Pediatric Lymphedema – PediaCast CME 093

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Description

  • Dr Min-Jeong Cho visits the studio as we consider pediatric lymphedema. Discover how this condition presents in children, along with the cause, diagnosis, management, complications and long-term outcomes. We hope you can join us!

Instructions to obtain CME/CE Credit

  1. Read this information page.
  2. Listen to the podcast.
  3. Complete the post test at Nationwide Children’s CloudCME.

Topic

  • Pediatric Lymphedema

Presenters

Learning Objectives

At the end of this activity, participants should be able to:

  1. Define pediatric lymphedema and understand why it happens.
  2. Outline strategies for diagnosing pediatric lymphedema.
  3. Counsel families on treatment options for pediatric lymphedema.
  4. Provide support and resources for families impacted by pediatric lymphedema.

Links

Disclosure Statement

  • No one in a position to control content has any relationships with commercial interests.

Commercial Support

  • Nationwide Children’s has not received any commercial support for this activity.

CME/CE Information

  • In support of improving patient care, Nationwide Children’s Hospital is jointly accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for the healthcare team. (1.0 ANCC contact hours; 1.0 ACPE hours; 1.0 CME hours)
  • Nationwide Children's Hospital has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. Approval is valid for 2 years from the date of the activity. PAs should only claim credit commensurate with the extent of their participation.
  • As a Jointly Accredited Organization, Nationwide Children's Hospital is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Nationwide Children's Hospital maintains responsibility for this course. Social workers completing this course receive 1.0 continuing education credits.
  • Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.

Contact Us

  • CMEOffice@nationwidechildrens.org

 

Episode Transcript

Announcer:     This is Pediacast CME. ♪♪♪ ♪♪♪ Welcome to Pediacast CME, a pediatric podcast for providers. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr Mike Patrick:     Hello everyone and welcome once again to Pediacast CME. It is a continuing medical education podcast for healthcare providers This is dr. Mike coming to you from the campus of Nationwide Children's Hospital We're in Columbus, Ohio It's episode 93. We're calling this 1 Pediatric Lymphedema. I want to welcome all of you to the program.

Dr Mike Patrick:     I also want to say Happy New Year. So I know it's getting late into January, but this is our very first CME episode of the new year, 2024, and we have lots in store for you this year. Actually some exciting news. We have assembled a brand new pediatric CME planning committee, and The reason that we needed a new 1, there wasn't anything wrong with the old 1. In fact, it was fantastic and a great committee.

Dr Mike Patrick:     But because we have joint accreditation, and I mentioned this in all of our programs, that we not only provide continuing medical education credit for physicians, and that is category 1 credit, by the way. But we also provide credit for nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. You've heard me say that. And so our new planning committee for 2024, we have representation from all of those disciplines. And I'm really excited about this because our planning members are going to serve as guest hosts for some of the episodes.

Dr Mike Patrick:     Now, I will still be here And I will provide some color commentary from the sideline. But, you know, for example, when we have a episode that really pertains to physician assistants, let's say, we will have a physician assistant kind of designing the show and talking about their field and also making it relevant to the rest of us. And so I think it's going to be fun and give a little bit of a different lens for some of these episodes on the CME program. But again, I will be here and I think it's going to improve things over the course of the next year. So I am excited about that.

Dr Mike Patrick:     It should be fun and informative. And we have already lots of great topics and shows lined up for you. That includes today's episode, which is on pediatric lymphedema. This, I think, is an important 1 because, you know, you may see the title and think, oh gosh, I've never actually seen that in my practice. Or, you know, I only have had 1 child with it because it is rare.

Dr Mike Patrick:     However, it's also because it's rare often leads to a delayed diagnosis. And so if we can add this to our differential, put it more in the forefront of our thinking, you know, we'll do all the normal things we would do to rule out an enlarged extremity. But a lot of times we don't think about this maybe at all. And then when we're doing other tests and sending them off to see other folks, We aren't really getting to the bottom of it. So when you see a enlarged extremity, especially unilateral, an arm or a leg, or they just feel uncomfortable, something just doesn't seem right, maybe 1 shoe is a little bit larger than the other shoe that they need to wear comfortably.

Dr Mike Patrick:     Pediatric lymphedema ought to at least enter our mind and it is the plastic and reconstructive surgery folks who take care of this because microsurgery is involved in terms of repairing lymphatic vessels. So we're gonna talk all about pediatric lymphedema today. We'll talk about primary versus secondary lymphedema, how it differs in children versus adults, how is this diagnosed and managed, what complications, what symptoms to look for, and then what complications can arise and sort of the long-term outlook for those who are impacted by pediatric lymphedema. All of that coming your way today. And we have a wonderful guest with us, Dr.

