Can Treatments Ease Lymphedema Symptoms?

Lymphedema is both a challenging condition to treat and a major annoyance for anyone who has it.

The condition causes swelling primarily in one of your arms or legs—sometimes in both—but may also affect other areas of your body. This swelling happens because your lymphatic system, an important part of the immune system, isn't working properly or is damaged as a result of surgery (especially for breast cancer), radiation treatment, infections, or injuries. Or, some people are born with a lymphatic system that doesn’t work properly.

The buildup of lymph fluid exerts pressure on the surrounding tissues, leading to pain and discomfort. The pain can be constant or intermittent and may range from a dull ache to a more intense throbbing sensation. The discomfort can be exacerbated by prolonged periods of standing or sitting, physical activity, or tight clothing.

“You can think of your lymphatic system as a network of tiny pipes or vessels that helps move a fluid called lymph around your body. Lymph helps to remove waste and toxins and also helps fight infections,” says Siba Haykal, MD, PhD, section chief of reconstructive oncology and a plastic and reconstructive surgeon who leads a Yale Medicine team that uses some of the newest techniques for alleviating signs and symptoms of the disease. “But if these tiny pipes get blocked or damaged, the lymph can't flow through them like it should. This causes the fluid to build up in the tissues, leading to painful swelling.”

In the United States, the vast majority of lymphedema cases involve women who have had breast cancer treatments, including radiation and surgery.

“We’ve learned a lot about lymphedema,” says Dr. Haykal. “While it can’t be cured, there are many techniques we use now that can significantly reduce symptoms.”

The fundamental principles of lymphedema treatment are generally consistent regardless of the underlying cause, whether it is due to cancer treatment or injury, such as a deep cut, bruise, or sports injury. The main goals are to reduce swelling, manage symptoms, and improve quality of life.

In addition to noninvasive care, such as massage and compression, to address swelling, there are “super microsurgeries,” which are highly intricate procedures used in different ways to reroute lymph fluid from the damaged lymphatic vessels, Dr. Haykal says.

Both Dr. Haykal and Kamal Addagatla, MD, a Yale Medicine plastic and reconstructive surgeon, are specially trained microsurgeons with expertise in lymphedema. They discussed what people need to know about the diagnosis and treatment of this condition.

Lymphedema is a chronic, progressive condition marked by a buildup of lymph fluid under the skin in the body's soft tissues. Lymph is a clear-to-white fluid composed of white blood cells (including lymphocytes, which attack bacteria) and other materials that travel through the body via a lymphatic system of drainage vessels. The lymph fluid carries nutrients to the body’s cells and tissues and fights infections.

Along the way, there are small glands, called lymph nodes, found in clusters in areas such as the armpit, groin, and neck, as well as other areas throughout the body. If these nodes are damaged or removed—sometimes by an injury or a cancer surgery—the lymph fluid can no longer flow properly. If the node is near the armpit, for instance, that arm may become bigger, and the skin may become discolored, cracked, and vulnerable to infection. (The lymph fluid that accumulates in the tissues is rich in proteins. This creates an environment that can promote the growth of bacteria and other pathogens.)

There are two types of lymphedema: primary, which is a rare genetic type people have when they are born, affecting how their lymphatic system develops. Secondary lymphedema, which is more common, affects one in 1,000 people in the U.S. It can be caused by injury, chronic venous disease, obesity, and certain cancers, as well as cancer treatments, such as radiation therapy or surgery.

In the U.S., lymphedema is most often associated with the removal of lymph nodes and radiation therapy for breast cancer. The first symptoms can surface anytime up to a decade after the surgery, but these patients often have very particular signs and symptoms early on—even before the swelling.

“They may feel pain, heaviness, and/or transient swelling that doesn't always last. They can also see skin changes,” says Dr. Haykal.

The removal of lymph nodes during breast cancer surgery is typically associated with lymphedema. But the surgical approach has evolved over the past two decades, in part to reduce the likelihood this issue will develop.

Because lymph nodes are among the first places cancer can spread, breast surgeons typically remove them during cancer surgery. A procedure called axillary lymph node dissection may be required by patients with cancer that has spread into the lymph nodes; it involves removing as many as 10 to 40 lymph nodes, but it also greatly raises the risk for lymphedema.

But starting in the early 1990s, a much less invasive approach called sentinel node biopsy greatly lowered the incidence of lymphedema. The sentinel node (or nodes) is the first lymph node where cancer is likely to spread, and if it contains no cancer, then removal of other lymph nodes may not be required.

In certain cases, even sentinel node biopsy is no longer necessary, says Rachel Greenup, MD, MPH, chief of Breast Surgical Oncology at Smilow Cancer Hospital. “We have identified many patients with small amounts of cancer in their lymph nodes who do not necessarily benefit from removal of the nodes,” she says. “The combination of systemic therapy, such as chemotherapy and/or endocrine therapy, in addition to radiation, can be as effective without the risk of lymphedema. It is critical to speak to your cancer team about what is right for you.”

Other factors can raise the risk of secondary lymphedema, including the cancer itself blocking lymph vessels. But in those who don’t have cancer, being overweight or obese or suffering a serious sports injury can raise risk as well, although those situations are less common.

