New bypass can prevent distressing side effect of breast cancer operation, trial shows 

Around 100,000 people in the UK experience lymphoedema — debilitating swelling of the tissues, often as a result of breast cancer surgery. 

Nicole Song, 43, a full-time mother of one from Hampstead, North London, underwent a new technique to prevent it, as she tells Matthew Barbour.

The patient

When I felt the lump under my left armpit two years ago, I was extremely worried because my mother had breast cancer.

After a telephone consultation with my GP, I was referred to Charing Cross Hospital, where I had a mammogram and biopsy. My husband, Hans, waited in the corridor due to Covid rules.

The results showed I had a 2cm tumour in my left breast and a 3cm tumour in my underarm, as well as a few smaller masses in the same area. Surgeon Paul Thiruchelvam said the cancer had spread to lymph nodes in my armpit and I would need chemotherapy before surgery.

After high-strength chemotherapy, scans showed the tumour in my breast had gone, while the tumour in my armpit was half the size — a great result.

During chemo, I discussed surgical options with the doctors. As I was found to have the BRCA2 mutation [which raises the risk of breast cancer], I opted for a double mastectomy and breast reconstruction. In addition, the lymph nodes would be removed.

With a young daughter [Elise, now four] and so much of my life ahead of me, I wanted to take no risks of the cancer returning. However, I was worried about developing lymphoedema as a result. My mum had had all her lymph nodes removed a few years earlier and had experienced swelling and limited arm movement afterwards.

Mr Thiruchelvam told me about the new LYMPHA procedure which may help minimise the risk of lymphoedema. He explained it was a bit like a bypass, so fluid from the lymphatic system draining my arm would continue to flow, avoiding the symptoms my mother had.

I said I would love to have this done, although I knew that I’d be one of the first in the UK to do so. Six weeks after the end of chemotherapy, I underwent six-and-a-half-hours of surgery to have the lymph nodes removed, the double mastectomy and reconstruction, and LYMPHA at the same time.

Afterwards, there wasn’t much pain and I was discharged two days later. I had three drains in place, one under the armpit and one into each breast, out of which fluid was expelled into a bag I carried around. These were removed about a week later in hospital.

I’m glad to say that, nearly ten months later, I don’t have any lymphoedema and scans show that I’m cancer free. I feel so lucky to have had this incredible level of care to provide me and my family with a future, without the longer-term issues my mum had to deal with.

The surgeon 

Paul Thiruchelvam is a consultant breast and reconstructive surgeon at Imperial College Healthcare NHS Trust and King Edward VII’s Hospital in London.

Lymphoedema, which causes debilitating swelling, is due to a problem with the lymphatic system — a network of tiny vessels all over the body that drain fluid, called lymph, from surrounding tissues into the blood.

The lymphatic system plays a role in regulating body fluid levels, absorption of nutrients from the blood and fighting infection. Lymph fluid passes through lymph nodes, where potentially harmful matter, including bacteria and viruses, can be removed.

If the lymph fluid cannot return to the bloodstream at a rate of about three litres per day, it accumulates in tissue, resulting in swelling. This commonly occurs in the trunk, arms and legs, the parts of the body most affected by infection, surgery, radiotherapy or injury.

If not treated early, this swelling can result in lifelong symptoms including numbness, pain, limitation in movement, emotional distress and reduced quality of life.

You can be cured of cancer but be left with the lifelong symptoms of lymphoedema.

In the UK, around 20 per cent of women having surgery to remove all the lymph nodes under their arm (axillary clearance surgery) develop it.

Thankfully, in recent years there’s been a significant reduction in such surgery due to improved targeted therapy and chemotherapy prior to surgery, and the replacement of surgery with radiotherapy.

However, some patients still require axillary clearance surgery. In addition, these patients will also have chemotherapy and radiotherapy following surgery, which further increases the risk of lymphoedema.

With new technology, including an infrared camera system which Imperial Healthcare NHS Trust was one of the first in the UK to use, we’re able accurately to identify the lymphatic vessels coming from the arm and reconnect them to the patient’s blood, bypassing the removed lymph nodes and enabling the lymph fluid to be drained.

This procedure is called lymphatic microsurgical preventative healing approach (LYMPHA).

Several studies in the U.S. and Europe have demonstrated that it can significantly reduce the risk of lymphoedema following breast cancer treatment, halving it from approximately 20 per cent to under 10 per cent.

First, during surgery, fluorescent green and blue dyes are injected into the upper arm to identify the lymphatic vessels measuring 150 microns (a micron is one-thousandth of a millimetre) to 1mm (by comparison, a human hair is between 17 and 180 microns). These can then be seen on a screen — they’re marked with a metal clip, causing them to swell and fill with lymph fluid, which facilitates identification by the surgeons.

Next, a magnetic tracer is injected into the breast around the tumour, helping to identify the lymphatic channels draining the breast. Using a magnetic sensing device, the surgeon is able to identify the lymphatic channels and nodes draining the breast.

The surgeon then performs an axillary lymph node clearance, removing the nodes in the underarm but preserving the lymph vessels and veins.

Using a microscope, a specialist surgeon connects these lymphatics to tiny veins in the underarm. This enables the lymph fluid to flow back to the bloodstream.

The surgical team at Imperial have now undertaken more than 30 LYMPHA procedures over the past three-and-a-half years, as part of an ongoing evaluation.

Our early study data are very encouraging, with no reported cases of lymphoedema as yet.

There is still much to learn about lymphoedema, and while the numbers in our study are small, our experience is growing.

Building on the success of LYMPHA in breast cancer, colleagues are starting to offer this surgery to those at risk of lymphoedema with other cancers, including some gynaecological cancers.

Lymphovenous bypass surgery can be used for treatment as well as prevention of lymphoedema.

The study is being funded by the Imperial Health Charity with support from the Winston Churchill Memorial Trust.