Lymphedema: New and Emerging Treatments

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Presented by: Stanley Rockson, MD
The Allan and Tina Neill Professor of Lymphatic Research and Medicine; Chief of Consultative Cardiology
Stanford University Medical Center
January 22, 2009

Lecture Overview:

  • Lymphedema is a chronic debilitating disease characterized by swelling in affected limbs and inflammation.
  • Approximately 10 million Americans have lymphedema, following cancer therapy, recurrent infections, injuries or vascular surgery.
  • When treated early, lymphedema can be managed successfully, but there is no cure.

For years, lymphedema has remained a mystery to many doctors. Most physicians don’t know enough about the lymphatic system to provide patients any real treatment options. Until recently, medical education has largely ignored the lymphatic system in its curriculum. In fact, the vast majority of physicians hear less than one hour about the lymphatic system in four years of medical school. Consequently, lymphedema is frequently misdiagnosed, treated too late or not treated at all, according to Stanley Rockson, MD, who gave a presentation sponsored by the Stanford Health Library on lymphedema and its possible treatment options.

“If you are a patient with lymphatic disease, you probably know more about lymphedema than most doctors,” Rockson pointed out.

What is Lymphedema?
The lymphatic system is part of the circulatory system. It drains fluid and helps it to find its way back to the heart, absorbs fats, maintains fluid balance in the body and helps defend the body against disease. Lymphedema occurs when the function of the lymphatic system is impaired, either through a genetic predisposition or because of surgery or radiation following cancer treatment.

When lymphedema sets in, fluid accumulates in the interstitial tissue causing swelling, most often in the arms and/or legs. The condition is often accompanied by inflammation. Lymphatic disorders often have profound implications for patients and their families. Patients with lymphedema run an increased risk of infection, and can suffer from loss of function and restriction of movement. Lymphedema also negatively affects a patient’s body image and self esteem, and can cause affective disorders and fear.

There are two types of lymphedema – primary and secondary. Primary lymphedema is an inherited condition that is determined by genetic factors present at birth. In primary lymphedema, the lymphatic vessels are either under-developed or functionally impaired; it can affect from one to as many as four limbs and/or other parts of the body, including internal organs. Worldwide, the most common cause of lymphedema is a tropical infection called filariasis.

But secondary lymphedema is a more common problem among adults and children in the United States. It can occur following any trauma, infection or surgery that disrupts the lymphatic channels or results in the loss of lymph nodes.

In the U.S., lymphedema most often occurs in patients who are treated for cancer, and whose lymph systems have been damaged by surgery or radiation. However, cancer treatment is not an automatic precursor to lymphedema. While only about 20 percent of cancer survivors will be affected, there is no indication that the type or duration of cancer treatment has any bearing on who will ultimately get this disease. Age, type of chemotherapy, surgery, radiation, menopausal status and early onset of lymphedema symptoms are not factors in the development of lymphedema.

One thing is clear about lymphedema, however. Early diagnosis is imperative to managing this condition. The earlier lymphedema is treated, the more that can be done to prevent the progression of the disease.

Detecting Lymphedema Early
One way to detect lymphedema early is through multi-frequency bioimpedance analysis. Using this technique, clinicians can measure the rate electricity travels through an affected limb. If there is fluid accumulation in the limb, electricity will flow more quickly. Bioimpedance analysis can help doctors predict the development of lymphedema in patients following cancer surgery.

Physicians can also use a lymphoscintigraphic nuclear scan to validate their diagnosis. In the future, doctors will be able to view lymphatic vessels by MRI, a procedure that is being used in Europe with success.

Early detection of lymphedema becomes increasingly important as the higher incidence of breast cancer is likely to increase the incidence of lymphedema. “We are going to see a burgeoning population of lymphedema,” according to Rockson. As he pointed out, the incidence of breast cancer in the United States is projected to increase from 185,000 patients per year to 420,000 per year in the next 20 years.

Treatment for Lymphedema
For most lymphedema patients, treatment typically involves 10 to 15 sessions of physical therapy for multi-layer bandaging, followed by the use of compression garments. “While we cannot restore damaged lymph vessels, we can augment function through a coordinated treatment plan,” Rockson said.

  • Multilayer Bandaging: This first phase of lymphedema treatment must be done by a licensed and trained physical therapist. The repeated application of relatively loose fitting bandaging improves the flow of fluids though lymph vessels. After multiple treatments using this technique, patients will experience a gradual reduction in the size of the affected limb.
  • Compression Garments: After significant reduction is achieved through bandaging, custom-fitted sleeves, stockings and other garments are used to maintain long-term reductions in limb volume.
  • Manual Lymphatic Drainage: This specialized massage technique stimulates lymphatic flow and has been shown to reduce the incidence of infection.
  • Other Devices: There are a variety of devices available that can help stimulate fluid flow as an additional therapy option.
  • Surgical Interventions. Chronic lymphedema patients can experience an increase in fat deposition between the muscle and skin as a long-term consequence of lymph malfunction. Stanford offers a surgical treatment to remove this increased fat, a technique that is similar to liposuction.

The Search for New Treatments
Because treatment options today are laborious and time consuming, researchers are looking at new ways to treat lymphedema with molecules and drugs. Rockson’s lab at Stanford has created an animal model for lymphedema, taking the first steps toward understanding how the molecular scenery of the body works and how it is affected by lymphedema.

“The changes we see in a mouse look identical to those that occur in humans,” he explained. “We have confidence that what we study in mice will translate to humans.”

There are a number of lymphedema research projects ongoing at Stanford.

  • Use of bio-impedance monitoring to improve early detection and prevention strategies for breast cancer lymphedema.
  • Development of a blood test to detect early/latent lymphedema.
  • Pilot study of drug therapy protocols to reduce the inflammation of lymphedema and restore the skin and tissues to normal consistency.
  • Assessment of metabolism as a pre-disposing factor to lymphedema development.
  • Treatment with growth factors in mouse models proved successful in curing lymphedema. However, growth factors may not be a safe treatment for secondary lymphedema patients, because they may stimulate the growth of cancer cells in cancer survivors.

About the Speaker
Stanley Rockson, MD, the Allan and Tina Neill Professor of Lymphatic Research and Medicine, is chief of Consultative Cardiology and an Associate Professor of Medicine in the Division of Cardiovascular Medicine at Stanford. Dr. Rockson also serves as the director of the Stanford Center for Lymphatic and Venous Disorders. A well-regarded expert in the lymphatic system, Dr. Rockson is involved in researching new treatment options for lymphedema. He is also interested in studying lymphangiogenesis in acute and chronic experimental lymphedema and in lymphatic insufficiency, and assessing therapeutic interventions in post-mastectomy and other forms of lymphedema.

Dr. Rockson received his medical degree from Duke University School of Medicine, and completed his internship and residency training at the Brigham and Women’s Hospital at Harvard Medical School in Boston. He serves as chair of the Scientific Advisory Committee for the Lymphatic Research Foundation, and is editor-in-chief of Lymphatic Research and Biology.

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

Stanford Lymphedema Center
http://www.stanfordhospital.com/clinicsmedServices/COE/heart/DiseasesConditions/lymphaticvenous.html

Lymphatic Research Foundation
http://www.lymphaticresearch.org/main.php?content=home

The National Lymphedema Network
http://www.lymphnet.org/