“You can have a sentinel lymph node biopsy and still develop lymphedema, but it lowers your risk dramatically,” says Dr. Addagatla. Estimates of the risk for lymphedema are about 5% after sentinel node biopsy compared to about 15% to 20% after axillary node dissection, he says. For people treated with radiation after surgery with an axillary dissection, the risk can rise to 30% or more, he adds.

Because the risk is so much higher with axillary dissection, those who have the procedure may also have a surgery at the same time the tumor is removed. The surgery is called an immediate lymphatic reconstruction. It involves connecting lymphatic vessels that were severed during the lymph node removal to nearby veins to help maintain the drainage of lymphatic fluid and reduce the risk of lymphedema.

Some breast surgeries may include a plan to perform a sentinel node biopsy at the same time, but if surgeons see, in the course of the operation, that the cancer has indeed spread beyond the sentinel node(s), then an axillary dissection may be performed instead.

The good news is that screening for lymphedema has become increasingly sophisticated. It can predict a person’s risk of lymphedema even before they undergo cancer surgery.

At Yale, a measurement system called SOZO®, which relies on technology called L-Dex®, is used to measure the swelling in a limb by calculating a value that is compared to the unaffected limb. These measurements are taken in people undergoing treatment for breast cancer before their surgery and a month after, then on a routine basis to monitor for any changes.

To get these measurements, the patient takes off their shoes and socks and stands on a scale-like device, which sends an imperceptible electrical current through their body. L-Dex measures the body’s response (the current travels more easily through an affected limb) and provides information about tissue composition and fluid levels, including lymph fluids.

“The information we get from this is very valuable,” Dr. Haykal says. “It can measure the amount of fluid in your body.” This can establish a baseline for a patient, determine whether they are experiencing early stages of lymphedema, and help determine treatment, she says.

The treatments for lymphedema won’t cure it, but they can make it more manageable, Dr. Haykal says. The first line of treatment—and the “gold standard” upon diagnosis—is combined decongestive therapy (CDT), a two-phase strategy in which a patient first addresses the initial symptoms with a lymphedema specialist and then follows up with ongoing independent maintenance.

Both phases include therapies, such as massage, to encourage lymph fluid draining; compression wraps, bandages, and garments to minimize swelling; and skin care to prevent infection.

There are different surgeries for lymphedema—none can cure lymphedema, but they may be able to reduce its symptoms. Factors such as the location and degree of swelling will help determine the type of surgery that is recommended.

Microsurgery, which is also used in breast reconstruction to restore function and form after mastectomy, makes these surgeries possible. For lymphedema, surgeons perform “super microsurgery,” working through tiny incisions with even finer instruments than those used in standard microsurgery, sutures thinner than a human hair, and high-magnification microscopes to move or reroute lymphatic vessels that are barely visible to the naked eye.

Two common surgeries are offered with the goal of restoring the flow of lymph fluid:

• Lympho-venous bypass: This is a “rerouting” of lymphatic fluid from damaged lymphatic channels into the veins in the circulatory system. “The procedure provides an alternative drainage route, much like creating a detour around a traffic jam,” Dr. Addagatla says. The plastic surgeon injects dye into the patient’s hand and allows it to travel up the arm so they can identify where the lymphatic channels are disrupted and need to be rerouted. It can be done through small incisions in one or two hours, and patients can go home the same day.
• Vascularized lymph-node transplant: For those with more severe lymphedema, this is a more invasive procedure—and a longer surgery—that takes functioning but expendable lymph nodes from one part of the body, such as the abdomen, and uses them to replace damaged lymph nodes in another. Microsurgery is used to disconnect and then reconnect tiny blood vessels to essentially build a new, functioning segment of the lymphatic system.

The success of a procedure for lymphedema often depends on the experience of the surgeon and the hospital where it’s being performed—as it does for almost any surgery, Dr. Haykal says. “Although data is still coming in, we estimate that the bypass procedure can decrease the amount of swelling in the affected area by about 30%, and in the lymph node transplants by about 30% to 50%,” she says.

As lymphedema advances, the nature of the accumulated lymph fluid can change. “We know that with time, as you get a chronic accumulation of fluid, it can affect your fat cells,” Dr. Haykal says. “Fat cells tend to grow, so when we find more, it means those patients are at a later stage of their lymphedema.” When the buildup is fibrotic or fatty, surgery becomes more difficult, and liposuction (a procedure that suctions out fat) or other debulking procedures may be used to remove that tissue.

When treatment for lymphedema works, it makes life easier—for example, a surgery may significantly decrease the time spent wearing a compression garment, says Dr. Addagatla. People with lymphedema are also at high risk for infections—the skin is vulnerable to even small injuries. “When it works, surgery can decrease or entirely eliminate the number of infections—and that’s a huge win,” he says.

Meanwhile, Dr. Haykal is involved in research to monitor patients’ progress for at least five years after treatment. One of her goals is to learn more about how to diagnose or predict the condition as early as possible to provide better care in general.

The better the overall care, the more quickly doctors will identify the early signs of lymphedema—and even prevent more cases from ever developing, she adds.

“We’re not going to tell a patient that they will be cured of lymphedema," says Dr. Addagatla. “But we can say with some certainty that one of the surgeries we offer may very well improve their symptoms."