An innovative approach to reducing lymphedema

Up to half of patients who have surgery for breast cancer will develop lymphedema — an often chronic, distressing and painful swelling in the arms, hands or chest.

Lymphedema can occur after lymph nodes under the arm are removed during breast cancer surgery. These nodes are tested to see if cancer has spread beyond the breast. However, removing lymph nodes can damage the lymphatic system, which drains excess fluid from the body, resulting in fluid buildup.

Breast cancer surgeons are increasingly focused on ways to reduce their patients’ risk of developing lymphedema. For Dr. Noran Barry, this means there’s extra focus in the operating room on keeping as many lymph nodes intact as possible.

Dr. Barry, a board-certified breast cancer surgeon with Sharp Rees-Stealy Medical Group, performs reverse lymphatic mapping. This innovative technique involves using special dyes to get a closer look at lymph nodes during surgery.

“It’s really important to remove lymph nodes and test them so that we can confirm cancer has not spread beyond the breast,” Dr. Barry says. “But not all lymph nodes in that area of the body are the same.”

Finding lymph nodes through color

During breast cancer surgery, doctors try to remove and test only “sentinel” lymph nodes — the first few lymph nodes to which cancer can spread.

Surgeons find those sentinel nodes by injecting two solutions near a tumor. One is a dye that turns sentinel breast nodes bright blue. The other is a solution that contains a small amount of radiation, which travels into the sentinel nodes and can be picked up as a “hot spot” by a small device called a gamma probe.

With reverse lymphatic mapping, a separate green dye is injected under the arm. This dye helps Dr. Barry identify different lymph nodes — ones located near sentinel nodes but that drain lymph fluid from the arm, not the breast.

“The blue and green colors make it easier for me to tell the difference between these incredibly small nodes that all exist in the same space,” says Dr. Barry, who performs surgery at Sharp Memorial Hospital and Sharp Mary Birch Hospital for Women & Newborns. “I avoid the green ones and remove the blue, radioactive ones.”

The result: Fewer lymph nodes are removed. Studies show that patients who keep more lymph nodes intact are less likely to develop lymphedema.

Delicately rerouting the lymph system

Sometimes, both blue and green dyes appear in a single lymph node, which means that the node drains fluid from both the breast and the arm in the body’s complex lymphatic system. In these instances, Dr. Barry can go one step further to reduce the risk of her patient developing lymphedema.

The presence of any blue dye means that a lymph node is a sentinel node and must be removed and tested for cancer cells. However, if green dye is present too, Dr. Barry can reroute the lymphatic pathway into a nearby vein to lessen the chance that fluid will build up.

This advanced procedure is called simplified lymphatic microsurgical preventing healing approach, or S-LYMPHA. “At the end of surgery, I’m better able to predict my patient’s risk of developing lymphedema because I know I’ve only removed sentinel nodes and I know exactly how many there were,” Dr. Barry says.

Reverse lymphatic mapping is not always possible, and S-LYMPHA is not always successful. In these cases, patients are at no greater risk of developing lymphedema than people who do not have either procedure.

Lymphedema education is key

Regardless of risk level, Dr. Barry often refers her patients to Sharp’s comprehensive Lymphedema Prevention and Treatment Program. Breast cancer surgery is just one risk factor for developing lymphedema — radiation and chemotherapy can also increase the risk — so it’s important for patients to be able to recognize symptoms, especially since lymphedema can develop years after treatment.

“At Sharp, our aim is to improve the quality of life for patients with breast cancer,” Dr. Barry says. “This is true for all stages of a woman’s breast cancer experience, from diagnosis and treatment all the way through recovery and into their future.”

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