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Weber WP, Hanson SE, Wong DE, Heidinger M, Montagna G, Cafferty FH, Kirby AM, Coles CE. Personalizing Locoregional Therapy in Patients With Breast Cancer in 2024: Tailoring Axillary Surgery, Escalating Lymphatic Surgery, and Implementing Evidence-Based Hypofractionated Radiotherapy. Am Soc Clin Oncol Educ Book 2024; 44:e438776. [PMID: 38815195 DOI: 10.1200/edbk_438776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient's risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.
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Affiliation(s)
- Walter Paul Weber
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Summer E Hanson
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Daniel E Wong
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Martin Heidinger
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Fay H Cafferty
- Institute of Cancer Research Clinical Trials and Statistics Unit, London, United Kingdom
| | - Anna M Kirby
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
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Meuli JN, Guiotto M, Elmers J, Mazzolai L, di Summa PG. Outcomes after microsurgical treatment of lymphedema: a systematic review and meta-analysis. Int J Surg 2023; 109:1360-1372. [PMID: 37057889 PMCID: PMC10389392 DOI: 10.1097/js9.0000000000000210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/03/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Microsurgical treatment options for lymphedema consist mainly of lymphovenous anastomosis (LVA) and vascularized lymph node transfers (VLNTs). There are no standard measurements of the effectiveness of these interventions and reported outcomes vary among studies. METHODS A systematic review and meta-analysis were performed based on a structured search in Embase, Medline, PubMed, Cinahl, Cochrane, and ProQuest in October 2020, with an update in February 2022. Firstly, a qualitative summary of the main reported outcomes was performed, followed by a pooled meta-analysis of the three most frequently reported outcomes using a random effects model. Randomized controlled trials, prospective cohorts, retrospective cohorts, and cross-sectional and case-control studies that documented outcomes following microsurgery in adult patients were included. Studies of other surgical treatments (liposuction, radical excision, lymphatic vessel transplantation) or without reported outcomes were excluded. The study protocol was registered on PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42020202417). No external funding was received for this review. RESULTS One hundred fifty studies, including 6496 patients, were included in the systematic review. The qualitative analysis highlighted the three most frequently reported outcomes: change in circumference, change in volume, and change in the number of infectious episodes per year. The overall pooled change in excess circumference across 29 studies, including 1002 patients, was -35.6% [95% CI: -30.8 to -40.3]. The overall pooled change in excess volume across 12 studies including 587 patients was -32.7% [95% CI: -19.8 to -45.6], and the overall pooled change in the number of cutaneous infections episodes per year across 8 studies including 248 patients was -1.9 [95% CI: -1.4 to -2.3]. The vast majority of the studies included were case series and cohorts, which were intrinsically exposed to a risk of selection bias. CONCLUSION The currently available evidence supports LVA and vascularized lymph node transfers as effective treatments to reduce the severity of secondary lymphedema. Standardization of staging method, outcomes measurements, and reporting is paramount in future research in order to allow comparability across studies and pooling of results.
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Affiliation(s)
| | | | | | - Lucia Mazzolai
- Angiology Division, Heart and Vessel Department, Lausanne University Hospital, University of Lausanne, Switzerland
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Knackstedt R, Chen WF. Current Concepts in Surgical Management of Lymphedema. Phys Med Rehabil Clin N Am 2022; 33:885-899. [DOI: 10.1016/j.pmr.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Coroneos CJ, Asaad M, Wong FC, Hall MS, Chen DN, Hanasono MM, Schaverien MV. Outcomes and technical modifications of vascularized lymph node transplantation from the lateral thoracic region for treatment of lymphedema. J Surg Oncol 2022; 125:603-614. [PMID: 34989418 DOI: 10.1002/jso.26783] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/19/2021] [Accepted: 12/13/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES This study evaluates clinical outcomes of vascularized lymph node transplantation (VLNT) from the lateral thoracic region and technical modifications. METHODS Consecutive patients that underwent lateral thoracic VLNT to treat extremity lymphedema were included. Demographic and treatment data were recorded, and outcomes data including limb volume, LDex score, and Lymphedema Life Impact Scale (LLIS), QuickDASH, and LEFS questionnaires, were collected prospectively. Consecutive patients that underwent single-photon emission computed tomography (SPECT/CT) lymphoscintigraphy axillary reverse lymphatic mapping (RLM) were analyzed to characterize the physiological drainage of the normal upper extremity. RESULTS A consecutive series of 32 flaps were included. At 24 months postoperatively mean reduction in limb volume excess was 47.2% (±11.6; p = 0.0085), LDex score was 63.1% (±8.5; p < 0.001), and LLIS score was 65.1% (±7.4; p < 0.001). Preoperatively 14/31 patients (45.2%) reported cellulitis, and postoperatively there were no episodes at up to 24 months (p < 0.001). No patient developed donor extremity lymphedema at mean 18.6 (±8.3) months follow-up. SPECT/CT-RLM of 182 normal axillae demonstrated that the sentinel lymph node(s) of the upper extremity was consistently anatomically located in the upper outer quadrant of the axilla (97%). CONCLUSIONS VLNT from the lateral thoracic region is effective and versatile for the treatment of lymphedema with a low donor site complication rate.
