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Luzardo González A, Planas Balagué R, Gómez Cuba M, Fernández Mariscal E, Arencibia Domínguez A, Salinas Huertas S. [Rehabilitation in lymphedema surgery]. Rehabilitacion (Madr) 2022; 56:215-225. [PMID: 35527077 DOI: 10.1016/j.rh.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/29/2021] [Accepted: 12/11/2021] [Indexed: 01/25/2023]
Abstract
Conservative treatment of lymphedema usually includes complex decongestive therapy in order to reduce the volume of the lymphedema, and compression garments in the maintenance phase. Follow-up is carried out in the Rehabilitation Services. Surgical treatment of lymphedema is a therapeutic option, the interest of which has increased in recent years, although there is no current evidence that it can cure lymphedema and it is always accompanied by conservative treatment. Most studies focus on results according to the type of surgery and there is no standardized protocol for conservative treatment before or after surgery. The objective of this work is to prepare a compendium about the most frequent lymphedema surgeries and their indications, focusing on the rehabilitation treatment for each surgery.
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Affiliation(s)
- A Luzardo González
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España.
| | - R Planas Balagué
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España; Universitat de Barcelona, Barcelona, España
| | - M Gómez Cuba
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España; Universitat de Barcelona, Barcelona, España
| | - E Fernández Mariscal
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - A Arencibia Domínguez
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - S Salinas Huertas
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
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Reverse Lymphatic Mapping and Immediate Microsurgical Lymphatic Reconstruction Reduces Early Risk of Breast Cancer-Related Lymphedema. Plast Reconstr Surg 2022; 149:1061-1069. [PMID: 35255010 DOI: 10.1097/prs.0000000000008986] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Breast cancer-related lymphedema is a progressive disease that poses tremendous physical, psychosocial, and financial burden on patients. Immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection is emerging as a potential therapeutic paradigm to decrease the incidence of breast cancer-related lymphedema in high-risk patients. METHODS Eighty-one consecutive patients underwent reverse lymphatic mapping and, when feasible, supermicrosurgical immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection at a tertiary care cancer center. Patients were followed prospectively in a multidisciplinary lymphedema clinic (plastic surgery, certified lymphatic therapy, dietary, case management) at 3-month intervals with clinical examination, circumferential limb girth measurements, and bioimpedance spectroscopy. An institutional control cohort was assessed for the presence of objectively diagnosed and treated breast cancer-related lymphedema. Data were analyzed by a university statistician. RESULTS Seventy-eight patients met inclusion, and 66 underwent immediate lymphaticovenular anastomosis. Mean follow-up was 250 days. When compared to a retrospective control group, the rate of lymphedema in patients who underwent immediate lymphaticovenular anastomosis was significantly lower (6 percent versus 44 percent; p < 0.0001). Patients with 6-month follow-up treated with combined adjuvant radiation therapy and chemotherapy had significantly greater risk of developing breast cancer-related lymphedema (p = 0.04) compared to those without combined adjuvant therapy. Arborized anastomotic technique had a statistically shorter operative time than end-to-end anastomosis (p = 0.005). CONCLUSIONS This series of consecutive patients demonstrate a 6 percent incidence of early-onset breast cancer-related lymphedema with immediate lymphaticovenular anastomosis and an increased risk in those undergoing combined adjuvant treatment. These early data represent an encouraging and substantial decrease of breast cancer-related lymphedema in high-risk patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Chang EI. Optimizing Treatment of Breast Cancer Related Lymphedema Using Combined DIEP Flap and Lymphedema Surgery. Arch Plast Surg 2022; 49:150-157. [PMID: 35832680 PMCID: PMC9045539 DOI: 10.1055/s-0042-1744414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Patients undergoing treatment for breast cancer who undergo an axillary dissection and require adjuvant therapies such as radiation and chemotherapy are at high risk of developing lymphedema of the associated extremity. Historically, patients with lymphedema were treated with ablative procedures aimed simply to remove excess fluid and adiposity; however, the field of lymphatic surgery employing super-microsurgery techniques has witnessed tremendous advances in a relatively short period of time. Advancements in surgical instruments, microscope magnification and optics, imaging technology, and surgeon experience have ushered in a new era of hope to treat patients suffering from breast cancer–related lymphedema (BCRL). Here we aim to present the available options for patients suffering from BCRL, and the pinnacle in reconstruction and restoration for these patients.
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Affiliation(s)
- Edward I. Chang
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
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Evaluation of Simplified Lymphatic Microsurgical Preventing Healing Approach (SLYMPHA) for the prevention of breast cancer-related lymphedema after axillary lymph node dissection using bioimpedance spectroscopy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1713-1717. [DOI: 10.1016/j.ejso.2022.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 04/13/2022] [Accepted: 04/27/2022] [Indexed: 01/19/2023]
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Corridi M, Kim L, McGrath L, Mehrara B, Dayan J. Immediate lymphatic reconstruction: Outcomes of a single-institution pilot study. J Plast Reconstr Aesthet Surg 2022; 75:1261-1282. [PMID: 35094952 PMCID: PMC8992546 DOI: 10.1016/j.bjps.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 11/30/2021] [Accepted: 01/09/2022] [Indexed: 10/19/2022]
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Chiang SN, Skolnick GB, Westman AM, Sacks JM, Christensen JM. National Outcomes of Prophylactic Lymphovenous Bypass during Axillary Lymph Node Dissection. J Reconstr Microsurg 2022; 38:613-620. [PMID: 35158396 DOI: 10.1055/s-0042-1742730] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Breast cancer treatment, including axillary lymph node excision, radiation, and chemotherapy, can cause upper extremity lymphedema, increasing morbidity and health care costs. Institutions increasingly perform prophylactic lymphovenous bypass (LVB) at the time of axillary lymph node dissection (ALND) to reduce the risk of lymphedema but reports of complications are lacking. We examine records from the American College of Surgeons (ACS) National Surgery Quality Improvement Program (NSQIP) database to examine the safety of these procedures. METHODS Procedures involving ALND from 2013 to 2019 were extracted from the NSQIP database. Patients who simultaneously underwent procedures with the Current Procedural Terminology (CPT) codes 38999 (other procedures of the lymphatic system), 35201 (repair of blood vessel), or 38308 (lymphangiotomy) formed the prophylactic LVB group. Patients in the LVB and non-LVB groups were compared for differences in demographics and 30-day postoperative complications including unplanned reoperation, deep vein thrombosis (DVT), wound dehiscence, and surgical site infection. Subgroup analysis was performed, controlling for extent of breast surgery and reconstruction. Multivariate logistic regression was performed to identify predictors of reoperation. RESULTS The ALND without LVB group contained 45,057 patients, and the ALND with LVB group contained 255 (0.6%). Overall, the LVB group was associated with increased operative time (288 vs. 147 minutes, p < 0.001) and length of stay (1.7 vs. 1.3 days, p < 0.001). In patients with concurrent mastectomy without immediate reconstruction, the LVB group had a higher rate of DVTs (3.0 vs. 0.2%, p = 0.009). Reoperation, wound infection, and dehiscence rates did not differ across subgroups. Multivariate logistic regression showed that LVB was not a predictor of reoperations. CONCLUSION Prophylactic LVB at time of ALND is a generally safe and well-tolerated procedure and is not associated with increased reoperations or wound complications. Although only four patients in the LVB group had DVTs, this was a significantly higher rate than in the non-LVB group and warrants further investigation.
