Vascularized lymph node transfer (VLNT) is an innovative surgical procedure that involves carefully removing healthy lymph nodes from one part of the body (known as harvesting), and then transferring them to a limb affected by lymphedema. The aim of this surgery is to naturally improve the drainage of lymphatic fluid in regions of the body where the lymphatic system is faulty. It is an effective treatment not only for arm and leg lymphedema but also for the face and groin regions.

How a Lymph Node Transfer works

Anatomical studies have shown there are a number of lymphatic basins ( a group of lymph nodes), in which there are nodes that can be removed without disturbing the lymphatic drainage of the arms or legs. Advanced imagery is used before surgery to help identify the best lymph nodes to harvest, which are known as non-sentinel lymph nodes. Special care is taken to make sure that these lymph nodes are not connected to the major drainage areas of lymphatic fluid at the donor site. Like this, only the most appropriate lymph nodes are taken which greatly reduces the risk of donor site lymphedema.

Image source: http://pubweb.fccc.edu/

During surgery, surgeons harvest three or four lymph nodes from the donor site, which are encased in fat and are removed along with an artery and a vein, ensuring blood supply to these lymph nodes. This mass of tissue collectively known as the ‘lymph node flap’ is transferred to the part of the body where lymph nodes no longer function. When the lymph node flap is transferred to the lymphoedematous limb, the artery is connected to the artery and the vein is connected to the vein- just like a finger transplant. This restores blood supply to the lymph nodes and allows them to survive and function. The lymph nodes don’t know they have been moved, and so they keep working (C. Becker, 2017).

The transferred lymph nodes are thought to stimulate lymphangiogenesis, during which new lymphatic vessels grow and connect to the lymphatic channels of the transplanted lymph nodes to create new pathways for lymph drainage.¹ This process can take anywhere up to two years following surgery, in which results will be gradually seen by the patient as the new lymphatic vessels grow and eliminate the excess liquid.

In advanced cases of LE, when the fluid is usually replaced with fatty fibrotic tissue, VLNT surgery can be combined with a special liposuction technique called SAPL, which removes the hardened tissue. Patients have been experiencing very good results combining the two surgical techniques. Lymph node transfer can also be performed in combination with DIEP (Deep Inferior Epigastric Perforator) flap breast reconstruction following a mastectomy. This approach simultaneously reconstructs the breast and treats the arm lymphedema.

The benefits of a Lymph Node Transfer

Patients who have undergone VLNT report a number of improvements, notably;

  1. A reduction in the size of the limb or normal contour of the limb returning, because the new functional nodes have restored the lymphatic function.
  2. The limb feeling is less heavy and/or painful.
  3. They have improved joint mobility.
  4. There is an improvement in skin quality and texture.
  5. A reduced frequency or complete disappearance of cellulitis and infections. This is due to restoring the important immunologic role of the lymphatic system in the damaged and fibrotic tissues.²
  6. A small percentage of patients are able to completely stop compression therapy, however, this is a case by case ruling and cannot be applied to all patients.

These three images show the same patient, a young boy with Congenital LE to the right leg. Photo [1]: Before any Lymphedema surgery. Photo [2]: Patient is 15 years old in this photo and was previously operated on with an outdated surgical technique, which made his LE worse. Corrective surgery was made with a lymph node transfer. Photo [3]: 2 years post-surgery following a LNT and SAPL surgery combined. (All photos supplied by Dr Corinne Becker).
To date, several studies have concluded that vascularized lymph node transfer is helpful in reducing lymphedema. One of the larger studies by Becker et al. evaluated 1500 patients with stage I, II, and III lymphedema who had undergone vascularized lymph node transfer. The minimum follow-up was 3 years. Findings included a 98% subjective improvement. Forty percent of patients with stage I and stage II lymphedema had significant improvement and required no further conservative therapy. For patients with stage III lymphedema, 95% had some improvement and 98% remained infection free. However, the stage III patients still required conservative therapy to help control edema in the limb.³

Diagnosing eligibility for a Lymph Node Transfer

The imaging involved in diagnosing a patient’s eligibility for VLNT is extremely important. The causes of the lymphedema must be clearly identified, in order to understand where the edema began and after what kind of trauma. Imaging used by Lymphedema surgeons differs around the world and depending on location and access to technologies, but the main modalities used include:

  • Lymphangioscintigraphy
  • Indocyanine Green (ICG) Immunofluorescence
  • Computed Tomographic Angiography (CTA)
  • Lymphatic MRI
Lymphatic MRI imagery which shows a comparison between the left and right legs. Black indicates the liquid which rests in the legs.

Who is a good candidate for VLNT?

