Amanda Wilde (Host): This is Community Connect: presented by Tampa General Hospital. I'm Amanda Wilde. And joining me is Dr. Nicholas J. Panetta, who is chair of the Department of Plastic Surgery at USF Health and Chief of Tampa General Hospital, Department of Plastic Surgery. We're talking about lymphedema, a common but underrecognized condition that affects millions of folks in the US and worldwide. Dr. Panetta, welcome. Thank you for being here.

Nicholas J. Panetta, MD: Fantastic to be here with you today. Thanks for having me.

Host: Before we can understand lymphedema, can you explain in simple terms what the lymphatic system does?

Nicholas J. Panetta, MD: Yeah, absolutely. So, the lymphatic system is kind of a third component of the vascular system that we have in our body. So, everybody's familiar with arteries and veins that help blood circulate through our body. The lymphatic system helps handle fluid that collects out on our tissues, transport that back through our lymph nodes, perform an important immune function, and then circulate that fluid outside of the blood vessels that's in our tissues back to the venous system so that it stays in circulation.

Host: And so, what is lymphedema?

Nicholas J. Panetta, MD: So, lymphedema, it is any variety of conditions or treatments that people undergo that can result in a disruption of that plumbing system. It's really an anatomy problem. And so, when that disruption in the normal flow of lymphatic fluid in your circulatory system happens, you essentially develop a condition where more fluid gets into one part of your body than can really get out through that normal flow through the lymphatic system, and that imbalance causes swelling. That can cause really a variety of patient's issues that patients suffer from over time.

Host: And how could someone tell the difference between lymphedema and other causes of swelling?

Nicholas J. Panetta, MD: That's really kind of where experts, such as myself come into play. It's astute to observe that swelling in extremities and throughout the body can come from a variety of underlying etiologies. A common one that people would think about is issues with venous circulation as well. Those components of the circulatory system are really kind of interrelated closely. And so, issues with obstructed venous outflow can also cause swelling. And so in treating patients with lymphedema, it's important to really get into studying what the underlying causes of a patient's swelling are so that you can appropriately treat those issues that may be causing the condition.

Host: Well, maybe this is a good time to define the difference between primary and secondary lymphedema. Can you do that for us?

Nicholas J. Panetta, MD: Yeah, absolutely. So, the vast majority of what we see and treat in the United States is secondary lymphedema. And specifically, lymphedema related to surgical or oncologic interventions we call cancer-related lymphedema. Primary lymphedema, it is an important cause of lymphedema as well, and you can think about the two. Primary lymphedema is something that in general has an anatomic cause or derangement that someone is born with and develops at an earlier stage in life. So, something that is maybe a bit awry with someone's lymphatic system, or circulatory system that causes obstruction or abnormalities in their lymphatic outflow. And some of those treatments for those conditions can be similar to secondary lymphedema. And then, that can be then compared to secondary lymphedema that arises from causes. Worldwide, often those causes can be related to infections that people suffer from. But again, as I mentioned here in the United States, the most common cause of secondary lymphedema is often cancer and its treatments.

Host: And are there symptoms of cancer-related lymphedema that are specific to secondary or cancer-related lymphedema?

Nicholas J. Panetta, MD: Swelling really is the main thing. Now, often patients will present even before they can notice swelling, if providers are following along their patients closely. Patients will present with things like they just feel like the extremity feels full or heavy. They'll present with kind of subjective symptoms like that, maybe some discomfort and pain. Patients might often present saying, you know, "My rings just aren't feeling right," or "My hand feels tight, a little bit of swelling." And those should really be red flags in patients who are at risk for developing this condition for a provider to dial in and really pay close attention.

And the reason that is important to pay such close attention to these patients who are at risk is because we definitively know that if we are able to get at these patients earlier in their disease process, our capacity, both as surgeons and as therapists that help on our team to meaningfully contribute to stopping the disease progression in its tracks or even reversing it, is increased.

Host: Well, what are some of the ways you treat lymphedema patients specifically at Tampa General Hospital?

Nicholas J. Panetta, MD: Yeah. We've really put together a fantastic team. So historically, lymphedema patients have been treated with what's called decongestive therapy or complete decongestive therapy, CDT. And that's been delivered by our certified lymphatic therapist here at Tampa General Hospital, and it's fantastic. It really can slow disease progression. But the issue is it doesn't treat the fundamental underlying anatomic abnormalities that are causing the disease to exist in the first place. And that's where kind of some of our really novel cutting-edge surgical and microsurgical treatments aimed at both preventing and treating established lymphedema have come into place.