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Affiliation(s)
- Sarah N Chiang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gary B Skolnick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Amanda M Westman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joani M Christensen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Ciudad P, Escandón JM, Bustos VP, Manrique OJ, Kaciulyte J. Primary Prevention of Cancer-Related Lymphedema Using Preventive Lymphatic Surgery: Systematic Review and Meta-analysis. Indian J Plast Surg 2022; 55:18-25. [PMID: 35444756 PMCID: PMC9015841 DOI: 10.1055/s-0041-1740085] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Several studies have proven prophylactic lymphovenous anastomosis (LVA) performed after lymphadenectomy can potentially reduce the risk of cancer-related lymphedema (CRL) without compromising the oncological treatment. We present a systematic review of the current evidence on the primary prevention of CRL using preventive lymphatic surgery (PLS). Patients and Methods A comprehensive search across PubMed, Cochrane-EBMR, Web of Science, Ovid Medline (R) and in-process, SCOPUS, and ScienceDirect was performed through December 2020. A meta-analysis with a random-effect method was accomplished. Results Twenty-four studies including 1547 patients fulfilled the inclusion criteria. Overall, 830 prophylactic LVA procedures were performed after oncological treatment, of which 61 developed lymphedema. The pooled cumulative rate of upper extremity lymphedema after axillary lymph node dissection (ALND) and PLS was 5.15% (95% CI, 2.9%-7.5%; p < 0.01). The pooled cumulative rate of lower extremity lymphedema after oncological surgical treatment and PLS was 6.66% (95% CI < 1-13.4%, p-value = 0.5). Pooled analysis showed that PLS reduced the incidence of upper and lower limb lymphedema after lymph node dissection by 18.7 per 100 patients treated (risk difference [RD] - 18.7%, 95% CI - 29.5% to - 7.9%; p < 0.001) and by 30.3 per 100 patients treated (RD - 30.3%, 95% CI - 46.5% to - 14%; p < 0.001), respectively, versus no prophylactic lymphatic reconstruction. Conclusions Low-quality studies and a high risk of bias halt the formulating of strong recommendations in favor of PLS, despite preliminary reports theoretically indicating that the inclusion of PLS may significantly decrease the incidence of CRL.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
- Academic Department of Surgery. School of Medicine Hipolito Unanue. Federico Villarreal National University, Lima, Perú
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, United States
| | - Valeria P. Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, United States
| | - Juste Kaciulyte
- Department of Surgery “P.Valdoni,” Unit of Plastic and Reconstructive Surgery, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
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Zaveri S, Romanoff A, Hirt L, Thompson L, Pisapati KV, Weltz C, Schmidt H, Port E. Choice of Mastectomy May Increase the Extent of Axillary Surgery in Women with Breast Cancer. Am Surg 2022; 88:2686-2694. [PMID: 35081002 DOI: 10.1177/00031348221074236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Based on the ACOSOG Z0011 trial, women who undergo breast conservation therapy (BCT) and have limited disease in the axilla on sentinel lymph node (SLN) biopsy do not require axillary lymph node dissection (ALND). In this study we investigate the incidence of ALND in patients undergoing elective mastectomy with limited disease in the axilla to identify how many women may have been spared additional axillary surgery if they chose BCT. METHODS All women with invasive breast cancer treated at a single tertiary care breast center from 2010-2018 who were candidates for BCT but elected mastectomy and underwent SLN biopsy were identified through retrospective review of a prospectively maintained database. The primary outcome of interest was the incidence of ALND in women found to have a limited burden of disease in the axilla (1-2 positive SLNs). RESULTS The study population comprised 151 patients with invasive breast cancer eligible for BCT who chose mastectomy. On final pathology, 34 patients had 1-2 positive SLNs, and 16 of these patients underwent completion ALND. These 16 patients out of 151 overall lumpectomy candidates electing mastectomy (10.6%) could have been spared ALND if they did not elect mastectomy. DISCUSSION BCT candidates electing mastectomy have a 10.6% chance of undergoing more extensive axillary surgery than would have been recommended with BCT alone. The increased risk of undergoing additional axillary surgery should be incorporated into the preoperative discussion for patients choosing between BCT and mastectomy.
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Affiliation(s)
- Shruti Zaveri
- Department of Surgery, 5925Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - Anya Romanoff
- Department of Global Health and Health System Design, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Leeza Hirt
- 5925Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - Lauren Thompson
- Breast Surgery, Dubin Breast Center, 5925Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - Kereeti V Pisapati
- Breast Surgery, Dubin Breast Center, 5925Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - Christina Weltz
- Breast Surgery, Dubin Breast Center, 5925Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - Hank Schmidt
- Breast Surgery, Dubin Breast Center, 5925Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - Elisa Port
- Breast Surgery, Dubin Breast Center, 5925Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
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Shah J, Zhao R, Yi J, Otterburn D, Patel A, Szpalski C, Tanna N, Taub PJ, Weichman KE, Ricci JA. Novel Quantification of Real-Time Lymphatic Clearance: Immediate Lymphatic Reconstruction in a Large-Animal Model. Plast Reconstr Surg 2022; 149:130-141. [PMID: 34936612 PMCID: PMC8691163 DOI: 10.1097/prs.0000000000008631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 05/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The real-time quantification of lymphatic flow remains elusive. Efforts to provide a metric of direct lymphatic function are not clinically translatable and lack reproducibility. Early reports demonstrate the promise of immediate lymphatic reconstruction (immediate lymphovenous bypass after lymphadenectomy) to reduce the risk of lymphedema development. However, there remains a heightened need to appraise this technique in a clinically translatable large-animal model. The aim of the authors' experiment was to evaluate the role of molecular imaging in the quantification of real-time lymphatic flow after lymphadenectomy, and lymphadenectomy with lymphovenous bypass using novel fluorophores in a swine model. METHODS A lymphadenectomy or lymphadenectomy with subsequent lymphovenous bypass was performed in 10 female swine. After subdermal fluorophore injection, near-infrared molecular imaging of blood samples was used to evaluate change in lymphatic flow after lymphadenectomy versus after lymphadenectomy with lymphovenous bypass. Continuous imaging evaluating fluorescence of the superficial epigastric vein in the torso and adjacent skin was performed throughout all experiments. Findings between modalities were correlated. RESULTS The near-infrared dye signal in central and peripheral blood samples was often difficult to separate from background and proved challenging for reliable quantification. Venous and skin near-infrared imaging demonstrated a lymphatic clearance rate decrease of 70 percent after lymphadenectomy versus a decrease by only 30 percent after lymphadenectomy with immediate lymphovenous bypass. CONCLUSIONS In this article, the authors describe a noninvasive, swine, large-animal model to quantify lymphatic clearance using skin imaging. The authors' findings were consistent with results yielded from real-time imaging of the vein. The authors believe this model may have important implications for eventual direct translation to the clinical setting.
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Affiliation(s)
- Jinesh Shah
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Ruya Zhao
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Joseph Yi
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - David Otterburn
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Ashit Patel
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Caroline Szpalski
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Neil Tanna
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Peter J. Taub
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Katie E. Weichman
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Joseph A. Ricci
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
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Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for Lymphedema Prevention after Axillary Lymph Node Dissection—A Single Institution Experience and Feasibility of Technique. J Clin Med 2021; 11:jcm11010092. [PMID: 35011833 PMCID: PMC8745451 DOI: 10.3390/jcm11010092] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022] Open
Abstract
While surgical options exist to treat lymphedema after axillary lymph node dissection (ALND), the lymphatic microsurgical preventive healing approach (LYMPHA) has been introduced as a preventive measure performed during the primary surgery, thus avoiding the morbidity associated with lymphedema. Here, we highlight details of our operative technique and review postoperative outcomes. For our patients, limb measurements and body composition analyses were performed pre- and postoperatively. Intraoperatively, axillary reverse lymphatic mapping was performed with indocyanine green (ICG) and lymphazurin. SPY-PHI imaging was used to visualize the ICG uptake into axillary lymphatics. Cut lymphatics from excised nodes were preserved for lymphaticovenous anastomosis (LVA). At the completion of the microanastomosis, ICG was visualized draining from the lymphatic through the recipient vein. A retrospective review identified nineteen patients who underwent complete or partial mastectomy with ALND and subsequent LYMPHA over 19 months. The number of LVAs performed per patient ranged between 1–4 per axilla. The operating time ranged from 32–95 min. There were no surgical complications, and thus far one patient developed mild lymphedema with an average follow up of 10 months. At the clinic follow up, ICG and SPY angiography were used to confirm intact lymphatic conduits with an uptake of ICG across the axilla. This study supports LYMPHA as a feasible and effective method for lymphedema prevention.
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Wagner JM, Dadras M, Ufton D, Huber J, Wallner C, Sogorski A, von Glinski M, Hong JP, Lehnhardt M, Behr B. Prophylactic lymphaticovenous anastomoses for resection of soft tissue tumors of the thigh to prevent secondary lymphedema-a retrospective comparative cohort analysis. Microsurgery 2021; 42:239-245. [PMID: 34951055 DOI: 10.1002/micr.30850] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 10/04/2021] [Accepted: 12/08/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients with soft tissue tumors of extremities are at risk to develop secondary lymphedema after tumor resection caused by disruption of lymphatic vessels and sclerosis. Subsequently, this study aimed to evaluate the beneficial effects of lymphaticovenous anastomoses (LVAs) after soft tissue tumor resection of the thigh in a prophylactic approach. METHODS In a retrospective cohort study, we compared eight patients with a median age of 68.5 years (49-80) who received LVAs in combination with tumor resection for treatment of soft tissue tumors of the thigh region with a prior cohort of 20 patients with a median age of 63.0 years (23-84) who received soft tissue sarcoma resection of the thigh region. All patients of LVA cohort received 1-2 LVAs (mean 1.25 ± 0.49) at the dorsum of the foot and three patients at the SEKI-point (mean 0.375 ± 0.51). Mean maximum tumor diameter of LVA group was 19.5 ± 5.2 cm and 12.3 ± 6.6 cm of control group. All patients receiving LVA were assessed for development of lymphedema via bilateral measurements of circumference and assessment of lymphedema quality of life index (LyQLI). RESULTS One of the eight patients who received LVAs showed moderate impairment in the LyQLI at a follow-up of 12 months while 45% of the control cohort complained about symptoms of secondary lymphedema at a median follow-up of 22 months (p-values LyQLI: p = .018 [physical domain]; p = .018 [psychosocial domain]; p = .020 [practical domain]). CONCLUSION LVAs performed in combination with tumor resection of thigh soft tissue tumors reduce negative consequences of lymph stasis and prevent development of secondary lymphedema.