Dr Mike Patrick:     Min-Jung Cho. She is a plastic and reconstructive surgeon at Nationwide Children's Hospital and the Ohio State University Wexner Medical Center. So she takes care of both kids and adults. Don't forget, you can find our podcast wherever podcasts are found. We're in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android, also on YouTube.

Dr Mike Patrick:     And please do subscribe to our show wherever you listen to your podcasts. And please consider leaving a review so that others who come along looking for free continuing medical education credit will know what to expect. Speaking of that credit, really easy to claim yours, just listen to the podcast, which you are about to do, and then you'll wanna head over to the show notes for this episode over at pediacastcme.org. You'll find a link to the post-test in the show notes. The link will take you to a place called Cloud CME, and you will need an account there.

Dr Mike Patrick:     It's free, really easy to sign up. And once you do that, you click on the materials link for the episode in question, and the post-test will show up in the materials link. Once you've taken past the post-test, the category 1 credit is yours. And again, since we are accredited by all of those professions that I had mentioned, it's likely we offered the credit you need to fulfill your state's continuing medical education requirements. Of course, you want to make sure the content of the episode matches your scope of practice.

Dr Mike Patrick:     Complete details are available at pdacastcme.org. We're also on social media. We love connecting with you there. I Just search for PDA Cast. And then that handy contact link is at pdacastcme.org.

Dr Mike Patrick:     If you would like to suggest a future topic for the program. Also want to remind you the information presented in every episode of our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. Our discussion may contain only a portion of relevant information and should not be solely relied upon for the diagnosis or treatment of any medical condition. We do not cover every possible treatment option and the treatment options we do cover do not include every possible use, percussion, side effect, or interaction.

Dr Mike Patrick:     Also, your use of this audio program is subject to the Pediacast CME Terms of Use Agreement, which you can find at pediacastcme.org. So let's take a quick break. We'll get Dr. Min-Jung Cho settled into the studio, and then we will be back to talk about pediatric lymphedema. It's coming up right after this.

Dr Mike Patrick:     Dr. Min-Jung Cho is a plastic and reconstructive surgeon at the Ohio State University Wexner Medical Center and Nationwide Children's Hospital and an assistant professor of plastic and reconstructive surgery at the Ohio State University College of Medicine. She has a passion for helping young patients and families impacted by pediatric lymphedema. That's our topic today. But before we get into it, let's give a warm Pediacast welcome to our guest, Dr.

Dr Mike Patrick:     Min Jung Cho. Thank you so much for being with us today.

Dr Min-Jeong Cho:     Thank you very much, Dr. Mike, for a fantastic avenue for us to discuss pediatric lymphedema today.

Dr Mike Patrick:     Yeah, I'm really excited to talk about this. I think a great place to start would be just with definitions. What exactly is lymphedema and what are the different types of lymphedema that 1 can get?

Dr Min-Jeong Cho:     So for lymphedema, it's a chronic swelling of any extremity, either arm or leg, typically, due to the impairment of lymphatic system. So primary lymphedema is when patients are mostly born with impaired lymphatic system. So typically, you know, these are for patients who are at pediatric age, who are, you know, at infancy or almost 50% of the time. At infancy, they'll present, and another 50% of the time is adolescents. When you have a patient, typically at the lower extremity, unilateral, that has an unknown, an unidentified swelling that it's difficult to figure out what is going on with the patient.

Dr Min-Jeong Cho:     Versus for adult patient, it's a secondary lymphedema. So for that cases, a lot of patients had an insult. So typically for me, I have another practice at Ohio State University, taking care of breast cancer patients with lymphedema. For those patients, they have axillary lymph node dissection, which removes the lymph nodes and then therefore the lymphatic vessels have a difficulty, you know, draining the arms. So these patients have secondary lymphedema because of the surgery, either radiation or exo-lymph node dissection.

Dr Min-Jeong Cho:     Similarly for patients with gynecological cancer as well, then they will present with the lower extremity swelling.

Dr Mike Patrick:     So we have primary lymphedema and secondary lymphedema. The primary 1 is you're born with a lymph node that maybe is malformed and so you get obstruction in the system and the lymph backs up and that's what causes the swelling. And then the secondary lymphedema is more common in adults where the lymph node is as damaged because of maybe a surgical procedure or trauma or something of that nature.

