the lymphatic circulation following surgery, chemotherapy, or radiation therapy.

Scope of Lymphedema Incidence:

Breast Cancer-related lymphedema is a debilitating disorder with no cure.
Frequently under-reported and under-diagnosed.
Misconceptions by physicians to true incidence.
Until recently, there has been no prospective protocols in place for patients at risk.

Lymphedema is often not diagnosed until there is visible swelling of the affected limb.
Trauma to the Lymphatic System:
- Triggers biologic repair response
- Lymphatic - Vascular Endothelial Growth Factor
VEGF-C is released

Chronic Lymphedema Results in:
- Collagen accumulation
- Fibrotic changes
- Lipid deposition
Pre and Post-Op arm measurements
- Tape Measurements
- Volumetric water tests
- Infrared Volumetric scan
- Bioimpedance Spectroscopy (BIS)
To Date:

Surgical Management of Breast Cancer
has focused on minimizing 'Normal' tissue disruption.
Adapted from "Therapeutic differentiation and maturation of lymphatic vessels after lymph node dissection and transplantation", Tuomas Tammela1, Anne Saaristo1,2, Tanja Holopainen1, Johannes Lyytikka¨1, Anna Kotronen1, Miia Pitkonen3, Usama Abo-Ramadan3, Seppo Yla¨-Herttuala4, Tatiana V Petrova5 & Kari Alitalo1, NATURE MEDICINE,VOLUME 13 /NUMBER 12 / DECEMBER 2007
VS.
Patients must have failed all conventional techniques for management.
Not for prophylactic use - Yet.
Not guaranteed to work - But data is promising.
VLNT appears to be a viable option
More research is needed and more is occurring.
Non-Vascularized Node Transfers

Vascularized Lymph Node Transfers
- vascular flap
- lymphaticovenous anastomosis

Vascularized Lymph Node "Relocation" or "Diverson"
Adapted From: http://yang-sheng.com/wp-content/uploads/2011/11/BodyG.png, Accessed October 1, 2012.
The Big
Vascularized Lymph Node Transfers can occur in combination with breast reconstruction
Most prospective patients have had Lymphedema for 6 months to 10 years
In the studies with breast cancer survivors, they must be NED.
Some with Mastectomy alone - Some with XRT and surgery
Anne M. Saaristo, MD, PhD, Tarja S. Niemi, MD, Tiina P. Viitanen, MD, Tomi V. Tervala, MD, Pauliina Hartiala, MD, PhD, and Erkki A. Suominen, MD, PhD, "Microvascular Breast Reconstruction and Lymph Node Transfer for Postmastectomy Lymphedema Patients", Annals of Surgery Volume 255, Number 3, March 2012
Reported surgery time - 5/7.5 hours average
Vascularized Lymph Node Transfers placed in the Wrist
Post - Op Care:
- No compression wraps on the graft site until 7-10 days post-op.
- Limited use of limb for 6 weeks
- Manual Lymphatic Drainage w/i 48hr of discharge
5x per week for 4 weeks
3x per week for 4 weeks
1x per week for 8 weeks
- Patient will utilize compression garments
- Lifetime risk of Lymphedema still exists
Patient
Education
Key!!!
Patients reporting some + improvement
80 - 90%
Measurement of
Lymphoscintography Improvement
83%
Volumetric Improvement
20-50% volume reduction in affected limb
Lymph Node Transfer
Cheng-Hung Lin, M.D.,Rozina Ali, M.D., Shin-Cheh Chen, M.D., Chris Wallace, M.D.,Yu-Chen Chang, M.D., Hung-Chi Chen, M.D., Ming-Huei Cheng, M.D., M.H.A. "Vascularized Groin Lymph Node Transfer Using the Wrist as a Recipient Site for Management of Postmastectomy Upper Extremity Lymphedema" Plastic and Reconstructive Surgery, Volume 123, Number 4, Pgs 1266-1267
References:

1. Improved regeneration of autologous transplanted lymph node fragments by VEGF-C treatment. Sommer T, Buettner M, Bruns F, Breves G, Hadamitzky C, Pabst R.
Anat Rec (Hoboken). 2012 May;295(5):786-91. doi: 10.1002/ar.22438. Epub 2012 Mar 15.

2. Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients. Saaristo AM, Niemi TS, Viitanen TP, Tervala TV, Hartiala P, Suominen EA.
Ann Surg. 2012 Mar;255(3):468-73.

3. Vascularized lymph node transfer based on the hilar perforators improves the outcome in upper limb lymphedema. Gharb BB, Rampazzo A, Spanio di Spilimbergo S, Xu ES, Chung KP, Chen HC.
Ann Plast Surg. 2011 Dec;67(6):589-93.

4. Experimental assessment of autologous lymph node transplantation as treatment of postsurgical lymphedema. Tobbia D, Semple J, Baker A, Dumont D, Johnston M.
Plast Reconstr Surg. 2009 Sep;124(3):777-86.

5. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Lin CH, Ali R, Chen SC, Wallace C, Chang YC, Chen HC, Cheng MH.
Plast Reconstr Surg. 2009 Apr;123(4):1265-75.

6. Postmastectomy neuropathic pain: results of microsurgical lymph nodes transplantation. Becker C, Pham DN, Assouad J, Badia A, Foucault C, Riquet M.
Breast. 2008 Oct;17(5):472-6. Epub 2008 May 1.

7. Therapeutic differentiation and maturation of lymphatic vessels after lymph node dissection and transplantation. Tammela T, Saaristo A, Holopainen T, Lyytikkä J, Kotronen A, Pitkonen M, Abo-Ramadan U,
Ylä-Herttuala S, Petrova TV, Alitalo K. Nat Med. 2007 Dec;13(12):1458-66. Epub 2007 Dec 2.

8. Postmastectomy lymphedema: long-term results following microsurgical lymph node transplantation. Becker C, Assouad J, Riquet M, Hidden G. Ann Surg. 2006 Mar;243(3):313-5.

9. National Lymphedema Network, www.lymphnet.org

10. Surgery for lymphedema:Not for everyone, Not just anyone/ Sarah McLaughlin, MD - Mayo Clinic Florida presentation, September 8, 2012

11. Circumfrential Suction-Assisted Lipectomy in end Stage Leg Lymphedema, Voesten, Wikkeling, Klinkert - Dutch Expert Center for Lymphovascular Medicine. Nij Smellinghe Hospital, Drachten Netherlands
zack.smith@brgeneral.org
zack.smith@brgeneral.org
4 Months
4 Years
Purpose:
Provides a network of defense against infection
Production of lymphocytes
Production of antibodies
Can manufacture blood if other sites unable
Absorbs fat and fat-soluble substance from GI tract
Lymphatic Drainage
Once swelling is detected, the process
can only be managed - not reversed.
(finally)
Reverse Mapping
Stages

I - reversible. Typically 'comes and goes'.
II - irreversible. Fibrotic changes begin.
III - Marked swelling and cellulitis/infections.
IV - Elephantiasis appearance - rare in cancer population.
Some literature calls for pts with swelling of 2cm or greater.
Also called LVA
Lymphovenous Anastomosis
(microsurgery)
(microsurgery)
New FLO System
In addition to Lymphedema Therapy

Functional Lymphatic Operations (FLO) Surgery
- lymphedema liposuction
- lymphnode transfer surgery
Why this might be better:
- chronic lymphedema can result in lipid deposits
- patient starts with a lymph system that is 'close' to normal.
Recipient Vein
Lymph Vessel w/ Blue Dye
Blue Dye flowing from LV into vein
Concerns:
Some patients experience "positive" results immediately
Little data on Upper vs. Lower Extremity vs. Head & Neck
Most surgeons not skilled in all procedures
Cost - procedure and maintenance
In Past, Only Charles' Procedures
were used for primary lymphedema.

Goal is a volume reduction so that the lymphedema arm will be close to the same size (or smaller than) the opposite arm.
Full transcript