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Affiliation(s)
- Johannes Maximilian Wagner
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Mehran Dadras
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Dominic Ufton
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Julika Huber
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Christoph Wallner
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Alexander Sogorski
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Maxi von Glinski
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Marcus Lehnhardt
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Björn Behr
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
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Chun MJ, Saeg F, Meade A, Kumar T, Toraih EA, Chaffin AE, Homsy C. Immediate Lymphatic Reconstruction for Prevention of Secondary Lymphedema: A Meta-Analysis. J Plast Reconstr Aesthet Surg 2021; 75:1130-1141. [PMID: 34955392 DOI: 10.1016/j.bjps.2021.11.094] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 11/06/2021] [Accepted: 11/14/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Secondary lymphedema remains one of the most notorious complications of axillary and pelvic lymph node surgery following mastectomy. There is a lack of high-level evidence found on the effectiveness of immediate lymphatic reconstruction (ILR) in preventing secondary lymphedema. This meta-analysis evaluates the outcomes of ILR for prevention of secondary lymphedema in patients undergoing different surgeries, and provides suggestions for lymphatic microsurgical preventive healing approach (LYMPHA). METHODS A review of PubMed, Embase, and Web of Science was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. All English-language studies published from January 1, 2009 to June 1, 2020 were included. We excluded non-ILR interventions, literature reviews/letters/commentaries, and nonhuman or cadaver studies. A total of 789 patients that were enrolled in 13 studies were included in our one-arm meta-analysis. RESULTS A total of 13 studies (n=789) met inclusion criteria: upper extremity ILR (n=665) and lower extremity ILR (n=124). The overall incidence of lymphedema for upper extremity ILR was 2.7% (95%CI: 1.1%-4.4%) and lower extremity ILR was 3.6% (95%CI: 0.3%-10.1%). For upper extremity ILR, the average follow-up time was 11.6 ± 7.8 months and the LE incidence appeared to be the highest approximately 1 to 2 years postoperation. CONCLUSIONS Lymphedema is a common complication in cancer treatment. ILR, especially LYMPHA, may be an effective technique to facilitate lymphatic drainage at the time of the index procedure but future studies will be required to show its short-term efficacy and long-term outcomes.
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Affiliation(s)
- Magnus J Chun
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, LA, 70112
| | - Fouad Saeg
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, LA, 70112
| | - Anna Meade
- Department of Plastic Surgery, University of Texas-Southwestern, Dallas, TX, 75390
| | - Taruni Kumar
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, LA, 70112
| | - Eman A Toraih
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, 70112; Department of Histology and Cell Biology, Genetics Unit, Faculty of Medicine, Suez Canal University, Ismailia, 41522, Egypt
| | - Abigail E Chaffin
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, LA, 70112
| | - Christopher Homsy
- Division of Plastic and Reconstructive Surgery, Tufts Medical Center, Boston, MA, 02111.
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Abstract
An estimated 250 million people worldwide suffer from lymphedema. In the past, the firstline option for treatment was nonsurgical management, either in the form of compression garments or wrapping, or comprehensive decongestive therapy, with debulking surgery reserved for the more advanced cases. However, with improvements in microsurgical techniques and imaging modalities, surgical intervention is increasingly being utilized. This review highlights recent advancements in the surgical treatment of lymphedema, specifically focusing on improvements in imaging, surgical techniques, and prevention of lymphedema.
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64
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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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Scaglioni MF, Meroni M, Fritsche E, Fuchs B. The use of pedicled chimeric superficial circumflex iliac artery perforator (SCIP) flap as lymphatic interpositional flap for deep thigh defect reconstruction: A case report. Microsurgery 2021; 42:360-365. [PMID: 34626139 DOI: 10.1002/micr.30823] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/23/2021] [Accepted: 09/28/2021] [Indexed: 11/06/2022]
Abstract
The tumors affecting the thigh region are complex to manage, requiring a patient-tailored and multidisciplinary approach. Because of their aggressiveness, soft tissue sarcomas (STS) often grow very quickly and they must be removed before they might cause major impairments. A safe margin excision may lead to large defects that require a surgical reconstruction with either free or pedicled flaps. Another relevant aspect, which is gaining more and more attention in the last few years, regards the lymphatic complications that commonly occur after these procedures. The thigh region anatomically accommodates the major lymphatics responsible for the whole leg drainage, and these vessels are often inevitably compromised during the tumor removal. For this reason, plastic surgeons should take into account not only to the aesthetic and functional result, but they should also try to prevent lymphatic sequelae such as lymphocele and lymphedema. The purpose of this report is to describe the potential of a pedicled SCIP flap, used as a lymphatic interpositional flap, in order to restore the lymphatic drainage of the thigh after a major impairment. A 57-year-old patient presenting a thigh sarcoma received a surgical excision leaving a 35 cm × 25 cm defect affecting the anterior compartment. To fulfill all these concerns, a lymphatic interpositional SCIP flap was performed, in pedicled and chimeric fashion. It allowed to completely bury a large (35 cm × 16 cm) soft tissue island, preserving a smaller (5 cm × 4 cm) skin paddle to monitor the whole flap survival. Moreover, the lymphatic issue was faced by preserving the lymphatic vessels running into the flap and moving them into the affected area in order to enhance the lymphatic neo-angiogenesis and offering an additional pattern for lymph drainage. Post-operative course was uneventful and at 9 months follow up the reconstructive result was successful with no signs of lymphatic sequelae. Therefore, we believe that the SCIP flap might be a promising solution for small-to-moderate size thigh defect reconstructions since it is able to satisfy all the typical requirements of this delicate region.
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Affiliation(s)
- Mario F Scaglioni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matteo Meroni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Bruno Fuchs
- Department of Orthopedic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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Immediate Lymphovenous Bypass Treated Donor Site Lymphedema during Phalloplasty for Gender Dysphoria. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3822. [PMID: 34549009 PMCID: PMC8448062 DOI: 10.1097/gox.0000000000003822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 07/28/2021] [Indexed: 12/04/2022]
Abstract
Demand for gender-affirming phalloplasty continues to grow worldwide, and the extended radial forearm flap phalloplasty remains one of the most commonly performed techniques. One potential morbidity that has emerged is postoperative donor site lymphedema, which was susceptible to develop after harvest of extended radial forearm flap. In the setting of preventative or immediate lymphovenous bypass (LVB) with axillary lymph node dissection for the treatment of breast cancer, it is possible that a subset of patients undergoing gender-affirmation surgery would benefit from immediate lymphatic reconstruction at the time of primary phalloplasty. Here, we report a case in which intraoperative indocyanine green lymphography demonstrated lymphatic obstruction within the left donor hand after flap harvest, and was treated with immediate LVB at the time of extended radial forearm phalloplasty. Two surgical teams operated simultaneously: the reconstructive urology team performed the vaginectomy, perineal urethral lengthening, scrotoplasty, and perineal reconstruction; and the microsurgery team harvested the extended radial forearm, constructed the penile urethra, shaped the phallus, and performed the immediate LVB. Lymphography showed no dermal backflow at 5 months follow-up; at 13 months, the patient demonstrated no signs or symptoms of lymphedema in the left forearm or hand. To the authors’ best knowledge, this is the first report of confirmed donor site lymphedema following extended radial forearm flap harvest, which was successfully treated with immediate LVB. Careful evaluation of lymphatic vessels with indocyanine green lymphography in the forearm before and after extended flap harvest may be warranted.
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Al-Hilli Z, Wilkerson A. Breast Surgery: Management of Postoperative Complications Following Operations for Breast Cancer. Surg Clin North Am 2021; 101:845-863. [PMID: 34537147 DOI: 10.1016/j.suc.2021.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Breast cancer surgery is associated with low rates of surgical morbidity. Postoperative complications related to breast surgery include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, persistent postsurgical pain, Mondor disease, fat necrosis, reduced tactile sensation after mastectomy, and venous thromboembolism. Postoperative complications related to axillary surgery include seroma, infection, lymphedema, nerve injury, and reduced shoulder/arm mobility. The overall rate of complication related to axilla surgery may be confounded by the type of breast surgery performed. The management of postoperative complications related to oncologic breast and axillary surgery independent of reconstruction is reviewed here.
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Affiliation(s)
- Zahraa Al-Hilli
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue /A80, Cleveland, OH 44195, USA.
| | - Avia Wilkerson
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue /A80, Cleveland, OH 44195, USA
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Mailey BA, Alrahawan G, Brown A, Yamamoto M, Hassanein AH. Sentinel Lymph Node Biopsy, Lymph Node Dissection, and Lymphedema Management Options in Melanoma. Clin Plast Surg 2021; 48:607-616. [PMID: 34503721 DOI: 10.1016/j.cps.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Melanoma tumor thickness and ulceration are the strongest predictors of nodal spread. The recommendations for sentinel lymph node biopsy (SLNB) have been updated in recent American Joint Committee on Cancer and National Comprehensive Cancer Network guidelines to include tumor thickness ≥0.8 mm or any ulcerated melanoma. Mitotic rate is no longer considered an indicator for determining T category. Improvements in disease-specific survival conferred from SLNB were demonstrated through level I data in the Multicenter Selective Lymphadenectomy Trial (MSLT) I. The role for completion lymph node dissection has evolved to less surgery in lieu of recent domestic (MSLT II) and international (Dermatologic Cooperative Oncology Group Selective Lymphadenectomy Trial [DeCOG-SLT]) level I data having similar melanoma-specific survival. Treatment options for the prevention of treatment of lymphedema have progressed to include immediate lymphatic reconstruction, lymphovenous anastomosis, and vascularized lymph node transfer.
