Outcomes of Lymphedema Microsurgery for Breast Cancer-related Lymphedema With or Without Microvascular Breast Reconstruction

Comprehensive Overview of Available Donor Sites for Vascularized Lymph Node Transfer

The field of lymphedema surgery has grown tremendously in recent years. In particular, the diversity of available donor sites for vascularized lymph node transfer has increased, and new donor sites are emerging. Researchers have explored a number of different donor sites, and their reports have demonstrated promising results with each site. Unfortunately, there are limited studies providing a comprehensive analysis of the available donor sites focusing on both the technical aspects of the harvest, including complications and donor site morbidity, and the efficacy and outcomes following transfer. The present review aims to present a comprehensive analysis of the available donor sites for vascularized lymph node transfer and a summary of the experience from a single center of excellence.

Lymphaticovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review

Background  Lymphedema is an accumulation of protein-rich fluid in the interstitial spaces resulting from impairment in the lymphatic circulation that can impair quality of life and cause considerable morbidity. Lower extremity lymphedema (LEL) has an overall incidence rate of 20%. Conservative therapies are the first step in treatment of LEL; however, they do not provide a cure because they fail to address the underlying physiologic dysfunction of the lymphatic system. Among several surgical alternatives, lymphaticovenous anastomosis (LVA) has gained popularity due to its improved outcomes and less invasive approach. This study aims to review the published literature on LVA for LEL treatment and to analyze the surgical outcomes. Methods  PubMed database was used to perform a comprehensive literature review of all articles describing LVA for treatment of LEL from Novemeber 1985 to June 2019. Search terms included "lymphovenous" OR "lymphaticovenous" AND "bypass" OR "anastomosis" OR "shunt" AND "lower extremity lymphedema." Results  A total of 95 articles were identified in the initial query, out of which 58 individual articles were deemed eligible. The studies included in this review describe notable variations in surgical techniques, number of anastomoses, and supplementary interventions. All, except one study, reported positive outcomes based on limb circumference and volume changes or subjective clinical improvement. The largest reduction rate in limb circumference and volume was 63.8%. Conclusion  LVA demonstrated a considerable reduction in limb volume and improvement in subjective findings of lymphedema in the majority of patients. The maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy of LVA in LEL treatment.

Building a Multidisciplinary Comprehensive Academic Lymphedema Program

Lymphedema is a debilitating clinical condition predominantly affecting survivors of cancer. It adversely affects patients' quality of life and results in substantial cost burdens to both patients and the healthcare system. Specialist lymphedema care is optimally provided within integrated clinical programs that align the necessary specialties to provide patient-focused, multidisciplinary, structured, and coordinated care. This article examines our experience building a specialist lymphedema academic program.

METHODS

We describe the critical components necessary for constructing a multidisciplinary comprehensive academic lymphedema program. Furthermore, lessons learned from our experience building a successful lymphedema program are discussed.

RESULTS

Building a comprehensive academic lymphedema program requires institutional support and engagement of stakeholders to establish the necessary infrastructure for comprehensive patient care. This includes the infrastructure for outpatient clinical assessment, diagnostic investigations, radiological imaging, collection of outcomes metrics, non-surgical treatment delivered by lymphedema-specialist therapists, surgical procedures using specialized equipment, and integration of an outpatient framework for comprehensive patient evaluation during follow-up at standardized time intervals.

CONCLUSIONS

This article examines our experience building a multidisciplinary comprehensive academic lymphedema program and provides a structured roadmap to benefit others that are embarking on this mission.

Vascularized Lymph Node Transfer for Patients with Breast Cancer-Related Lymphedema Can Potentially Reduce the Burden of Ongoing Conservative Management

Background: Vascularized lymph node transfer (VLNT) microsurgery is conducted in selected specialist lymphatic programs as a surgical treatment option for breast cancer-related lymphedema (BCRL) with variation in treatment outcomes. Methods and Results: Ten patients with BCRL underwent VLNT from 2012 to 2015. Donor sites were the inguinal (n = 6) or supraclavicular fossa/neck (n = 4) regions and recipient sites were the axilla (n = 6) or elbow regions (n = 4). Outcomes included changes in limb volume and extracellular fluid ratios, postoperative garment use, number of cellulitis episodes, and self-reported symptom improvement. At a mean follow-up of 46 months from surgery (range: 28-66 months), the excess volume in the affected arm had reduced (n = 4) or remained stable (n = 1) for 5 of 10 patients (50%) (mean change: -106.4 mL, range: -515.5 to +69.6 mL). Four of these five patients had also reduced (n = 3) or discontinued (n = 1) wearing compression garments and three reported a reduction in episodes of cellulitis. The remaining five patients had an increase of over 100 mL in postoperative excess volume (mean change: 295.8 mL, range: 142.1-382.8 mL). Three of these five patients reported noncompliance with compression garments. Despite the increase in limb volume, some patients reported softness in swelling (n = 3) and better response to conservative treatment (n = 1). Conclusion: Our results warrant continuation of VLNT as a surgical treatment option for patients with BCRL and show that the burden of conservative management such as wearing garments can be reduced over time for some patients. Longer term follow-up with standardized measures across all centers is required to further investigate VLNT.

