Report on the Lymphedema meeting, Montreal, October 27-28, 2017
By Leda Raptis
The 2017 National Lymphedema conference was held in Montreal in October 27-28, 2017. The conference was organised by Dr. Anna Towers of McGill University, a lymphedema expert, Anna Kennedy, President of the Lymphedema association of Canada and others.
The highlight of the meeting was the plenary session given by Dr Alex Munnoch, a plastic surgeon from Dundee, Scotland, who has helped develop surgical lymphedema treatment techniques. Dr Munnoch gave a historical overview of the evolution of surgical treatments of lymphedema. He showed photos of cases where liposuction (“debulking”) reduced the excess volume of a leg from 15 liters (!) down to 1 liter. This reduction was maintained for over a year, although bandaging was still required.
Surgical techniques to improve lymphatic drainage are three main categories:
** Lymphatico-venous anastomosis (LVA) is a technique where functioning subdermal or deeper collecting lymphatic vessels are identified and anastomosed (ie joined) to adjacent veins to improve drainage of lymph. It requires super-microsurgical techniques, since these vessels are less than 1mm in diameter. Multiple anastomoses are done throughout the length of the limb, usually under local anesthesia.
** Lymph node transfer is extremely popular and many surgeons offer this procedure, although not yet in Canada. A flap with lymph nodes is removed from a donor site (groin, omentum, the membrane holding the intestines together, or others) and transferred to the arm that has lymphedema. There arteries and veins are anastomosed to revascularize the tissue. Some surgeons place the tissue with the lymph nodes in the old nodal basin, while others place it distally on the arm. It is expected that new lymphatics will grow out of the tissue (by a process called “lymphagiogenesis”) and anastomose with the lymphatics in the arm, creating new drainage pathways. The results regarding reduction of the volume of the arm are variable. Interestingly however, a significant reduction in incidence of cellulitis (ie infection) was reported. There are potential risks, such as lymphedema developing at the donor site or failure of the flap to take.
** Release of axillary vein scarring is another technique, where up to 60% reduction in volume has been reported. Dr Munnoch said that this may be the underlying principle behind the improvement seen in some lymph node transfer patients.
With all reconstructive techniques, intervention at earlier stages has better outcomes.
All these techniques are not yet available in Canada, but will be available hopefully in the near future. According to the magazine of the James Ohio state University comprehensive cancer center, Dr. Roman Skoracki’s group has pioneered and is performing such surgeries at the center1.
A paper was published recently in Science Translational Medicine and it created lots of excitement not only because it offered hope for lymphedema sufferers but especially because it described lymphedema as an inflammatory process, rather than a “broken plumbing” issue. In short, the enzyme 5-lipooxygenase (5LO) can cause inflammation. An inhibitor of this enzyme (Bestatin) has been used for over 30 years in Japan to treat some forms of leukemia and it has almost no side effects. A placebo-controlled clinical trial has started using Bestatin for lymphedema treatment, but final results are not available yet. Some panel members were sceptical of the notion that lymphedema is an inflammatory process, since there is no pain with lymphedema, while inflammation causes pain2.
Exercise in lymphedema
There were presentations showing that exercise increases the function of the arm, range of motion and strength. The intensity has to increase gradually and be combined with breathing exercises. However, in the studies reported the volume of the arm was not consistently reduced. Apparently, the temperature and heat generated by the exercise may play a role in the final result in some cases.
Apart from the talks, the booths of various companies selling lymphedema products generated substantial interest. Cellulitis, ie infection of the arm with lymphedema is the most serious concern. To avoid it, skin care is very important. Lymphoderm cream, available from the Lymphedema Depot (St Catharine’s) or the Canadian bandage shoppe (Regina, Saskachewan) contains a number of plant-based oils and extracts that have antiseptic properties and help prevent infection. The tea-tree oil it contains repels fleas and mosquitoes too, that can cause a nasty infection.
Medicus is an interesting company from Montreal (5050 boul. St Laurent). They adapt the ready-made sleeves and especially gloves to fit better. Eg they adapt pediatric gloves to position the thumb at a right angle to the palm, rather than being on the same plane with the rest of the hand, as in other custom-made gloves.
1 Chang, DW et al. Lymphedema: Surgical and medical therapy. Plastic and reconstructive surgery 138:209S (2016)
2 Pathways, Canada’s lymphedema magazine, Fall 2017, pages 5-8.