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Affiliation(s)
- Brian A Mailey
- Brachial Plexus and Tetraplegia Clinic, Institute for Plastic Surgery, Southern Illinois University School of Medicine, 747 N. Rutledge Street, PO Box 19653, Springfield, IL 62794, USA.
| | - Ghaith Alrahawan
- University of Missouri Columbia, School of Medicine, 1 Hospital Dr, Columbia, MO 65212, USA
| | - Amanda Brown
- Southern Illinois University, School of Medicine, 747 N. Rutledge Street, PO Box 19653, Springfield, IL 62794, USA
| | - Maki Yamamoto
- Division of Surgical Oncology, Department of Surgery, University of California, Irvine, 333 City Blvd West, Suite 1600, Orange, CA 92868, USA
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Suite 232, Indianapolis, IN 46202, USA
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Herremans KM, Cribbin MP, Riner AN, Neal DW, Hollen TL, Clevenger P, Munoz D, Blewett S, Giap F, Okunieff PG, Mendenhall NP, Bradley JA, Mendenhall WM, Mailhot-Vega RB, Brooks E, Daily KC, Heldermon CD, Marshall JK, Hanna MW, Leyngold MM, Virk SS, Shaw CM, Spiguel LR. Five-Year Breast Surgeon Experience in LYMPHA at Time of ALND for Treatment of Clinical T1-4N1-3M0 Breast Cancer. Ann Surg Oncol 2021; 28:5775-5787. [PMID: 34365563 DOI: 10.1245/s10434-021-10551-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/20/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Breast cancer-related lymphedema (BCRL) is a source of postoperative morbidity for breast cancer survivors. Lymphatic microsurgical preventive healing approach (LYMPHA) is a technique used to prevent BCRL at the time of axillary lymph node dissection (ALND). We report the 5-year experience of a breast surgeon trained in LYMPHA and investigate the outcomes of patients who underwent LYMPHA following ALND for treatment of cT1-4N1-3M0 breast cancer. METHODS A retrospective review of patients with cT1-4N1-3M0 breast cancer was performed in patients who underwent ALND with and without LYMPHA. Diagnosis of BCRL was made by certified lymphedema therapists. Descriptive statistics and lymphedema surveillance data were analyzed using results of Fisher's exact or Wilcoxon rank-sum tests. Logistic regression and propensity matching were performed to assess the reduction of BCRL occurrence following LYMPHA. RESULTS In a 5-year period, 132 patients met inclusion criteria with 76 patients undergoing LYMPHA at the time of ALND and 56 patients undergoing ALND alone. Patients who underwent LYMPHA at the time of ALND were significantly less likely to develop BCRL than those who underwent ALND alone (p = 0.045). Risk factors associated with BCRL development were increased patient age (p = 0.007), body mass index (BMI) (p = 0.003), and, in patients undergoing LYMPHA, number of positive nodes (p = 0.026). CONCLUSIONS LYMPHA may be successfully employed by breast surgeons trained in lymphatic-venous anastomosis at the time of ALND. While research efforts should continue to focus on prevention and surveillance of BCRL, LYMPHA remains an option to reduce BCRL and improve patient quality of life.
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Affiliation(s)
- Kelly M Herremans
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Morgan P Cribbin
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Andrea N Riner
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Dan W Neal
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Tracy L Hollen
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Pamela Clevenger
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Derly Munoz
- Department of Physical Therapy, University of Florida College of Public Health and Health Professions, Gainesville, FL, USA
| | - Shannon Blewett
- Department of Physical Therapy, University of Florida College of Public Health and Health Professions, Gainesville, FL, USA
| | - Fantine Giap
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Paul G Okunieff
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Raymond B Mailhot-Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Eric Brooks
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Karen C Daily
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Coy D Heldermon
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Julia K Marshall
- Department of Radiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Mariam W Hanna
- Department of Radiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Mark M Leyngold
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Sarah S Virk
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christiana M Shaw
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Lisa R Spiguel
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.
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Evaluating the Impact of Immediate Lymphatic Reconstruction for the Surgical Prevention of Lymphedema. Plast Reconstr Surg 2021; 147:373e-381e. [PMID: 33620920 DOI: 10.1097/prs.0000000000007636] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Breast cancer-related lymphedema affects one in five patients. Its risk is increased by axillary lymph node dissection and regional lymph node radiotherapy. The purpose of this study was to evaluate the impact of immediate lymphatic reconstruction or the lymphatic microsurgical preventative healing approach on postoperative lymphedema incidence. METHODS The authors performed a retrospective review of all patients referred for immediate lymphatic reconstruction at the authors' institution from September of 2016 through February of 2019. Patients with preoperative measurements and a minimum of 6 months' follow-up data were identified. Medical records were reviewed for demographics, cancer treatment data, intraoperative management, and lymphedema incidence. RESULTS A total of 97 women with unilateral node-positive breast cancer underwent axillary nodal surgery and attempt at immediate lymphatic reconstruction over the study period. Thirty-two patients underwent successful immediate lymphatic reconstruction with a mean patient age of 54 years and body mass index of 28 ± 6 kg/m2. The median number of lymph nodes removed was 14 and the median follow-up time was 11.4 months (range, 6.2 to 26.9 months). Eighty-eight percent of patients underwent adjuvant radiotherapy of which 93 percent received regional lymph node radiotherapy. Mean L-Dex change was 2.9 units and mean change in volumetry by circumferential measurements and perometry was -1.7 percent and 1.3 percent, respectively. At the end of the study period, we found an overall 3.1 percent rate of lymphedema. CONCLUSION Using multiple measurement modalities and strict follow-up guidelines, the authors' findings support that immediate lymphatic reconstruction at the time of axillary surgery is a promising, safe approach for lymphedema prevention in a high-risk patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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71
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DeSnyder SM, Yi M, Boccardo F, Feldman S, Klimberg VS, Smith M, Thiruchelvam PTR, McLaughlin S. American Society of Breast Surgeons' Practice Patterns for Patients at Risk and Affected by Breast Cancer-Related Lymphedema. Ann Surg Oncol 2021; 28:5742-5751. [PMID: 34333706 DOI: 10.1245/s10434-021-10494-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/01/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND In 2017, the American Society of Breast Surgeons (ASBrS) published expert panel recommendations for patients at risk for breast cancer-related lymphedema (BCRL) and those affected by BCRL. This study sought to determine BCRL practice patterns. METHODS A survey was sent to 2975 ASBrS members. Questions evaluated members' clinical practice type, practice duration, and familiarity with BCRL recommendations. Descriptive statistics, the chi-square test, and Fisher's exact test were used. RESULTS Of the ASBrS members surveyed, 390 (13.1%) responded. Most of the breast surgeons (58.5%, 228/390) indicated unfamiliarity with recommendations. Nearly all respondents (98.7%, 385/390) educate at-risk patients. Most (60.2%, 234/389) instruct patients to avoid venipuncture, injection or blood pressure measurements in the at-risk arm, and 35.6% (138/388) recommend prophylactic compression sleeve use during air travel. Nearly all (97.7%, 380/389) encourage those at-risk to exercise, including resistance exercise (86.2%, 331/384). Most do not perform axillary reverse mapping (ARM) (67.9%, 264/389) or a lymphatic preventive healing approach (LYMPHA) (84.9%, 331/390). Most (76.1%, 296/389) screen at-risk patients for BCRL. The most frequently used screening tools include self-reported symptoms (81%, 255/315), circumferential tape measure (54%, 170/315) and bioimpedance spectroscopy (27.3%, 86/315). After a BCRL diagnosis, most (90%, 351/390) refer management to a lymphedema-certified physical therapist. For affected patients, nearly all encourage exercise (98.7%, 384/389). Many (49%, 191/390) refer affected patients for consideration of lymphovenous bypass or lymph node transfer. CONCLUSION Most respondents were unfamiliar with the ASBrS expert panel recommendations for patients at risk for BCRL and those affected by BCRL. Opportunities exist to increase awareness of best practices and to acquire ARM and LYMPHA technical expertise.
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Affiliation(s)
- Sarah M DeSnyder
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Min Yi
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - V Suzanne Klimberg
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,The University of Texas Medical Branch, Galveston, TX, USA
| | - Mark Smith
- Northwell Health Cancer Institute, New Hyde Park, NY, USA
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Li Y, Xue D, Lu L, Chen X, Lu P, Ni Q. Analysis of the application value of internet home nursing in the prevention of lymphedema after breast cancer operation. Minerva Med 2021; 113:597-599. [PMID: 34236158 DOI: 10.23736/s0026-4806.21.07601-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Yiju Li
- Thyroid Breast Surgery, The Affiliated Hospital of Nantong University, Nantong, China
| | - Dandan Xue
- Thyroid Breast Surgery, The Affiliated Hospital of Nantong University, Nantong, China
| | - Lihua Lu
- Thyroid Breast Surgery, The Affiliated Hospital of Nantong University, Nantong, China
| | - Xiaofeng Chen
- Thyroid Breast Surgery, The Affiliated Hospital of Nantong University, Nantong, China
| | - Ping Lu
- Thyroid Breast Surgery, The Affiliated Hospital of Nantong University, Nantong, China
| | - Qichao Ni
- Thyroid Breast Surgery, The Affiliated Hospital of Nantong University, Nantong, China -
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Abstract
Lymphedema is a common, complex, and inexplicably underappreciated human disease. Despite a history of relative neglect by health care providers and by governmental health care agencies, the last decade has seen an explosive growth of insights into, and approaches to, the problem of human lymphedema. The current review highlights the significant advances that have occurred in the investigative and clinical approaches to lymphedema, particularly over the last decade. This review summarizes the progress that has been attained in the realms of genetics, lymphatic imaging, and lymphatic surgery. Newer molecular insights are explored, along with their relationship to future molecular therapeutics. Growing insights into the relationships among lymphedema, obesity, and other comorbidities are important to consider in current and future responses to patients with lymphedema.
