Science and technology have made significant strides in the treatment of cancer but contrary to popular belief the work doesn’t end at the surgical table.
A multidisciplinary approach is key for optimum cure and restoration of quality of life. This means intervention by a team of experts from multiple departments — including a cancer surgeon, a medical oncologist for chemotherapy, a radiation oncologist for radiation and a plastic surgeon. Each plays a pivotal role in caring for the person and being instrumental in bringing a lingering smile to their face.
One such person who benefitted from our inclusive approach is a 52-year-old woman from Mysore. The success of the case is an instant and constant source of joy and pride for our entire team.
Diagnosis of cancer
In 2022, she developed a swelling in her left arm and was treated for thrombosis for a month and a half. When the swelling didn’t subside, the doctor advised her to see an oncologist in Bengaluru. On evaluation, our attention was drawn to something that had probably been overlooked. We noticed that her left breast was red and swollen. And on detailed examination, we found the presence of a very big lymph node in her left armpit and a small tumor in her left breast.
Biopsies of the lymph node and the breast tumor were conducted, and the diagnosis was a locally advanced breast cancer at stage 3 B with lymph edema. Lymph edema is rarely seen in people, primarily due to the spread of awareness and regular health screenings. So her case brought with it an element of surprise for us.
After eight cycles of chemotherapy, we conducted a modified radical mastectomy of the left breast which involved the affected lymph nodes under the arm being removed. But, as stated earlier, our work wasn’t completely done.
The lymph edema had to be taken care of and for that we did a primary lymphovenous anastomosis (LVA), a procedure that includes connecting the cut lymphatics to suitable similar-sized veins with very fine sutures to maintain the continuity of the lymphatic system in the armpit.
Cancer: challenging treatment
The procedure sounds simple, but it is very challenging. Imagine finding lymph vessels around the size of 600-800 microns (visible only under a microscope) deeply embedded in the tissue, and connecting them with precision to the veins. This cannot be achieved without a special microscope, specialised training and a state-of-the-art facility. Although currently there are only a handful of centres that perform LVA in our country, there is scope and indication of tremendous growth in this sector.
Coming back to the case, for most people, the edema subsides after primary LVA and is maintained well with a follow-up manual lymphatic drainage, massaging and exercise schedule. But the woman’s case turned out to be an exception.
After four weeks, when we sent her for radiation, she complained that the swelling in her arm, though reduced, had not entirely subsided and there was wrinkling in her upper arm and forearm. The relapse could be attributed to radiation which can compress the connections between the veins and the lymphatics, leading to their collapse and causing the swelling to return.
Therefore, a year after, when the radiation was completed, we re-evaluated her edema status by visualising it through indocyanine green (ICG), a fluorescent dye injected into the web spaces between the fingers of the hand and which highlights the blocked lymphatics through an infrared camera. Unfortunately, she had blocked lymphatics — and since untreated lymph edema can be life-threatening (due to recurrent infections), we had to do something about it.
The solution was secondary LVA. This time, the procedure was to be carried out on her forearm through tiny incisions under local anesthesia.
The decision paid off and it proved to be a turning point for her.
After six months when the woman visited us, the size of her arm had reduced significantly and the difference between her right and left arm was less than 5%. Her cancer had gone too, and we couldn’t document any disease. But we probably wouldn’t have registered this transformation if she hadn’t walked in confidently and jubilantly wearing a sleeveless dress that she had missed wearing for a long time.
The joy and happiness she exuberated were priceless and have been etched in our memories forever. The entire episode also keeps reminding us how we fail to acknowledge the impact small things have in our lives and the magnitude of satisfaction they bring that lingers forever.
Our earnest message to all people dealing with cancer:
- Always adhere to the follow-up schedule advised by the doctor.
- Be very optimistic and have faith in the process as well as the outcome. Positivity always heals.
Dr Shabber Zhaveri is chairman & HOD, surgical oncology, Manipal Hospitals, and Dr Ashok BC is consultant plastic and reconstructive surgeon, Manipal Hospitals