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Weber WP, Hanson SE, Wong DE, Heidinger M, Montagna G, Cafferty FH, Kirby AM, Coles CE. Personalizing Locoregional Therapy in Patients With Breast Cancer in 2024: Tailoring Axillary Surgery, Escalating Lymphatic Surgery, and Implementing Evidence-Based Hypofractionated Radiotherapy. Am Soc Clin Oncol Educ Book 2024; 44:e438776. [PMID: 38815195 DOI: 10.1200/edbk_438776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient's risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.
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Affiliation(s)
- Walter Paul Weber
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Summer E Hanson
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Daniel E Wong
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Martin Heidinger
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Fay H Cafferty
- Institute of Cancer Research Clinical Trials and Statistics Unit, London, United Kingdom
| | - Anna M Kirby
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
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Roka-Palkovits J, Freystätter C, Tinhofer IE, Keck M, Steinbacher J, Meng S, Weninger WJ, Cheng MH, Tzou CHJ. Retroauricular lymph node flap: An anatomic and surgical feasibility study. J Surg Oncol 2023; 127:1103-1108. [PMID: 36912899 DOI: 10.1002/jso.27234] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/26/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND The study investigated the anatomy of the retroauricular lymph node (LN) flap and evaluate its surgical feasibility as a new donor site for a free LN flap in lymphedema surgery. METHODS Twelve adult cadavers were examined. The course and perfusion of the anterior auricular artery (AAA) and the location and sizes of the retroauricular LNs were studied. RESULTS The AAA was available in 87% and absent in 13% specimens. The AAA's origin had a mean vertical distance of 12.2 ± 6.9 mm and a mean horizontal distance of 19.1 ± 4.2 mm from the superior attachment of the ear. The mean diameter of the AAA was 0.8 ± 0.2 mm. The mean number of LN per region was 7.7 ± 2.3, with an average LN size of 4.1 ± 1.9 × 3.2 ± 1.7 mm. The LN were categorized into anterior (G1) and posterior (G2) groups, with a total of 59 and 10 LN, respectively. In a cluster analysis, three LN clusters could be detected across the anterior group (G1). CONCLUSIONS The retroauricular LN flap is a delicate but feasible flap with reliable anatomy, containing a mean of 7.7 LNs.
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Affiliation(s)
- Julia Roka-Palkovits
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior (Krankenhaus Goettlicher Heiland), Vienna, Austria
| | - Christian Freystätter
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Austria
| | - Ines E Tinhofer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior (Krankenhaus Goettlicher Heiland), Vienna, Austria
| | - Maike Keck
- Department of Plastic and Reconstructive Surgery, Agaplesion Diakonieklinikum Hamburg, Hamburg, Germany.,Department of Plastic and Reconstructive Surgery, University of Luebeck, Luebeck, Germany
| | - Johannes Steinbacher
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior (Krankenhaus Goettlicher Heiland), Vienna, Austria
| | - Stefan Meng
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria.,Department of Radiology, Hanusch Hospital, Vienna, Austria
| | - Wolfgang J Weninger
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chieh-Han J Tzou
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior (Krankenhaus Goettlicher Heiland), Vienna, Austria.,Faculty of Medicine, Sigmund Freud University, Vienna, Austria.,Lymphedema Center, TZOU MEDICAL., Vienna, Austria
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Seth I, Bulloch G, Gibson D, Seth N, Hunter-Smith DJ, Rozen WM. Quantification and Effectiveness of Vascularized Neck Lymph Node Transfer for Lymphedema: a Systematic Review and Meta-Analysis. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03627-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Knackstedt R, Chen WF. Current Concepts in Surgical Management of Lymphedema. Phys Med Rehabil Clin N Am 2022; 33:885-899. [DOI: 10.1016/j.pmr.