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Affiliation(s)
- Stanley G Rockson
- Allan and Tina Neill Professor of Lymphatic Research and Medicine, Stanford University School of Medicine, Stanford, CA
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74
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A Novel Technique for Preventive Lymphovenous Anastomosis: Anastomosing a Ligated Lymphatic Vessel. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3509. [PMID: 33968557 PMCID: PMC8099411 DOI: 10.1097/gox.0000000000003509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/29/2021] [Indexed: 11/26/2022]
Abstract
Background: Lymphedema is defined as a chronic condition, caused by lymphostasis. A major part in the Western world consists of iatrogenic lymphedema caused by surgery to the lymph nodes of the axilla or groin. Prophylactic lymphovenous anastomosis (LVA) could be beneficial in the prevention of lymphedema of the extremities. These procedures require experienced supramicrosurgeons and can be time consuming, which might be the reasons why prophylactic LVA has not yet been widely implemented in the treatment of cancer. Due to the small diameter of lymphatic vessels, it remains challenging to identify the lumen, and therefore, anastomoses are prone to back wall stitching. Different inventive procedures have been described making use of stents or monofilament sutures. Methods: In this article, we describe a newly developed and straightforward technique for LVA in 4 patients who underwent an axilla dissection and 1 patient who underwent a dissection of the groin lymph nodes. This latter approach makes use of clipping of the lymphatic vessel during lymph node dissection, and remains ligated during anastomosis. The candidate vein was the V. thoracodorsalis for the axilla and the V. circumflexa superficialis for the groin. We describe the feasibility, average duration, and complications. Results: Performing an end-to-side anastomosis on a clipped lymphatic vessel minimizes the problem of back wall stitching as well as the trouble of finding the lumen due to collapsing of the vessel. The turgor of the lymphatic vessel is maintained and makes anastomosing easy. Average time for LVA was 33.4 minutes and 1 minor complication was seen. Conclusion: We believe that this approach might be of value in popularizing LVA in the treatment or prevention of different conditions such as breast cancer-related lymphedema.
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McEvoy MP, Ravetch E, Patel G, Fox J, Feldman S. Prevention of Breast Cancer-Related Lymphedema. Clin Breast Cancer 2021; 21:128-142. [PMID: 33771439 DOI: 10.1016/j.clbc.2021.02.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/25/2021] [Accepted: 02/20/2021] [Indexed: 01/15/2023]
Abstract
Tremendous progress has been made over the past several decades in the treatment of breast cancer. Mortality and recurrence rates continue to decline. Our ability to tailor patient- and tumor-specific treatments has rapidly advanced. The vast majority of our patients can safely have breast conservation. Unfortunately, for many patients, survivorship is burdened by ongoing quality-of-life issues. Most breast cancer patients are asymptomatic at presentation, and the onus is on us to preserve this. Surgery, radiation, and systemic therapy can result in long-term toxicities that can be amplified with multimodality approaches. We must strive to apply minimally effective therapies rather than a maximally tolerated approach. Breast cancer-related lymphedema (BCRL) is a particularly dreaded chronic complication. This review strives to give the reader a better understanding of BCRL and shed light on wisely choosing an integration of treatment modalities that minimizes BCRL risk. Key literature on emerging concepts is highlighted.
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Affiliation(s)
- Maureen P McEvoy
- Breast Surgery Division, Montefiore Einstein Center for Cancer Care, Bronx, NY.
| | - Ethan Ravetch
- Breast Surgery Division, Montefiore Einstein Center for Cancer Care, Bronx, NY
| | - Gunj Patel
- Breast Surgery Division, Montefiore Einstein Center for Cancer Care, Bronx, NY
| | - Jana Fox
- Breast Surgery Division, Montefiore Einstein Center for Cancer Care, Bronx, NY
| | - Sheldon Feldman
- Breast Surgery Division, Montefiore Einstein Center for Cancer Care, Bronx, NY
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76
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Chen K, Sinelnikov MY, Shchedrina MA, Mu L, Lu P. Surgical Management of Postmastectomy Lymphedema and Review of the Literature. Ann Plast Surg 2021; 86:S173-S176. [PMID: 33346539 DOI: 10.1097/sap.0000000000002642] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
ABSTRACT Upper limb lymphedema is one of the most common complications after breast cancer surgery and radiotherapy. At present, physical methods and surgical methods can be used for treatment. Surgical operations are mainly based on lymphovenous anastomosis and vascularized lymph node transfer. For these 2 surgical methods, we analyzed and compared the literature review and our own clinical experience. We summarized the differences between the 2 surgical techniques and the selection methods. We hope to help more young plastic surgeons and breast doctors understand how to treat upper limb lymphedema through surgical methods and help patients improve their quality of life.
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Affiliation(s)
- Kuo Chen
- From the The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | | | | | - Lan Mu
- Hainan Tumor Hospital, Haikou, China
| | - Pengwei Lu
- From the The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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77
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Immediate Lymphatic Reconstruction: Technical Points and Literature Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3431. [PMID: 33680675 PMCID: PMC7929616 DOI: 10.1097/gox.0000000000003431] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/23/2020] [Indexed: 11/26/2022]
Abstract
Recent studies have provided evidence that lymphovenous bypass—microsurgical re-routing of divided lymphatics to an adjacent vein—performed at the time of lymph node dissection decreases the rate of lymphedema development. Immediate lymphatic reconstruction in this setting is technically demanding, and there is a paucity of literature describing the details of the surgical procedure. In this report, we review the literature supporting immediate lymphatic reconstruction and provide technical details to demystify the operation for surgeons who wish to provide this option to their patients.
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78
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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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79
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Mele A, Fan B, Pardo J, Emhoff I, Beight L, Serres SK, Singhal D, Magrini L, James TA. Axillary lymph node dissection in the era of immediate lymphatic reconstruction: Considerations for the breast surgeon. J Surg Oncol 2021; 123:842-845. [PMID: 33524160 DOI: 10.1002/jso.26355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/20/2020] [Accepted: 11/26/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Alessandra Mele
- Breast Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Betty Fan
- Breast Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jaime Pardo
- Breast Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Isha Emhoff
- Breast Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Leah Beight
- Breast Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Stephanie K Serres
- Breast Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Dhruv Singhal
- Breast Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Leo Magrini
- Breast Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ted A James
- Breast Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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80
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Vignes S, Albuisson J, Champion L, Constans J, Tauveron V, Malloizel J, Quéré I, Simon L, Arrault M, Trévidic P, Azria P, Maruani A. Primary lymphedema French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins). Orphanet J Rare Dis 2021; 16:18. [PMID: 33407666 PMCID: PMC7789008 DOI: 10.1186/s13023-020-01652-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 12/19/2020] [Indexed: 11/10/2022] Open
Abstract
Primary lymphedema is a rare chronic pathology associated with constitutional abnormalities of the lymphatic system. The objective of this French National Diagnosis and Care Protocol (Protocole National de Diagnostic et de Soins; PNDS), based on a critical literature review and multidisciplinary expert consensus, is to provide health professionals with an explanation of the optimal management and care of patients with primary lymphedema. This PNDS, written by consultants at the French National Referral Center for Primary Lymphedema, was published in 2019 (https://has-sante.fr/upload/docs/application/pdf/2019-02/pnds_lymphoedeme_primaire_final_has.pdf).
Primary lymphedema can be isolated or syndromic (whose manifestations are more complex with a group of symptoms) and mainly affects the lower limbs, or, much more rarely, upper limbs or external genitalia. Women are more frequently affected than men, preferentially young. The diagnosis is clinical, associating mild or non-pitting edema and skin thickening, as confirmed by the Stemmer’s sign (impossibility to pinch the skin on the dorsal side or the base of the second toe), which is pathognomonic of lymphedema. Limb lymphoscintigraphy is useful to confirm the diagnosis. Other causes of swelling or edema of the lower limbs must be ruled out, such as lipedema. The main acute lymphedema complication is cellulitis (erysipelas). Functional and psychological repercussions can be major,
deteriorating the patient’s quality of life. Treatment aims to prevent those complications, reduce the volume with low-stretch bandages, then stabilize it over the long term by exercises and wearing a compression garment. Patient education (or parents of a child) is essential to improve observance.