Dr Min-Jeong Cho:     Right, and then for primary lymphedema as well, it's so rare, so now the studies are being more discussed, but now there's thoughts about lymphatic hypoplasia, valvular dysfunction, So the patients may be born with lack of lymphatic vessels or lymph nodes for there. And then also maybe they have a dysfunctional lymphatic. So they are born with lymphatics, but then they're not as functional as the normal patients without lymphedema. So any types of disease within the lymphatic system that you're born with are primary lymphedema, and then any insults like trauma, surgery, radiation are done to the patient. Those are considered as a secondary.

Dr Mike Patrick:     Great, And the primary 1 is more common in children and the secondary 1 is more common in adults.

Dr Min-Jeong Cho:     Right. So primary lymphedema, you know, patients hopefully not would go such an extensive surgery such as cancer surgery. So therefore, if you ever see patients without any insult and then have a unilateral lower extremity swelling, the primary lymphedema, although it's 1 in 100,000 patients, is common to see in a pediatric patient because not too many of pediatric patients would have undergone cancer surgery.

Dr Mike Patrick:     Yeah, yeah, absolutely. But the overall incidence of primary lymphedema is still pretty rare. And that means it's something that maybe as pediatricians, we don't see all that often. And you probably see it more because you get referrals from all over the place.

Dr Min-Jeong Cho:     But

Dr Mike Patrick:     in terms of local cases, there probably aren't a ton of those because it is unusual. So when what and it sounds like there are multiple possibilities for the cause of primary lymphedema. Do we think that there's a genetic component to it?

Dr Min-Jeong Cho:     So about 70% of patients are idiopathic. There's no genetic involvement. And then there aren't any identified genetic causes that are associated with lymphedema, Although there are like genes that are believed to be associated with it, but it's, there's no 1 like for breast cancer, there's BRCA, but there aren't any for the, as much evidence on it. Cause like you said, it's so rare.

Dr Mike Patrick:     And then as, As pediatric providers, how will we see this in the office? Like what would make us concerned that that's what could be going on for a particular child?

Dr Min-Jeong Cho:     So for infancy, it's usually lower extremities. So unilateral lower extremities swelling that without any trauma, without any injury, and then, and then just suddenly it's progressive as well. It doesn't get better. And it's usually at infancy. I have a pediatric population, you know, from infancy, and then I have another group comes at adolescence.

Dr Min-Jeong Cho:     So those, a lot of these patients actually go to orthopedic clinic, joint clinic or rheumatology because they think, oh, is this a swelling? There must be like, you know, something going on with the bones or maybe something, rheumatology cause that's causing it. So a lot of my patients, special adolescent patients, have gone to these clinics actually, and then tons of studies were done, but then there are no identifiable causes. So then we have a vascular anomalous clinic that's where the patients come in.

Dr Mike Patrick:     And probably the reason that there's sometimes this delay in diagnosis is because it's so unusual. It's not the first thing that we think about and it's much more likely that the individual patient has 1 of those other problems, but it's always unfortunate when it takes a while. It's so frustrating for the patient, for the family, for the providers who also wanna get to the answer. So what are then the key steps in diagnosing pediatric lymphedema and separating it out from all of those other things?

Dr Min-Jeong Cho:     Right. So first step would be is it bilateral or unilateral? Because if bilateral you're using systemic causes, maybe cardiovascular or general urinary causes. Once you know that it's not a systemic cause and it's unilateral and it's also progressive, there are a couple of studies that a lot of I've seen a lot of providers get it, which are typically like MRI or ultrasound DVT duplex, which you know, you want to rule out the DVT as well. But those studies actually doesn't show you the lymphatic systems, actually.

Dr Min-Jeong Cho:     A lot of study that they have gone everything under the moon and then there's 1 key study, which I know a lot of systems provide, is lymphocentigraphy, actually. So in this study, you have a patient, you inject a radionucleotide into their foot or hand for the operation, and then you see how this dye travels over time. So it is very typical for me to get 1 side, like you could see a clear linear lymphatic channel going up, and then lymph nodes are taking up this dye versus the other side, there's no clear lymphatic channels, you see the dye just kind of spreads. And then you could actually see the time travel as well, that 1 side, like lymph nodes already, I mean, dye is already in the lymph nodes, is already going into the intra-abdominal nodes, while the other 1 is like, dye is still at the leg, is trying really hard to get to it. So that's like the key study.

Dr Min-Jeong Cho:     You're like, okay, this patient has lymphedema.

Dr Mike Patrick:     And is this something that typically, do you find primary care providers order that test and then find it and then refer to you or do they get referred to you and you usually order that test to sort of confirm?

Dr Min-Jeong Cho:     So they get referred to me because I mean, it kind of sounds scary, lymphocentigraphy, radioisotope. So I have seen patients who get more non-invasive study like MRI and ultrasound DVT. So they have kind of ruled out everything they can. And then the patients are referred to me, kind of more the patterns I see is a rule out. So not DVT, not soft tissue issues.