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Mohos B, Czedik-Eysenberg M, Steinbacher J, Tinhofer I, Meng S, Tzou CHJ. Long-term Use of Ultrasound for Locating Optimal LVA Sites: A Descriptive Data Analysis. J Reconstr Microsurg 2021; 38:238-244. [PMID: 34820800 DOI: 10.1055/s-0041-1740124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Preoperative mapping of lymphatic vessels for lymphovenous anastomosis (LVA) surgery is frequently performed by indocyanine green (ICG) lymphography solely; however, other imaging modalities, such as ultrasound (US), might be more efficient, particularly for Caucasian patients. We present our preoperative assessment protocol, experience, and approach of using US for locating optimal LVA sites. MATERIAL AND METHODS Fifty-six (16 males) lymphedema patients who underwent LVA surgery were included in this study, 5 of whom received two LVA operations. In total, 61 LVA procedures with 233 dissected lymphatic vessels were evaluated. Preoperative US was performed by the author S.M. 2 days before intraoperative ICG lymphography. Fluid-predominant lymphedema regions were scanned more profoundly. Skin incisions followed preoperative US and ICG lymphography markings. Detection of lymphatic vessels was compared between ICG lymphography and the US by using the intraoperative verification under the microscope with 20 to 50x magnification as the reference standard. RESULTS Among the dissected lymphatic vessels, 83.3% could be localized by US, and 70% were detectable exclusively by it. In all, 7.2% of US-detected lymphatic vessels could not be found and verified intraoperatively. Among the lymphatic vessels found by US, only 16% were apparent with ICG before skin incision. In total, 23.2% of the dissected lymphatic vessels could be visualized with ICG lymphography preoperatively. Only 9.9% of the lymphatic vessels could be found by ICG alone. CONCLUSION High-frequency US mapping accurately finds functional lymphatic vessels and matching veins. It locates fluid-predominant regions for targeted LVA surgeries. It reveals 3.6 times as many lymphatic vessels as ICG lymphography. In our practice, it has an integral role in planning LVA procedures.
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Affiliation(s)
- Balazs Mohos
- Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior (Krankenhaus Goettlicher Heiland Wien), Vienna, Austria
| | - Manon Czedik-Eysenberg
- Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior (Krankenhaus Goettlicher Heiland Wien), Vienna, Austria
| | - Johannes Steinbacher
- Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior (Krankenhaus Goettlicher Heiland Wien), Vienna, Austria
| | - Ines Tinhofer
- Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior (Krankenhaus Goettlicher Heiland Wien), Vienna, Austria
| | - Stefan Meng
- Department of Radiology, Hanusch Hospital, Vienna, Austria
| | - Chieh-Han John Tzou
- Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior (Krankenhaus Goettlicher Heiland Wien), Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria.,TZOU MEDICAL, Lymphedema Center, Vienna, Austria
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Chung JH, Hwang YJ, Park SH, Yoon ES. Preliminary outcomes of combined surgical approach for lower extremity lymphedema: supraclavicular lymph node transfer and lymphaticovenular anastomosis. J Plast Surg Hand Surg 2021; 56:261-269. [PMID: 34423730 DOI: 10.1080/2000656x.2021.1964980] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Vascularized lymph node transfer (VLNT) is a well-established surgical approach for treating lower extremity lymphedema (LEL). Since VLNT takes time to show effect, a combined approach with lymphaticovenular anastomosis (LVA) may be more advantageous to patients by inducing an immediate improvement. This study aims to describe our experience and evaluate the results of a combined approach. METHODS In this retrospective review, we analyzed a total of 12 patients that underwent simultaneous supraclavicular VLNT and LVA for the treatment of secondary LEL with the ISL stage II or III. Patients who had a follow-up period of less than 12 months were excluded. The supraclavicular flap, including superficial lymphoid tissue as well as deep cervical nodes, was harvested and anastomosed to the posterior tibial vessels. The pre- and postoperative change of circumference difference ratios and LEL index were compared. RESULTS All twelve flaps survived without re-exploration. An average of 2.3 LVAs were simultaneously performed. At 12.9 months of follow-up (range, 12-16 months), the postoperative mean circumference ratio was significantly improved than pre-operative in 10 cm above the knee (7.9 ± 7.2% vs 15.0 ± 7.6%, p = 0.01), 10 cm below the knee (8.5 ± 7.5% vs 17.4 ± 12.7%, p = 0.03) and lateral malleolus (16.5 ± 15.5% vs 28.6 ± 17.9%, p = 0.03). Also, the mean LEL index was decreased (preoperative 324.3 ± 53.0 vs postoperative 298.0 ± 44.6, p = 0.242) and eight patients showed improvement in LEL stage. CONCLUSIONS The combined approach showed a significant decrease in the circumference of LEL. Additional LVAs could reinforce the effect of a VLNT. Larger series with longer follow-up is needed to confirm our findings.