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Affiliation(s)
- Stéphane Vignes
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, rue Eugène-Millon, 75015, Paris, France.
| | | | - Laurence Champion
- Department of Nuclear Medicine, René Huguenin-Curie Hospital, 35, rue Dailly, 92210, Saint-Cloud, France
| | - Joël Constans
- Department of Vascular Medicine, Saint-André Hospital, CHU de Bordeaux, 1, rue Jean-Burguet, 33000, Bordeaux, France
| | - Valérie Tauveron
- Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU Tours, 37044, Tours Cedex 9, France
| | - Julie Malloizel
- Department of Vascular Medicine, Rangueil Hospital, 1, avenue du Pr Jean-Poulhès, 31059, Toulouse, France
| | - Isabelle Quéré
- Department of Vascular Medicine and Reference Center for Rare Vascular Diseases, CHU Montpellier, 80, avenue Augustin-Fliche, 34090, Montpellier, France
| | - Laura Simon
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, rue Eugène-Millon, 75015, Paris, France
| | - Maria Arrault
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, rue Eugène-Millon, 75015, Paris, France
| | | | - Philippe Azria
- Department of Internal Medicine, Saint-Joseph Hospital, 185, rue Raymond-Losserand, 75014, Paris, France
| | - Annabel Maruani
- Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU Tours, 37044, Tours Cedex 9, France.,INSERM 1246 - SPHERE, Universities of Tours and Nantes, 37000, Tours, France
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81
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Coroneos CJ, Woodward WA, Wong FC, Caudle AS, Shaitelman SF, Kuerer HM, Schaverien MV. Anatomy and physiology of the sentinel lymph nodes of the upper extremity: Implications for axillary reverse mapping in breast cancer. J Surg Oncol 2020; 123:846-853. [PMID: 33333583 DOI: 10.1002/jso.26343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/29/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND This study characterizes the physiological drainage of the normal upper extremity using single-photon emission computed tomography/computed tomography (SPECT/CT) lymphoscintigraphy axillary reverse lymphatic mapping (ARM). METHODS A consecutive series of patients assessed with SPECT/CT lymphoscintigraphy ARM of the upper extremity were included. Anatomical localization of the axillary sentinel lymph nodes (SLN) was completed in normal axillae in relation to consistent anatomic landmarks. Retrospective case note analysis was performed to collect patient demographic data. RESULTS A total of 169 patients underwent SPECT/CT lymphoscintigraphy, and imaging of 182 normal axillae was obtained. All patients (100%) had an axillary SLN identified: 19% had a single contrast-enhanced SLN in the axilla and the remainder had multiple. The SLN(s) of the upper extremity was located in the upper outer quadrant (UOQ) of the axilla in 97% of cases (177 axillae). When the SLN(s) was found in the UOQ of the axilla, second-tier lymph nodes were found predominantly in the upper inner quadrant (50% of cases). CONCLUSIONS The upper extremity SLN(s) is located in a constant region of the axilla. This study provides the most complete investigation to date and results can be directly applied clinically to ARM techniques and adjuvant radiation planning.
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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
| | - Wendy A Woodward
- Division of Radiation Oncology, Department of Radiation Oncology, 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
| | - Abigail S Caudle
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Simona F Shaitelman
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Henry M Kuerer
- Division of Surgery, Department of Breast Surgical Oncology, 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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82
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Shah C, Zambelli-Weiner A, Delgado N, Sier A, Bauserman R, Nelms J. The impact of monitoring techniques on progression to chronic breast cancer-related lymphedema: a meta-analysis comparing bioimpedance spectroscopy versus circumferential measurements. Breast Cancer Res Treat 2020; 185:709-740. [PMID: 33245458 PMCID: PMC7921068 DOI: 10.1007/s10549-020-05988-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/20/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Chronic breast cancer-related lymphedema (BCRL) is a potentially serious complication following treatment. Monitoring for progression to BCRL may allow for earlier detection and intervention, reducing the rate of progression to chronic BCRL. Therefore, the purpose of this meta-analysis is to evaluate the impact of monitoring techniques on the incidence of chronic BCRL among patients monitored by bioimpedance spectroscopy (BIS) and circumference as compared to background rates. METHODS Eligible peer-reviewed studies from PubMed, CINHAL, or Google Scholar that were published in English from 2013 onward and conducted in North America, Europe, or Oceania. Incidence rates abstracted from studies were classified by BCRL monitoring method: background (no standardized BIS or circumference assessments), BIS or circumference. A random-effects model was used to calculate a pooled annualized estimate of BCRL incidence while accounting for clinical and methodological heterogeneity. Subgroup analyses examined differences in duration of follow-up as well as breast and axillary surgery. RESULTS 50 studies were included, representing over 67,000 women. The annualized incidence of BCRL was 4.9% (95% CI: 4.3-5.5) for background studies (n = 35), 1.5% (95% CI: 0.6-2.4) for BIS-monitored studies (n = 7), and 7.7% (95% CI: 5.6-9.8) for circumference-monitored studies (n = 11). The cumulative BCRL incidence rate in BIS-monitored patients was 3.1% as compared to 12.9% with background monitoring (69% reduction) and 17.0% with circumference-monitored patients (81% reduction). CONCLUSIONS Evidence suggests that monitoring with BIS allowing for early intervention significantly reduces the relative risk of chronic BCRL with a 69% and 81% reduction compared to background and circumference, respectively. Circumference monitoring did not appear to provide a benefit with respect to chronic BCRL incidence. Based on these results, BIS should be considered for BCRL screening in order to detect subclinical BCRL and reduce rates of chronic BCRL, particularly in high-risk patients.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
| | | | | | - Ashley Sier
- TTi Health Research and Economics, Westminster, MD, USA
| | | | - Jerrod Nelms
- TTi Health Research and Economics, Westminster, MD, USA
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83
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Cook JA, Sasor SE, Loewenstein SN, DeBrock W, Lester M, Socas J, Ludwig KK, Fisher CS, Hassanein AH. Immediate Lymphatic Reconstruction after Axillary Lymphadenectomy: A Single-Institution Early Experience. Ann Surg Oncol 2020; 28:1381-1387. [PMID: 32909127 DOI: 10.1245/s10434-020-09104-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/17/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE Lymphedema is progressive arm swelling from lymphatic dysfunction which can occur in 30% patients undergoing axillary dissection/radiation for breast cancer. Immediate lymphatic reconstruction (ILR) is performed in an attempt decrease the risk of lymphedema in patients undergoing axillary lymph node dissection (ALND). The purpose of this study was to assess the efficacy of ILR in preventing lymphedema rates in ALND patients. METHODS An institutional review board-approved retrospective review was performed of all patients who underwent ILR from 2017 to 2019. Patient demographics, comorbidities, operative and pathologic findings, number of LVAs, limb measurements, complications, and follow-up were recorded and analyzed. Student's sample t-test, Fisher's exact test, and ANOVA were used to analyze data; significance was set at p < 0.05. RESULTS Thirty-three patients were included in this analysis. Three patients (9.1%) developed persistent lymphedema, and two patients (6.1%) developed transient arm edema that resolved with compression and massage therapy. A significant effect was found for body mass index and the number of lymph nodes taken on the development of lymphedema (p < 0.01). CONCLUSIONS The rate of lymphedema in this series was 9.1%, which is an improvement from historical rates of lymphedema. Our findings support ILR as a technique that potentially decreases the incidence of lymphedema after axillary lymphadenectomy. Obesity and number of lymph nodes removed were significant predictive variables for the development of lymphedema following LVA.
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Affiliation(s)
- Julia A Cook
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sarah E Sasor
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Scott N Loewenstein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Will DeBrock
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mary Lester
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Juan Socas
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kandice K Ludwig
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carla S Fisher
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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84
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Cook JA, Hassanein AH. ASO Author Reflections: Immediate Lymphatic Reconstruction: A Proactive Approach to Breast Cancer-Related Lymphedema. Ann Surg Oncol 2020; 28:1388-1389. [PMID: 32886287 DOI: 10.1245/s10434-020-09110-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 08/22/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Julia A Cook
- Division of Plastic Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Suite #232, Indianapolis, IN, 46202, USA
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Suite #232, Indianapolis, IN, 46202, USA.
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85
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Oza S, Badillo SA, Breevoort S, Florendo J. Women’s Cancer Rehabilitation: a Review of Functional Impairments and Interventions Among Breast and Gynecologic Cancer Survivors. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00261-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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86
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Arié A, Yamamoto T. Lymphedema secondary to melanoma treatments: diagnosis, evaluation, and treatments. Glob Health Med 2020; 2:227-234. [PMID: 33330812 PMCID: PMC7731060 DOI: 10.35772/ghm.2020.01022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/22/2020] [Accepted: 07/29/2020] [Indexed: 01/20/2023]
Abstract
Approximately 300,000 new cases of melanoma are annually diagnosed in the world. Advanced stage melanomas require sentinel lymph node biopsy (SLNB), sometimes lymph node dissections (LND). The development rate of lower extremity lymphedema ranges from 7.6% to 35.1% after inguinal SLNB, and from 48.8% to 82.5% after inguinal LND. Development rate of upper extremity lymphedema ranges from 4.4% to 14.6% after axillary LND. Lymphedema management has constantly improved but effective evaluation and surgical management such as supermicrosurgical lymphaticovenular anastomosis (LVA) are becoming common as minimally invasive lymphatic surgery. Diagnosis and new classification using indocyanine green lymphography allowing pre-clinical secondary lymphedema stage management are improving effectiveness of supermicrosurgical LVA and vascularized lymph node transfer. Lymphatic transfer with lymph-interpositional-flap can restore lymph flow after large oncologic excision even without performing lymphatic anastomosis. Since lymphatic reconstructive surgery may affect local to systemic dissemination of remnant tumor cells, careful consideration is required to evaluate indication of surgical treatments.
