Lymphatic mapping and lymphedema surgery in the breast cancer patient

Current and Developing Lymphatic Imaging Approaches for Elucidation of Functional Mechanisms and Disease Progression

Study of the lymphatic system, compared to that of the other body systems, has been historically neglected. While scientists and clinicians have, in recent decades, gained a better appreciation of the functionality of the lymphatics as well as their role in associated diseases (and consequently investigated these topics further in their experimental work), there is still much left to be understood of the lymphatic system. In this review article, we discuss the role lymphatic imaging techniques have played in this recent series of advancements and how new imaging techniques can help bolster this wave of discovery. We specifically highlight the use of lymphatic imaging techniques in understanding the fundamental anatomy and physiology of the lymphatic system; investigating the development of lymphatic vasculature (using techniques such as intravital microscopy); diagnosing, staging, and treating lymphedema and cancer; and its role in other disease states.

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.

The effect of the combined use of complex decongestive therapy with electrotherapy modalities for the treatment of breast cancer-related lymphedema: a randomized clinical trial

Background

We evaluated the effects of combined complex decongestive therapy (CDT) with electrotherapy modalities (ultrasound and faradic currents) in patients with breast cancer-related lymphedema (BCRL), investigating upper extremity circumference, volume, pain, and functional disability.

Methods

Thirty-nine patients with unilateral BCRL were randomly allocated to three groups (n = 13) as the following: The control group received CDT, the ultrasound group received CDT and therapeutic ultrasound, and the faradic group received CDT and faradic current. All the participants underwent treatment for 10 sessions. The outcomes including volume, circumference (measured at five points), pain intensity, and functional disability of the affected upper extremity were evaluated at baseline and after the treatment.

Results

Following the treatment, an improvement was noted in lymphedema volume, pain, and functional disability in all the three groups and there was a significant difference between the groups (P < 0.05). However, changes in limb circumference at the end of the treatment were not significantly different among the three groups in any sites (P > 0.05).

Conclusion

The combination of electrotherapy modalities, faradic current or ultrasound, with CDT can result in a greater reduction in lymphedema volume, pain, and functional disability in patients with BCRL.

Trial registration

IRCT, IRCT201310292391N14, registered 03/01/2016.

The relationship between lymphedema severity and awareness of lymphedema surgery

BACKGROUND

During the early stages of lymphedema, active physiologic surgical treatment can be applied. However, lymphedema patients often have limited knowledge and misconceptions regarding lymphedema and surgical treatment. We analyzed the correlations between lymphedema severity and surgical technique according to patients' awareness of surgical treatment for secondary upper extremity lymphedema (UEL).

METHODS

Patients with UEL diagnosed between December 2017 and December 2019 were retrospectively evaluated. At the time of their presentation to our hospital for the treatment of lymphedema, they were administered a questionnaire about lymphedema and lymphedema surgery. Based on the results, patients were classified as being aware or unaware of surgical treatment. Lymphedema severity was classified according to the arm dermal backflow (ADB) stage and the MD Anderson Cancer Center (MDACC) stage based on indocyanine green lymphography conducted at presentation. Surgical techniques were compared between the two groups.

RESULTS

Patients who were aware of surgical treatment had significantly lower initial ADB and MDACC stages (P<0.05) and more frequently underwent physiologic procedures than excisional procedures (P=0.003).

CONCLUSIONS

If patients are actively educated regarding surgical treatment of lymphedema, physiologic procedures may be performed during the early stages of UEL.

Is bioimpedance spectroscopy a useful tool for objectively assessing lymphovenous bypass surgical outcomes in breast cancer-related lymphedema?

PURPOSE

We sought to determine if bioimpedance spectroscopy (BIS) measurements can accurately assess changes in breast cancer-related lymphedema (BCRL) in patients undergoing lymphovenous bypass (LVB).

METHODS

Patients undergoing LVB for BCRL refractory to conservative treatment from 1/2015 to 12/2018 were identified from an IRB-approved prospectively maintained database at a single institution. All breast cancer patients were assessed with baseline BIS measurements prior to any oncologic surgery and serial BIS during follow-up office visits including before and after LVB. Clinicopathologic information, LVB operative details, and pre- and post-LVB operative BIS measurements were collected. Analysis focused on clinically significant BIS change, defined as two standard deviations (SD), and comparing LVB anastomosis to BIS changes.