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Affiliation(s)
- Jae-Ho Chung
- Department of Plastic and Reconstructive Surgery, Korea University Hospital, Seoul, Republic of Korea
| | - Yong-Jae Hwang
- Department of Plastic and Reconstructive Surgery, Korea University Hospital, Seoul, Republic of Korea
| | - Seung-Ha Park
- Department of Plastic and Reconstructive Surgery, Korea University Hospital, Seoul, Republic of Korea
| | - Eul-Sik Yoon
- Department of Plastic and Reconstructive Surgery, Korea University Hospital, Seoul, Republic of Korea
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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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8
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Schaverien MV, Chang EI. Combined deep inferior epigastric artery perforator flap with vascularized groin lymph node transplant for treatment of breast cancer-related lymphedema. Gland Surg 2021; 10:460-468. [PMID: 33634003 DOI: 10.21037/gs.2020.02.14] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
For survivors of breast cancer lymphedema is their greatest survivorship burden. Modern surgical techniques to treat lymphedema are effective at reducing limb volume, symptoms of lymphedema, episodes of cellulitis, and improving patient quality of life. Physiologic procedures, including lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT), restore physiological lymphatic function within the affected extremity. In patients with post-mastectomy breast cancer-related upper extremity lymphedema that desire breast reconstruction, microvascular abdominal flap breast reconstruction can be combined with superficial inguinal (groin) VLNT to provide breast reconstruction and treatment of lymphedema in a single operation. This article reviews the indications, preoperative assessment, surgical technique, outcomes, and tips and pearls for performing this procedure.
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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, TX, USA
| | - Edward I Chang
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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9
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Comprehensive Overview of Available Donor Sites for Vascularized Lymph Node Transfer. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2675. [PMID: 32537339 PMCID: PMC7253262 DOI: 10.1097/gox.0000000000002675] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/18/2019] [Indexed: 11/26/2022]
Abstract
The field of lymphedema surgery has grown tremendously in recent years. In particular, the diversity of available donor sites for vascularized lymph node transfer has increased, and new donor sites are emerging. Researchers have explored a number of different donor sites, and their reports have demonstrated promising results with each site. Unfortunately, there are limited studies providing a comprehensive analysis of the available donor sites focusing on both the technical aspects of the harvest, including complications and donor site morbidity, and the efficacy and outcomes following transfer. The present review aims to present a comprehensive analysis of the available donor sites for vascularized lymph node transfer and a summary of the experience from a single center of excellence.
