Surgical Approach to Lymphedema Reduction

ICG fluorescence-guided sentinel lymph node biopsy for decision-making in lateral lymph node dissection in local advanced rectal cancer: a retrospective study

Local advanced rectal cancer (LARC) carries high recurrence risks, especially with lateral lymph node (LLN) involvement. This study aims to evaluate the role of ICG-guided sentinel lymph node biopsy (SLNB) in patients with clinical negative LLNs (maximum diameter < 7 mm), potentially reducing unnecessary surgeries and associated complications in patients with LARC. A retrospective analysis of 301 consecutive patients with lower LARC who underwent fluorescent lateral pelvic sentinel lymph node biopsy (FL-SLNB) or conventional LLND at the Cancer Hospital, Chinese Academy of Medical Sciences between 2018 and 2022 was conducted. Clinical and pathological data were collected, and the patients were grouped into FL-SLNB and non-SLNB groups. Postoperative complications, recurrence rates, and survival outcomes were assessed. Statistical analysis was performed using χ2 tests, Mann-Whitney U tests, Kaplan-Meier survival curves, and Cox proportional hazards models. FL-SLNB (173 patients) showed better perioperative outcomes than non-SLNB (128 patients), with shorter hospital stays (7 vs. 10 days, P = 0.027), less blood loss (150 vs. 180 mL, P = 0.032), and fewer complications: intraoperative bleeding (2.9% vs. 6.3%, P = 0.041), anastomotic leakage (1.7% vs. 3.9%, P = 0.045), and urinary dysfunction (3.5% vs. 7.0%, P = 0.039). No significant differences were observed in survival or recurrence rates (P > 0.05). pN stage was a significant predictor of distant metastasis (HR 1.953, P = 0.037). ICG-guided SLNB enhanced surgical precision and reduced unnecessary LLND in lower LARC with clinically negative LLNs, and improved surgical decision-making and minimizes postoperative complications.

Vascularized lymph node transfer (VLNT) versus lymphaticovenous anastomosis (LVA) for chronic breast cancer-related lymphedema (BCRL): a retrospective cohort study of effectiveness over time

PURPOSE

Microsurgical reconstruction, including vascularized lymph node transfer (VLNT) and lymphaticovenous anastomosis (LVA), have emerged as promising treatment options for chronic breast cancer-related lymphedema (BCRL). Despite their clinical relevance, the precise timelines for patient improvement following these interventions remain rather unexplored. Therefore, the goal of this study was to compare the long-term outcomes and improvement patterns over time of VLNT versus LVA to lay open potential differences and aid in personalized counseling of future patients.

METHODS

A prospectively maintained, encrypted database was analyzed for patients with chronic BCRL treated with either VLNT or LVA with a minimum follow-up of one year. Patient-specific variables, such as body weight and circumferential arm measurements at distinct locations on both arms were documented preoperatively and on regular postoperative outpatient follow-ups.

RESULTS

This study comprised 112 patients, of which 107 patients fully completed the one-year follow-up period. Both VLNT and LVA achieved significant arm size reductions. LVA showed an early peak in effectiveness within the first three months, followed by a subsequent decrease and eventual stabilization. Contrarily, VLNT exhibited a distinct pattern with two significant peaks at three and eighteen months.

CONCLUSIONS

VLNT and LVA are both effective in long-term lymphedema management, yet they demonstrate marked differences in the timing of improvement. VLNT shows a delayed but more durable response, in contrast to the greater but shorter-lasting surge in effectiveness achieved by LVA. Interestingly, VLNT demonstrates an earlier onset of therapeutic impact than previously understood.

A systematic review and meta-analysis of risk factors influencing patient-reported arm symptoms post-breast cancer treatment: Accounting for radiotherapy impact

OBJECTIVES

To systematically review risk factors for patient-reported arm symptoms (AS) in breast cancer (BC), considering radiotherapy (RT) impact, using the EORTC QLQ-BR23 questionnaire (BR23).

METHODS

PubMed, Embase, Cochrane Library, MEDLINE, and Web of Science were searched using the keywords "breast neoplasms", "radiotherapy", and "BR23" up to March 5th, 2024.

INCLUSION CRITERIA

both univariate and multivariate analyses.

