Improving quality of life after breast cancer: a comparison of two microsurgical treatment options for breast cancer-related lymphedema (BCRL)

PURPOSE

Vascularized lymph node transfer (VLNT) entails the autologous relocation of lymph nodes to a lymphedematous region of the body, whereas lymphaticovenous anastomosis (LVA) creates a direct bypass between the lymphatic and venous system. Both techniques are meant to lastingly bolster the local lymphatic drainage capacity. This study compared safety and effectiveness of VLNT and LVA in patients with chronic breast cancer related lymphedema (BCRL).

METHODS

A retrospective cohort study was conducted using data from our encrypted database composed of patients with chronic BCRL who were treated with either VLNT or LVA and had a minimum follow-up of two years. Patient-specific variables analyzed included pre- and postoperative arm circumferences, lymphedema stages and postoperative complications.

RESULTS

A total of 105 patients met the inclusion criteria, of which 96 patients demonstrated a complete follow-up period of two years. The VLNT group displayed larger preoperative circumferential measurements, evident in both in the isolated examination of the affected arm, as well as when adjusted for the contralateral unaffected arm. Significant reduction in arm volume was achieved by both groups. However, VLNT demonstrated superior relative reduction rates than LVA, neutralizing any significant arm size disparities after 24 months. Surgery duration was slightly longer for VLNT than LVA. Postoperative complications, predominantly minor, were exclusively observed in the VLNT group.

CONCLUSIONS

Both VLNT and LVA offer significant improvement for patients suffering from chronic BCRL. VLNT shows an even greater potential for improvement in more severe cases of BCRL, but involves a higher risk for (mostly minor) complications.

Retroauricular lymph node flap: An anatomic and surgical feasibility study

BACKGROUND

The study investigated the anatomy of the retroauricular lymph node (LN) flap and evaluate its surgical feasibility as a new donor site for a free LN flap in lymphedema surgery.

METHODS

Twelve adult cadavers were examined. The course and perfusion of the anterior auricular artery (AAA) and the location and sizes of the retroauricular LNs were studied.

RESULTS

The AAA was available in 87% and absent in 13% specimens. The AAA's origin had a mean vertical distance of 12.2 ± 6.9 mm and a mean horizontal distance of 19.1 ± 4.2 mm from the superior attachment of the ear. The mean diameter of the AAA was 0.8 ± 0.2 mm. The mean number of LN per region was 7.7 ± 2.3, with an average LN size of 4.1 ± 1.9 × 3.2 ± 1.7 mm. The LN were categorized into anterior (G1) and posterior (G2) groups, with a total of 59 and 10 LN, respectively. In a cluster analysis, three LN clusters could be detected across the anterior group (G1).

CONCLUSIONS

The retroauricular LN flap is a delicate but feasible flap with reliable anatomy, containing a mean of 7.7 LNs.

3D color doppler ultrasound for postoperative monitoring of vascularized lymph node flaps

BACKGROUND

Vascularized lymph node transfer (VLNT) is a relatively well-established microsurgical treatment for lymphedema that is especially beneficial for advanced cases in which lymphovenous anastomosis is not indicated due to lymphatic vessel sclerosis. When VLNT is performed without a skin paddle, such as a buried flap, the possibilities for postoperative monitoring are limited. The aim of our study was to evaluate the use of ultra-high-frequency color Doppler ultrasound with 3D reconstruction in a pedicled axillary lymph node flap.

METHODS

Flaps were elevated in 15 Wistar rats based on the lateral thoracic vessels. We preserved the axillary vessels to maintain the rats' mobility and comfort. The rats were divided into three groups as follows: Group A, arterial ischemia; group B, venous occlusion; and group C, healthy.

RESULTS

Ultrasound and color Doppler scan images revealed clear information on flap morphology changes and pathology if it was present. Surprisingly, we detected venous flow in group A rats, supporting the pump theory and venous lymph node flap concept.

CONCLUSION

We conclude that 3D color Doppler ultrasound is an effective method for monitoring buried lymph node flaps. 3D reconstruction makes it easier to visualize the flap anatomy and detect pathology if it is present. Moreover, the learning curve for the technique is short. Our setup is user-friendly even in the inexperienced hands of a surgical resident, and images can be reevaluated at any time if necessary. The use of 3D reconstruction removes the complications associated with observer-dependent monitoring of VLNT.