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Affiliation(s)
- Christopher J Coroneos
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Malke Asaad
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Franklin C Wong
- Division of Diagnostic Imaging, Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Melissa S Hall
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Dawn N Chen
- Department of Rehabilitation Services, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Matthew M Hanasono
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark V Schaverien
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Bamba R, Chu A, Gallegos J, Herrera FA, Hassanein AH. Outcomes analysis of microsurgical physiologic lymphatic procedures for the upper extremity from the United States National Surgical Quality Improvement Program. Microsurgery 2021; 42:305-311. [PMID: 34812535 DOI: 10.1002/micr.30844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 08/21/2021] [Accepted: 10/28/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Physiologic microsurgical procedures to treat lymphedema include vascularized lymph node transfer (VLNT) and lymphovenous bypass (LVB). The purpose of this study was to assess 30-day outcomes of VLNT and LVB using the National Surgical Quality Improvement Program (NSQIP) database. METHODS NSQIP was queried (2012-2018) for lymphatic procedures for upper extremity lymphedema after mastectomy. Prophylactic lymphatic procedures and those for lower extremity lymphedema were excluded. Outcomes were assessed for three groups: LVB, VLNT, and patients who had procedures simultaneously (VLNA+LVB). Primary outcomes measured were operative time, 30-day morbidities, and hospital length of stay. RESULTS The study included 199 patients who had LVB (n = 43), VLNT (n = 145), or VLNT+LVB (n = 11). There was no difference in co-morbidities between the groups (p = 0.26). 30-day complication rates including unplanned reoperation (6.9% VLNT vs. 2.3% LVB) and readmission (0.69% VLNT vs. none in LVB) were not statistically significant (p = 0.54). Surgical site infection, wound complications, deep vein thromboembolism, and cardiac arrest was also similar among the three groups. Postoperative length of stay for VLNT (2.5 days± 2.3), LVB (1.9 days± 1.9), and VLNT+LVB (2.8 days± 0.3) did not differ significantly (p = 0.20). Operative time for LVB (305.4 min ± 186.7), VLNT (254 min ± 164.4), and VLNT+LVB (295.3 min ± 43.2) was not significantly different (p = 0.21). CONCLUSIONS Our analysis of the NSQIP data revealed that VLNT and LVB are procedures with no significant difference in perioperative morbidity. Our results support that choice of VLNT versus LVB can be justifiably made per the surgeon's preference and experience as the operations have similar complication rates.