Dr Min-Jeong Cho:     So then here's a patient potentially considered for a lymphedema.

Dr Mike Patrick:     Now the extremity swelling, whether it's upper extremity or lower extremity, is it subtle or is it significant? Because I'm thinking like if someone gets to be a teenager and they have primary lymphedema, it must have been pretty mild when they were younger. So are there cases where it's, you're kind of, cause you know, you're looking at the extremities and thinking, is it, is 1 larger, you know, and parents oftentimes will, you know, say, yes, it is. But we have to kind of almost, you know, take a step back and look a second time.

Dr Min-Jeong Cho:     Right, right. I mean, I have seen patients before puberty. So those patients actually is very subtle. Patients may say, actually the patients say, this leg feels heavier. So you don't, the disease, the progression of lymphedema is that you have impaired lymphatic system, and then you have the swelling, which is more fluid component.

Dr Min-Jeong Cho:     And then as it progresses, the fluid, and then also there's the fat hypertrophy. So that's when you actually start seeing more. So if in the earlier stage, patients will be like, tell their parents, it feels heavier, somehow it feels heavier, especially at the end of the day. And then when I wake up in the morning, it's actually better. Difficulty to run.

Dr Min-Jeong Cho:     So their tolerance actually goes down because it feels heavier. For the shoes as well, they will say, they have a hard time fitting with shoes because of the swelling. So those are kind of subtle changes that will let you know. And then patients who are an adult, actually I see them quite, that's when they start to recognize more. So then that's actually quite like this leg is definitely larger and it's been getting larger.

Dr Min-Jeong Cho:     We have tried icing and different kinds of, you know, remedies for it, keeps getting larger. And then there are some patients actually have to wear different size shoes because they cannot fit into the same size shoes.

Dr Mike Patrick:     So that's a, That's really interesting because as primary care providers, especially in teenagers, I mean, those are the kind of things that you hear and they just make you go, because maybe you haven't heard of lymphedema before. It's not in the forefront of your diagnosis. And that's where I think AI in the future may be helpful in terms of it doesn't have the biases for what's more common and less common. And so, you know, that may be something in the future where we get some help with a diagnosis. So once you land on that diagnosis, so you've done the nucleotide testing, the imaging, and we determine that it is lymphedema.

Dr Mike Patrick:     How is that then treated?

Dr Min-Jeong Cho:     So typically the first step of any kind of primary or secondary lymphedema is compression therapy because the lymphatic system is impaired. So unfortunately you have to start the compression therapy, which patients are measured at different length. And then there are different kinds of pressures applied to help with external pressure to this lymphatic fluid to overcome the lymphatic dysfunction. Once you start that compression therapy, because some patients are very swollen, like literally they have pitting edema, you will put 2 plus pitting edema, so you have to control that swelling. And then once that's controlled, then you could determine, okay, if this is a patient is a candidate for surgical treatment.

Dr Min-Jeong Cho:     So before, there are recent advances these days. Before then, pediatric lymphedema especially put a compression garment, you know, kind of hope for the best actually. And then later on when they're adult, all that fat hypertrophy could be liposuction. So it's like a debulking surgery essentially. A lot of lymphedema's were treated that way until recently now we have what we call super microsurgery.

Dr Min-Jeong Cho:     So with that, I actually have a microscope that lets me 40 times of what my eyes see, and then suture that's thinner than my hair, and then to help me perform what we call physiologic surgery. So here, what we'll do is that we will try to reestablish the lymphatic system using super micro surgery.

Dr Mike Patrick:     Are you able to evaluate the effectiveness of it in the operating room?

Dr Min-Jeong Cho:     Yes. So what we do is that in addition to the lymphocentigraphy, we have what we call endocyte-green lymphangiography. So what that means is that we'll inject a dye, it's a fluorescent dye actually, into the foot or hand, and then we could actually see real-time dye traveling through the lymphatic system. And as you see that lymphatic system travel, you can identify the areas that are the channels are blocked. So you could target those areas.

Dr Min-Jeong Cho:     Okay, that channel is blocked right there. Or in pediatric patients, maybe there's a backflow of the channel. So sometimes you can literally see the dye travel up and then it backflows back into the leg. So then you target those areas and we do what we call lymphovenous bypass. So what that means is that, for example, If you're at a grocery store, you're in line, and then someone opens a new cash register and everyone kind of flows in.

Dr Min-Jeong Cho:     So similarly in lymphovenous bypass, I find a lymphatic that's been having issues, whether blocked or have a backflow. And then I find a vein that's next to it and I create a connection between that. So now it bypasses the area of obstruction or a dysfunction and then it returns back to the system.

