Week 5: The human factor

 I began the week with an integrated meeting where we orally recounted our progress thus far in the immersion term, and became inspired by tentative project plans from my peers, which ranged from finite element analysis to biomimetic 3D cell culture constructs to artificial intelligence for MRI image processing. After going about my program in relative isolation for the past few weeks, it was constructive and helpful to compare experiences with others, to reconnect with the ultimately human clinical factors that drive our research to improve healthcare. 

This theme continued into my busiest experience of the week, once again joining a physician in Dr. Mehrara's clinic at the Koch Center of MSK. It was here that I solidified my plans for my clinical project, which will entail a comprehensive examination of the specificity and sensitivity of specifically ICG imaging as a diagnostic tool for lymphedema. About one-third of breast cancer patients develop lymphedema primarily from iatrogenic lymphatic damage during axillary lymph node dissection (ALND), and there is currently no universally accepted screening method or early treatment regimen for lymphedema even if it does manage to become detected. In the case that lymphedema is detected at a period where intervention can be performed, the physician at the clinic told me that three methods are available: lymphovenous bypass (LVB), vascularized lymph node transfer (VLNT), and liposuction. 

LVB is most non-invasive and preferable procedure, in which microsurgery is performed to connect unblocked lymphatic vessels near the lymphedematous tissue to a nearby vein and effectively bypass the lymphatic blockage to restore flow. However, this method requires the patient to have relatively intact and healthy lymphatic channels for the fluid to be rerouted, and is not a viable option for patients where excess dermal backflow and extensive lymphatic damage has already occurred. In this case, the second most preferable course of action would be the more intensive VLNT, based on the principle that excising healthy lymph nodes from elsewhere in the body and transferring them to the lymphedematous tissue will restore the lymphatic drainage function of the damaged lymph nodes. The transferred lymph node also contains growth factors to encourage the growth of a new lymphatic network at the transfer site. Nevertheless, an ironic potential complication is that lymphedema can sometimes develop in the area from which the transferred lymph node was removed. Therefore, surgeons harvest lymph nodes from the omentum, which is already abundant in lymph nodes, or rely on reverse lymphatic mapping, in which radioactive dye is injected into the potential site of harvest to label more active lymph nodes versus less active ones for the ideal nodes to harvest. If neither of these techniques is optional, perhaps if the lymphedema is very severe, the last resort is liposuction, or effectively removing excess fat and interstitial tissue from the site of lymphedema to reduce weight and drainage burden. This works quite well as a short-term solution, but adipose tissue will rapidly regrow after three or more months and necessitate future liposuctions as a palliative management technique. 

Thus, my role is to help in the data analysis for a study under the hypothesis that ICG possesses high sensitivity and specificity as a diagnostic tool for lymphedema. Using image analysis software, I will be able to quantify lymphatic pumping, dermal backflow, and clearance capacity from ICG images of patients, and compare the accuracy of ICG with L-Dex, manual measurements, and symptom questionnaires. 

Many of these concepts I saw in action immediately with the first patient of the day, a woman who was treated for breast cancer and experienced lymphedema mostly in the right volar forearm, which was confirmed by diffuse and signal from ICG imaging. As the diffuse signal did not reveal many functional channels, we deemed that VLNT may be the best course of action. The patient inquired more about the details of the procedure, and gradually became more pessimistic about the grim nature of her diagnosis. In what was perhaps the most transformative experience of my immersion term thus far, the patient became emotional and tearful over being resigned to a life of constant compression sleeves and limb pain interfering with her livelihood as a jeweler, on top of the burden of cancer that had taken her parents. In that moment I set aside my role a scientific researcher and was able to emphasize with this woman as a human, for I knew as well the pain of accepting a potentially lifelong diagnosis of disease. When I discovered I had rheumatoid arthritis a few years ago, I was devastated that I may never be able to run or work with my hands again without fear of constant joint pain getting in the way of the things I love. It was only after time and contemplation that I gained an appreciation for the medicine that was able to improve my condition to the point it is today, and accept that I had done all I could. This singular experience with a patient reminded me that ultimately, as a biomedical engineer, I design and research for people and have a chance to make a palpable impact in human lives.