EXCLUSION CRITERIA

pregnancy, recurrence, distant metastasis BC, reirradiation, or lack of RT. The risk of bias of included papers was assessed using the Critical Appraisal Skills Program (CASP) checklist. Descriptive and meta-analyses were conducted using risk ratio (RR) or standardized mean difference (SMD) with 95 % confidence intervals (CI) as effect measures. A random-effects model was applied if I2 > 50 %.

RESULTS

Eighteen out of 734 studies were included, with sample sizes ranging from 172 to 2208. Commonly reported risk factors included axillary lymph node dissection (ALND), mastectomy, chemotherapy (CT), and RT (6, 5, 4, and 4 studies, respectively). In meta-analyses, ALND was a risk factor for arm pain (RR [95 % CI] = 1.75 [1.14; 2.71]), lymphedema (RR [95 % CI] = 5.41 [3.48; 8.39]), and overall AS (SMD [95 % CI] = 0.49 [0.14; 0.83]) compared to sentinel lymph node biopsy. RT was not a risk factor, but axillary RT significantly increased overall AS (SMD [95 % CI] = 0.55 [0.40; 0.70]) compared to no axillary RT.

CONCLUSION

ALND and mastectomy were the primary risk factors for patient-reported AS. Axillary RT was a significant risk factor, whereas general RT was not.

Molecular pathophysiology of secondary lymphedema

Lymphedema occurs as a result of lymphatic vessel damage or obstruction, leading to the lymphatic fluid stasis, which triggers inflammation, tissue fibrosis, and adipose tissue deposition with adipocyte hypertrophy. The treatment of lymphedema is divided into conservative and surgical approaches. Among surgical treatments, methods like lymphaticovenular anastomosis and vascularized lymph node transfer are gaining attention as they focus on restoring lymphatic flow, constituting a physiologic treatment approach. Lymphatic endothelial cells form the structure of lymphatic vessels. These cells possess button-like junctions that facilitate the influx of fluid and leukocytes. Approximately 10% of interstitial fluid is connected to venous return through lymphatic capillaries. Damage to lymphatic vessels leads to lymphatic fluid stasis, resulting in the clinical condition of lymphedema through three mechanisms: Inflammation involving CD4+ T cells as the principal contributing factor, along with the effects of immune cells on the VEGF-C/VEGFR axis, consequently resulting in abnormal lymphangiogenesis; adipocyte hypertrophy and adipose tissue deposition regulated by the interaction of CCAAT/enhancer-binding protein α and peroxisome proliferator-activated receptor-γ; and tissue fibrosis initiated by the overactivity of Th2 cells, leading to the secretion of profibrotic cytokines such as IL-4, IL-13, and the growth factor TGF-β1. Surgical treatments aimed at reconstructing the lymphatic system help facilitate lymphatic fluid drainage, but their effectiveness in treating already damaged lymphatic vessels is limited. Therefore, reviewing the pathophysiology and molecular mechanisms of lymphedema is crucial to complement surgical treatments and explore novel therapeutic approaches.

The Role of Inflammation in Lymphedema: A Narrative Review of Pathogenesis and Opportunities for Therapeutic Intervention

Lymphedema is a chronic and progressive disease of the lymphatic system characterized by inflammation, increased adipose deposition, and tissue fibrosis. Despite early hypotheses identifying lymphedema as a disease of mechanical lymphatic disruption alone, the progressive inflammatory nature underlying this condition is now well-established. In this review, we provide an overview of the various inflammatory mechanisms that characterize lymphedema development and progression. These mechanisms contribute to the acute and chronic phases of lymphedema, which manifest clinically as inflammation, fibrosis, and adiposity. Furthermore, we highlight the interplay between current therapeutic modalities and the underlying inflammatory microenvironment, as well as opportunities for future therapeutic development.

Lymphoscintigraphy is frequently recommended but seldom used in a "real world setting"

OBJECTIVE

Lymphedema (LED) lacks a standard, simple, guiding noninvasive diagnostic test, unlike the two other circulatory disorders-arterial or venous disease. Lymphoscintigraphy (LSG) has been recommended by several guidelines as the diagnostic test of choice for LED. Several recent expert panels, however, have suggested from anecdotal experience that LSG was used infrequently, and that the diagnosis of LED is usually based on clinical examination.