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Affiliation(s)
- Ravinder Bamba
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Amanda Chu
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jose Gallegos
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Fernando A Herrera
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Hanson SE, Chu CK, Chang EI. Surgical Treatment Options of Breast Cancer-Related Lymphedema. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00286-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Schaverien MV, Chang EI. Combined deep inferior epigastric artery perforator flap with vascularized groin lymph node transplant for treatment of breast cancer-related lymphedema. Gland Surg 2021; 10:460-468. [PMID: 33634003 DOI: 10.21037/gs.2020.02.14] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
For survivors of breast cancer lymphedema is their greatest survivorship burden. Modern surgical techniques to treat lymphedema are effective at reducing limb volume, symptoms of lymphedema, episodes of cellulitis, and improving patient quality of life. Physiologic procedures, including lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT), restore physiological lymphatic function within the affected extremity. In patients with post-mastectomy breast cancer-related upper extremity lymphedema that desire breast reconstruction, microvascular abdominal flap breast reconstruction can be combined with superficial inguinal (groin) VLNT to provide breast reconstruction and treatment of lymphedema in a single operation. This article reviews the indications, preoperative assessment, surgical technique, outcomes, and tips and pearls for performing this procedure.
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Affiliation(s)
- Mark V Schaverien
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Edward I Chang
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Robotically Assisted Omentum Flap Harvest: A Novel, Minimally Invasive Approach for Vascularized Lymph Node Transfer. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2505. [PMID: 32440389 PMCID: PMC7209865 DOI: 10.1097/gox.0000000000002505] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 08/28/2019] [Indexed: 01/11/2023]
Abstract
Background: The omentum provides abundant lymphatic tissue with reliable vascular anatomy, representing an ideal donor for vascularized lymph node transfer without risk for donor site lymphedema. We describe a novel, robotically assisted approach for omental flap harvest. Methods: All patients undergoing robotically assisted omentum harvest for vascularized lymph node transfer from 2017 to 2019 were identified. Patient demographics, intraoperative variables, and postoperative outcomes were reviewed. Results: Five patients underwent robotically assisted omentum flap harvest for vascularized lymph node transfer. The average patient age and body mass index were 51.2 years and 29.80 kg/m2, respectively. Indications for lymph node transfer were upper extremity lymphedema following mastectomy, radiation, and lymphadenectomy (60.0%); congenital unilateral lower extremity lymphedema (20.0%); and bilateral lower extremity/scrotal lymphedema following partial penectomy and bilateral inguinal/pelvic lymphadenectomy (20.0%). Four patients (80.0%) underwent standard robotic harvest, whereas 1 patient underwent single-port robotic harvest. The average number of port sites was 4.4. All patients underwent omentum flap transfer to 2 sites; in 2 cases, the flap was conjoined, and in 3 cases, the flap was segmented. The average overall operative time was 9:19. The average inpatient hospitalization was 5.2 days. Two patients experienced cellulitis, which is resolved with oral antibiotics. There were no major complications. All patients reported subjective improvement in swelling and softness of the affected extremity. The average follow-up was 8.8 months. Conclusions: Robotically assisted omental harvest for vascularized lymph node transfer is a novel, safe, and viable minimally invasive approach offering improved intra-abdominal visibility and maneuverability for flap dissection.
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Gazyakan E, Bigdeli AK, Kneser U, Hirche C. Chimeric thoracodorsal lymph node flap with a perforator-based fasciocutaneous skin island for treatment of lower extremity lymphedema: A case report. Microsurgery 2020; 40:792-796. [PMID: 32259343 DOI: 10.1002/micr.30584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 01/18/2020] [Accepted: 03/20/2020] [Indexed: 11/11/2022]
Abstract
Free vascularized lymph node transfer (VLNT) is applied more and more in the treatment of lymphedema. A random-pattern skin island with VLNT is of use but can have its limitations in flap inset. We describe an option for free VLNT in the treatment of lower extremity lymphedema. We present the case of a chimeric thoracodorsal lymph node flap (TAP-VLNT) with a thoracodorsal artery perforator (TAP) flap (5 × 9 cm) to the lower leg in a 22-year old female patient with stage 2 lower leg lymphedema caused by severe traumatic skin decollement and postoperative scarring after a car accident. TAP flap enabled tailored and tension-free wound closure at the recipient site after scar release and lymph node flap inset. The anastomosis was performed to the anterior tibial artery. The postoperative course was uneventful with no complications or secondary donor-site lymphedema. Follow-up at 6 months showed reasonable cosmetic and functional outcomes. The circumference reduction rate was up to 11% and the patient reported improved quality of life. The purpose of this report is to describe a case of a more flexible lymph node flap inset and tension-free wound closure by harvesting a thin thoracodorsal artery perforator (TAP) skin island together with a thoracodorsal VLNT as a chimeric flap (TAP-VLNT) for treatment of lower extremity lymphedema. Larger series with longer follow-up data are needed to justify its widespread use and demonstrate long-term results.
