Pharmacological Treatment of Secondary Lymphedema

Lymphedema is a chronic disease that results in swelling and decreased function due to abnormal lymphatic fluid clearance and chronic inflammation. In Western countries, lymphedema most commonly develops following an iatrogenic injury to the lymphatic system during cancer treatment. It is estimated that as many as 10 million patients suffer from lymphedema in the United States alone. Current treatments for lymphedema are palliative in nature, relying on compression garments and physical therapy to decrease interstitial fluid accumulation in the affected extremity. However, recent discoveries have increased the hopes of therapeutic interventions that may promote lymphatic regeneration and function. The purpose of this review is to summarize current experimental pharmacological strategies in the treatment of lymphedema.

Accuracy, Sensitivity, and Specificity of the LLIS and ULL27 in Detecting Breast Cancer-Related Lymphedema

INTRODUCTION

Breast cancer-related lymphedema occurs in up to 30% of women following axillary lymph node dissection (ALND) and less commonly following sentinel lymph node biopsy. To quantify disability in these patients, patient-reported outcome measures (PROMs) have proven useful; however, given the overlap of symptoms between ALND and lymphedema, examination of their accuracy, sensitivity, and specificity in detecting lymphedema in breast cancer patients undergoing ALND is needed.

METHODS

The Lymphedema Life Impact Scale (LLIS) and the Upper Limb Lymphedema 27 scale (ULL27) were administered to patients who had undergone ALND at least 2 years prior and either did or did not develop lymphedema. Survey responses and the degree of disability were compared to generate receiver operator characteristic (ROC) curves, and the sensitivity and specificity of PROMs to diagnose lymphedema were analyzed.

RESULTS

Both PROMs were highly accurate, sensitive, and specific for detecting lymphedema. The LLIS had an accuracy of 97%, sensitivity of 100%, and specificity of 84.8% at a cutoff of ≥ 5.88 overall percent impairment score (higher scores indicate worse disability). The ULL27 had an accuracy of 93%, sensitivity of 88.6%, and specificity of 90.9% at a cutoff of ≤ 83.3 global score (lower scores indicate worse disability).

CONCLUSIONS

The LLIS and the ULL27 appear to be highly specific for lymphedema and capable of differentiating it from symptoms resulting from ALND alone. Our findings suggest that use of these questionnaires with a threshold may be effective for diagnosing lymphedema, potentially reducing the need for frequent clinic visits and time-consuming measurements.

Perioperative Inpatient Opioid Consumption Following Autologous Free-Flap Breast Reconstruction Patients: An Examination of Risk and Patient-Reported Outcomes

BACKGROUND

The response to the unprecedented opioid crisis in the US has increased focus on multimodal pain regimens and enhanced recovery after surgery (ERAS) pathways to reduce opioid use. This study aimed to define patient and system-level factors related to perioperative consumption of opioids in autologous free-flap breast reconstruction.

METHODS

We conducted a retrospective study to identify patients who underwent autologous breast reconstruction between 2010 and 2016. A multivariate linear regression model was developed to assess patient and system-level factors influencing opioid consumption. Opioid consumption was then dichotomized as total postoperative opioid consumption above (high) and below (low) the 50th percentile to afford more in-depth interpretation of the regression analysis. Secondary outcome analyses examined postoperative complications and health-related quality-of-life outcomes using the BREAST-Q.

RESULTS

Overall, 601 patients were included in the analysis. Unilateral reconstruction, lower body mass index, older age, and administration of ketorolac and liposomal bupivacaine were associated with lower postoperative opioid consumption. In contrast, history of psychiatric diagnoses was associated with higher postoperative opioid consumption. There was no difference in the rates of postoperative complications when comparing the groups, although patients who had lower postoperative opioid consumption had higher BREAST-Q physical well-being scores.

CONCLUSION

System-level components of ERAS pathways may reduce opioid use following autologous breast reconstruction, but surgical and patient factors may increase opioid requirements in certain patients. ERAS programs including liposomal bupivacaine and ketorolac should be established on a system level in conjunction with continued focus on individualized care, particularly for patients at risk for high opioid consumption.

Patient-Reported Outcome Measures in Lymphedema: A Systematic Review and COSMIN Analysis

BACKGROUND

Lymphedema is a chronic and debilitating condition that affects many cancer survivors. Patient-reported outcome measures (PROMs) can give valuable insight into the impact of lymphedema on a patient's quality of life and can play an essential role in treatment decisions. This study aims to (1) identify PROMs used to assess health-related quality of life (HRQoL) in patients with lymphedema; and (2) assess the quality of the lymphedema-specific PROMs.

