Five-Year Breast Surgeon Experience in LYMPHA at Time of ALND for Treatment of Clinical T1-4N1-3M0 Breast Cancer

Immediate lymphatic reconstruction: Lessons learned over eight years

Immediate lymphatic reconstruction (ILR) is recognized as a surgical approach used to reduce the risk of developing secondary lymphedema, and evidence demonstrating the efficacy of ILR is favorable. Our Lymphatic Center has become a centralized location offering ILR for the risk-reduction in breast cancer-related lymphedema (BCRL) in New England. Over the course of our experience, we made several modifications and adapted our approach to enhance the operative success of this procedure. These include advancements in our use of indocyanine green (ICG) imaging to identify baseline lymphatic anatomical variation, utilization of fluorescein isothiocyanate for lymphatic vessel visualization, application of the lymphosome concept to guide arm injection sites, verification of anastomotic patency (using ICG), localization of reconstruction to guide radiation therapy, incorporation of intraoperative tools to facilitate better anatomic visualization of the axilla, and addition of a lower extremity vein graft to mitigate venous-related complications. Collecting information from each surgery in a standardized manner, including intraoperative lymphatic channel measurements, and deploying clips for possible future radiation exposure, enables future studies on ILR patient outcomes. In this contribution, we aimed to share our institutional modifications with the surgical community to facilitate further adoption, conversation, and advancement of ILR for the risk-reduction in BCRL.

[Oncological Rehabilitation for Breast Cancer]

As a result of increasingly individualized and multimodal therapy, prognosis of breast cancer has improved significantly over the last years. However, multimodal treatment and the use of new medications can lead to a variety of somatic, sometimes new, side effects such as fatigue, polyneuropathy or autoimmune toxicities. This and the oncological diagnosis lead to a high level of psychological distress in the women affected and often to subsequent psychological disorders (sleep/anxiety disorders, depression, ...). Both the diverse complaints after oncological therapy and the increasingly improved overall prognosis underline the importance of multimodal rehabilitation concepts to improve quality of life and successful professional reintegration.In the following, these secondary disorders after breast cancer, their multimodal therapy and their significance for social-medical performance assessment are presented in more detail.

United States insurance coverage of immediate lymphatic reconstruction

INTRODUCTION

Immediate Lymphatic Reconstruction (ILR) is a prophylactic microsurgical lymphovenous bypass technique developed to prevent breast cancer related lymphedema (BCRL). We investigated current coverage policies for ILR among the top insurance providers in the United States and compared it to our institutional experience with obtaining coverage for ILR.

METHODS

The study analyzed the publicly available ILR coverage statements for American insurers with the largest market share and enrollment per state to assess coverage status. Institutional ILR coverage was retrospectively analyzed using deidentified claims data and categorizing denials based on payer reason codes.

RESULTS

Of the 63 insurance companies queried, 42.9% did not have any publicly available policies regarding ILR coverage. Of the companies with a public policy, 75.0% deny coverage for ILR. In our institutional experience, $170,071.80 was charged for ILR and $166 118.99 (97.7%) was denied by insurance.

CONCLUSIONS

Over half of America's major insurance providers currently deny coverage for ILR, which is consistent with our institutional experience. Randomized trials to evaluate the efficacy of ILR are underway and focus should be shifted towards sharing high level evidence to increase insurance coverage for BCRL prevention.

Demystifying vascularized lymph node transfers and lymphatico-venous anastomoses

Lymphedema continues to be a widely prevalent condition with no definitive cure. It affects a wide range of patients across different ages and backgrounds. The significant burden of this chronic and debilitating condition necessitates more research and comprehensive healthcare coverage for affected patients. In developed countries, cancer survivors are disproportionality affected by this condition. Risk factors including lymph node dissections and radiation render many cancer patients more susceptible to the development of lymphedema. Part of the challenge with lymphedema care, is that it exits on a broad spectrum with significant variability of symptoms. Advances and broader availability of various imaging modalities continue to foster progress in lymphedema surgery. The conservative management of lymphedema remains the primary initial management option. However, lymphedema surgeries can provide significant hope and may pave the way for significant improvements in the quality-of-life for many patients afflicted by this progressive and enfeebling condition. Reductive and physiologic procedures are becoming an important part of the armamentarium of the modern plastic and reconstructive surgeon. Recent advances in physiologic lymphedema surgeries are accelerating their transition from experimental surgeries to broadly adopted and widely accepted procedures that can lead to major successes in the fight against this condition. Prophylactic lymphedema surgery also presents a promising choice for many patients and can help prevent lymphedema development in high-risk patients.

Prevention of Breast Cancer-Related Lymphedema: An Up-to-Date Systematic Review of Different Surgical Approaches

Breast cancer-related lymphedema (BCRL) affects approximately 20% of women after breast cancer therapy. Advances in treatment have increased the life expectancy; thus, the prevalence of BCRL will continue to rise with the number of cancer survivors, hence the need to develop strategies to prevent this condition. We provide a systematic review of the literature on the primary prevention of BCRL by prophylactic lymphatic surgery (PLS). Between June and August 2022, we conducted a search of PubMed, Google Scholar and Cochrane. In the end, a total of eighteen papers were selected. The eleven studies without a control group reported only 15 of 342 patients who developed lymphedema at least six months after PLS (4.59%). The seven studies with a control group included 569 patients, 328 cases and 241 controls. Among the cases, 36 (10%) developed lymphedema. In contrast, the incidence of lymphedema in the controls was 40% (98 of 241 patients). The formulation of definite recommendations in favor of PLS is hindered by low-quality studies. There is no consensus on which technique should be preferred, nor on whether adjuvant radiotherapy might affect the efficacy of PLS. Randomized controlled trials are mandatory to conceive evidence-based recommendations.