METHODS

To determine the use of LSG in a large real-world LED population, the International Business Machines MarketScan Research Database was examined from April 2012 to March 2020 for patients with a new diagnosis of LED (the index date). Use of LSG (LSG+) was ascertained during the period beginning 12 months prior to the initial coding of a LED diagnosis and ending 12 months after the index date based on the corresponding Current Procedural Terminology code; LSG use for sentinel node mapping at the time of oncologic surgery was excluded. Demographic profiles, comorbidities, and causes of LED among patients with and without evidence of LSG were characterized.

RESULTS

We identified 57,674 patients, aged ≥18 years, who had a new diagnosis of LED and health care coverage for ≥12 months before and after this index date. Only a small number (1429; 2.5%) of these patients underwent LSG during the study period. The LSG + cohort was younger (53.7 vs 60.7 years), had a higher proportion of women (91.3% vs 73.4%), but a lower percentage of diabetes (12.8% vs 27.5%), heart failure (2.2% vs 8.7%), hypertension (32.4% vs 51.0%), and obesity (15.1% vs 22.2%) compared with the LED population who did not undergo LSG (all P < .001). Most importantly, the use of LSG for diagnosis varied with the etiology of LED (LSG was most frequently utilized among patients with melanoma-LED (9.5%) and patients with breast cancer-LED (6.7%), in contrast to patients with advanced venous disease-related LED (1.1%; P < .05 for both comparisons).

CONCLUSIONS

Despite four guidelines recommending LSG, including the Guidelines of the American Venous Forum (Handbook of Venous and Lymphatic Disease-4th edition), which recommended LSG "for the initial evaluation of patients with LED" with a 1B recommendation, LSG plays a minor role in establishing the diagnosis of LED in the United States. This underlines the need for a better, simple diagnostic test for LED to complement clinical examination.

Comparison of the Effectiveness of Liposuction for Lower Limb versus Upper Limb Lymphedema

OBJECTIVE

Liposuction is the most frequently performed debulking procedure in patients with lymphedema. However, it remains uncertain whether liposuction is equally effective for upper extremity lymphedema (UEL) and lower extremity lymphedema (LEL). In this study, we retrospectively compared the effectiveness of liposuction according to whether it was performed for LEL or UEL, and identified factors associated with outcomes.

MATERIALS AND METHODS

All patients had been treated at least once by lymphovenous anastomosis or vascularized lymphatic transplant before liposuction but without sufficient volume reduction. The patients were divided into an LEL group and a UEL group, and then subdivided further according to whether they completed their planned compression therapy into an LEL compliance group, an LEL non-compliance group, a UEL compliance group, and a UEL non-compliance group. The reduction rates in LEL (REL) and in UEL (REU) were compared between the groups.

RESULTS

In total, 28 patients with unilateral lymphedema were enrolled (LEL compliance group, n = 12; LEL non-compliance group, n = 6; UEL compliance group, n = 10; UEL non-compliance group, n = 0). The non-compliance rate was significantly higher in the LEL group than in the UEL group (p = 0.04). REU was significantly higher than REL (100.1 ± 37.3% vs. 59.3 ± 49.4%; p = 0.03); however, there was no significant difference between REL in the LEL compliance group (86 ± 31%) and REU in the UEL group (101 ± 37%) (p = 0.32).

CONCLUSION

Liposuction seems to be more effective in UEL than in LEL, probably because the compression therapy required for management after liposuction is easier to implement for UEL. The lower pressure and smaller coverage area required for postoperative management after liposuction in the upper limb may explain why liposuction is more effective in UEL than in LEL.

Use of fluorescence imaging during lymphatic surgery: A Delphi survey of experts worldwide

BACKGROUND

Fluorescence imaging with indocyanine green is increasingly used during lymphedema patient management. However, to date, no guidelines exist on when it should and should not be used or how it should be performed. Our objective was to have an international panel of experts identify areas of consensus and nonconsensus in current attitudes and practices in fluorescence imaging with indocyanine green use during lymphedema surgery patient management.

METHODS

A 2-round Delphi study was conducted involving 18 experts in the use of fluorescence imaging during lymphatic surgery, all asked to vote on 49 statements on patient preparation and contraindications (n = 7 statements), indocyanine green dosing and administration (n = 10), fluorescence imaging uses and potential advantages (n = 16), and potential disadvantages and training needs (n = 16).