Combining reconstructive and ablative surgical treatment of chronic breast cancer-related lymphedema (BCRL): safe and effective

PURPOSE

We investigated whether a one-stage combination of vascularized lymph node transfer (VLNT) with water jet-assisted liposuction (WAL) can be safely performed and results in improved patient outcomes such as a greater reduction in arm volume when treating chronic breast cancer-related lymphedema (BCRL).

METHODS

In this retrospective cohort study, we included all patients from our encrypted lymphedema database treated for chronic BCRL with VLNT or VLNT + WAL who had a minimum follow-up of two years. We analyzed patient-specific variables including arm circumferences as well as patient-reported outcomes before and after surgery as well as surgery time, surgery-related complications and patient satisfaction.

RESULTS

Only the mean preoperative differences of the circumferences between the lymphedematous and the unaffected arm in individual patients showed a statistically significant difference between treatment groups (p < 0.05). Indeed, patients treated with VLNT + WAL had consistently larger differences in individual sets of arms and therefore more pronounced chronic BCRL. The mean surgery time was significantly longer in the VLNT + WAL group (p < 0.05). Complications were seldom and similar in both groups. Using a numeric rating scale, the level of patient satisfaction following treatment did not differ significantly between groups (p = 0.323).

CONCLUSIONS

Our findings suggest that a one-stage combination of VLNT with WAL does not result in more complications even though it also entails a longer surgery time. This is acceptable as secondary interventions resulting in overall longer surgery times and higher costs can be avoided. A one-stage combination might be especially favourable for patients suffering from more severe chronic BCRL.

Approach to Lymphedema Management

Millions of people worldwide suffer from lymphedema. In developed nations, lymphedema most commonly stems secondarily from oncologic treatment, but may also result from trauma. More recently, lymphedema has been identified in patients after gender-affirmation phalloplasty reconstruction. Regardless of the etiology, the underlying pathophysiology involves blockage of lymphatic flow, resulting in lymph stasis, thus triggering a cascade of inflammation culminating in fibrosis and adipose deposition. Recent technical advances led to the refinement of physiologic and reductive surgeries-including lymphovenous anastomosis and free functional lymphatic transfer, which collectively encompass a variety of flap procedures including lymph node transfer, lymph channel transfer, and lymphatic system transfer. This article provides a summary of our approach in the assessment and management of the lymphedema patient, including detailed intraoperative photography and imaging, in addition to advanced technical considerations in physiologic reconstruction.

Distal facial vein catheterization for prevention and management of thrombosis in vascularized lymph node transfers

BACKGROUND

This study investigated the outcomes of the distal facial vein catheterization (DFVC) to manage venous thrombosis in vascularized submental lymph nodes (VSLN) flap transplantations.

METHODS

Between March 2017 and December 2020, patients who underwent VSLN flaps were divided into Group I: combined delayed primary retention sutures (DPRS) with DFVC, and Group II: DPRS alone. Primary outcomes were early (within 72 h) and late venous thrombosis. Secondary outcomes included other nonvascular complications and mechanical factors of the thrombosis.

RESULTS

A total of 105 patients who underwent 106 VSLN flaps, including 37 and 69 flaps in Groups I and II, respectively, were included. There were no statistically significant differences in age, body mass index, Taiwan lymphoscintigraphy staging, and surgical factors between the two groups (all p > 0.05). Early venous thrombosis requiring re-exploration developed in one (2.7%) and three (4.3%) flaps in Groups I and II, respectively (p = 0.20). One flap (2.7%) and eight (11.5%) flaps developed late venous thrombosis in Groups I and II, respectively (p < 0.01). There was no statistically significant difference in total complication rates between both groups (p = 0.9).

CONCLUSION

VSLN flap transplantation had a significantly higher risk of late venous thrombosis. DFVC significantly decreased the late venous thrombosis.