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Affiliation(s)
- Azuelos Arié
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor University Hospital, Creteil, France
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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87
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Lymphedema Incidence After Axillary Lymph Node Dissection: Quantifying the Impact of Radiation and the Lymphatic Microsurgical Preventive Healing Approach. Ann Plast Surg 2020; 82:S234-S241. [PMID: 30855393 DOI: 10.1097/sap.0000000000001864] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Axillary surgery and radiotherapy are important aspects of breast cancer treatment associated with development of lymphedema. Studies demonstrate that Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) may greatly reduce the incidence of lymphedema in high-risk groups. The objective of this study is to summarize the evidence relating lymphedema incidence to axillary lymph node dissection (ALND), regional lymph node radiation (RLNR) therapy, and LYMPHA. METHODS We performed a literature search to identify studies involving breast cancer patients undergoing ALND with or without RLNR. Our primary outcome was the development of lymphedema. We analyzed the effect of LYMPHA on lymphedema incidence. We chose the DerSimonian and Laird random-effects meta-analytic model owing to the clinical, methodological, and statistical heterogeneity of studies. RESULTS Our search strategy yielded 1476 articles. After screening, 19 studies were included. Data were extracted from 3035 patients, 711 of whom had lymphedema. The lymphedema rate was significantly higher when RLNR was administered with ALND compared with ALND alone (P < 0.001). The pooled cumulative incidence of lymphedema was 14.1% in patients undergoing ALND versus 2.1% in those undergoing LYMPHA and ALND (P = 0.029). The pooled cumulative incidence of lymphedema was 33.4% in those undergoing ALND and RLNR versus 10.3% in those undergoing ALND, RLNR, and LYMPHA (P = 0.004). CONCLUSION Axillary lymph node dissection and RLNR are important interventions to obtain regional control for many patients but were found to constitute an increased risk of development of lymphedema. Our findings support that LYMPHA, a preventive surgical technique, may reduce the risk of breast cancer-related lymphedema in high-risk patients.
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88
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Abstract
Lymphoedema is the accumulation of protein-rich interstitial fluid within subcutaneous tissue and skin as a result of dysfunction of the lymphatic system. It is an underestimated, widely neglected and debilitating chronic condition. This article presents an overview of lymphoedema and recent advances in its management.
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Affiliation(s)
- Kai Yuen Wong
- Plastic and Reconstructive Surgery Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Dominic Furniss
- Plastic and Reconstructive Surgery Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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89
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Wang D, Lyons D, Skoracki R. Lymphedema: Conventional to Cutting Edge Treatment. Semin Intervent Radiol 2020; 37:295-308. [PMID: 32773955 DOI: 10.1055/s-0040-1713447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Lymphedema of the extremities related to oncologic therapies such as cancer surgery, radiation therapy, and chemotherapy is a major long-term cause of morbidity for cancer patients. Both nonsurgical and surgical management strategies have been developed. The goals of these therapies are to achieve volume reduction of the affected extremity, a reduction in patient symptoms, and a reduction in associated morbidities such as recurrent soft-tissue infections. In this article, we review both nonsurgical and surgical management strategies. Traditional surgical therapy has focused on more ablative techniques such as the Charles procedure and suction-assisted lipectomy/liposuction. However, newer more physiologic surgical methods such as lymphovenous anastomoses and vascularized lymph node transfers have become a more common treatment modality for the management of this complex problem.
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Affiliation(s)
- Duane Wang
- Department of Plastic Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Daniel Lyons
- Department of Plastic Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Roman Skoracki
- Department of Plastic Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
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90
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Surgical Approaches to the Prevention and Management of Breast Cancer–Related Lymphedema. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00372-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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91
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Coombs DM, Djohan R, Knackstedt R, Cakmakoglu C, Schwarz GS. Advances and current concepts in reconstructive surgery for breast cancer. Semin Oncol 2020; 47:217-221. [PMID: 32522379 DOI: 10.1053/j.seminoncol.2020.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/05/2020] [Accepted: 05/05/2020] [Indexed: 01/09/2023]
Abstract
In this article, we report on recent advancements in reconstructive care of the breast cancer patient. New developments in sensate breast reconstruction to help address the problem of numbness after mastectomy have emerged and show promise. Methods to restore lymphatic physiologic flow after axillary lymphadenectomy using supermicrosurgical techniques have begun to show benefit by reducing the short-term incidence of breast cancer related lymphedema (BRCL). Breast implant safety has received significant recent attention and we explore the emergence of BIA-ALCL (Breast Implant Associated Anaplastic Large Cell Lymphoma) and its implications for the breast cancer patient and their multidisciplinary care team.
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Affiliation(s)
- Demetrius M Coombs
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, United States of America
| | - Risal Djohan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, United States of America
| | - Rebecca Knackstedt
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, United States of America
| | - Cagri Cakmakoglu
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, United States of America
| | - Graham S Schwarz
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, United States of America.
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92
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Suami H. Anatomical Theories of the Pathophysiology of Cancer-Related Lymphoedema. Cancers (Basel) 2020; 12:E1338. [PMID: 32456209 PMCID: PMC7281515 DOI: 10.3390/cancers12051338] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/14/2020] [Accepted: 05/21/2020] [Indexed: 12/30/2022] Open
Abstract
Lymphoedema is a well-known concern for cancer survivors. A crucial issue in lymphoedema is that we cannot predict who will be affected, and onset can occur many years after initial cancer treatment. The variability of time between cancer treatment and lymphoedema onset is an unexplained mystery. Retrospective cohort studies have investigated the risk factors for lymphoedema development, with extensive surgery and the combination of radiation and surgery identified as common high-risk factors. However, these studies could not predict lymphoedema risk in each individual patient in the early stages, nor could they explain the timing of onset. The study of anatomy is one promising tool to help shed light on the pathophysiology of lymphoedema. While the lymphatic system is the area least investigated in the field of anatomical science, some studies have described anatomical changes in the lymphatic system after lymph node dissection. Clinical imaging studies in lymphangiography, lymphoscintigraphy and indocyanine green (ICG) fluorescent lymphography have reported post-operative anatomical changes in the lymphatic system, including dermal backflow, lymphangiogenesis and creation of alternative pathways via the deep and torso lymphatics, demonstrating that such dynamic anatomical changes contribute to the maintenance of lymphatic drainage pathways. This article presents a descriptive review of the anatomical and imaging studies of the lymphatic system in the normal and post-operative conditions and attempts to answer the questions of why some people develop lymphoedema after cancer and some do not, and what causes the variability in lymphoedema onset timing.
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Affiliation(s)
- Hiroo Suami
- Australian Lymphoedema Education, Research and Treatment Program, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW 2109, Australia
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93
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Invernizzi M, Lopez G, Michelotti A, Venetis K, Sajjadi E, De Mattos-Arruda L, Ghidini M, Runza L, de Sire A, Boldorini R, Fusco N. Integrating Biological Advances Into the Clinical Management of Breast Cancer Related Lymphedema. Front Oncol 2020; 10:422. [PMID: 32300557 PMCID: PMC7142240 DOI: 10.3389/fonc.2020.00422] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/10/2020] [Indexed: 12/15/2022] Open
Abstract
Breast cancer-related lymphedema (BCRL) occurs in a significant number of breast cancer survivors as a consequence of the axillary lymphatics' impairment after therapy (mainly axillary surgery and irradiation). Despite the recent achievements in the clinical management of these patients, BCRL is often diagnosed at its occurrence. In most cases, it remains a progressive and irreversible condition, with dramatic consequences in terms of quality of life and on sanitary costs. There are still no validated pre-surgical strategies to identify individuals that harbor an increased risk of BCRL. However, clinical, therapeutic, and tumor-specific traits are recurrent in these patients. Over the past few years, many studies have unraveled the complexity of the molecular and transcriptional events leading to the lymphatic system ontogenesis. Additionally, molecular insights are coming from the study of the germline alterations involved at variable levels in BCRL models. Regrettably, there is a substantial lack of predictive biomarkers for BCRL, given that our knowledge of its molecular milieu remains extremely puzzled. The purposes of this review were (i) to outline the biology underpinning the ontogenesis of the lymphatic system; (ii) to assess the current state of knowledge of the molecular alterations that can be involved in BCRL pathogenesis and progression; (iii) to discuss the present and short-term future perspectives in biomarker-based patients' risk stratification; and (iv) to provide practical information that can be employed to improve the quality of life of these patients.
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Affiliation(s)
- Marco Invernizzi
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy
| | - Gianluca Lopez
- School of Pathology, University of Milan, Milan, Italy.,Division of Pathology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Michelotti
- Division of Pathology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Venetis
- Ph.D. Program in Translational Medicine, University of Milan, Milan, Italy.,Divison of Pathology, IRCCS European Institute of Oncology (IEO), Milan, Italy
| | - Elham Sajjadi
- Division of Pathology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Michele Ghidini
- Division of Medical Oncology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Letterio Runza
- Division of Pathology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro de Sire
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy.,Rehabilitation Unit, "Mons. L. Novarese" Hospital, Moncrivello, Italy
| | - Renzo Boldorini
- Pathology Unit, Department of Health Sciences, Novara Medical School, Novara, Italy
| | - Nicola Fusco
- Divison of Pathology, IRCCS European Institute of Oncology (IEO), Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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94
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Fournier DE, Groh AM, Nair SM, Norley CJ, Pollmann SI, Holdsworth DW, Power NE, Beveridge TS. Microcomputed Tomography Is a Precise Method That Allows for Topographical Characterization of Lymph Nodes and Lymphatic Vessels. Lymphat Res Biol 2020; 18:166-173. [DOI: 10.1089/lrb.2019.0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Dale E. Fournier
- Health and Rehabilitation Sciences (Physical Therapy), Faculty of Health Sciences, Collaborative Specialization in Musculoskeletal Health Research, and Bone and Joint Institute, The University of Western Ontario, London, Ontario, Canada
| | - Adam M.R. Groh
- Department of Anatomy and Cell Biology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Shiva M. Nair
- Urology Division, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
- Surgical Oncology Division, Department of Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Chris J.D. Norley
- Imaging Research Laboratories, John P. Robarts Research Institute, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Steven I. Pollmann
- Imaging Research Laboratories, John P. Robarts Research Institute, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - David W. Holdsworth
- Imaging Research Laboratories, John P. Robarts Research Institute, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Nicholas E. Power
- Urology Division, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
- Surgical Oncology Division, Department of Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Tyler S. Beveridge
- Department of Anatomy and Cell Biology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
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95
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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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96
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Abstract
BACKGROUND Lymphedema is a chronic condition that carries a significant physical, psychosocial, and economic burden. The authors' program was established in 2017 with the aims of providing immediate lymphatic reconstruction in high-risk patients undergoing lymphadenectomy and performing delayed lymphatic reconstruction in patients with chronic lymphedema. The purpose of this study was to describe the authors' clinical experience in the first year. METHODS A retrospective review of our clinical database was performed on all individuals presenting to the authors' institution for lymphatic surgery consideration. Patient demographics, clinical characteristics, and surgical management were reviewed. RESULTS A total of 142 patients presented for lymphatic surgery evaluation. Patients had a mean age of 54.8 years and an average body mass index of 30.4 kg/m. Patients with lymphedema were more likely to be referred from an outside facility compared to patients seeking immediate lymphatic reconstruction (p < 0.001). For patients with lymphedema, the most common cause was breast cancer related. Thirty-two percent of all patients evaluated underwent a lymphatic procedure. Of these, 32 were immediate lymphatic reconstructions and 13 were delayed lymphatic reconstructions. In the authors' first year, 94 percent of eligible patients presenting for immediate lymphatic reconstruction underwent an intervention versus only 38 percent of eligible lymphedema patients presenting for delayed lymphatic reconstruction (p < 0.001). CONCLUSIONS First-year review of our lymphatic surgery experience has demonstrated clinical need evidenced by the number of patients and high percentage of outside referrals. As a program develops, lymphatic surgeons should expect to perform more time-sensitive immediate lymphatic reconstructions, as evaluation of chronic lymphedema requires development of a robust team for workup and review.