Summary of hands-on supermicrosurgery course and live surgeries at 8th world symposium for lymphedema surgery

The hands-on supermicrosurgery course provided participants a valuable learning experience of in-depth practices of supermicrosurgical skills with experts. Seven live surgeries were successfully demonstrated at 8th World Symposium for Lymphedema Surgery. Variable donor sites for vascularized lymph node transfer were the submental, supraclavicular, groin, and omental; while the recipient sites included the wrist and axilla in upper limb; and popliteal and groin in the lower limb. The therapeutic and preventive lymphovenous anastomosis was also satisfactorily performed.

Clinical features, microbiological epidemiology and recommendations for management of cellulitis in extremity lymphedema

BACKGROUND

This high volume, single center study investigated the prevalence, bacterial epidemiology, and responsiveness to antibiotic therapy of cellulitis in extremity lymphedema.

METHODS

From 2003 to 2018, cellulitis events from a cohort of 420 patients with extremity lymphedema were reviewed. Demographics, lymphedema grading, symptoms, inflammatory markers, cultures and antibiotic therapy regimens were compiled from cellulitis episodes data. Univariate and multivariate analyses were performed for detailed analysis.

RESULTS

A total of 131 separate episodes of cellulitis were recorded from 43 (81.1%) lower limb and 10 (19.9%) upper limb lymphedema patients. The prevalence and recurrence rates for cellulitis in lymphedema patients were 12.6% (53 of 420) and 56.6% (30 of 53), respectively. The most common findings were increased limb circumference (127 of 131; 96.9%) and abnormal C-reactive protein (CRP) level (86 of 113; 76.1%). Blood cultures were obtained in 79 (60.3%) incidents, with 9 (11.4%) returning positive. Streptococcus agalactiae was the most isolated bacterium (5 of 9; 55.5%).

CONCLUSIONS

The cellulitis prevalence and recurrence rate in extremity lymphedema were 12.6%, and 56.6%, respectively. Strongest indicators of cellulitis were increased affected limb circumference and elevated CRP level. Empiric antibiotic therapy began with coverage for Steptococcus species before broadening to anti-Methicillin-resistant Staphylococcus aureus and anti-Gram negatives if needed for effective treatment of extremity lymphedema cellulitis.

Secondary angiosarcoma: A fatal complication of chronic lymphedema

Secondary Angiosarcoma (Stewart-Treves Syndrome) is a rare malignant cutaneous lesion, which arises in chronic lymphedema of the extremity, often observed after breast cancer treatment. We reviewed the history and the oncological outcome of two patients with this disease. Multimodal therapy including hyperthermic isolated limb perfusion with TNF-alpha and Melphalan, combined with radical resection of the affected skin and subcutaneous tissue including the fascia, with large safety margins may probably lead to better survival.

Near-infrared fluorescence imaging for the prevention and management of breast cancer-related lymphedema: A systematic review

Sentinel lymph node identification by near infrared (NIR) fluorescence with indocyanine green (ICG) is recognized in the literature as a useful technique. NIR fluorescence technology could become key in the prevention and management of lymphedema after axillary dissection for breast cancer. Here, we conducted a systematic review focusing on ICG imaging to improve lymphedema prevention and treatment after axillary surgery. A systematic literature review was performed using MEDLINE and Embase to identify articles focused on ICG imaging for breast-cancer-related lymphedema (BCRL). Qualitative analysis was performed to summarize the characteristics of reported ICG procedures. In situ tissue identification and functionality assessment based on fluorescence signal were evaluated. Clinical outcomes were appraised when reported. Studies relating to axillary reverse mapping, lymphography and upper limb supermicrosurgery combined with ICG imaging were identified. We included a total of 33 relevant articles with a total of 2016 patients enrolled. ICG imaging for axillary reverse mapping was safe for all 951 included patients, with identification of arm nodes in 80%-88% of patients with axillary lymph nodes dissection. However, the papers discuss the oncologic safety of the approach and how - regardless of the contrast agent - concerns limit its adoption. ICG lymphography is openly supported in BCRL management, with 1065 patients undergoing this procedure in 26 articles. The technique is reported for lymphedema diagnosis, with high sensitivity and specificity, staging, intraoperative mapping and patency control in lymphaticovenular anastomosis. The substantial advantages/disadvantages of ICG imaging procedures are finally described.