METHODS

We performed a systematic search to identify articles on lymphedema, quality of life, and PROMs. An overview was created of all PROMs used to assess HRQoL in patients with lymphedema. The methodological quality of the lymphedema-specific PROMs was assessed using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) criteria.

RESULTS

A total of 235 articles met the inclusion criteria, of which 200 described studies using one or more PROMs as an outcome measure in patients with lymphedema. The other 35 studies described the development and/or validation of a lymphedema-specific PROM. The COSMIN assessment demonstrated that none of these PROMs met all quality standards for development.

CONCLUSION

The use of PROMs in lymphedema is increasing; however, based on our findings, we cannot fully support the use of any of the existing instruments. A well-developed lymphedema-specific PROM, based on patient input, is needed to gain better insight into the impact of this condition, and can be used to measure the effect of possible medical and surgical treatments.

Goal-directed fluid therapy in autologous breast reconstruction results in less fluid and more vasopressor administration without outcome compromise

OBJECTIVE

Aggressive or restricted perioperative fluid management has been shown to increase complications in patients undergoing microsurgery. Goal-directed fluid therapy (GDFT) aims to administer fluid, vasoactive agents, and inotropes according to each patient's hemodynamic indices. This study assesses GDFT impact on perioperative outcomes of autologous breast reconstruction (ABR) patients, as there remains a gap in management understanding. We hypothesize that GDFT will have lower fluid administration and equivocal outcomes compared to patients not on GDFT.

METHODS

A single-center retrospective review was conducted on ABR patients from January 2010-April 2017. An enhanced recovery after surgery (ERAS) using GDFT was implemented in April 2015. With GDFT, patients were administered intraoperative fluids and vasoactive agents according to hemodynamic indices. Patients prior to April 2015 were included in the pre-ERAS cohort. Primary outcomes included the amount and rate of fluid delivery, urine output (UOP), vasopressor administration, major (i.e., flap failure) and minor (i.e., seroma) complications, and length of stay (LOS).

RESULTS

Overall, 777 patients underwent ABR (ERAS: 312 and pre-ERAS: 465). ERAS patients received significantly less total fluid volume (ERAS median: 3750 mL [IQR: 3000-4500 mL]; pre-ERAS median: 5000 mL [IQR 4000-6400 mL]; and p<0.001), had lower UOP, were more likely to receive vasopressor agents (47% vs 35% and p<0.001), and had lower LOS (ERAS: 4 days [4-5]; pre-ERAS: 5 [4-6]; and p<0.001) as compared to pre-ERAS patients. Complications did not differ between cohorts.

CONCLUSIONS

GDFT, as part of ERAS, and the prudent use of vasopressors were found to be safe and did not increase morbidity in ABR patients. GDFT provides individualized perioperative care to the ABR patient.

Regional Patterns of Fluid and Fat Accumulation in Patients with Lower Extremity Lymphedema Using Magnetic Resonance Angiography

BACKGROUND

Fat accumulation is frequently observed in patients with lymphedema but is not accounted for in existing staging systems. In addition, the specific regional patterns of fat and fluid accumulation remain unknown and might affect outcomes following medical or surgical intervention. The purpose of this study was to evaluate fluid and fat distribution in patients with lower extremity lymphedema using magnetic resonance angiography.

METHODS

Magnetic resonance angiographic examinations of patients with lower extremity lymphedema were reviewed. Fluid-fat grade and location were assessed by three observers. Three-point scales were developed to grade fluid (0 = no fluid, 1 = reticular pattern of fluid, and 2 = continuous stripe of subcutaneous fluid) and fat (0 = normal, 1 = subcutaneous thickness less than twice that of the unaffected side, and 2 = subcutaneous thickness greater than twice that of the unaffected side) accumulation.

RESULTS

In total, 76 magnetic resonance angiographic examinations were evaluated. Using the proposed grading system, there was good interobserver agreement for fat and fluid accumulation location (91.5 percent; κ = 0.9), fluid accumulation grade (95.7 percent; κ = 0.95), and fat accumulation grade (87.2 percent; κ = 0.86). Patients with International Society of Lymphology stage 2 lymphedema had a wide range of fluid and fat grades (normal to severe). The most common location of fluid accumulation was the lateral lower leg, whereas the most common location of fat accumulation was the medial and lateral lower leg.