RESULTS

During the study timeframe, nine patients underwent LVB for treatment of BCRL. The majority (78%) received radiation, taxane chemotherapy, and underwent axillary dissection. An average of 5.6 LVB anastomoses were performed per patient. The average change in BIS following LVB was a 3SD reduction, indicating a clinically significant change. This improvement was stable over time, with persistent 2SD reduction at 22 months postoperatively. The number of LVB anastomoses performed did not significantly correlate with the degree of BIS change.

CONCLUSIONS

This is the first study to utilize BIS measurements to assess response to LVB surgical intervention for BCRL. BIS measurements demonstrated clinically significant improvement after LVB, providing objective evidence in support of this surgical treatment for BCRL. BIS changes should be reported as key objective data in future studies assessing BCRL interventions, including response to LVB.

Technical Challenges in "Micro" Lymph Node Identification during Vascularized Submental Lymph Node Flap Harvesting

Background:

The outcome of autologous lymph node (LN) transfer has depended on the number of LNs in the donor site. Unknown accuracy of the LN counting method has thrown some doubts on the reliability of the previous statistics. This study aimed to assess the accuracy of naked eye (NK) and stereo microscopy (SM) as tools for LN count.

Methods:

In total, 40 vascularized submental LN flaps were harvested from 23 fresh cadavers. The colored polymer was injected into the external carotid arteries before the harvest. LNs in each flap were counted by NK, SM, and histology in sequential order.

Results:

An estimated 175 LNs were confirmed, 4.4 ± 1.8 per flap. NK sensitivity was 33.7% compared with that of SM at 63.5%. Both methods missed all micro-lymph nodes (micro-LNs), contributing to 5.1% (9 nodes) of all LNs. Non-LN structures (647 negative counts) were composed of fat lobules, salivary gland lobules, and muscle fibers. NK specificity was 98.0%, compared with that of SM at 96.1%. SM showed a higher false positive rate at 14.3%, compared with NK at 7.4%. False positive counts were located mostly in Ib sublevel.

Conclusions:

NK and SM are imperfect tools for LN count due to poor sensitivity. If the method needs to be applied, points of considerations are (1) undetectable micro-LNs, (2) interposition of LNs with the digastric muscle and submandibular salivary gland, (3) confusion of LNs with lobules of salivary gland supplied by glandular artery or fat lobules supplied by lobular artery.

Effects of the Traditional Chinese Medical Prescription Linba Fang as a Treatment for Lymphedema

Lymphedema can lead to a series of complicated and irreversible chronic pathological changes, including lymphatic fluid retention, infiltration of inflammatory cells, lipid deposition, and fibrosis of the surrounding tissues. Typically, compression physiotherapy is recommended for early lymphedema. However, the chronic fluid compartments will lead to fat deposition, skin fibrosis, and hyperkeratosis. Few treatment methods are available for patients with lymphedema. Previous studies have attempted to apply diuretics, diosmin, and sodium β-aescinate to treatment for venous edema, but the curative effect was unsatisfactory. There is currently no established effective treatment for lymphedema. In this paper, we investigated the effects of the traditional Chinese medical prescription Linba Fang as a treatment for lymphedema using a mouse model. A lymphedema model was established in C57BL/6 mice through lymphatic ablation at the base of tails. Negative controls were administered with 0.5% sodium carboxymethyl cellulose solution by gavage twice daily, positive controls with aescuvenforte, and test mice with Linba Fang. Aescuvenforte and Linba Fang were dissolved in 0.5% sodium carboxymethyl cellulose solution to produce a homogeneous mixture. After treatment for 2-4 weeks, tail diameter and weight, inflammatory cytokine levels (IL-1, IL-6, and TNF-α), lipid deposition, and fibrosis were evaluated. The results showed that none of the mice died during the treatment with Linba Fang. The levels of tail swelling, inflammation, lipid deposition, and fibrosis in mice treated with Linba Fang were significantly decreased compared with negative and positive controls. Among mice treated with the same dose of Linba Fang, the levels of tail swelling, inflammation, lipid deposition, and fibrosis in mice treated for 4 weeks were significantly lower than those treated for 2 weeks. Among mice treated for the same duration of time, the levels of tail swelling, inflammation, lipid deposition, and fibrosis showed a decreasing tendency following increasing doses. Notably, the inflammation in tail tissues decreased to the similar level of normal group after treatment for 4 weeks using the high dose of Linba Fang. In conclusion, the traditional Chinese medical prescription Linba Fang could inhibit the pathological changes caused by lymphedema, including swelling, inflammation, lipid deposition, and fibrosis.