RESULTS

Consensus ultimately was reached on 40/49 statements, including consistent consensus regarding the value of fluorescence imaging with indocyanine green in almost all facets of lymphedema patient management, including early detection, assessing disease extent, preoperative work-up, surgical planning, intraoperative guidance, monitoring short- and longer-term outcomes, quality control, and resident training. All experts felt it was very safe, while 94% felt it should be part of routine care and that indocyanine green was superior to colored dyes and ultrasound. Nonetheless, there also was consensus that limited high-quality evidence remains a barrier to its widespread use and that patients should still be provided with specific information and asked to sign specific consent for both fluorescence imaging and indocyanine green.

CONCLUSION

Fluorescence imaging with or without indocyanine green appears to have several roles in lymphedema prevention, diagnosis, assessment, and treatment.

Early Blood Flow Abnormalities in Axillary and Brachial Arteries Precede the Onset of Persistent Lymphedema in Women Treated Surgically for Breast Cancer

Background: surgery to treat breast cancer (BC) is associated with upper limb (UL) lymphedema, which in some cases may become permanent. It is uncertain whether lymphedema results from injury to either lymphatic or blood vessels, or to both. Methods and Results: a cohort of 200 BC patients was examined 1, 3, 6, 12, and 24 months after surgery. Axillary and brachial blood vessels were evaluated using Doppler Ultrasound, and patients had their UL examined for lymphedema at each visit. Patients who developed lymphedema 24 months after surgery presented with higher mean flow velocity (MFV) and end diastolic velocity (EDV) in both axillary (MFV = 13.57 vs. 10.7 cm/s, p = 0.02; EDV = 5.62 vs. 3.47 cm/s; p = 0.004) and brachial (MFV = 11.44 vs. 8.74 cm/s; p = 0.03; EDV = 5.08 vs. 3.04; p = 0.04) arteries as early as 1 month after surgery. Similar associations were found 3, 6, and 12 months after surgery. Early abnormalities of the resistive and pulsatility indexes were also significantly associated with persistent lymphedema. EDV measured 1 month after surgery had the best performance to detect patients who will later develop long-term lymphedema, (sensitivity = 73.7%; specificity = 71.2%; negative predictive value = 57.6%). Conclusion: vascular abnormalities precede and are possible causal factors for UL lymphedema in BC patients.

Healthcare Practitioners' Knowledge of Lymphedema

Objectives

Lymphedema is neglected in medical education, and a review on healthcare practitioners' (HCPs) knowledge is necessary to shed light on gaps and to provide evidence for establishing educational programs on lymphedema.

Methods

This systematic review was performed based on the PRISMA guideline in PubMed, Scopus, Web of Science, and Google Scholar databases. There was no limitation on the type of lymphedema or HCPs. The quality assessment was performed based on QATSDD. Data regarding study characteristics, questionnaire context, and findings of the study were summarized from each article.

Results

After the screening, 16 articles were included that 12 were cross-sectional, two were qualitative, and two were interventional pilot studies. Breast cancer and other cancer-related lymphedema, lymphatic filariasis, and podoconiosis were included, and the majority of articles were focused on primary HCPs. The overall knowledge was low and average in five and 11 articles, respectively, and prior education was a significant factor related to higher knowledge of lymphedema in two studies.

Conclusion

Structured education of lymphedema is needed to increase the knowledge of HCPs and to enhance their collaboration in multidisciplinary care teams. Improvement of HCPs' knowledge may lead to better outcomes of lymphedema patients' management which are neglected.

Study protocol for a 10-year prospective observational study, examining lymphoedema and patient-reported outcome after breast reconstruction

INTRODUCTION

Over the last decades, treatment of breast cancer has become increasingly more effective. Consequently, an increasing number of women are living with late effects of breast cancer treatment, including disfiguring scars, deformity or asymmetry of the breast, secondary lymphoedema and other physical and psychosocial late effects. Data from this study will provide knowledge on how to guide breast reconstruction in the future towards outcomes with fewer complications, higher long-term quality of life (QoL) and satisfaction with the aesthetic outcome. The development of secondary lymphoedema, for which the effect of breast reconstruction has yet to be established, will be thoroughly examined.

METHODS AND ANALYSIS

Women receiving breast reconstruction (autologous and implant based) at the Department of Plastic Surgery and Burns Treatment, Rigshospitalet, will be invited to participate. The patients will be followed for 10 years postoperatively. Demographic, health-related, oncological characteristics and treatment data will be registered. Validated assessment tools, such as the BREAST-Q and Beck Depression Inventory, will be used to measure an extensive range of clinical outcomes, including QoL, life and aesthetic satisfaction and depression. Arm range of motion will be measured with a goniometer and lymphoedema by bioimpedance spectroscopy, compared with circular arm measurements.