Influence of vascularized lymph node transfer (VLNT) flap positioning on the response to breast cancer-related lymphedema treatment

OBJECTIVE

to evaluate the initial therapeutic experience of transplantation of vascularized lymph nodes in patients with lymphedema of the upper limbs secondary to the treatment of breast cancer, and to verify if the positioning of the transplant influences the surgical result.

METHODS

we conducted a prospective, comparative test of two therapeutic modalities, with 24 patients with lymphedema of the upper limb after breast cancer treatment, classified as grades 2 and 3, according to the International Lymphedema Society. The two types of procedures performed were: 1) total breast reconstruction with - deep inferior epigastric perforator (DIEP) flap associated with lymph node flap, in patients with no previous breast reconstruction or loss of previous reconstruction (axillary positioning); 2) isolated inguinal lymph node flap performed in patients with completed breast reconstruction or without the desire to perform the breast reconstruction (wrist positioning).

RESULTS

the reduction percentage of the affected limb volume was 20.1% (p=0.0370). The number of infectious episodes (cellulites) also decreased significantly, from 41% in the preoperative period to 12.5% in the postoperative one (p=0.004). There were no differences between the proximal and distal groups.

CONCLUSION

the transplantation of lymph nodes positively affected the postoperative evolution of patients with lymphedema secondary to breast cancer. We observed no differences in relation to flap positioning.

Comparisons of Submental and Groin Vascularized Lymph Node Flaps Transfer for Breast Cancer-Related Lymphedema

Background:

The vascularized groin and submental lymph node (VGLN and VSLN) flaps are valuable options in the treatment of lymphedema. This study was to compare outcomes between VGLN and VSLN transfers for breast cancer–related lymphedema.

Methods:

Between January 2008 and December 2016, VGLN and VSLN transfers for upper limb lymphedema were compared including flap characteristics, flap elevation time, complications, and limb circumference changes.

Results:

All flaps survived. Similar vein (2.6 versus 3.2 mm; P = 0.3) and artery diameter (2.1 versus 2.8 mm; P = 0.3) and number of lymph nodes (3 versus 4; P = 0.4) were found between VGLN and VSLN groups, respectively. Circumferential reduction rate was higher in VSLN than VGLN (P = 0.04) group. Vascular complication rate with salvage rate was not statistically different between the 2 groups. Donor-site complication and total complication rates were statistically higher in VGLN than VSLN flaps (7.7% versus 0%, P = 0.004; 46.2% versus 23.3%, P = 0.002). At a mean 39.8 ± 22.4 months, the circumferential reduction rate was statistically higher in VSLN than in the VGLN group (55.5 ± 14.3% versus 48.4 ± 23.9%, P = 0.04). Both flaps were effectively decreased in the episodes of cellulitis.

Conclusions:

Both VGLN and VSLN flaps are valuable surgical options in treating breast cancer–related lymphedema. However, the VSLN flap for breast cancer–related lymphedema is better in providing more significant improvements in limb circumference, a faster flap harvest time, decreased complication rates, and minimal donor-site iatrogenic lymphedema.

Combining Autologous Breast Reconstruction and Vascularized Lymph Node Transfer

Breast cancer patients are at risk for developing postmastectomy lymphedema syndrome of the ipsilateral upper extremity following treatment for breast cancer in the setting of an axillary dissection, postoperative radiation, and chemotherapy. For patients suffering from lymphedema who are also seeking breast reconstruction, combining an autologous abdominal free flap with a vascularized inguinal lymph node transfer provides patients the opportunity to have an aesthetic breast reconstruction as well as the potential to improve their lymphedema in a single operation. The present article aims to provide a description of the salient features of this approach including the preoperative preparation, the surgical technique, the postoperative management and complications, and a summary of the outcomes.

Vascularized lymph node transfer for treatment of extremity lymphedema: An overview of current controversies regarding donor sites, recipient sites and outcomes

As lymphatic microsurgery has become more common, vascularized lymph node transfer ascended to the forefront in many centers for the surgical management of advanced stages of lymphedema showing substantial clinical improvement. However, no consensus has been reached among experts regarding many details of the procedures, including patient selection criteria, type of treatment, donor, and recipient sites and postoperative evaluation of the outcome. Here, we will review these issues and provide the current results of this procedure.