Risk factors for long-term arm morbidities following breast cancer treatments: A systematic review

PURPOSE

To examine the risk factors for arm morbidity following breast cancer treatments, taking a broad view of all types of physical morbidity, including prolonged pain, lymphedema, decreased range of motion, and functional limitations.

METHODS

A systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Studies exploring the risk factors for prolonged arm morbidity following breast cancer surgery and treatments were included. The studies were assessed independently according to pre-eligibility criteria, following data extraction and methodological quality assessment.

RESULTS

1,242 articles were identified. After removing duplicates, the full texts of 1,153 articles were examined. Sixty-nine of these articles met the criteria and were included in the review. These 69 articles identified 29 risk factors for arm morbidity following treatments for breast cancer. The risk of bias was evaluated using NIH study quality assessment tools. The studies reviewed were published between 2001 and 2021 and included a total of 22,886 patients who were followed up for between three months and 10 years.

CONCLUSIONS

The main risk factors for long-term morbidity are removal of lymph nodes from the axilla, body mass index >30, having undergone a mastectomy, the stage of the disease, radiation therapy, chemotherapy, infection and trauma to the affected arm after surgery. An understanding of the risk factors for prolonged arm morbidity after surgery can help doctors and therapists in making personalized decisions about the need and timing of rehabilitation treatments.

The effect of immediate lymphatic reconstruction on the post-operative drain output after axillary lymph node dissection for breast cancer: A retrospective comparative study

INTRODUCTION

Axillary lymph node dissection (ALND) for breast cancer has been considered to be associated with a variety of complications, such as excessive postoperative wound drainage, prolonged drain placement, or seroma formation in the short term, or arm lymphedema in the long run. Immediate lymphedema reconstruction (ILR) has been proposed to reduce the occurrence of arm lymphedema by anastomosing the transected arm lymphatics to nearby branches of the axillary vein immediately after ALND. This study aims to demonstrate that ILR can also reduce the postoperative drainage amount.

PATIENTS AND METHODS

Between April 2020 and January 2022, a total of 76 breast cancer patients receiving ALND were reviewed. Forty four of them also received ILR immediately after ALND. The assignment of ILR surgery was non-random, based on patients' willingness and plastic surgeons' availability. The lymphatic vessels in the axillary wound were anastomosed with nearby terminal branches of the axillary vein under surgical microscope. Patients' characteristics, including age, body mass index (BMI), neoadjuvant therapy, type of breast surgery, the occurrence of seroma formation, number of removed lymph nodes, number of positive nodes, and the drainage amount from the operative wounds were compared between ILR and non-ILR groups.

RESULTS

No statistically significant difference was noted between groups in terms of age (56.5 ± 9.8 vs. 60.9 ± 10.7, p = .09), BMI (22.6 ± 3.7 vs. 23.7 ± 3.8, p = .27), type of breast surgery (p = .32), the occurrence of seroma formation (p = 1.0), the likelihood of receiving neoadjuvant therapy (p = .12), number of lymph nodes removed (17.5 ± 7.6 vs. 17.4 ± 8.3, p = .96), or number of positive nodes on final pathology (3.7 ± 5.4 vs. 4.8 ± 8.5, p = .53) except the ILR group had statistically significantly less drainage amount than non-ILR group (39.3 ± 2.6 vs. 48.3 ± 3.7, p = .046).

CONCLUSION

For breast cancer patients receiving ALND, the immediate lymphatic reconstruction can reduce the postoperative drainage amount from the operative wound.

Distally Prophylactic Lymphaticovenular Anastomoses after Axillary or Inguinal Complete Lymph Node Dissection Followed by Radiotherapy: A Case Series

Background and Objectives: Lymphedema is an important and underestimated condition, and this progressive chronic disease has serious implications on patients’ quality of life. The main goal of research would be to prevent lymphedema, instead of curing it. Patients receiving radiotherapy after lymph node dissection have a significantly higher risk of developing lymphedema. Through the prophylactic use of microsurgical lymphaticovenular anastomoses in selected patients, we could prevent the development of lymphedema. Materials and Methods: Six patients who underwent prophylactic lymphaticovenular anastomoses in a distal site to the axillary or groin region after axillary or inguinal complete lymph node dissection followed by radiotherapy were analyzed. Patients characteristics, comorbidities, operative details, postoperative complications and follow-up assessments were recorded. Results: Neither early nor late generic surgical complications were reported. We observed no lymphedema development throughout the post-surgical follow-up. In particular, we observed no increase in limb diameter measured at 1, 3, 6 and 12 months postoperatively. Conclusion: In our experience, performing LVA after axillary or groin lymphadenectomy and after adjuvant radiotherapy, and distally to the irradiated area, allows us to ensure the long-term patency of anastomoses in order to obtain the best results in terms of reducing the risk of iatrogenic lymphedema. This preliminary report is encouraging, and the adoption of our approach should be considered in selected patients.