Novel Procedure Performed for Post Mastectomy Arm Lymphoedema
Swelling of the arm and forearm (lymphoedema) due to accumulation of tissue fluid (lymph)following axillary dissection for breast cancer management, is a dreaded complication and not entirely preventable. It occurs due to disruption or obstruction of lymphatic pathways draining the arm and forearm while they are passing through the axilla (armpit) Several management strategies and surgical techniques have been employed to lessen the incidence of this complication. The Oncology Team at KIMS Cancer Center employs several methods to mitigate the chances of developing lymphoedema.
Latest News Senior Surgical Oncologist, Dr. Sabyasachi Parida who is also an Advanced Oncoplastic Breast Surgeon, has been employing most of the established techniques for de-escalation of axillary surgery for several years now, like meticulous technique, axiliary reverse mapping, Sentinel lymph node biopsy with intra-operative frozen section reporting from Pathology Department, Low axiliary clearance in appropriate cases, achieving the lowest possible lymphoedema rates (comparable to the best reported worldwide).
However, a few patients develop some degree of lymphoedema of the arm and forearm. Most such patients can get relief by physiotherapy techniques like manual lymphatic drainage, and graded compression stockings combined with dietary and lifestyle modifications. Very rarely, some patients experience progression.
One such Patient, who was operated for Breast Cancer by Dr. Parida in 2018 with Breast Conserving Surgery, Onco-plastic Reconstruction and Axiliary lymph node dissection presented with progressive swelling of her arm and forearm despite conservative management. In her 60s now, diabetic and hypertensive, she was experiencing a decline in performance status and hence lymphoedema would have further compromised her ability to live an independent lifestyle without assistance. This was considered and discussed in detail during the follow-up visit. To assess the lymphatic flow in her arm and forearm, Indocyanine Green-based Lymphography was performed about a month ago by Dr. Parida.
Such a procedure was performed for the first time in Odisha. This is a non-radioactive method of lymphatic flow assessment that employs a near- infrared based imaging system. It showed a diffuse pattern of lymphoedema, primarily showing contrast holdup in her forearm. Different surgical procedures were considered and discussed.
This was further discussed with Dr. Sunil Ku Rout, Senior Consultant, Plastic Surgery and a consensus was reached on Vascularized Lymph Node Transfer to the lymphoedema-affected forearm of the Patient. In this novel procedure, a group of lymph nodes is harvested from one part of the patient’s body(supraclavicular, inguinal regions) along with their blood vessels and transplanted into the lymphoedema-affected forearm of a Patient with micro-vascular anastomosis of the donor artery and vein/veins to Radial artery and cephalic vein of the forearm. This has been seen to achieve about a 30% reduction in the swelling of the forearm, thus greatly improving comfort and function. It is performed in only a few centres in our Country.
KIMS Super specialty and Cancer Centre became the first centre in Odisha to perform the procedure when a Team of Doctors comprising Dr. Sabyasachi Parida, Dr. Sunil Ku Rout, Dr. Samir Kumar Patel(Plastic Surgeon), T. Rajmohan Rao(Chief of Anaesthesia) performed the surgery successfully on 2nd May 2024.
At the beginning of the procedure, Dr. Parida in the presence of Dr. Rout, surveyed the right and left supraclavicular regions of a patient with high-frequency ultrasound and found that the right-side supraclavicular lymph node packet was suitable and that the transverse cervical vessels were of good diameter ideal for anastomosis. Dr Rout, Dr. Parida and Dr Patel carefully harvested the lymph node packet from the right supra-clavicular region and transverse cervical vessels. Subsequently, the Plastic Surgery team led by Dr. Rout and assisted by Dr. Patel performed the anastomosis of the donor’s vessels to the Radial artery and cephalic vein of the affected forearm with the help of a high-end operating microscope. Dr. Purabi Acharya(Consultant, Anaesthesia) successfully extubated the patient on the table. The patient was transferred to her cabin bed after surgery.
Mr. Hemanta Kumar Sahoo(Senior OT Technician); Mrs. Sumitra(Senior OT Sister), Sasmita(Nursing Officer); and Mikina Pradhan(Senior OT Support Staff) were part of the core team that made the surgery successful. Mrs. Kalpana Ojha(Senior OT Sister) provided support from the Surgical Oncology side. The graft is viable and the Patient is recovering well. Dr. Rout is keeping a close watch on the graft. This success opens up new possibilities for the treatment of breast cancer patients suffering from lymphoedema. With the addition of this procedure, to existing advanced oncoplastic surgery for cancer and minimally invasive surgery for benign breast lumps, and other services, KIMS Cancer Centre is now on the fast track to becoming the Centre of Excellence for Breast Surgery.