ETHICS AND DISSEMINATION

This study will be conducted according to the 5th version of the Helsinki Declaration. The regional ethical committee for Capital Region Denmark did not find the study notifiable, according to the law of the committee § 1, part 4. All data will be anonymised before its publication. This study will be conducted according to the Danish data protection regulation and is catalogued and approved by the Capital Region Head of Knowledge Centre. According to the Danish health law § 46, part 2, this study does not need the Danish Patient Safety Authority's approval. The findings of this study will be submitted to international peer-reviewed journals.

Longitudinal, Long-Term Comparison of Single- versus Multipoint Upper Limb Circumference Periodical Measurements as a Tool to Predict Persistent Lymphedema in Women Treated Surgically for Breast Cancer: An Optimized Strategy to Early Diagnose Lymphedema and Avoid Permanent Sequelae in Breast Cancer Survivors

PURPOSE

We aim to evaluate whether upper limb (UL) circumference (ULC) and UL swelling sensation (ULSS) performed shortly after surgery or later on during follow-up can predict long-term/persistent forms of lymphedema in women who underwent surgery for breast cancer.

PATIENTS AND METHODS

Eighty-five women completed at least 24 months of follow-up. At each follow-up visit (1, 3, 6, 12, and 24 months after surgery), patients were tested for lymphedema using ULC and ULSS. Two different approaches to ULC were compared: (1) a "positive" lymphedema diagnosis if a difference ≥ 2 cm between the affected and contralateral UL was detected in at least two contiguous measurement points (MPs) and (2) a "positive" result if just one MP ≥ 2 cm. Patients were also questioned about their perception of weight, swelling, and/or tension (ULSS). The gold standard for long-term lymphedema was a water displacement difference between the UL ≥ 200 mL 24 months after surgery (ULWD).

RESULTS

Twenty-four months after surgery, 19 (22.4%) women were diagnosed with long-term lymphedema. Using 24-month data, comparison of log-likelihoods denoted a clear superiority of the ULC approach 1 compared with 2 for the diagnosis of long-term lymphedema (p < 0.001). Using approach 1, the best prediction of a woman developing long-term lymphedema if she had a positive ULC in the follow-up was obtained at 6 months after surgery (posterior probability of 60%).

CONCLUSIONS

Our study reveals that performing ULC 6 months after surgery, regarding as "positive" only women with a difference ≥ 2 cm at two contiguous MPs, is the best strategy to identify women at increased risk of later developing permanent forms of lymphedema.

Cost-Effectiveness Analysis: Lymph Node Transfer vs Lymphovenous Bypass for Breast Cancer-Related Lymphedema

BACKGROUND

Lymph node transfer (LNT) and lymphovenous bypass (LVB) have been described as 2 major surgical options for patients with breast cancer-related lymphedema (BCRL) who have failed conservative therapy. The objective of our study was to perform a cost-effectiveness analysis comparing LNT and LVB for the treatment of BCRL.

STUDY DESIGN

Rates of infection, lymph leak, and failure of LNT and LVB were obtained from a previously published meta-analysis. Failure of surgery was defined as the inability to cease compression therapy postoperatively. Procedural costs were calculated from Medicare reimbursement rates. Cost of conservative management of postoperative surgical site infection, lymph leak, and continued decongestive physiotherapy after failed surgery were obtained from literature review. Average utility scores for each health state were calculated using a visual analog scale survey, then converted to quality-adjusted life years (QALYs). A decision tree was constructed, and incremental cost-effectiveness ratio was assessed at $50,000/QALY. Deterministic and probabilistic sensitivity analyses were performed to evaluate the robustness of our findings.

RESULTS

LNT was less costly ($22,492 vs $31,927) and more effective (31.82 QALY vs 29.24 QALY) than LVB. One-way (deterministic) sensitivity analysis demonstrated that LNT became cost-ineffective when its failure rate was more than 43.8%. LVB became more cost-effective than LNT when its failure rate was less than 21.4%. Probabilistic sensitivity analysis using Monte-Carlo simulation indicated that even with uncertainty present in the variables analyzed, the majority of simulations (97%) favored LNT as the more cost-effective strategy.

CONCLUSIONS

LNT is a dominant, cost-effective strategy compared to LVB for the treatment of BCRL.