Dr Mike Patrick:     Yeah, boy, that sounds like it's tedious and some trial and error, especially if there's not a vein next door that you can drain into. Are these typically long procedures? Do these take quite a bit of time?

Dr Min-Jeong Cho:     It does take quite a bit of time because we have to identify and that these lymphatic channels are actually translucent. So then these are, the reason it's a super micro is because these channels are less than 0.8 millimeter. So you know, it takes time to find the correct lymphatic vessel and then also find a vein that's caliber, same size for this lymphatic channel and then use the 11-0 or 12-0 or the typical sutures we use. And if you think about, if I close the skin, I will use, for example, pediatric patient 4-0, 5-0 sutures. These are 11-0 and then usually vascular repairs are done with 8-0.

Dr Min-Jeong Cho:     So it's quite a small suture under the magnification 40 times. So it does take quite a bit of time, but however, it's a really satisfying surgery for the patient.

Dr Mike Patrick:     Yeah, yeah, absolutely. And I'm sure satisfying for you too, because a lot of times there is that delay in diagnosis and folks are just like, I want this taken care of and you're the, you're the 1 to do it.

Dr Min-Jeong Cho:     So that's,

Dr Mike Patrick:     that's, that's exciting. Now, quick question. I'm wondering in addition to the treatments that you've talked about, is it possible to take a lymph node from 1 area of the body and move it to help? Or would that then cause a problem at the, at the site with it? You're getting the, the, the lymph node from.

Dr Min-Jeong Cho:     Yeah, that's a great question. And for the 1 of the physiologic surgeries that first, you know, reconstruct lymphatic vessels using the lymphovenous bypass. And then also another part is reconstruct the lymph nodes. So these are actually for patients with more severe disease, because whenever you have earlier disease, the lymphatic vessels are less diseased. So you have ability to reconstruct them.

Dr Min-Jeong Cho:     However, as the patient's stage progresses, we have to do, sometimes we have to do the lymph node transfers. So as you have mentioned, these are vascular lymph node transfer. So we will take lymph nodes from different body parts and then we'll put them in the areas where the lymph nodes are having issues. So there are different areas that my lymphatic surgeons will take lymph nodes. You could take it from your super clavicular area.

Dr Min-Jeong Cho:     You could take it from your groin area.

Dr Mike Patrick:     You could take it from your supraclavicular area.

Dr Min-Jeong Cho:     You could take it from your groin area. You could take it from your abdomen area. So there are different, a variety of options. I do prefer to take them from intra-abdominal area just because there's tons of lymphatic lymph nodes in that area. And also the concerns are for, like you said, like causing iatrogenic lymphedema in the areas of donor site is less concern versus if I have to take it from supraclavicular or groin area, then we have to be very selective on which lymph nodes to take because we have to identify which lymph nodes are draining the extremity or the lower extremity.

Dr Mike Patrick:     So then that's going to be an even longer surgical procedure because you're going to have to make sure that where you took the donor site where you took the lymph node from that everything is working and appropriate there before you get out of dodge, right?

Dr Min-Jeong Cho:     Yeah, so for lymphvenous bypass is usually outpatient surgery, 3 to 4 hours versus the vascular lymph node transfer. We have to make sure the lymph nodes actually survive. So the patients are admitted and then there'll be intense monitoring just to make sure that the nose itself are well vascularized and not having any vascular issues before the patients are discharged.

Dr Mike Patrick:     Yeah. Yeah. Is there a role in milder cases still for sort of non-surgical approaches to treating lymphedema?

Dr Min-Jeong Cho:     Yeah. So, you know, compression therapy, regardless, primarily or secondary lymphedema is always first line treatment because even if I do the lymphovans bypass, you have to wear compression therapy. I always tell my patient it goes hands in hand, external compression, and then reconstruction lymphatic system. And then there are certain times There are other therapies there, for example, there are areas that the fat hypertrophy, that I cannot address that with a phygiologic surgery. So for those areas, I would do a liposuction because that's the area that patients have difficulty wearing pants or clothes because of the volume discrepancy.

Dr Min-Jeong Cho:     So for those areas, I will do liposuction.

Dr Mike Patrick:     And then as I was researching this, physical therapy kept coming up. Is physical therapy a routine part of the treatment for both primary and secondary lymphedema?