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97
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He L, Qu H, Wu Q, Song Y. Lymphedema in survivors of breast cancer. Oncol Lett 2020; 19:2085-2096. [PMID: 32194706 PMCID: PMC7039097 DOI: 10.3892/ol.2020.11307] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 11/07/2019] [Indexed: 12/16/2022] Open
Abstract
The tremendous improvement of survival in patients with breast cancer can be attributed to several treatment strategies, but these strategies also lead to the occurrence of breast cancer-related lymphedema (BCRL). BRCL is regularly associated with factors such as axillary lymph node dissection and local lymph node radiotherapy and manifests as an increase of >10% in the volume of affected limbs. Being overweight or having obesity (body mass index ≥25 kg/m2), an excessive number of positive lymph nodes (>8) and capsular invasion by a tumor are additional risk factors for lymphedema. It is worth assessing the risk before surgery as this can prevent the occurrence of BCRL at the initial stage of breast cancer management. The clinical utility of many diagnostic tools and lymphedema surveillance allows early stage and even subclinical BCRL to be diagnosed, and allows real-time monitoring of the disease. The early diagnosis of BRCL allows treatment at an early stage, which is beneficial to the reduction of excess limb volume and the improvement of quality of life. At present, the major therapeutic methods of BCRL include complex decongestive therapy, pneumatic compression devices, participating in exercise, microsurgery and liposuction, each of which alleviates lymphedema effectively. No medications for treatment of BRCL have yet been developed. However, the recent findings on the success of molecular therapy in animal models may remedy this deficiency. Furthermore, the volume reduction of swollen limbs without swelling rebound by transplanting autologous stem cells has been successfully reported in some pilot studies, which may provide a new technique for treating BCRL. This review aimed to discuss the pathogenesis, clinical manifestation, risk factors, advantages and disadvantages of diagnostic tools, lymphedema surveillance and the characteristics of traditional and newly emerging BCRL treatments.
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Affiliation(s)
- Lin He
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Huili Qu
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Qian Wu
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Yuhua Song
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
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98
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Schaverien MV, Baumann DP, Selber JC, Chang EI, Hanasono MM, Chu C, Hanson SE, Butler CE. Building a Multidisciplinary Comprehensive Academic Lymphedema Program. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2670. [PMID: 32537334 PMCID: PMC7253282 DOI: 10.1097/gox.0000000000002670] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/06/2020] [Indexed: 12/29/2022]
Abstract
Lymphedema is a debilitating clinical condition predominantly affecting survivors of cancer. It adversely affects patients' quality of life and results in substantial cost burdens to both patients and the healthcare system. Specialist lymphedema care is optimally provided within integrated clinical programs that align the necessary specialties to provide patient-focused, multidisciplinary, structured, and coordinated care. This article examines our experience building a specialist lymphedema academic program. METHODS We describe the critical components necessary for constructing a multidisciplinary comprehensive academic lymphedema program. Furthermore, lessons learned from our experience building a successful lymphedema program are discussed. RESULTS Building a comprehensive academic lymphedema program requires institutional support and engagement of stakeholders to establish the necessary infrastructure for comprehensive patient care. This includes the infrastructure for outpatient clinical assessment, diagnostic investigations, radiological imaging, collection of outcomes metrics, non-surgical treatment delivered by lymphedema-specialist therapists, surgical procedures using specialized equipment, and integration of an outpatient framework for comprehensive patient evaluation during follow-up at standardized time intervals. CONCLUSIONS This article examines our experience building a multidisciplinary comprehensive academic lymphedema program and provides a structured roadmap to benefit others that are embarking on this mission.
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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, Tex
| | - Donald P. Baumann
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Jesse C. Selber
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Edward I. Chang
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Matthew M. Hanasono
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Carrie Chu
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Summer E. Hanson
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Charles E. Butler
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
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99
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Akita S, Yamaji Y, Takeuchi N, Wakai K, Azuma K, Nakagawa A, Fujimoto H, Sangai T, Nagashima T, Mitsukawa N, Ikehara Y. Detection of Nonpalpable Tiny Axillary Lymph Nodes Surrounded by Adipose Tissue Using a Near-Infrared Camera. Lymphat Res Biol 2020; 18:455-463. [PMID: 32048903 DOI: 10.1089/lrb.2019.0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: It is not always possible to detect nonpalpable small lymph nodes (LNs) surrounded by adipose tissue under the wavelength of visible light. A newly developed near-infrared camera with InGaAs element was able to capture photographs using light at >1000-nm wavelength, at which the difference in absorbance between water and lipids is large. This study investigated the ability to detect nonvisible small LNs using light at 1300-nm wavelength. Methods and Results: Following retrieval of LNs through axillary LN dissection from 20 patients with breast cancer, residual specimens were simultaneously photographed using light at 970-, 1070-, 1200-, 1300-, 1450-, and 1600-nm wavelengths. A total of 45 specimens were observed pathologically at the selected portions in which the 1300-nm light was absorbed (high absorbance group [HA group], n = 25) and those in which the 970-nm light was absorbed instead (low absorbance group [LA group], n = 20). All specimens categorized in the HA group detected the LNs, whereas none of those categorized in the LA group detected an LN. The sensitivity and specificity in the identification of an LN were 1.0. The LNs detected using this camera were significantly smaller than those detected by surgeons (3.00 ± 2.93 mm vs. 5.90 ± 3.91 mm, p < 0.01). Discussion: The light at 1300-nm wavelength was absorbed by axillary LNs. This camera detected LNs that were undetectable by surgeons. This novel technology may be applied to lymphatic microsurgery and contribute to the development of a minimally invasive LN dissection method.
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Affiliation(s)
- Shinsuke Akita
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Yoshihisa Yamaji
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Nobuyoshi Takeuchi
- Department of Pathology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Ken Wakai
- Department of Pathology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Kazuhiko Azuma
- Department of Pathology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Ayako Nakagawa
- Department of Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Hiroshi Fujimoto
- Department of Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Takafumi Sangai
- Department of Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Takeshi Nagashima
- Department of Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Yuzuru Ikehara
- Department of Pathology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan.,Biotechnology Research Institute for Drug Discovery, National Institute of Advanced Industrial Science and Technology, Tsukuba, Japan
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100
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Abstract
OBJECTIVE This manuscript is the first to employ rigorous methodological criteria to critically appraise a surgical preventative technique for breast cancer-related lymphedema from a cost-utility standpoint. SUMMARY OF BACKGROUND DATA Breast cancer-related lymphedema is a well-documented complication of breast cancer survivors in the US. In this study, we conduct a cost-utility analysis to evaluate the cost-effectiveness of the LYMPHA. METHODS Lymphedema rates after each of the following surgical options: (1) ALND, (2) ALND + LYMPHA, (3) ALND + RLNR, (4) ALND + RLNR + LYMPHA were extracted from a recently published meta-analysis. Procedural costs were calculated using Medicare reimbursement rates. Average utility scores were obtained for each health state using a visual analog scale, then converted to quality-adjusted life years (QALYs). A decision tree was generated and incremental cost-utility ratios (ICUR) were calculated. Multiple sensitivity analyses were performed to evaluate our findings. RESULTS ALND with LYMPHA was more cost-effective with an ICUR of $1587.73/QALY. In the decision tree rollback analysis, a clinical effectiveness gain of 1.35 QALY justified an increased incremental cost of $2140. Similarly, the addition of LYMPHA to ALND with RLNR was more cost-effective with an ICUR of $699.84/QALY. In the decision tree rollback analysis, a clinical effectiveness gain of 2.98 QALY justified a higher incremental cost of $2085.00. CONCLUSIONS Our study supports that the addition of LYMPHA to both ALND or ALND with RLNR is the more cost-effective treatment option.
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