CONCLUSION

The proposed magnetic resonance angiographic grading system may help stratify patients with International Society of Lymphology stage 2 lymphedema on the basis of tissue composition.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, IV.

Preoperative Assessment of Upper Extremity Secondary Lymphedema

Introduction: The purpose of this study was to evaluate the most commonly used preoperative assessment tools for patients undergoing surgical treatment for secondary upper extremity lymphedema. Methods: This was a prospective cohort study performed at a tertiary cancer center specializing in the treatment of secondary lymphedema. Lymphedema evaluation included limb volume measurements, bio-impedance, indocyanine green lymphography, lymphoscintigraphy, magnetic resonance angiography, lymphedema life impact scale (LLIS) and upper limb lymphedema 27 (ULL-27) questionnaires. Results: 118 patients were evaluated. Limb circumference underestimated lymphedema compared to limb volume. Bioimpedance (L-Dex) scores highly correlated with limb volume excess (r2 = 0.714, p < 0.001). L-Dex scores were highly sensitive and had a high positive predictive value for diagnosing lymphedema in patients with a volume excess of 10% or more. ICG was highly sensitive in identifying lymphedema. Lymphoscintigraphy had an overall low sensitivity and specificity for the diagnosis of lymphedema. MRA was highly sensitive in diagnosing lymphedema and adipose hypertrophy as well as useful in identifying axillary vein obstruction and occult metastasis. Patients with minimal limb volume difference still demonstrated significantly impaired quality of life. Conclusion: Preoperative assessment of lymphedema is complex and requires multimodal assessment. MRA, L-Dex, ICG, and PROMs are all valuable components of preoperative assessment.

The Impact of Obesity on Patient-Reported Outcomes Following Autologous Breast Reconstruction

BACKGROUND

Obesity is a significant public health concern and clear risk factor for complications following breast reconstruction. To date, few have assessed patient-reported outcomes (PROs) focused on this key determinant.

OBJECTIVE

Our study aimed to investigate the impact of obesity (body mass index ≥ 30) on postoperative satisfaction and physical function utilizing the BREAST-Q in a cohort of autologous breast reconstruction patients.

METHODS

An Institutional Review Board-approved prospective investigation was conducted to evaluate PROs in patients undergoing autologous breast reconstruction from 2009 to 2017 at a tertiary academic medical center. The BREAST-Q reconstruction module was used to assess outcomes between cohorts preoperatively and at 6 months, 1 year, 2 years, and 3 years after reconstruction.

RESULTS

Overall, 404 patients underwent autologous breast reconstruction with abdominal free-tissue transfer (244 non-obese, 160 obese) and completed the BREAST-Q. Although obese patients demonstrated lower satisfaction with breasts preoperatively (p = 0.04), no significant differences were noted postoperatively (p = 0.58). However, physical well-being of the abdomen was lower in the obese cohort compared with their non-obese counterparts at long-term follow-up (3 years; p = 0.04).

CONCLUSION

Obesity significantly impacts autologous breast reconstruction patients. Although obese patients are more likely to present with dissatisfaction with breasts preoperatively, they exhibit comparable PROs overall compared with their non-obese counterparts, despite increased complications.

Nasal Reconstruction Using the Integra Dermal Regeneration Template

The reconstruction of nasal defects following oncologic resection has traditionally involved the use of locoregional flaps or full-thickness skin grafts. However, these options are not always feasible because of limitations in donor tissues, defect size or shape, oncologic issues, or patient preference. Reconstruction in this setting has been limited and unsatisfactory. In this report, the authors present their experience in reconstruction of nasal defects using the dermal regeneration template Integra. In most cases, reconstruction with Integra enabled a single-stage, satisfactory reconstruction. The authors present a simple, standardized technique for application and postoperative care, which has resulted in good aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

The importance of indocyanine green near-infrared fluorescence angiography in perfusion assessment in vascularized omentum lymphatic transplant

BACKGROUND AND OBJECTIVE

Vascularized omentum lymphatic transplant (VOLT) for treatment of lymphedema has become popular because of no risk of iatrogenic lymphedema and abundant lymphatic tissue. However, perfusion to the omentum can be difficult to assess clinically. The purpose of this study was to clarify the incidence and degree of ischemia in the omentum.