Dr Min-Jeong Cho:     Yep, so actually for my breast cancer clinic, physical therapy is actually right next to clinics. So they go hand in hand because compression therapy, you know, the physical therapist, lymphatic physical therapist will measure their garments and also there's a manual lymphatic drainage. So then all the patients I have learned how to do manual lymphatic drainage themselves. So then, because they could tell like, okay, my leg is swelling, I did a little bit more activity today, it's a little bit decompensated, so they will do manual lymphatic drainage at home. And also there are different kinds of modality, you know, sometimes some patients are over decongested, so then we will do extra compression therapy for those.

Dr Mike Patrick:     And the physical therapy folks kind of follow them along and help them learn how to do that and support them in those non-surgical kind of measures. And then how can pediatricians, and when we do take care of kids and families who are impacted by this, how can we best support the patients and the families with lymphedema?

Dr Min-Jeong Cho:     I think it is a very difficult diagnosis because it's non-curative. And what it's difficult for a pediatric patient, especially to wear a compression garment, even for adults, because it's for life and then it's progressive disease. So the measures I do with surgery is trying to slow down the progress and actually make, you know, quality of life difference. However, I think it's a very difficult for a patient and their family, especially sometimes my some families ask family members, is this something they did during, you know, pregnancy or is this hereditary? I get that a lot, which I'm like, I totally understand because you have a child and then, or infant in different types of different ages, and you feel like, oh my God, my son or daughter's leg is getting bigger, or arm is getting bigger, and what can we do?

Dr Min-Jeong Cho:     And then I think for pediatrician is to recognize the lymphedema and also, because we don't probably see, you know, I will see them throughout, but however, they're very, have more established relationships especially to help them, you know, understand the disease and then the the life-term commitment to treating the disease.

Dr Mike Patrick:     Yeah, yeah. So as pediatric providers, you know, we may not be the 1 to actually diagnose it or to manage the primary disease. But we are in a great position to provide education about the condition. If some questions come up in their mind and it's not at a time when it's convenient for them to see you or ask you, just having sort of a knowledge base of it can help us support families. So we will have lots of resources in the show notes for folks to check out over at pdacastcme.org.

Dr Mike Patrick:     This is episode 93, so just look for that. And we will have resources that you can look to, and we'll talk a little bit more about those as we get to the end of the program, but stuff for both providers and also for families and education and to improve health literacy about lymphedema all are going to be in the show notes for you. And then is there anything that can be done to prevent this from happening? It sounds like maybe not since it's either genetic or the result of surgery or cancers and trauma. But is there anything that we can do to reduce the risk of this, especially in children?

Dr Min-Jeong Cho:     Yes. So for children who are going cancer surgery, So I have actually a couple of patients who went under cancer surgery and then actually have symptoms of lymphedema. So those patients are actually, we could do what we call prophylactic lymphobinus bypass. So at the time that they, whether they're going to take the exo-lymph node or the growing lymph nodes, then I could do a preventive measure. So then what I will do is identify the lymphatic vessels that will be cut as a part of lymph node dissection, and then I'll perform the bypass right there.

Dr Min-Jeong Cho:     So then actually, you know, there's for that's a lot of things, a lot of procedures that I do for the breast cancer patients, because that the risk for having a lymphedema after after exo-lymph node dissection, it goes up to 40 to 50%. So then we perform those preventives, which is applicable for the pediatric patients. Doesn't happen often, but these patients do have, I have seen a couple of patients who got secondary lymphedema after the third cancer.

Dr Mike Patrick:     So in kids, as we're thinking about kids who then have secondary lymphedema because it happened during like a lymph node removal surgery. In those kids, it may be worthwhile to at least get a consult with you to see if that's something like if it's a high risk lymph node that they are removing then that may be something that you would want to be in the operating room at the same time. Yeah, completely agree with you.

Dr Min-Jeong Cho:     If I know that for patients will be like for sure we'll get grand lymph node dissection or athero lymph node dissection that I want to be there for the kids because that, you know, for example, these are very young kids so that I know that the risk is very high. So I'll rather perform that procedure. And also they go into the surveillance protocols. So typically I'll see them preoperatively and then I follow them every 3 months with a physical therapy and then we'll get measurements of the leg or the arm. And then depending on how they're feeling and also how the measurements are looking, sometimes we actually, even the radiation patients, so even if you know, they don't get the lymph node dissection, but you know that they'll get a heavy dose of radiation, we do see patients after radiation also get secondary lymphedema as well.

Dr Min-Jeong Cho:     So those patients, I follow them for 2 years. It could take up to 2 years for those patients to show whether lymphedema symptoms. So whenever I see a patient every 3 months, and then I'm like, okay, this patient, even if we did the prophylactic approach, I know that that patient's going to get lymphedema. Most of the time with the lip radiation, heavy dose radiation, I see a lot of patients with that. Then I will get ICG again.

