Dr. Joseph Dayan is a board certified plastic surgeon specializing in microsurgical cancer reconstruction and lymphatic surgery. His work on vascularized lymph node transfer has been presented internationally and he is a founder of the American Society for Lymphatic Surgery. Dr. Dayan also performed the first lymph node transfer in the tri-state area and in Israel with his colleague, Dr. Mark Smith. His work in this arena includes prospective clinical study of lymph node transfer and lymphovenous bypass, collaborative efforts with basic science researchers and certified lymphedema therapists, and patient advocacy.
Dr. Dayan: I am a breast cancer survivor who has developed lymphedema in my chest and back after DIEP flap reconstruction. I have tried manual lymphatic drainage treatments and have used the arm sleeves required by Medicare which only exasperated the problem in my trunk. As Medicare refuses to cover any further physical therapy for my condition and denies coverage of the truncal pump I suffer daily from the increasing pressure in my chest and back to include not only chest pain but pain in my spine and migraines. I have read about VLTN and wonder if there is any evidence that it can help in the situation of truncal lymphedema.
As per Dr. Dayan-
Thank you for your question, this is a very challenging and under-appreciated problem. I have seen good results with decongestive therapy over time, and this is still the primary treatment. The barriers to receive this necessary treatment because of limits in insurance coverage are a serious problem and I wish I could give you an easy solution. Vascularized lymph node transfer (VLNT) is generally not an alternative to lymphedema therapy. It is standard practice for a lymphedema surgeon to work with a lymphedema therapist, often before and after surgery as decongestive therapy provides a good environment for lymphatic vessels to grow. Most patients in my experience still require some form of compression. While there are some patients who have ultimately stopped using a compression garment following VLNT, this surgery is not typically a cure.
To date I have not seen any published outcomes on VLNT for breast lymphedema. I have personally used VLNT in one patient with very painful lymphedema of the breast with promising early results. Specifically we performed a omentum lymphatic flap (taken from inside the abdomen) which was placed under the skin from the edge of her outer breast across the underarm. While she has had significant improvement, it is too early to claim victory as I would normally wait at least 2 years to see if the results are durable. We do not yet have the data to give you a better answer but I do believe this is an area that will gain a lot more visibility and progress.
Dr. Dayan, I became aware of the surgical treatment for lymphedema recently. In my research I found a blog from a woman in France,lymphosaurusrex, who said that only the French Doctor Becker has the MRI technology to best assess one's lymphatic system. On the blog she shows her lymphoscintigraphy film and the colored MRI. The MRI detail was amazing. Is this true? Are there any US surgeons who have this more precise technology available? Does MSKCC? Thank you for your response. JPG
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Thank you for your question, this is a very interesting and exciting topic! There have been some significant recent advances in imaging technology which allow the surgeon to see the lymphatic vessels, assess the damage, and help determine what type of surgery is most appropriate. The technique you are referring to is MR lymphangiography or MRL. While it is not commonly performed it is offered at some centers in the U.S. where lymphatic surgery is commonly practiced. I would suggest you reach out to a lymphatic surgeon in your region and ask them directly if you are interested. We do have all patients undergo MRL, as well as MRA (magnetic resonance angiography), and ICG as part of their standard pre-surgical work-up. We have found this imaging to be helpful as all lymphedema is not the same; two patients with similar appearing lymphedema in terms of their limb size may have differences in their lymphatic function, as well as the amount of fluid versus fat in their limb. These differences may affect the outcome of surgery and may impact the type of surgery that is offered.
MRL provides a high resolution snapshot of the lymphatic vessels. ICG lymphangiography also allows you to see the lymphatics but in real time with video so you can see the pumping function of the vessels as well. This does require typically two or more injections of a small amount of dye into the skin, and a special near-infrared camera is used to project a detailed image on a computer monitor. MRA allows you to see the anatomy of the blood vessels and can also tell you how much fat growth has occurred versus how much fluid you have in your limb. Over time, the fluid may be replaced by fat overgrowth and can affect the outcome following surgery.