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Affiliation(s)
- Emre Gazyakan
- Department of Hand, Plastic, and Reconstructive Surgery, University of Heidelberg, BG Clinic Ludwigshafen, Ludwigshafen, Germany
| | - Amir Khosrow Bigdeli
- Department of Hand, Plastic, and Reconstructive Surgery, University of Heidelberg, BG Clinic Ludwigshafen, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, University of Heidelberg, BG Clinic Ludwigshafen, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, University of Heidelberg, BG Clinic Ludwigshafen, Ludwigshafen, Germany
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Abu-Rustum NR, Angioli R, Bailey AE, Broach V, Buda A, Coriddi MR, Dayan JH, Frumovitz M, Kim YM, Kimmig R, Leitao MM, Muallem MZ, McKittrick M, Mehrara B, Montera R, Moukarzel LA, Naik R, Pedra Nobre S, Plante M, Plotti F, Zivanovic O. IGCS Intraoperative Technology Taskforce. Update on near infrared imaging technology: beyond white light and the naked eye, indocyanine green and near infrared technology in the treatment of gynecologic cancers. Int J Gynecol Cancer 2020; 30:670-683. [PMID: 32234846 DOI: 10.1136/ijgc-2019-001127] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/29/2020] [Accepted: 02/04/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- Nadeem R Abu-Rustum
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | | | - Arthur E Bailey
- Research and Development, Stryker Endoscopy, San Jose, California, USA
| | - Vance Broach
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Alessandro Buda
- Department of Obstetrics and Gynecology, Azienda Ospedaliera San Gerardo, Monza, Italy
| | - Michelle R Coriddi
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Joseph H Dayan
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Michael Frumovitz
- Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yong Man Kim
- Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Rainer Kimmig
- Gynecology and Obstetrics, University Hospital of Duisburg-Essen, Essen, Germany
| | - Mario M Leitao
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Mustafa Zelal Muallem
- Department of Gynecology with Center for Oncological Surgery, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Virchow Campus Clinic, Charité Medical University, Berlin, Germany
| | - Matt McKittrick
- Research and Development, Stryker Endoscopy, San Jose, California, USA
| | - Babak Mehrara
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Roberto Montera
- Universita Campus Bio-Medico di Roma Facolta di Medicina e Chirurgia, Roma, Lazio, Italy
| | - Lea A Moukarzel
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Raj Naik
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, UK
| | - Silvana Pedra Nobre
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Marie Plante
- Obstetrics and Gynecology, Centre Hospitalier Universitaire de Quebec, Quebec, Quebec, Canada
| | - Francesco Plotti
- Universita Campus Bio-Medico di Roma Facolta di Medicina e Chirurgia, Roma, Lazio, Italy
| | - Oliver Zivanovic
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Controversies in Surgical Management of Lymphedema. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2671. [PMID: 32537335 PMCID: PMC7253258 DOI: 10.1097/gox.0000000000002671] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/18/2019] [Indexed: 12/01/2022]
Abstract
Surgical treatment of lymphedema has expanded in recent years. Lymphovenous bypass and vascularized lymph node transfer are both modern techniques to address the physiologic dysfunction associated with secondary lymphedema. While efficacy of both techniques has been demonstrated in numerous studies, there are several questions that remain. Here, the authors discuss the most pertinent controversies in our practice as well as the current state of surgical management of lymphedema.
