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December 16, 2020

A regenerative detour for lymphedema

By Susan Buckles

Mayo Clinic is refining its regenerative approach to treating lymphedema, a debilitating buildup of fluid after cancer treatment. Research by Antonio Forte, M.D., Ph.D., a Mayo Clinic plastic surgeon, seeks to better pinpoint who is most likely to benefit from surgery aimed at regenerating a faulty lymphatic system.

Mayo Clinic's Center for Regenerative Medicine supports this work as part of it mission to deliver new regenerative solutions to the practice. Mayo Clinic's Center for Individualized Medicine is funding research to identify new biomarkers that could predict which patients are most likely to respond to this regenerative surgery.

Antonio Forte, M.D., Ph.D.

"Without surgery, lymphedema gets progressively worse due to accumulation of the lymphatic fluid in tissue and the chronic changes that causes. The upper and lower extremities can feel heavy, and the affected area is more prone to infections. Wounds take longer to heal, and some people lose dexterity to the point that it's hard to put a shoe on," says Dr. Forte.

Lymphatic damage is most often associated with cancer treatment, although some cases of lymphedema are congenital. During cancer treatment, lymph nodes may be damaged or removed, and the lymphatic fluid no longer drains. Then lymphedema can develop months or years after cancer treatment.

Surgical options at Mayo Clinic

Mayo Clinic is a leader in surgical options to reverse the damage from lymphedema. Dr. Forte specializes in lymphovenous bypass, a microsurgery done under powerful microscopes that are magnified 20 to 25 times. Through an incision no larger than a paper cut, the surgery connects tiny lymphatic vessels smaller than a strand of hair to tiny veins, creating a type of detour around the damaged area. The new vessel connections restore the body's ability to drain lymphatic fluids.

"When you remove that fluid, we don't know why, but the body is able to reverse these chronic changes in the tissue. In a way, what we're trying to do is reverse the damage that was done by the accumulation of the lymphatic fluid," says Dr. Forte. "It is a regenerative approach because not only do you restore function, but you actually heal the tissues."

Like a ton of bricks

Rebecca, who asked that her last name not be used, was diagnosed with triple-negative breast cancer in 2009. She prayed she'd live long enough to see her two youngest sons graduate college.

The Savannah, Georgia, resident waged a grueling battle that included chemotherapy, mastectomy and lymph node removal. She emerged victorious and was able to not only attend her sons' graduations, but also their weddings. However, a noxious side effect surfaced four years after her cancer treatment. Lymphedema developed in her right arm, causing swelling and fibrous tissue that progressively got harder.

"I felt as if I was dragging a ton of bricks everywhere I went. I could not go away to visit family without being sure I had all materials and compression garments with me. I had to make a checklist to include everything I needed to care for myself anywhere I went," she says.

Occupational therapy, compression wraps and a disciplined exercise regimen helped control her lymphedema, but it never really went away. A devastating reality set in when she realized that no matter how closely she followed medical advice, the lymphedema would not be cured.

9 was the lucky number

By luck, coincidence or maybe even a miracle, Rebecca discovered a new path to treatment while at the ninth green of the Players Championship at TPC Sawgrass in Ponte Vedra Beach, Florida. She and her family had gathered at the ninth green to watch a golfer sink a putt. Rebecca's right hand had swollen during the day.

"I had left my compression glove at home," she says.

She decided to stand in the shade and rest her hand on a tree to see if the swelling would go down. While standing there, with her right hand above her head resting on an ancient live oak tree, a nearby spectator noticed the compression sleeve.

"She said: 'Excuse me. I see you are a lymphedema patient. Did you know that Mayo Clinic offers lymphovenous bypass surgery?' This woman turned out to be a plastic surgery nurse practitioner at Mayo Clinic in Florida. I had not heard about the surgery until our chance meeting," says Rebecca.

Despite her initial apprehension, preparations for surgery started falling in place. Dr. Forte examined her and found the procedure to be a suitable match, and her insurance approved. One year after lymphovenous bypass surgery, Rebecca says the fluid has drained and her right arm is nearly normal.

"I can now feel the bone in my elbow. I hadn't felt that bone in three years," she says. "This surgery has taken a weight, ball and chain and a ton of bricks off my life. Resentment, fear and worry also have been removed. I truly do not have words to express the depth of gratitude and appreciation I have for Dr. Forte and his nurse practitioner. I weep with private tears of joy and relief."

While surgery relieved Rebecca's symptoms, Dr. Forte says there is a chance it might not work the same for others. However, he believes lymphovenous bypass is a safe and low-risk procedure.

"I love the bypass because the morbidity is so low that there's little downside to the procedure. If lymphovenous surgery doesn't relieve fluid buildup, then all you have to heal from is small incisions similar to paper cuts. If it does work, it's life-changing," he says.

By better understanding how each patient responds to the surgery, Dr. Forte hopes to improve the success rate. He also hopes to learn whether a targeted drug or complementary treatment might lead to quicker recovery.

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This article was originally published on the Center for Regenerative Medicine blog.

Learn more

Watch a video of Dr. Forte explaining lymphedema treatment:

Review lymphedema research by Dr. Forte:

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Tags: Antonio Forte, cancer, Center for Individualized Medicine, Center for Regenerative Medicine, Innovations, lymphedema, News, People, republished

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