While these technologies have provided greater insight into a patient’s particular disease process, there is still no consensus regarding the ideal work-up prior to surgery. Lymphatic imaging is a field which will continue to advance and I am optimistic that it will further improve our ability to select patients for surgery and guide treatment for a better outcome. It is a very large topic and difficult to cover in a brief response, but I hope this is helpful to you!
I have a concern. I am a breast feeding mother and I found lump in my breast went to have a ultrasound done. The radiologist noted an aggressive mass which she performed a core needle biopsy on. She also noted that I had active axillary lymph node and she did a core needle biopsy on that as well. The pathology result was a lactation adenoma and reactive changes to lymph node no malignancy. My question is is there any risk of developing lymphedema post a core needle biopsy of a lymph node? Do you think I should follow lymphedema precautions for the rest of my life?
As per Dr. Dayan-
Thank you for your question. I think it would be very rare to develop lymphedema from a core biopsy if you have an otherwise normal lymphatic system, although we rarely say “never” in medicine. I personally have not yet encountered a patient with lymphedema from a core biopsy and I could not find any reports of this in the literature. I believe lifelong lymphedema precautions would probably be excessive in your case.
Dr. Dayan, We are considering having LVA surgery performed on our almost 16 year old son. We recently found out he has primary lymphedema in his feet and legs. His left foot has been swollen since first grade without any pain and still fits in the same size shoe as the other foot. This March during track he had pain and swelling in his right foot. We saw a PT who had a certified lymphedema specialist in his office and she diagnosed him with lymphedema. We have done some therapy 9 ( and the pain is gone ) with her and she found Dr. Chen in Iowa city and referred us to him to talk about possible surgery. They performed the ICG test and didn't really find any linear pattern of lymph flow in either leg. We are wondering about the effectiveness of the surgery and since he is so young if the surgery will continue to be effective over the course of his life. Wondered what your experience doing the LVA surgery on young patients is? Thanks
Thank you for your question, it is clear you are doing everything possible for your son. There are a number of considerations regarding primary lymphedema and LVA, all best answered by the lymphedema surgeon examining your son. Not all forms of primary lymphedema are the same, they may have different features, progress differently, and respond differently to LVA. Some patients may have a normal number of lymph nodes but abnormal lymphatic vessels, some patients have few or no identifiable lymphatic vessels, and others may have a problem with the ability of the lymphatic vessels to pump lymph. For LVA to function there needs to be a lymphatic vessel or vessels present to bypass. In patients with heavily scarred, or non-functional lymphatics, my personal experience has been disappointing, and we will tend to offer lymph node transfer in that setting. I do not have a lot of personal experience attempting LVA in patients without any lymphatics seen on ICG who have primary lymphedema, so I cannot comment on the results—I would ask your surgeon their experience for patients similar to your son. As a community, lymphatic surgeons are exploring a number of promising treatments for this disease and I believe our collective experience will shed more light in this field in the next few years, I only wish I had a clearer answer for you now.
Dr. Dayan’s response-
Liposuction treats the fat accumulation associated with lymphedema, it does not treat the fluid build up component and requires constant compression to be effective. If one has significant pitting edema (press your thumb firmly into your leg and if it leaves a dent, that is pitting edema) they are generally not ideal candidates for liposuction because there is a lot of fluid in their limb as opposed to fat. Patients with minimal to no pitting who are always wearing a compression garment may be a candidate, but should be evaluated by an expert in the field.