We have a variety of microsurgical interventions where we can actually reroute the plumbing, I tell patients. So, rerouting that obstructed flow, getting that lymphatic fluid back into the venous system where it's supposed to exist at a time point where we can limit the amount of damage that's happened to the anatomy from that accumulated fluid and kind of get the train back on the tracks.

Host: Well, when you talk about rerouting the plumbing, can lymphedema be cured?

Nicholas J. Panetta, MD: It's very exciting there's an increasing body of evidence that if we apply these microsurgical techniques in early stage or even preclinical lymphedema—so what we would call stage 0 or stage I lymphedema—if we can perform some of these novel imaging and diagnostic techniques that we have, intervene at a very early time point, there is a growing body of evidence that we can certainly stop this disease in its tracks before it can really cause problems that are going to affect patients for their life.

Just most recently in clinic yesterday, we actually completely released two patient from wearing garments whatsoever. And we'll observe those moving forward. But two great examples, again, in the real-world where we have identified a patient at an early disease stage point and completely reversed their disease through surgical intervention.

Building on that, in addition, we're currently involved in randomized trials that are looking at preventing this in the first place. So, we've got a whole algorithm in place at this point where we're collaborating with our breast oncologist to actually perform microvascular lymphatic reconstruction at the time when their breast cancer is treated. So at the time when those lymph nodes are removed and the lymphatic system is altered, we're actually efforting to put those lymphatic channels back together at the time of surgery and prevent this issue from occurring in the first place. And we have some really strong preliminary evidence that supports that we can significantly reduce the development of cancer-related lymphedema in this patient population.

Host: Wow. That is all very hopeful news. Really positive emerging trends and innovations in the treatment of lymphedema. And for those who have already been through the process, how have you seen treatment affect quality of life for those patients?

Nicholas J. Panetta, MD: Yeah, there's no doubt that the negative impacts that living with lymphedema imparts on patients' day-to-day lives. It is just profound. And I think educating patients and educating providers is a really important part of this journey. Treating lymphedema is something that it is a daily time-consuming process for patients. You can ask any of them. It involves daily wrapping, pumping, massage therapy, compression garment-wearing, and these things just are really challenging to be compliant with on a longitudinal basis. When you speak to patients who we've successfully intervened upon and reversed or stopped this disease process, I mean it's really hard to describe the positive impact that has on their day-to-day life and the people that are involved in their life that they're interacting with on a daily basis. It's important to know as well that not only does it improve their day-to-day function and quality of life, and that's measured through validated quality of life tools that we actually deploy to patients as we monitor their progress over time.

But we're also reducing the secondary problems that arise from lymphedema, the form of infections, hospitalizations, treatment with antibiotics and such. All of those things are meaningfully reduced through surgical intervention, and stopping this disease process from evolving.

Host: It's like you're strengthening all the systems in the body when you deal directly with the lymphedema.

Nicholas J. Panetta, MD: Yeah, 100% true.

Host: Well, Dr. Panetta, thank you so much for this information. I definitely have some big takeaways from this, and one of them is how important early diagnosis and treatment is. So if you've had cancer treatment and you have swelling and suspect lymphedema, it's a good time to see the doctor.

Nicholas J. Panetta, MD: I appreciate it so much, Amanda, for taking the time again. The more we can get this out there to patients, the better we are. There's some really fantastic capacity and technology coming down the road to help this patient population, especially in the setting of robotic surgery and robotic microsurgery that we have available here at the hospital that's really helping us define what's possible for this patient population. So, I appreciate you taking the time and getting this information out there.

Host: Such exciting advancements and trends in the field of lymphedema treatment. Thank you, Dr. Panetta. That was Dr. Nicholas J. Panetta. He is Chair of the Department of Plastic Surgery at USF Health and Chief of Tampa General Hospital, Department of Plastic Surgery.

For more information, please visit tgh.org/lymphedema. If you enjoyed this episode, please be sure to like, subscribe, and follow Community Connect: presented by TGH on your favorite podcast platform. This is Community Connect: presented by Tampa General Hospital.