Effectiveness and Safety of Acupuncture Moxibustion Therapy Used in Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis

Objective

To evaluate the effectiveness and safety of acupuncture moxibustion therapy (AMT) for the breast cancer-related lymphedema (BCRL).

Methods

Four English databases (MEDLINE, PubMed, Embase, and Cochrane CENTRAL) and four Chinese databases were searched from their inception to Feb 1, 2020. Eligible randomized controlled trials (RCTs) investigating AMT against any type of controlled intervention in patients for BCRL and assessing clinically relevant outcomes (total effective rate, circumference difference, and Karnofsky performance score) were included. The methodological quality of all selected trials was estimated in accordance with the guidelines published by the Cochrane Collaboration. Review Manager 5.3 was used to conduct analyses.

Results

Twelve eligible RCTs are confirmed. Most of the trials selected are regarded as low methodological quality. Compared with Western medicine, physiotherapy, and functional training, traditional AMT has significantly higher treatment effect (RR 1.03 (95% CI: 1.22, 1.45); p < 0.00001). In comparison with physiotherapy, AMT is better in reducing edema symptoms (MD = −0.77; 95% CI (−1.13–0.41); p < 0.00001). Moreover, pooled results demonstrate that AMT results in better outcomes than functional training and Western medicine in improving Karnofsky performance score of BCRL patients (SMD = 0.69; 95% CI (0.38–1.00); p < 0.00001).

Conclusion

This systematic review and meta-analysis provides evidence that AMT is serviceable and safe in treating BCRL. With the limited number of available studies and methodology drawbacks, further high-quality RCTs with reasonable designs are still warranted.

Lymph node transfer combined with deep inferior epigastric perforators and transverse rectus abdominis myocutaneous procedures: a systematic review

The surgical treatment of lymphedema can be conducted alone or in combination with microsurgical autologous breast reconstruction. We performed a systematic review of the literature at PubMed database regarding autologous breast reconstruction for deep inferior epigastric perforators (DIEP) or muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) and vascularized lymph node transfer (VLNT) in patients with lymphedema following breast cancer surgery. We hypothesized that autologous breast reconstruction combined with VLNT has positive outcomes. Eligibility criteria included investigations reporting data studies evaluating female patients with lymphedema in an upper extremity after breast cancer who underwent autologous breast reconstruction combined with VLNT. The search resulted in 93 potential papers, but only 6 studies fulfilled the study eligibility criteria. The total number of patients was 103. Most of the studies evaluated the outcomes in patients treated with DIEP or ms-TRAM combined with VLNT. The studies described groin lymph node transfer as treatment for lymphedema. In most of the studies, all patients reported a reduction of arm circumference, volume, and symptoms of the upper extremity with lymphedema comparing the preoperative to the postoperative period. Overall, patients experienced successful breast reconstruction. All authors reported reduction of the circumferential size of the affected upper limb, as well as a decrease in cellulitis, in addition to favorable breast reconstruction results.

Omental Lymph Node Transfer for Lymphedema Patients: A Systematic Review

Lymph node transfer is a surgical treatment that is becoming more prevalent. The lymph nodes from the groin and neck are most frequently used. Iatrogenic lymphedema can be a consequence of the dissection of the groin nodes; thus, some surgeons prefer to use the neck as a donor site. Literature reporting surgical algorithms for the treatment of lymphedema is scarce. Thus, we conducted a systematic review of vascularized omentum lymph node transfer (VOLT) in patients with lymphedema to provide more information about this increasingly common procedure. We hypothesize that the analyzed studies will show that VOLT has positive outcomes. Two reviewers (G.J.C., D.B.) performed independent searches using the PubMed database without timeframe limitations initially through title and abstract descriptions and then by full-text review. The search was done using the following keywords: Breast cancer lymphedema OR lymphedema AND lymph node transfer OR lymph node flap OR lymph node graft AND omental OR omentum OR gastroepiploic. Eligibility criteria included publications evaluating patients with lymphedema in the upper extremity and lower extremity, who underwent VOLT. Our search yielded 35 potential papers in the literature, but only six studies fulfilled the study eligibility criteria. The total number of patients was 137. Three studies described single VOLT, two studies described double VOLT and one study described two cohort patients, one that was treated with single VOLT and another one that was treated with double VOLT. Postoperative reduction of arm circumference, arm volume, and symptoms of the upper extremity were reported in all patients. Nonetheless, in one study, seven patients did not notice any extremity circumference reduction during the follow-up period and four patients noticed an increase in arm volume. Flap loss was reported by two authors in a total of two patients. Overall, patients experienced successful lymphedema treatment with VOLT. All authors presented results with reduced circumferential size of the affected upper and lower limbs, as well as reduction of the infectious intercurrences, such as cellulitis, with a small incidence of associated complications.

