Doctors have begun to transplant lymph nodes from other parts of the body to treat lymphedema, a condition that arises when women with breast cancer have their lymph nodes near the breast area removed. (Kim Hairston/Baltimore Sun video)
Sharon Lanza was too self-conscious to wear sleeveless shirts before last summer.
The 73-year-old from upstate New York suffers from lymphedema, a side effect from breast cancer that caused her left arm to swell to twice its normal size.
She tolerated the condition for years until a surgeon at MedStar Franklin Square Medical Center transferred lymph nodes from her stomach to her armpit. Much of the swelling subsided after the life-changing procedure, and Lanza’s wardrobe choices have since grown to include arm-baring blouses.
“I haven’t shown my arms in years,” she said.
Lymph node transfer surgery is an emerging option for breast cancer survivors with lymphedema, a condition that causes not only swelling, but also numbness, tingling, pain and heaviness. Some people have trouble moving their arms, writing or holding a fork. They can no longer wear a ring or a watch. Lymphedema catches many women by surprise, sometimes showing up years after they have beaten cancer.
The condition is caused by damage to the veins from radiation treatments or the removal of lymph nodes from the armpits during breast cancer treatment. Because of the damage, lymphatic fluid that normally moves through the body pushing out waste and bacteria from tissues, gets backed up in the arm instead. Sometimes painful scar tissue develops as a result of the fluid sitting in the arm for so long.
“It can be horrible,” said Dr. Justin M. Sacks, director of oncological reconstruction at the Sidney Kimmel Cancer Center at Johns Hopkins. “There is massive swelling of the arm. Sometimes you can’t hold pencils; you can’t open doors. Your daily activity gets compromised.”
There are some remedies for the condition, including gentle massage to squeeze the fluid out. Others turn to physical therapy sessions a few days a week as well as wrapping the arms in compression materials, which many women find uncomfortable. All these treatments help improve the flow of fluid and prevent more swelling, but are not permanent cures. And, for some women, they offer only limited relief.
In the past several years, surgeries such as the lymph node transfer Lanza received have emerged as treatment options for patients with the most severe cases of lymphedema. The surgeries are not widespread, done mostly at large academic medical institutions, and still considered experimental by some. In Baltimore, the procedure is offered by at least two hospitals — Medstar Franklin Square and Johns Hopkins Hospital.
The two- to four-hour procedure involves taking lymph nodes from the groin, stomach or neck and attaching them to blood vessels in the armpit using a microscope. Patients typically start to see improvement in six to 12 months after fluid is able to once again drain from the arm.
“It relieves traffic of the lymphatic system,” Sacks said. “If you can’t get past the armpit, it gets clogged.”
Plastic surgeons typically perform the procedure, sometimes in conjunction with breast reconstruction surgery.
“It opens the doors for another treatment option for patients who have advanced stage lymphedema and no other treatment has worked for them,” said Dr. Gabriel Del Corral, the Medstar Franklin Square doctor who did Lanza’s surgery.
Del Corral has been doing such surgeries for around four years.
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Lanza beat her cancer decades ago, being declared cancer-free in 1982, but 16 years later she developed the unexpected extreme swelling in her left arm.
Every four months, the retired principal spent three days a week in physical therapy and wrapped her arms with compression cloth everyday to manage the swelling. She kept her arms covered in long sleeves and bought shirts a size bigger to fit the swollen limb.
Lanza had come to terms with the idea of nursing her swollen arm forever.
Then a woman at a Christmas party in Ellicott City noticed her wrapped arm. There was another option, said the woman, who introduced her to Del Corral.
Doctors at home in New York had not heard about the lymph node transfer Del Corral suggested. Still, Lanza took a leap of faith after some research on her own.
In the summer of 2017, Del Corral took lymph nodes from Lanza’s right leg and transferred them to her left armpit.
Del Corral said the lymph node transfers are not a cure for the disorder and that symptoms could reoccur. Some doctors still recommend patients use compression and get physical therapy, though not necessarily as often.
It is unclear how widespread lymph node transfers will become. As the surgery has emerged, the medical community also has become better at determining which women need their lymph nodes removed, said Dr. Emily Bellavance, a surgical oncologist at the University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center and an assistant professor of medicine at the University of Maryland School of Medicine.
At one time, doctors would remove all of a woman’s lymph nodes from the armpit no matter the severity of the disease. This is not the case anymore for women with microscopic traces of the disease, Bellavance said.
Mapping has allowed doctors to remove only lymph nodes that drain into the breast and not the arm. And doctors will treat patients with chemotherapy and antibodies before reassessing whether lymph nodes need to be removed.
“Now we can be more selective for patients,” Bellavance said.
The Greenebaum Cancer Center does not offer lymph node transplants, although Bellavance said she would recommend a patient to a doctor who does in extreme cases of the disorder. So far, she hasn’t had to do that.
“I think if you have someone struggling with their lymphedema symptoms and other methods aren’t working, then it is something to consider,” she said.
For Lanza, the procedure was well worth it, she said.
At a follow-up appointment with Del Corral in August, Lanza wore crisp white pants with a sleeveless black shirt — the difference in the size of her arms barely noticeable.