As explained by Doctor Corinne Becker, a pioneer of the VLNT surgery, “Lymph Node Transfer is possible in 98% of patients with Lymphedema.” This equally applies to both Primary and Secondary Lymphedema. Ideally, the best time to undergo surgery is during the early stages of Lymphedema when an excess volume of the limb is predominantly due to an accumulation of lymphatic fluid and not an increase in fat. However, it has been shown that patients with advanced cases of LE who no longer respond to conservative treatments (such as MLD and bandaging) can also be successfully treated with VLNT.

In cases of Congenital Lymphedema, patients with hypoplasia (an underdevelopment of the lymphatic system), who experience pain and chronic infections are good candidates for the procedure. Children with underdeveloped lymphatic systems who are operated on at an early age respond, “even better and faster than adults and the results can be normal or near normal,” (C.Becker, 2017).

This child has been followed since birth and was operated on at 1-year-old (VLNT). Photo [1] The child before surgery. Photo [2]: Results two years after surgery. The child no longer wears compression garments and does not have any more swelling. (Photos supplied by Dr Corinne Becker).

Is Lymph Node Transfer a safe surgery?

Lymph Node Transfers have been carried out in operating theatres for the last 20 years and are a hot topic in the medical world, with people often asking, ‘are they safe?’ VLNT’s have significantly developed over time to become effective, safe procedures. Like any surgical procedure, VLNT’s carries certain risks that people need to consider before they go under the knife.

The biggest fear associated with VLNT is that removal of lymph nodes from the donor site could cause a secondary lymphedema in the region they were harvested. Although this is an acknowledged risk of surgery, modern practice uses many techniques (such as reverse lymphatic mapping and MRI) to avoid this and to ensure that lymph nodes are appropriate for removal and not connected to major draining points in the body.

Other risks and side effects that have been reported include:

  • General surgical complications – bleeding, infection, bruising, poor healing, damage to adjacent vessels or nerves.
  • Some regional numbness in the donor site and complications of a general anaesthetic.
  • Flap failure- there is a 2% chance that the transfer will not work
  • No improvement- a VLNT generally works in the majority of patients, however, it is possible that some patients experience minimal improvement and other surgical techniques would, therefore, need to be considered.

A more expansive list of risks and side effects of surgery can be found here.

Choosing a surgeon 

Vascularized lymph node transfer is a technically demanding operation and should only be performed by surgeons with successful experience. Dr Jay Granzow (California, USA), a world-renowned Lymphedema Surgeon explains, “It is critical for the safety and success of any Lymphedema surgery that the surgery is performed by a Lymphedema surgeon who is not only an experienced microsurgeon and familiar both with technical aspects of the surgery, but also with the overall care and treatment of Lymphedema patients.”

Lymphedema microsurgery procedures require specific training and experience, which is simply not included in standard residency training. Surgeons must go beyond what is commonly taught at medical school and undergo highly specialised Lymphedema microsurgery training. Lymphedema surgery is very different to other types of microsurgery and a successful outcome depends on a highly qualified Lymphedema surgeon who not only has great experience in the technical aspects of surgery but who also carefully integrates LE therapy before and after the surgical procedures.

Dr Granzow advises that when evaluating a surgeon to care for you, “Be sure to carefully investigate his or her qualifications and experience. Look up their Board Certification(s) and be sure to look into their training and experience with your specific procedure.”

Lymph Node Transfer: an effective alternative to conservative therapies.

Lymph Node Transfer has the potential to reduce the lymphatic load in the limb and slow the progression of lymphedema. We have learned a significant amount about the lymphatic system in recent times and are now beginning to understand better the pathogenesis and treatment of lymphedema. The challenges to successfully manage lymphedema are many, but with more clinical research efforts in recent times, we are beginning to see promising results that offer a substantial improvement to patients quality of life and overall health.

 

 

References:

[1] Surgical Options for Lymphedema, MD Anderson Cancer Center.

[2] Treatment Options for Lymphedema (Dr Corinne Becker, 2017).

[3] A comprehensive overview on the surgical management of secondary lymphedema of the upper and lower extremities related to prior oncologic therapies. Garza R, Skoracki R, Hock K and Povoski S. 5th July 2017.

Additional Links:

Microlymphatic surgery for the treatment of iatrogenic lymphedema. Becker C, Vasile JV, Levine JL, Batista BN, Studinger RM, Chen CM, Riquet M. Clin Plast Surg. 2012 Oct; 39(4):385-98.

Dr Corinne Beckerhttp://www.lymphoedemacenter.com/

Dr Jay Granzowhttp://lymphedemasurgeon.com/

Dr Anne Dancey: https://www.annedancey.co.uk/

 

NOTES:

Consent for Publication: All patient photographs have been de-identified. We have obtained consent to publish all the above photographs.

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