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.

Complex Therapy Physical alone or Associated with Strengthening Exercises in Patients with Lymphedema after Breast Cancer Treatment: a Controlled Clinical Trial

Objective:

To compare a complex physical therapy (CPT) protocol alone or combined with complex physical therapy muscle more strength training (CPT+ST) in patients with lymphedema after breast cancer treatment regarding strength and limb muscle volume.

Methods:

In this controlled clinical trial, consecutive patients treated from breast cancer from April 2014 to December 2015 were allocated in two groups, the CPT group 1 and the CPT+ST group 2, that performed CPT associated with muscle strengthening. Patients in the CPT group 1 received the routine protocol of care, consisting of manual lymphatic drainage (MLD), multilayer bandage compression therapy, skin care and regular exercises. Patients CPT+ST performed, 2 sets of 10 repetitions exercises at 40% of maximal voluntary contraction the first week, increasing to 3 sets with 10 repetitions during the second and third weeks, 3 sets with 15 repetitions, for 8 weeks, 50 minutes per session, twice per week. Strength and muscle volume were analyzed.

Result:

In the study period, 42 patients were enrolled, 22 in the CPT group 1 and 20 in the CPT+ST group 2. Only 36 completed treatment. Both groups showed similar increases in the range of movement in: shoulder flexion, extension, adduction, abduction and external rotation. Internal rotation showed less improvement in CPT+ST group 2 (p = 0,034). Strength improvement was similar between groups. The CPT+ST group 2 seemed to have a greater volume in the upper limb when compared to CPT group 1, but it was not possible to prove any significant difference (p = 0.555).

Conclusion:

There was no difference of muscular limb volume between the two interventions. This means that strengthening exercises can be performed by patients with lymphedema safely, without the risk of increasing upper limb volume with edema.

Supermicrosurgery: History, Applications, Training and the Future

Supermicrosurgery, a technique of dissection and anastomosis of small vessels ranging from 0.3 to 0.8 mm, has revolutionized the fields of lymphedema treatment and soft tissue reconstruction. The technique offers several distinct benefits to microsurgeons, including the ability to manipulate small vessels that were previously inaccessible, and to minimize donor-site morbidity by dissecting short pedicles in a suprafascial plane. Thus, supermicrosurgery has become increasingly popular in recent years, and its applications have greatly expanded since it was first introduced 20 years ago. While supermicrosurgery was originally developed for procedures involving salvage of the digit tip, the technique is now routinely used in a wide variety of microsurgical cases, including lymphovenous anastomoses, vascularized lymph node transfers and perforator-to-perforator anastomoses. With continued experimentation, standardization of supermicrosurgical training, and high quality studies focusing on the outcomes of these novel procedures, supermicrosurgery can become a routine and valuable component of every microsurgeon's practice.

New diagnostic modalities in the evaluation of lymphedema

OBJECTIVE

Currently, lymphedema (LED) is typically diagnosed clinically on the basis of a patient's history and characteristic physical findings. Whereas the diagnosis of LED is sometimes confirmed by lymphoscintigraphy (LSG), the technique is limited in both its ability to identify disease and to guide therapy. Recent advancements provide opportunities for new imaging techniques not only to assist in the diagnosis of LED, based on anatomic changes, but also to assess contractile function and to guide therapeutic intervention. The purpose of this contribution was to review these imaging techniques.

METHODS

Literature for each technique is reviewed and discussed, and the evidence for each of these new diagnostic techniques was assessed on several criteria to determine if each could (1) establish whether disease is present, (2) determine the severity of the disease process, (3) define the pathophysiologic mechanism of the disease process, (4) demonstrate whether intervention is possible as well as what type, and (5) objectively grade the response to therapy.

