Real-Time Lymphedema Literature Review

The key to understanding most medical conditions relies upon a thoughtful review of established medical publications. This requires commitment from your care providing team as peer-reviewed literature moves quickly. Novel medical advances are commonly introduced in a variety of specialty-specific medical journals and at national meetings of differing professional societies. Attention to these introductions is a primary goal of the National Institute of Lymphology.

Marga F. Massey, MD, CLT, FACS has established a research relationship with Andrea L. Pusic, MD, MHS to address this need for not only breast cancer patients, but those patients receiving care for cancers of the head and neck, gynecologic cancers, skin cancers, and soft tissue sarcomas, all of which are treated with a variety of surgical interventions and irradiation complicated by lymphedema. Dr. Pusic has a national reputation in the field of breast reconstruction and is a full-time faculty member at Memorial Sloan Kettering Cancer Center in New York City, NY (www.mskcc.org/prg/prg/bios/935.cfm).

Developing the “LYMPH-Q”™ as a 360 Degree Clinical Outcomes Evaluation Tool

One of the basic fundamentals of performing quality clinical outcomes research is the identification of appropriate outcomes measures and the tools to follow such in real time. For lymphedema patients, limb circumference, limb volume and frequency of infection have been common variables followed to evaluate the success of novel interventions in lymphedema care.

Regrettably, such measures are inadequate in providing a clear view of many psychosocial issues that complicate effective lymphedema care. Further, concomitant issues of depression and overlapping pain syndromes are seldom evaluated. Fewer investigations track financial support of care along with clinical treatment strategies.

Collaborative researchers of the National Institute of Lymphology are committed to addressing these clinical outcomes research challenges. With this charge, development of the “LYMPH-Q”™ as a validated clinical outcomes questionnaire was conceived to evaluate lymphedema patients in a 360 degree approach including not only the objective measurements found on physical exam, but with a focus on capturing changes in subjective patient perceptions of pain, self esteem, body image, social isolation, depression and family unit / medical care team social and financial support.

Currently, no such clinical outcomes research tool has been described in parallel with the development of novel surgical strategies to address the devastating effects of secondary lymphedema. We predict the development of the “LYMPH-Q”™ will empower researchers of today and in the future to study lymphedema patients independent of specific therapeutic interventions.

Development of the “LYMPH-Q”™ was initiated in the Spring of 2010 with the support of Marga F. Massey, MD, CLT, FACS and Andrea L. Pusic, MD.

At-Risk Limb Bioimpedance Spectroscopy Tracking During Autologous Breast Reconstruction

Bioimpedance spectroscopy has been identified as a useful method of identifying early Stage 0 lymphedema in “at risk” limbs after axillary lymphadenectomy. It has been suggested that post-operative breast cancer patients with subjective complaints of limb “heaviness” and increasing bioimpedance measurements may benefit from early intervention with Class I daytime lymphedema compression garments (Stout N, Pfalzer L, McGarvey C, et al., Cancer 112(12): 2809-19, 2008).

Breast reconstruction commonly can be initiated at the time of mastectomy and more times than not, requires repeat surgical interventions over time. The effect of multiple surgical interventions in the development of extremity lymphedema has not been evaluated.

Patients receiving care at our dedicated Centers of Excellence in Lymphedma Care are provided the opportunity to participate in IRB-approved clinical outcomes studies where they are followed prospectively with sequential bioimpedence measurements during multi-stage autologous breast reconstruction. Patients with Stage 0 lymphedema are identified and treated prospectively with Class 1 compression garments. Stage 1/2 lymphedema patients are treated with peri-operative manual lymphatic drainage and compression bandaging. Patients receive personalized post-operative treatment planning with a focus on risk reduction, weight reduction, conservative management strategies and surveillance for infection. Additionally, patients are provided patient education regarding air travel and exercise related to care with an “at risk” limb.