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Dayan JH, Wiser I, Verma R, Shen J, Talati N, Goldman D, Mehrara BJ, Smith ML, Dayan E, Coriddi M, Kagan A. Regional Patterns of Fluid and Fat Accumulation in Patients with Lower Extremity Lymphedema Using Magnetic Resonance Angiography. Plast Reconstr Surg 2020; 145:555-563. [PMID: 31985658 PMCID: PMC7473406 DOI: 10.1097/prs.0000000000006520] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Joseph H. Dayan
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Itay Wiser
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richa Verma
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jody Shen
- Department of Radiology, Mt. Sinai Health System, New York, New York
| | - Nishi Talati
- Department of Radiology, Mt. Sinai Health System, New York, New York
| | - Debra Goldman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Mark L. Smith
- Division of Plastic Surgery, Northwell Health System and Cancer Institute, Lake Success, New York
| | - Erez Dayan
- Division of Plastic Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Michelle Coriddi
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexander Kagan
- Department of Radiology, Mt. Sinai Health System, New York, New York
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14
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Pappalardo M, Chang DW, Masia J, Koshima I, Cheng MH. Summary of hands-on supermicrosurgery course and live surgeries at 8th world symposium for lymphedema surgery. J Surg Oncol 2019; 121:8-19. [PMID: 31309553 DOI: 10.1002/jso.25619] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 06/06/2019] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Marco Pappalardo
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - David W Chang
- Department of Surgery, Section of Plastic and Reconstructive Surgery, The University of Chicago, Chicago, Illinois
| | - Jaume Masia
- Department of Surgery, Faculty of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Isao Koshima
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Orthotopic transfer of vascularized groin lymph node flap in the treatment of breast cancer-related lymphedema: Clinical results, lymphoscintigraphy findings, and proposed mechanism. J Plast Reconstr Aesthet Surg 2018; 71:1033-1040. [DOI: 10.1016/j.bjps.2018.02.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 02/02/2018] [Accepted: 02/17/2018] [Indexed: 11/24/2022]
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16
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Schaverien MV, Badash I, Patel KM, Selber JC, Cheng MH. Vascularized Lymph Node Transfer for Lymphedema. Semin Plast Surg 2018; 32:28-35. [PMID: 29636651 DOI: 10.1055/s-0038-1632401] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Advances in our understanding of the lymphatic system and the pathogenesis of lymphedema have resulted in the development of effective surgical treatments. Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes into an extremity to restore physiological lymphatic function. It is most commonly performed by transferring combined deep inferior epigastric artery perforator and superficial inguinal lymph node flaps for postmastectomy breast reconstruction. For patients who do not require or are unable to undergo free abdominal breast reconstruction or have lymphedema affecting the lower extremity, several other VLNT options are available. These include flaps harvested from within the axillary, inguinal, or cervical lymph node basins, and lymph node flaps from within the abdominal cavity. This article reviews the lymph node flap options and techniques available for VLNT for lymphedema.
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Affiliation(s)
- Mark V Schaverien
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ido Badash
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, Keck Medical Center of USC, University of Southern California, Los Angeles, California
| | - Jesse C Selber
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ming-Huei Cheng
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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17
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Vascularized Lymph Node Transfer to the Profunda Artery Perforator Pedicle: A Reliable Proximal Recipient Vessel Option in the Medial Thigh. Plast Reconstr Surg 2017; 140:366e-367e. [PMID: 28406821 DOI: 10.1097/prs.0000000000003559] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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McLaughlin SA, DeSnyder SM, Klimberg S, Alatriste M, Boccardo F, Smith ML, Staley AC, Thiruchelvam PTR, Hutchison NA, Mendez J, MacNeill F, Vicini F, Rockson SG, Feldman SM. Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema, Recommendations from an Expert Panel: Part 2: Preventive and Therapeutic Options. Ann Surg Oncol 2017; 24:2827-2835. [DOI: 10.1245/s10434-017-5964-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Indexed: 12/25/2022]
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19
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Ciudad P, Agko M, Perez Coca JJ, Manrique OJ, Chang WL, Nicoli F, Chen SH, Chen HC. Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center's approach to the treatment of lymphedema. J Surg Oncol 2017; 116:671-682. [PMID: 28695707 DOI: 10.1002/jso.24730] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/21/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Department of Biological Science and Technology; China Medical University; Taichung Taiwan
- Peru Plastic and Reconstructive Surgery Research Institute; Lima Peru
| | - Mouchammed Agko
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - John Jaime Perez Coca
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital; Chang-Gung University; Linkou Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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20
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Blei F. Update March 2017. Lymphat Res Biol 2017. [DOI: 10.1089/lrb.2017.29019.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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