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Pharmacy and Therapeutics Committee Approvals

Pharmacy Focus

Highlights of the June meeting of the Pharmacy and Therapeutics Committee are summarized in the PDF link below.

P and T Approvals - June 2016 (PDF)

Mark Your Calendar

Surgery Grand Rounds

Click the "read more" to see information about upcoming Surgery Grand Rounds.

Grand Rounds

Click here to view a schedule of all upcoming grand rounds.

Education Schedule

Click the PDF links below to see the Department of Surgery's education schedule.

Education Schedule - August 2016 (PDF)

Education Schedule - September 2016 (PDF)  

Surgery Scheduling

Click the "read more" for hours and contact information for surgery scheduling.

Share Your News

Know an interesting colleague we should profile? A story we should tell? Submit your ideas, meetings and events for consideration.

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Vascularized Lymph Node Transfer

The Frontier of Lymphedema Management

By Edward Ray, MD, and Randy Sherman, MD

Secondary lymphedema is a vexing problem that is not well understood. Up to 40 percent of axillary lymph node dissection and 10 percent of sentinel node biopsy patients develop some degree of lymphatic dysfunction. Once clinically apparent, it may gradually worsen, manifesting as progressive swelling, recurrent infections, pain and diminished quality of life. Over time, fatty deposition and skin changes become irreversible. While there is currently no definitive cure for secondary lymphedema, there is an increasing interest in treatments that may stem the progression of this disease or reduce its severity. Toward this goal, microsurgical procedures to address lymphatic dysfunction are under investigation at Cedars-Sinai and academic centers around the world.

Currently, first-line management of lymphedema involves skin care, compressive garments, manual lymph drainage techniques and intermittent pneumatic compression devices. This approach requires strict patient compliance and adherence to an onerous regimen. Surgical approaches have focused on either debulking lymphedematous tissues or re-establishing extremity lymph flow. In current practice, the latter employs lymphovenous bypass or vascularized lymph node transfer.

Lymphovenous bypass aims to channel lymph into veins or venules, effectively bypassing areas of lymphatic obstruction. Because of the low morbidity and modest but observable symptomatic improvement achieved, this technique has held promise since it was first studied in the 1960s. The technical challenge of performing "supermicrosurgery" is the primary factor limiting its use in most centers.

A decade ago, the first series of successful microvascular lymph node autotransplantations into the axilla and forearm were published. A significant proliferation of research into vascularized lymph node transfer has occurred since then. The idea of bringing vascularized lymphatic tissue into an affected extremity dates back over 50 years, when researchers used tunneled omentum to help drain lymphedematous extremities. This approach suffered from high morbidity and a questionable degree of clinical improvement.

In contrast, vascularized lymph node transfer from a healthy donor site appears to have lasting benefits, though the exact mechanism is not yet well understood. Theories include:

  • The transferred nodes act as pumps, siphoning lymph into the venous drainage system.
  • The nodes promote lymphangiogenesis, "sprouting" new conduits that reestablish lymphatic channel continuity.

The low morbidity and lower technical difficulty of this procedure has prompted wider adoption of vascularized lymph node transfer.

Contributing to the enhanced success of these microvascular procedures are recent advances in imaging. Most notably, fluorescence lymphography is a powerful tool that allows dynamic visualization of lymphatic channels following injection of indocyanine green, a dye that is absorbed quickly into the lymphatic system. This is helpful in multiple ways. First, the severity of a patient’s disease, even in early stages, can be assessed by observing the movement of the fluorescent dye and peristalsis of lymphatic channels. Second, it helps to identify the overall lymphatic anatomy and site(s) of lymphatic obstruction. Third, follow-up lymphography studies have been shown to accurately demonstrate improvement in lymphatic function. More traditional lymphoscintigraphy and gamma probe detection are still used to identify and avoid extremity sentinel nodes to minimize the risk of causing lymphatic dysfunction at vascularized lymph node transfer donor sites (e.g., the axilla or groin).

Current vascularized lymph node transfer technique involves several important steps. First, the patient must be identified as an appropriate candidate with early-stage disease and some residual lymphatic function if success is to be expected. Second, appropriate lymph node donor sites are planned before surgery and radiolabeled tracer is injected in distal donor extremities to help identify and preserve the sentinel nodal basins. Third, the harvested flap of tissue containing the donor lymph nodes is transferred to the recipient site (axilla and/or forearm, e.g.) and the flap vessels are anastomosed to appropriate recipient vessels using standard microvascular technique.

Outcome studies have demonstrated symptomatic and objective improvement in extremity lymphedema following these microvascular procedures in appropriately selected patients. Objective measurements of lymphedema severity are difficult, however, as each factor studied (pain, extremity girth and volume) tend to fluctuate day-to-day and improve very slowly. What has become clear is that surgical options tend to work best when administered during the early phases of secondary lymphedema, and that once advanced stages of the disease are manifest, these modalities fail to provide noticeable benefit. At Cedars-Sinai and elsewhere, these techniques are being refined to improve patient selection and achieve predictable results.