RESULTS

LSG is currently the standard test to confirm LED. Duplex ultrasound (DUS) is a simple, readily available noninvasive test that can identify LED by specific tissue characteristics as well as the response to therapy. Magnetic resonance imaging and computed tomography scans similarly demonstrate the alterations in epidermal and subcutaneous tissue, but the latter can also detect obstructing neoplasms as a cause of secondary LED. Moreover, magnetic resonance lymphangiography details lymphatic vessels and nodes and their function. Newer fluorescence imaging techniques provide opportunities to image lymphatic anatomy and function. Visible microlymphangiography by fluorescein sodium is limited by tissue light absorption to imaging depths of 200 μm. Near-infrared fluorescence lymphatic imaging, a newer test using intradermal injection of indocyanine green, can penetrate several centimeters of tissue and can visualize the initial and conducting lymphatics, the lymph node basins, and the active function of lymphangions (the key module) in exquisite detail.

CONCLUSIONS

The availability and the noninvasive nature of DUS should make this modality the first choice for establishing the diagnosis of LED based on tissue changes. Further studies comparing DUS with LSG, however, are needed. The costs of magnetic resonance imaging and computed tomography limit their adoption as a means to regularly assess the lymphatics. Whereas lymphatic truncal anatomy and transit times can be delineated by the older technique of LSG, near-infrared fluorescence lymphatic imaging is rapid, highly sensitive, and repeatable and provides exquisite detail for lymphatic vessel anatomy and function of the lymphangions as well as the response to therapy.

[What physiotherapeutic method for the treatment of post-mastectomy lymphedema is the most effective?]

We have undertaken the search for the publications of interest in the following databases: Scopus, Web of Science, MedLine, The Cochrane Library, CyberLeninka, and Russian science citation index. In addition, we evaluated the effectiveness of the physical agents and procedures having different mechanisms of action of the known factors responsible for the development of post-mastectomy lymphedema. Such agents and procedures include self-massage, manual lymphatic drainage, therapeutic physical exercises, compression bandaging, wearing elastic compression garments, Kinesio Tex taping, pneumatic compression, ultrasonic, electrostatic, extracorporeal shock wave therapy, electrical muscle stimulation, microcurrent and low-intensity laser therapy. These methods and products were used by the authors of selected publications either separately or in the combined modes taking into consideration the significant differences between effects of the application of individual techniques. The results of the treatment are presented for different time periods, either in absolute units (cm or ml) in the majority of the cases or in relative units (%) only in part of them without information concerning the statistical significance of the results obtained. There is thus far neither the universal classification of post-mastectomy lymphedema nor the generally accepted approaches to its diagnostics and treatment. Therefore, it is impossible to give an unambiguous answer as regards the effectiveness of one or another method for the diagnostics and treatment of this condition. The author of the present article observed 172 patients at the age of 56.8±9.7 years suffering from late grade I-IV lymphedema treated with the use of local low-intensity low-frequency electric and magnetic therapy in the combination with pneumatic compression applied during 15 days. The results of the treatment were evaluated using water and impedance plethysmography. Within 4 weeks after the onset of therapy, the volume of the upper limb decreased on the average for all stages of lymphedema by 37.7±9.3% under effect of pneumatic compression alone, by 49.5±10.7% under the influence of its combination with electrotherapy, by 59.9±5.4% under the action of the combination of pneumatic compression with magnetotherapy, and by 76.3±7.3% after the application of all the three techniques together (p<0.05). Electrical neurostimulation of the blood vessels and skeletal muscles proved especially effective for the treatment of I-II grade lymphedema while magnetic therapy was most efficient for the management of grade III-IV lymphedema. The proposed method of combined physiotherapy looks very encouraging for the treatment of late lymphedema but does not completely solve all problems pertaining to the management of this pathological condition.

The Lymphatic System: Integral Roles in Immunity

The lymphatic vasculature is not considered a formal part of the immune system, but it is critical to immunity. One of its major roles is in the coordination of the trafficking of antigen and immune cells. However, other roles in immunity are emerging. Lymphatic endothelial cells, for example, directly present antigen or express factors that greatly influence the local environment. We cover these topics herein and discuss how other properties of the lymphatic vasculature, such as mechanisms of lymphatic contraction (which immunologists traditionally do not take into account), are nonetheless integral in the immune system. Much is yet unknown, and this nascent subject is ripe for exploration. We argue that to consider the impact of lymphatic biology in any given immunological interaction is a key step toward integrating immunology with organ physiology and ultimately many complex pathologies.

Advances in fluorescent-image guided surgery

Fluorescence imaging is increasingly gaining intraoperative applications. Here, we highlight a few recent advances in the surgical use of fluorescent probes.