METHODS

A retrospective study was conducted to review indocyanine green perfusion findings on patients undergoing VOLT. Patients were placed into 4 categories based on the percentage surface area of omentum that was ischemic: normal, less than 25%, between 25% and 50%, and greater than 50% ischemic. Spearman correlation was performed to determine whether an association exists between prior abdominal surgery and the presence of ischemia.

RESULTS

Twenty-six patients underwent VOLT for treatment of extremity lymphedema. Twelve (46.2%) patients had normal perfusion, 8 patients (30.8%) had less than 25% ischemia, and 6 patients (23.1%) had 25% to 50% ischemia. Prior abdominal surgery was not significantly associated with the presence of ischemia.

CONCLUSIONS

Normal flap perfusion is a requisite for successful VOLT harvest. However, over half the patients had some degree of abnormal perfusion irrespective of prior abdominal surgery. Indocyanine green angiography is an important tool in ensuring a healthy lymphatic reconstruction.

Double vascularized omentum lymphatic transplant (VOLT) for the treatment of lymphedema

BACKGROUND AND OBJECTIVES

Orthotopic vascularized lymph node transplant has been successfully used to treat lymphedema. A second, heterotopic lymph node transplant in the distal extremity may provide further improvement. The vascularized omentum lymphatic transplant (VOLT) provides adequate tissue for two simultaneous flap transfers to one limb. The purpose of this study was to review our experience with this technique.

METHODS

We conducted a retrospective study of patients who underwent VOLT, with a subgroup analysis of patients who underwent double VOLT. Technical aspects of the procedure, complications, and early outcomes were reviewed.

RESULTS

From May 2015 to August 2017, 54 VOLTs were performed in 38 patients, of whom 16 received double VOLT. Among patients in the double VOLT group with postoperative imaging at 1 year, uptake into the transplanted omentum was seen in three of six (50%) patients on lymphoscintigraphy and in one of five (20%) patients on indocyanine green lymphangiography. One patient (3.1%) in the double VOLT group required a return to the operating room. There were no donor site complications in the double VOLT group. The overall complication rate was 15.8%.

CONCLUSIONS

Double VOLT to the mid-level and proximal extremity is a safe and viable option.

Lymphedema: Pathogenesis and Novel Therapies

Lymphedema affects up to 1 in 6 patients who undergo treatment for a solid tumor in the United States. Its prevalence has increased as more effective oncologic therapies have improved patient survival, but there remains no definitive cure. Recent research has elucidated new details in the pathogenesis of the disease and has demonstrated that it is fundamentally an immunologic process that ultimately results in inflammation, fibroadipose deposition, impaired lymphangiogenesis, and dysfunctional lymphatic pumping. These findings have allowed for the development of novel medical and surgical therapies that may potentially alter the standard of care for a disease that has largely been treated by compression. This review seeks to provide an overview of the emerging therapies and how they can be utilized for effective management of lymphedema.

Heterotopic vascularized lymph node transfer to the medial calf without a skin paddle for restoration of lymphatic function: Proof of concept

BACKGROUND

The use of heterotopic vascularized lymph node transfer (HVLNT) for the treatment of lower extremity lymphedema is still evolving. Current techniques, either place the lymph nodes in the thigh without a skin paddle or at the ankle requiring an unsightly and often bulky skin paddle for closure. We explored the feasibility of doing a below-knee transfer without a skin paddle using the medial sural vessels as recipient vessels and report our experience in 21 patients.

METHODS

A retrospective review of all patients who underwent HVLNT to the medial calf was performed. Postoperative magnetic resonance angiography (MRA) and lymphoscintigraphy (LS) were analyzed to assess lymph node viability and function after transfer.

RESULTS

Twenty-one patients underwent HVLNT to the medial calf. Postoperative imaging was performed at an average of 11 months after surgery. Thirteen patients had postoperative MRA, of whom 12 demonstrated viable lymph nodes. Seven patients underwent postoperative LS, of whom three demonstrated uptake in the transferred nodes. In the other four patients, the injectate failed to reach the level of the proximal calf.

CONCLUSION

We provide proof of concept that HVLNT to the lower leg using the medial sural vessels without a skin paddle can result in viable and functional lymph nodes in the setting of lower extremity lymphedema. J. Surg. Oncol. 2017;115:90-95. © 2016 Wiley Periodicals, Inc.

