Seeing your knuckles may not seem like much to get excited about. But for patients such as Jeannette Aspden, knuckles represent progress -- significant progress.
Aspden has lymphedema -- throbbing, dramatic swelling in her right arm. It developed after some of her lymph nodes were removed following breast cancer surgery four years ago. The distension got so bad that she literally could not see her knuckles or the veins in her hands for years. Forget about wearing a ring. “It’s painful, it severely hinders your ability to do everyday things, and it’s not particularly pleasant to look at,” she said.
The lymphatic system circulates lymph fluid throughout the body to vacuum up and expel unneeded bacteria, viruses, and waste products. But surgeons are often forced to remove lymph nodes from the armpit area to ensure that breast cancer doesn’t spread. If the remaining nodes can't pick up the slack, bodily detritus builds up and lymphedema may result. Bacteria can also accumulate, resulting in serious infection -- which is what repeatedly happened in Aspden’s case.
To address Aspden’s symptoms, Suhail Kanchwala, MD, of Plastic Surgery, performed a vascularized lymph node transfer, a new approach to treating lymphedema in the US. The complex, microvascular surgery entails relocating lymph nodes to a region where lymph nodes were removed due to previous cancer surgery. In Aspden’s case, Kanchwala transplanted lymph nodes from her abdomen to her axilla. “Our hope is that once everything is connected, the newly transplanted nodes pick up where the old nodes left off,” he said.
Regaining a Good Quality of Life
In this country, lymphedema has been primarily managed by physical therapists. Since the disease can’t be cured, the goal has been to reduce pain and swelling while increasing limb strength. Therapists use compression bandaging (typically a sleeve that covers the entire arm and hand) and manually apply light pressure to the lymph system, which lies just below the surface of the skin, to help drain the fluid and reduce the swelling.
“The traditional physical therapy treatments can be extremely effective,” said Kanchwala. “But many patients with serious, repeated infections and severe symptoms need additional help.”
The lymph node transfer surgery, formally called an autologous vascularized lymph node transfer, was popularized in France by Dr. Corinne Becker, who has been performing the procedure in Europe and other parts of the world for years. In 2011 Kanchwala joined a number of other plastic surgeons from around the country in New York City to observe Becker carry out the surgery on several patients. He then went to France and participated in her clinic and other surgeries as well. In speaking to patients, he noted that they were generally pleased with the results. "About 60 per cent of those who underwent the procedure at one hospital showed clear improvement in their lymphedema symptoms," he said.
“I became comfortable with the idea of performing the surgery but only in cases where patients had no other options for regaining a good quality of life,” Kanchwala recalled. “Any surgery should be a last resort, particularly lymph node transfers, which have very little history in this country and few formal studies to rely on to assess effectiveness.” A major worry is removing too many lymph nodes from the donor site. “The last thing you want to do is cause lymphedema in another limb,” he noted. “We prevent this by being extremely careful. By using special dyes, we are able to avoid nodes that drain the arm or the leg. In this way the risk of causing donor site lymphedema is negligible.”
Another concern is damaging nerves and blood vessels. “Before you transfer nodes to their new location, you have to scrape away scar tissue at the destination site which may be obstructing the lymphatic channels and hampering fluid circulation,” he said. “Too much scouring can destroy important tissue and cause serious damage.”
Satisfied that he was fully prepared, Kanchwala performed his first lymph node transfer on a 38-year old melanoma patient's leg. After the surgery, the patient’s leg went from being badly deformed to only moderately swollen a few weeks later. “She had achieved the kind of results we were looking for. This surgery is not intended to be a cure for lymphedema but to see such a significant improvement in our first case was very encouraging.”
Significant Decrease in Swelling
Meanwhile Jeannette Aspden was being treated for yet another lymphedema infection in Washington, D.C., where this Germantown native and her husband live. Their daughter Rebecca, then a psychiatry resident at Penn, had been making inquiries about helping her mother and learned about the Penn Lymphedema Team, a specialist unit widely recognized as a national leader in treating the condition. She discussed what she learned with her mother, who soon came to Penn for treatment with physical therapist Joy Cohn, the team’s leader.
“After Dr. Kanchwala told me about lymph node transfer surgery, he asked me to help identify possible candidates,” said Cohn. “He also said that since he would be doing this surgery on an increasing basis, he and the Lymphedema Team would be working closely together. Step one was for me to be in the OR while the procedure was being carried out. I’m a carpenter’s daughter and love seeing how things work, so I found the experience fascinating.”
“I recommended Jeannette to Dr. Kanchwala for his second procedure,” Cohn says. “She is a very smart person and had realistic expectations. We knew this wasn’t a complete cure, but it could reduce the pain and swelling and make the disease easier to deal with. The analogy I use is that lymphedema is like having diabetes. You have to take care of it every day or serious problems can result. That would still be the case with Jeannette after the surgery.”
Aspden recalled, “I know that one of the first things you ordinarily ask a surgeon is how many times he or she has done the procedure. In this case, however, that question was irrelevant, and as Dr. Kanchwala and I talked I became even more confident that he would do an excellent job. He’s extremely thorough and very detail-oriented. After hearing that the procedure was new in this country, I felt a sense of responsibility and possibility. Certainly I wanted to improve my own situation but I also felt that this was something that could help other patients down the road.”
After the surgery she was amazed how much the swelling had gone down. “For the first time in four years my arms and hands were almost the same size. The week after the surgery, while I was recovering at a nearby hotel, I had a visiting nurse to help with my recuperation. She said that if I hadn’t told her I had lymphedema, she wouldn’t have believed it. Dr. Kanchwala did an outstanding job.”
For the first month after surgery, Aspden returned to Cohn three times a week for manual lymph drainage; the sessions then dropped to twice a week and eventually will become weekly. “The swelling is still down and the pain is almost gone. Joy is terrific to work with. She’s a pro in her field and has enormous empathy for the patient. Dr. Kanchwala is simply the best. Between the two of them, Penn has got it right!”
Photo above: far left: The lymphedema following breast cancer surgery caused throbbing and dramatic swelling in Jeannette Aspden’s right arm. (Her hand shows markings from the bandaging she needed to wear to help control her lymphedema). Left: Now, months after the vascularized node transfer, the swelling not only decreased significantly, but has remained so. Much to her delight, her wedding band slides easily onto her finger.