Dr Min-Jeong Cho:     And then I will do very therapeutic, early therapeutic lymphovenous bypass because you want to treat this patient early because as the disease progresses, severe, it's very difficult to treat. So those patients, I follow them very closely for 2 years and then perform the lymphoblemus bypass as needed.

Dr Mike Patrick:     Gotcha. And so, so really there's a whole range of possibilities here from you being there for the primary surgery, especially if it's a really high risk lymph node, but if it's a lower risk 1, it's something that you might just follow them frequently and see if it develops and then, and then treat it from there. Very interesting. Now, what are the, and I think you kind of alluded to it a little bit, but in terms of untreated or poorly managed lymphedema, what are some of the complications? And it sounds like 1 of them is that it could become severe and then be more difficult to treat.

Dr Min-Jeong Cho:     Yeah, I mean, like some studies say patients who have lymphedema, actually for like breast cancer patients, they actually said that having lymphedema is actually worse than surviving cancer. That's how much of impact it has on the patient. And then the cost, the compression garment, and also the activity restrictions from that. And because you feel heavier, it's difficult for them to run. Also do a lot of activities outside.

Dr Min-Jeong Cho:     And also the social stigma. So a lot of times for pediatric patients will be like, you know, especially when you're going on their puberty, their peers will recognize difference in the size of the extremity. So they could get bullied. That's another concern. So some of my patients don't want to wear the compression garment because they feel like, okay, they see them and then their peers talk about it.

Dr Min-Jeong Cho:     And then medically is you're at more risk, so higher risk for developing cellitis. So a lot of patients will, because you have an impaired lymphatic clearance, so patients are at risk. So a lot of patients, I tell my patients, be careful when you're gardening, make sure you wear a glove, almost like diabetic patients almost that you have to make sure there's no cuts. And then if you're getting any symptoms that you feel like they know that if you're getting cellitis you have to immediately let my contact my office so they you know prevent the hospitalization.

Dr Mike Patrick:     Yeah yeah and we could that makes sense because we know that lymph vessels you know carry foreign material to lymph nodes where the immune system can interact with it. And so if you have a problem with that system, then you certainly could get bacteria that's that's growing and not the immune system isn't being able to effectively get to it to treat it. So certainly that's another area where pediatric providers can, you know, if you have a kid who went through this, that's something to think about. And the mental health part of it, I don't want to gloss over that. There is definitely with any chronic illness, you know, anxiety, depression, and just stress in general, and not only for the kids, but also for parents and the family.

Dr Mike Patrick:     And so we're in a great position to make sure that those kids are getting their mental health needs met as well.

Dr Min-Jeong Cho:     Right, definitely. And then especially the greatest thing is that 1 of my pediatric patient came back to my clinic after lymphobinus bypass and said I ran. I ran with you know my you know my friends and I didn't have issues after running. That's the greatest thing and and if patients not for pediatrics I haven't seen it but a patient who used to get tons of cellulitis, I haven't gotten it for a couple of years. And I think that's the fantastic part about this procedure is that, and then also the reason that, you know, the prevention and early diagnosis is so critical is because it's a very non-invasive surgery compared to for severe patients, it's more invasive.

Dr Min-Jeong Cho:     So that's why I'm so glad that we have an opportunity to talk about today to prevent those patients to diagnose late or delayed and then present with a severe symptom.

Dr Mike Patrick:     Yeah, yeah. What are some of the upcoming advancements in the treatment of pediatric lymphedema? What sort of research and new things are on the horizon?

Dr Min-Jeong Cho:     So definitely doing lymphobin bypass in pediatric patients is very new because almost the majority of treatment was to do compression therapy, do debulking surgery later. So that's 1 of the upcoming treatments per se because and also you used to wait. You used to wait and then maybe patients are bigger, but now our centers are doing a more early procedure for those patients. And then this is also because of the advances in the imaging as well. And I also perform ultrasound guided lymphatic mapping.

Dr Min-Jeong Cho:     So the ICG and lymphocentigraphy, the downside of it is that it's dependent on the status of patient's fluid status. So ICG only penetrates about 2 centimeters. But with ultrasound-guided lymphatic mapping, I'm able to see further than 2 centimeters. So then even some patients would have been, okay, you don't have channels or you don't have any good channels. Now I could use ultrasound.

Dr Min-Jeong Cho:     And then this is called ultra high frequency ultrasound because they literally see less than a 2 centimeter that I'm actually able to see which channels are open and then able to do provide the prevention surgery. I mean, not prevention, but surgeries for the patients.