Use of Distal Medial Sural Vessels as Recipient Vessels in Free Tissue Transfer

Background The medial sural vessels have been used extensively as donor vessels in free tissue transfer; however, there is sparse literature detailing their use as recipient vessels. The few existing reports involve small numbers of patients and describe operative approaches that are unnecessarily cumbersome. We explored our experience in free tissue transfer to the medial sural vessels and share a simplified operative approach to this recipient site. Methods A retrospective review was performed of all patients who underwent free tissue transfers to the medial sural vessels between December 2012 and December 2015 at a single institution. Preoperative imaging, operative approach, and technique for microvascular free tissue transfer to the medial sural vessels were reviewed. Postoperative results and complications were also analyzed. Results Using preoperative magnetic resonance angiography (MRA) to image the medial sural vessels and a retrograde perforator dissection technique, we successfully performed free tissue transfer to the distal medial sural vessels in 20 of 21 patients, representing the largest series reported. Postoperatively, 13 of 21 patients underwent MRA with a patent vascular pedicle demonstrated in all. There were no postoperative complications or resultant morbidities. Conclusion Surgeons should be aware of the medial sural vessels as a valuable recipient option for free tissue transfer to the lower extremity.

Aesthetic scrotal reconstruction following extensive Fournier's gangrene using bilateral island pedicled sensate anterolateral thigh flaps: A case report

Achieving an aesthetic appearance of the scrotum after extensive Fournier's gangrene is a reconstructive challenge. Testicular coverage is often prioritized over scrotal cosmesis due to the comorbidities typically seen in this patient population. We describe our treatment of a young, healthy male with extensive Fournier's gangrene, with loss of the scrotum. Bilateral neurotized anterolateral thigh flaps were used to achieve a sensate and aesthetically acceptable result.

Fibula osteo-adipofascial flap for mandibular and maxillary reconstruction

BACKGROUND

The fibula free flap is a reliable method for reconstructing composite head and neck defects. However, its skin paddle has drawbacks, including its thickness, hair-bearing surface, desquamation, difficulty insetting it into maxillary defects, and the potential need for skin-grafting the donor site. The fibula osteo-adipofascial flap (FOAFF) is a modification of the fibula flap that overcomes these problems.

METHODS

A retrospective study of 6 consecutive patients who underwent FOAFF reconstruction was evaluated for outcomes and complications.

RESULTS

The mean follow-up was 22.6 months. All flaps survived, with complete oral mucosalization by 7 weeks. Four patients had dental implants placed at the time of reconstruction. Two patients received radiation therapy. Aside from loss of the labial sulcus in anterior maxillary reconstructions, complications were negligible.

CONCLUSION

The FOAFF is useful for reconstructing defects requiring bone, soft tissue, and mucosal replacement without the disadvantages of the traditional fibula skin paddle.

Reconstruction of the buccal mucosa following release for submucous fibrosis using two radial forearm flaps from a single donor site

BACKGROUND

Oral submucous fibrosis is a collagen disorder affecting the submucosal layer and can severely limit mouth opening. The use of bilateral forearm flaps to fill buccal defects following trismus release has proven to be effective and reliable. However, it requires the sacrifice of radial arteries from both forearms. We have developed a technique that allows for the harvest of two independent flaps from a single forearm donor site.

METHODS

Two separate flaps are designed on the same radial artery and concomitant vein pedicle. The distal flap is marked in the standard fashion and the proximal skin paddle is designed in the middle third of the forearm, based on septocutaneous branches of the radial artery. The two flaps are elevated and subsequently divided into two independent free flaps. Between June 2004 and June 2007, a total of 16 flaps were harvested from eight donor sites for buccal mucosa defects following trismus release. Improvements in mouth opening and buccal pliancy were evaluated by comparing preoperative and postoperative inter-incisal distance (IID) and maximal mouth capacity.

RESULTS

All flaps survived completely, and all donor sites were closed primarily, except for one. The mean flap size was 6.6x2.6cm (range: 6x2.5cm-7x3cm), mean pedicle length was 5.7cm, mean ischaemia time was 46min and mean total operating time was 8h 45min. At an average of 19.8 months follow-up, the inter-incisal distance averaged 29.13mm, an increase of 20.88mm compared with the preoperative measurement. The maximal mouth capacity averaged 55.63cc, an increase of 9.38cc compared with the preoperative measurement.

CONCLUSION

Two independent small flaps can be harvested safely from one radial forearm donor site. This approach is a useful option for reconstruction of bilateral buccal defects, particularly following submucous fibrosis release. The donor-site morbidity is minimal and limited to one forearm.