Dear Dr. Dayan I have some burning questions and no one can answer me: 1/ Do you think someone dying or dead could donate their lymphnodes? Why or why not? 2/ can we harvest from apes? Or other animals? 3/ can we use stem cells to grow Lymphnodes, and then transfer it back to the body? 4/ can we put in artificial 'pumps' to act as working lymphnodes? Like how they have artificial hearts for those with heart problems. 5/ where can I follow up on the latest news about Lymphedema and cure research? I would like to keep updated on this topic just in case... Never know when there might just be a cure round the corner... I figured if they could make these and replace hearts, shouldn't they be able to do something to replace lymphnodes too? Thank you so much, Hopeful for the future
Thank you for your very thoughtful questions and creative ideas! These are all great questions that could be the subject of a long discussion but I will do my best:
1) Unless this person was an identical twin, donating lymph nodes from someone else, living or not, is currently not practiced. This is because your body’s immune system would recognize that these lymph nodes are not part of your body and would attack the lymph nodes (rejection). Avoiding rejection would require lifelong medications that a patient who has received an organ transplant would take and these can have major side effects which reduces your immunity and can make you susceptible to serious infections and some forms of cancer.
2) For similar reasons, we cannot yet transplant lymph nodes from other animals. Any organ transplanted from an animal would be rejected by your body.
3) Growing lymph nodes using stem cells and transferring them back to the body is not yet a reality for patients with lymphedema. There has been a lot of promising work done in the past two decades in tissue engineering and stem cell research which offer a lot of hope in the future.
4) An artificial pump for the lymphatic system is not as simple as it might sound because the lymphatic system is very different from the circulation of the blood in your body. Blood is pumped by your heart; the lymphatic system does not have a heart or any type of central pump mechanism. More importantly, lymphedema is not just a pump or plumbing problem, it is an immunologic problem very different from congestive heart failure and heart disease. The lymphatic system is a one-way sewage system which transports fluid waste back into your bloodstream by several ways. The lymphatic vessels are long tubes which have muscle cells inside their walls which squeeze rhythmically and push fluid all the way up to your neck where the lymph empties into large veins and enters the bloodstream. These muscle contractions are similar to those found in your intestine which pushes food through your digestive tract. Lymph also flows toward the heart during skeletal muscle contraction which occurs when moving your arms and legs. The muscles actually squeeze the lymphatic vessels, forcing lymph through one-way valves and out of your limbs. This is one of the underlying mechanisms for short stretch bandages that provide a firm platform against which your muscles contract to improve lymphatic flow. External forms of pumping lymph have been practiced by lymphedema therapists for years (manual lymphatic drainage) and lymphedema pumps have been developed as an additional supplement to MLD. These techniques have been very effective at reducing swelling. The underlying disease process, however, is not a problem of pump failure alone, so pumping lymph externally or internally may only be part of the solution in lymphedema treatment.
5) One of the best resources to follow up on the latest news in lymphedema is the LE&RN; website (and scientific journal) which is dedicated to advancing lymphedema research. As a physician, like most of my colleagues, we often use PubMed which searches all of the peer-reviewed medical journals which you can google. You can look at the abstracts for free, but it is best to review these articles with someone in the medical or research field who can help interpret the significance of the particular study.
All of this being said, there is a lot more interest in lymphedema research now than there was in the past, but we still have a long way to go. The more people that are aware of this disease, the more likely we are able fund and develop a cure for lymphedema.
Joseph H. Dayan, M.D.
I am 48 and have had primary lymphoedema in my left leg since 2006. I am Italian and on last may went through surgery here in Italy (4 LVA) performed with supermicrosurgery (the same technique used by prof. Koshima in Japan). After three months and half I do not see significant improvements, even if I strictly follow directions (constantly wearing garment and/or applying bandaging). I’ve been told the results may come slowly but I am wondering whether I should start to see some change in the condition…
Thank you for your question—the best person to advise you would be your surgeon as there are different ways to perform an LVA. Prof. Koshima has described a variety of different vessel arrangements and techniques for LVA. While LVA can yield early improvement because blocked lymphatics are directly decompressed by connecting them to neighboring veins, it can take time to achieve final results. I would speak to your surgeon about your specific procedure.