From Bench to Bedside: The Role of a Multidisciplinary Approach to Treating Patients with Lymphedema

Background: Lymphedema is a condition characterized by dysfunction of the lymphatic system resulting in chronic, progressive soft tissue edema that can negatively impact individuals' function, self-image, and quality of life. Understanding of the disease process has evolved significantly in the past two decades with advances in diagnostic modalities and surgical techniques revolutionizing prior treatment algorithms. Methods and Results: We reviewed our current approach at the University of Southern California to improving outcomes in lymphedema treatment. Given the complexity of this medical condition, patients are best served by a multidisciplinary approach. At our institution, this involves a collaborative effort between bench researchers, lymphatic therapists, medical physicians, and lymphedema surgeons. Basic science and translational research provide further understanding into the underlying mechanisms of lymphangiogenesis and the possibility for potential therapeutic interventions. Our surgical algorithms require patients to undergo a thorough diagnostic evaluation and consultation with certified lymphatic therapists prior to undergoing either physiologic or debulking operations. Patients are followed clinically following any interventions. Further community outreach and education is carried out in order to improve upon early diagnosis and symptom recognition. Conclusions: Optimizing lymphedema care requires a collaborative interplay between researchers, physicians, and therapists. Additionally, patient and provider education on early disease recognition and treatment options is an equally critical aspect of improving patient outcomes.

Submental flap for vascularized lymph node transfer; a CTA-based study on lymph node distribution

Background

Amongst various options of vascularized lymph node transfers, the submental flap has the lowest risk for iatrogenic lymphedema. The aim of this study was to gain insight into distribution, number, and size of lymph nodes along the mandible using computed tomography angiography (CTA).

Methods

A total of 52 CTA scans of head/neck region were evaluated retrospectively. Lymph nodes in the submental and submandibular region, related to the origin of the submental artery, were recorded using a three‐dimensional coordinate system, and standardized using an iterative closest point algorithm. Results were analyzed for gender, location, size, and number.

Results

The mean number and size of lymph nodes were 5.30 ± 2.00 and 5.28 ± 1.29 mm, respectively. The mean distance of the lymph nodes to the origin of the submental artery was 25.53 ± 15.27 mm. There was no significant difference between both sides when comparing size (left: 5.39 ± 1.28; right: 5.17 ± 1.34; P = .19), number (left: 5.46 ± 2.10; right: 5.17 ± 1.96; P = .49), and distance (left: 24.78 ± 12.23; right: 26.32 ± 14.73; P = .19). No significance was found between males and females concerning number (P = .60), size (P = .50), and distance (P = .06).

Conclusion

The variance of lymph node distribution along the mandible may warrant conducting a CTA scan to maximize the number of transferred lymph nodes and aid in flap design.

Mesoappendix as potential donor site for vascularized lymph node transfer: anatomic study

BACKGROUND

The standard of care for treatment of lymphedema is manual lymphatic drainage and compression therapy, which is time intensive and requires a life-long commitment. Autologous lymph node transfer is a microsurgical treatment in which a vascularized lymph node flap is harvested with its blood supply and transferred to the lymphedematous region to assist with lymph fluid clearance. An ideal donor lymph node site minimizes the risk of iatrogenic lymphedema and other donor site morbidity. To address this, we have used jejunal mesentery lymph nodes and omental flaps and hypothesize that the mesoappendix, as a "spare part," may be an ideal autologous lymph node transfer donor site.

METHODS

In this Institutional Review Board-approved study, 25 mesoappendix pathology specimens resected for benign disease underwent gross pathologic examination for the presence of lymph nodes and measurement of the appendicular artery and vein caliber and length.

RESULTS

A single lymph node was present in two of 25 specimens (8%). Mean arterial and vein calibers at the point of ligation were 0.87 ± 0.44 mm and 0.86 ± 0.48 mm (range 0.30-2.2 mm and 0.25-2.2 mm), respectively. Mean arterial and vein length was 1.70 ± 1.06 cm and 1.84 ± 1.09 cm (range 0.8-4.5 cm for each), respectively.

CONCLUSIONS

The mesoappendix rarely contains a lymph node. The artery and vein calibers of 46% of the specimens were greater than 0.8 mm, the minimum caliber preferred for microsurgical anastomosis. If transplantation of a vascularized lymph node for the treatment of lymphedema is desired, the mesoappendix is inconsistent in providing adequate lymph nodes.