Connections is a quarterly newsletter for primary care providers covering the latest developments and advances in medicine at OHSU. Learn about the many clinical, education and outreach resources available to you and your patients.
From OHSU Knight Cancer Institute
Allison C. Nauta, M.D.
Dr. Nauta is a plastic and reconstructive surgeon with interests in complex reconstructive surgery, microsurgery and lymphedema. She serves on the global oversight committee of the Lymphedema Education and Research Network and is the director of the Lymphatic Program at OHSU.
Secondary lymphedema is an unfortunate and often overlooked consequence of some oncology treatments. At this time, secondary lymphedema is an incurable, progressive, disfiguring and disabling disorder that is difficult to predict and treat.
To address this challenging issue, OHSU Knight Cancer Institute established a comprehensive program to serve our region with the goals of education, prevention, conservative therapy and surgery.
Center of Excellence for lymphedema designation granted
OHSU applied to the Lymphedema Education & Research Network as a Comprehensive Center of Excellence for lymphedema and was recently granted the highest level of designation; an honor that has only been granted to 15 institutions worldwide.
OHSU has created an interdisciplinary program combining expertise from oncology, rehabilitation therapy, infectious disease, endocrinology, nutrition, surgical oncology and plastic surgery to treat the whole patient at risk for this complex disease. We triage these patients to the appropriate specialties and provide a home base for them.
Prevention emphasis: bioimpedance measurement simple and effective
OHSU now has three bioimpedance spectroscopy devices, which provide precise measurements of fluid status and tissue composition in less than 30 seconds.
This noninvasive measurement tool can identify early progression by giving an L-dex score, measuring changes in extracellular fluid in the at-risk limb in comparison to the noncancerous side.
For example, if a patient’s L-dex measurement bumps 10 points from baseline, that signals higher risk and the patient should go to compression therapy immediately to prevent or reverse progression.
We establish a baseline before procedures on all patients undergoing sentinel lymph node biopsy or axillary lymph node dissection. Then we continue to measure and monitor these parameters at regular intervals for the first two to three years after their cancer intervention.
Efforts to launch a lymphedema chapter
OHSU is supporting patients and volunteers to create an Oregon chapter of LE&RN. The chapter would organize events, lobby for changes, and be a resource for people with lymphedema.
Surgical interventions for lymphedema available at OHSU
The first goal is conservative therapy. Compression will be part of the ongoing treatment in all therapies, and patients must be compliant with compression therapy to qualify for surgery.
There is no cure for lymphedema. Operations to address lymphedema aim to improve quality of life by providing some relief from discomfort and reducing incidence of infections, repeated hospitalizations and chronic antibiotic use.
Surgical options depend on a patient’s clinical stage. With the assistance of a microscope that magnifies to 42X, our plastic surgeons can offer “supermicrosurgery” for the lymphedema in the early, fluid-predominant stage.
- For mild lymphedema: We redirect fluid from lymphatic vessels in the affected arm or leg to nearby venous channels. Lymphovenous bypass allows the body to clear the fluid through the venous system.
- For moderate lymphedema: Through vascularized lymph node transfer, we move lymph nodes from other parts of the body (often the omentum in the abdomen) to the area of the body affected by lymphedema. This transplant allows drainage of the fluid away from the affected arm or leg.
- For chronic lymphedema: Over time, the fluid turns to fat. We can offer liposuction debulking to reduce the discomfort.
Risk factors for lymphedema
Patients whose breast cancer treatment included any of the following are at increased risk for developing lymphedema:
- Sentinel lymph node biopsy: 4–7% chance
- Axillary lymph node dissection: 20–40% chance
- Lymph node dissection plus radiation therapy or Taxol-based chemotherapy: elevated risk
For patients with these risk factors, getting them into compression therapy and referred to a certified lymphedema therapist improves the likelihood of preventing or halting the condition.
Lymphedema can have delayed onset. Primary care and oncology providers can help patients be proactive if they carry risk factors and help look out for symptoms that need intervention to avoid complications.
When to refer
If you have patients with lymphedema or at risk for it, you can refer them at any point.
- Patients whose oncology treatment puts them at high risk for developing lymphedema.
- Patients with lymphedema with recurrent infections.
- Patients with lymphedema who have worsening symptoms/quality-of-life issues.
From the latest technology to the newest drugs that are increasing survival, OHSU Knight Cancer Institute, Oregon’s only NCI-designated Cancer Center, offers a full range of options for cancer patients.