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of the patient’s upper airway during sleep, to accurately pinpoint the area
of obstruction. Dr. Ahn is among the first to use an endoscope equipped
with a tiny video camera to highlight problem areas while a patient sleeps.
The robotic procedure was adapted from a technique pioneered at the
University of Pennsylvania to remove cancer from the back of the tongue.
Dr. Ahn completed a rigorous training program to gain certification for
the surgery. Presently, he is the only surgeon in New York specializing in
the robotic treatment of obstructive sleep apnea.
Dr. Ahn cautions patients that sleep apnea can return if they do not keep
their weight under control, but most patients lose weight after surgery.
Forestalling Lymphedema, a Preventive Strategy
By Dan Harvey
After surviving breast cancer, many patients
must battle lymphedema, a common side effect of
breast cancer surgery that causes painful, debilitating,
and disfiguring swelling in the arms.
Breast cancer specialists at NewYork-Presbyterian/Columbia
University Medical Center
now have a way to detect lymphedema early
– before patients notice symptoms and when
treatments are more effective. “Clinicians can
now be more proactive than reactive,” says
Sheldon Feldman, M.D., the Vivian L. Milstein
Associate Professor of Clinical Surgery and
chief of breast surgery.
Lymphedema is a common side effect of
lymph node removal in breast cancer treatment,
but doctors cannot predict when, or if, it will
occur. Lymphedema can appear immediately
after treatment or it can take months, or even
years, to develop.
Clinicians can now use bioimpedance spectroscopy
to detect the earliest signs of lymphedema.
The small portable device applies a mild electric
current to the upper arm and measures the amount
of fluid in the limb. “The patient might be asymptomatic
– that is, no visible swelling – but we can
detect increased volume,” says Dr. Feldman.
The test is non-invasive and painless and best
serves those at the highest risk: patients with invasive
breast cancer who undergo surgery, radiation
therapy, and chemotherapy. NYP/Columbia is the
only academic medical center in New York that
offers a lymphedema prevention program.
Lymphedema cannot be cured, but early
detection can forestall the condition. “By the
time swelling is visible, it may be too late to
provide optimal treatment,” Dr. Feldman says.
“But if it’s detected early, we can pre-empt
lymphedema development with therapy and
avoid long-lasting effects.”
Therapy typically includes several visits with
a physical therapist for decongestive therapy,
which involves massage, wrappings, compression
bandages, and support garments. Treatment
typically lasts for a month and reduces
swelling in most cases.
In the year since the program started, several
patients have been identified with subclinical
levels of lymphedema. Before the program
began, testing was typically performed only
after swelling was noticeable. Now, Dr. Feldman
says, “Even before a patient has lymph
node surgery, we do a baseline study to determine
normal fluid levels. We then follow up on
a three- to six-month basis after surgery. We can
see very quickly if the levels increase.”
Surgeons are also working to prevent lymphedema
by becoming more selective about
removing lymph nodes. Until the mid-1990s,
most or all lymph nodes in the armpit were
removed to prevent the spread of cancer to
other organs. Then techniques were developed
that allowed surgeons to determine if some of
these lymph nodes could be spared. If the sentinel
lymph node – the node closest to the cancer
– was clear, the other nodes were spared. If the
sentinel lymph node contained tumor cells, the
surrounding lymph nodes were removed. “We
now understand that even if the sentinel node
In the two months after her procedure, Mrs. Oderwald lost 30 pounds,
which she attributes to her newfound energy. “When you’re tired, I think
you go for the wrong foods,” she says. “I’m now out walking the dogs
every night, I’m eating better, and the weight’s come off.”
“Sleep apnea that stems from tongue base has troubled me for the 15
years I’ve been doing sleep apnea surgery,” Dr. Ahn says. “But I think
now we have a technique that is finally capable of helping the majority
of our patients.”
More information is available from Dr. Ahn, 212-714-9494.
has cancer, it may not be necessary to remove
additional lymph nodes,” says Dr. Feldman.
A technique called reverse arm mapping
also has helped surgeons reduce the number of
nodes removed. “Mapping better defines the
function of the lymph nodes in the armpit. Two
nodes may be close together, but one affects the
arm while the other affects the breast,” says Dr.
Feldman. In reverse arm mapping, the lymph
nodes related to the arm are identified with a
special dye so they can be spared. “This reduces
the risk of lymphedema,” Dr. Feldman says.
Soon, Columbia breast surgeons also will
start offering patients at the highest risk of
lymphedema a new surgical technique to prevent
lymphedema. These patients have more
advanced breast cancer with lymph node
metastases that requires complete lymph node
dissection and radiation treatment of the armpit
region. The risk of developing lymphedema
after this treatment is 40 percent.
To reduce that risk, Columbia surgeons will
use dye to identify the lymphatic vessels from
the arm and then connect the vessels to a branch
of the axillary vein after the lymph nodes are
removed. “This will re-establish the lymph flow
and significantly reduce the risk of lymphedema
developing,” Dr. Feldman says.
“These are important advances that we think
will reduce the incidence of lymphedema and help
us improve quality of life for survivors.”
More information is available from the Clinical
Breast Cancer Program, 212-305-9676.
Spring 2012 ColumbiaMedicine 17