Dr Mike Patrick:     Yeah, yeah. That's exciting advances for sure. And I think the key take home here for pediatric providers out there is just to have some awareness of this, especially in a kid who may have had a lymph node removed. But also if you're seeing subtle differences in size of between the 2 legs or between the 2 arms, just to put this in your differential and make sure that folks get directed to the right place. And of course, that is going to be through plastic and reconstructive surgery at a Nationwide Children's Hospital, also at Ohio State.

Dr Mike Patrick:     I know you're at both places. Tell us about those programs.

Dr Min-Jeong Cho:     Yes, so we, for the Nationwide, I'm a part of vascular anomalous clinic. So in addition to the lymphedema, we treat a variety of vascular anomalies. And then if you have any patient that you are concerned about lymphedema or just want me to kind of evaluate and then decide whether patient has a lymphedema, I'm happy to see those patients because like we discussed, the early diagnosis is the key. And for Ohio State, we're 1 of the recognized centers of excellence for lymphedema. There are very few around the world.

Dr Min-Jeong Cho:     So for those patients, I actually see patients with primary lymphedema who were born with it, and that there weren't any options available then. So I have like 40-year-old patients who come up to 30, 40-year-old patients who said, I was told that there were no treatment for this, but now there are options. So then we'll do the procedure and then they're very happy. So we are 1 of those centers. So we do see primary and secondary lymphedema and at the Ohio state.

Dr Mike Patrick:     Yeah. Yeah. And we will put links to both plastic and reconstructive surgery at Nationwide Children's Hospital and at the Ohio State University Wexner Medical Center in the show notes for folks. There's also a nice article called Why Choose Ohio State and Nationwide Children's for Pediatric Plastic Surgery and we'll put a link to that as well. And then I mentioned those resources that are going to be in the show notes for you to find.

Dr Mike Patrick:     1 of them is a blog post that you had written for the 700 Children's blog, Lymphedema in Kids, What Parents Need to Know. So we'll put a link to that in the show notes. What are lymphatic disorders? Pediatricians need to know about lymphedema. These are all articles that are going to be in the show notes.

Dr Mike Patrick:     So folks that may want to look into this a little bit further, we will have those resources for you. So Dr. Min-Jung Cho with Plastic and Reconstructive Surgery at Nationwide Children's Hospital and the Ohio State University Wexner Medical Center. Thank you so much for stopping by and chatting with us today.

Dr Min-Jeong Cho:     Thank you very much for having me. It has been really fantastic. And thank you very much for giving me the opportunity to discuss the importance of the diagnosing the lymphedema and then also doing surgeries in the early stage of lymphedema.

Dr Mike Patrick:     We are back with just enough time to say thanks once again to all of you for taking time out of your day and making Pediacast CME a part of it. Really do appreciate that. Thanks also To our guests this week, Dr. Min-Jung Cho, Plastic and Reconstructive Surgeon at Nationwide Children's Hospital and the Ohio State University Wexner Medical Center. Don't forget you can find us wherever podcasts are found.

Dr Mike Patrick:     We're in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android, also on YouTube. And then don't forget about our landing site, pdacastcme.org. You will find our entire archive of past programs there, along with show notes for each of the episodes, our CME information, the terms of use agreement, and our handy contact page if you would like to suggest a future topic for the program. Reviews are also helpful wherever you get your podcasts. We always appreciate when you share your thoughts about the show.

Dr Mike Patrick:     And we love connecting with you on social media. You'll find us on Facebook, Instagram threads, LinkedIn, and Twitter, or X, and simply search for PDA Cast. You'll find us in all of those places. So you have listened to the podcast. Now be sure to claim your free category 1 continuing medical education credit.

Dr Mike Patrick:     Really easy to do. Just head over to the show notes for this episode at pediacastcme.org. It's episode 93. You'll find a link to the post-test in the show notes for this episode. Follow that link to Cloud CME, take and pass the post-test and the category 1 credit is yours.

Dr Mike Patrick:     Again, you'll want to click the materials link to find the post-test super easy, right? And again, we offer credit to pediatric professionals of all sorts, including doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. Of course, you want to make sure the content of this episode matches your scope of practice. Complete details are available at pediacastcme.org. Also, don't forget about our evidence-based podcast for moms and dads, Plain Pediacast, without the CME.

Dr Mike Patrick:     Lots of pediatricians and other providers also tune in as we cover pediatric news, we answer listener questions, and interview pediatric and parenting experts. Shows are available at the landing site for that podcast, Pediacast.org also available wherever podcasts are found simply search for Pediacast Thanks again for stopping by and until next time. This is dr Mike saying stay informed keep it evidence-based and take care of those kids so long everybody

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