Post-Mastectomy Pain Syndrome in Autologous Breast Reconstruction Patients

Post-Mastectomy Pain Syndrome (PMPS) is defined as pain symptoms that persist after normal expected tissue healing following breast surgery. Research shows that it is a relatively common problem after breast cancer surgery, affecting nearly 50% of patients. The term “Post-Mastectomy Pain Syndrome” is actually a misnomer as the syndrome has been commonly seen in patients after simpler or less invasive surgeries like lumpectomy, isolated axillary node dissection, breast reduction and even cosmetic breast augmentation. Typically, patients with symptoms will experience dull, aching, or burning sensations in the chest wall or breast, in the axilla (armpit area), and sometimes in the arm on the site of surgery. Some patients describe their pain as “stinging”, “itchy”, “nagging”, “stabbing” or “shooting”. The pain is typically made worse with movement of the arm, pressure, or even light touch from clothing, towels, or bed-sheets.

The cause of PMPS is unclear. In some cases, there is unavoidable injury to the small nerves in the chest wall, breast or axilla during the course of surgery. Neuroma formation, or “nerve scar”, can develop at the incision sites of your surgery and can be a source of these symptoms of pain. In other cases, radiation therapy or chemotherapy can irritate or further damage these nerves. The severity of symptoms varies from patient to patient but can affect mood, sleep, ability to function, and general quality of life.

A few risk factors for developing PMPS have been identified and include younger age and perioperative radiation. Treatment of this type of pain includes medication that decreases the overactivity of the damaged nerve endings. Some examples include membrane stabilizers/anti-convulsants and certain types of anti-depressants. Though medications often have side effects, they are neither addictive nor habit forming. New treatments and discoveries are being made in this area of pain management, but early identification and treatment of “nerve pain” after breast surgery is crucial.

Collaboration between Northwestern University Department of Anesthesia and our Centers of Excellence in Lymphedema Care provides a unique opportunity for patients to participate in ground-breaking clinical research while receiving the most sophisticated surgical care in the area of perforator flap breast reconstruction. Clinical researchers at the National Institute of Lymphology are committed to characterizing the intimate relationship of PMPS and Lymphedema as it is seen in breast reconstruction patients.

Our research program on PMPS is headed by Dr. David Richard Walega. Dr. Walega is a fellowship-trained, double board certified Anesthesiologist with post graduate training in chronic pain. He is an Assistant Professor of Anethesiology at Northwestern Memorial Hospital and serves as the Program Director of the Multispeciality Pain Management Fellowship at the Feinberg School of Medicine. Dr. Walega sees patients in Chicago and interested persons should call (312) 926-8369 (Read Dr. Walega's bio).

ICG Lymph Node Mapping in the Setting of VLNTx




Indocynide green (ICG) is inert flurophore that has been used in several areas of medicine. Intra-vascular injection of ICG has guided cardiac revascularization procedures. Further, ICG has assumed a clinical application in the field of ophthalmology and plastic surgery. Novel applications have been described using ICG to define lymphatic anatomy with possible use in “axillary reverse lymph node mapping,” or ARM, for Sentinel Lymph Node and Axillary Dissection as a means to preserve essential extremity lymph nodes. Wide acceptance of ARM in the treatment of breast cancer may be the next major clinical step in reducing the incidence of secondary lymphedema in the US - a step as large as that of the introduction of the Sentinel Lymph Node Procedure in the 1990's.

Investigators at our Center at Roper St. Francis Hospital in Charleston, SC in cooperation with Novadaq Technologies (Toronto, ON, Canada, www.novadaq.com) have defined the use of ICG-NIR Fluroscopy in the field of lymph node mapping to reduce donor site morbidity and improved lymphangiogesis of Vascularized Lymph Node Transfers. Further, this collaboration has extended to our Center at the St. Charles Surgical Hospital in New Orleans, LA in June of 2009. This research has evolved into an exciting area of development of a dual signal flurophore for use in ARM that we believe will revolutionize novel surgical interventions for the treatment of lymphedema patients who have failed conservative management.

Individuals interested in ICG lymph node mapping or dual flurophore ARM should contact Dr. Massey at the Institute for additional information (drmarga@nilymph.com).