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10
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Ngo QD, Munot S, Mackie H, Czerniec S, Koelmeyer LA, Lam T, Heydon-White A, Suami H, Boyages J. Vascularized Lymph Node Transfer for Patients with Breast Cancer-Related Lymphedema Can Potentially Reduce the Burden of Ongoing Conservative Management. Lymphat Res Biol 2020; 18:357-364. [PMID: 31944882 DOI: 10.1089/lrb.2019.0048] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Vascularized lymph node transfer (VLNT) microsurgery is conducted in selected specialist lymphatic programs as a surgical treatment option for breast cancer-related lymphedema (BCRL) with variation in treatment outcomes. Methods and Results: Ten patients with BCRL underwent VLNT from 2012 to 2015. Donor sites were the inguinal (n = 6) or supraclavicular fossa/neck (n = 4) regions and recipient sites were the axilla (n = 6) or elbow regions (n = 4). Outcomes included changes in limb volume and extracellular fluid ratios, postoperative garment use, number of cellulitis episodes, and self-reported symptom improvement. At a mean follow-up of 46 months from surgery (range: 28-66 months), the excess volume in the affected arm had reduced (n = 4) or remained stable (n = 1) for 5 of 10 patients (50%) (mean change: -106.4 mL, range: -515.5 to +69.6 mL). Four of these five patients had also reduced (n = 3) or discontinued (n = 1) wearing compression garments and three reported a reduction in episodes of cellulitis. The remaining five patients had an increase of over 100 mL in postoperative excess volume (mean change: 295.8 mL, range: 142.1-382.8 mL). Three of these five patients reported noncompliance with compression garments. Despite the increase in limb volume, some patients reported softness in swelling (n = 3) and better response to conservative treatment (n = 1). Conclusion: Our results warrant continuation of VLNT as a surgical treatment option for patients with BCRL and show that the burden of conservative management such as wearing garments can be reduced over time for some patients. Longer term follow-up with standardized measures across all centers is required to further investigate VLNT.
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Affiliation(s)
- Quan D Ngo
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Sonali Munot
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Helen Mackie
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia.,Mt. Wilga Rehabilitation Hospital, Hornsby, Australia
| | - Sharon Czerniec
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Louise A Koelmeyer
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Thomas Lam
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Asha Heydon-White
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Hiroo Suami
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - John Boyages
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
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Abstract
Limb lymphoedema is common in patients who have undergone inguinal or axillary lymph node dissection. Lymphoedema seriously impacts the patient's quality of life by inducing adipogenesis, fibrosis and repeated episodes of lymphangitis and cellulitis. Following failure of compression therapies, several curative or symptomatic surgical options have been proposed over recent decades, such as liposuction or lymphovenous anastomosis. Vascularized lymph node transfer techniques have recently been described, with promising results. Vascularized lymph node transfer with submental free flap appears to be the most reliable of these technique, associated with the lowest morbidity. The flap harvesting technique presents several specific differences compared to conventional submental free flap. A good knowledge of neck anatomy is essential and multimodal and multidisciplinary management is often required. In the light of a case report, we describe the basic submental free flap technique for vascularized lymph node transfer for the treatment of lower limb lymphoedema. This technique may be used by head and neck surgeons performing flap harvest, as well as plastic surgeon surgeons or gynaecologists ensuring long-term management of these patients.
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13
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Visconti G, Tartaglione G, Bartoletti R, Salgarello M. Compartimental harvesting of dual lymph node flap from the right supraclavicular area for the treatment of lower extremity lymphedema: A case series. J Plast Reconstr Aesthet Surg 2019; 72:211-215. [PMID: 30503371 DOI: 10.1016/j.bjps.2018.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 08/28/2018] [Accepted: 10/28/2018] [Indexed: 10/27/2022]
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Liu HL, Chung JCK. The Lymph Node Content of Supraclavicular Lymph Node Flap: A Histological Study on Fresh Human Specimens. Lymphat Res Biol 2019; 17:537-542. [PMID: 30694716 DOI: 10.1089/lrb.2018.0056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Vascularized lymph node transfer (VLNT) has become the established treatment for secondary lymphedema. The proposed mechanisms of VLNT include lymphangiogenesis and absorptive action of transplanted lymphatic tissue. Therefore, in theory, the lymph node content of lymph node flap is crucial to clinical response. The supraclavicular lymph node flap (SCLNF) has been described as one of the flap options for VLNT. However, its lymph node content has not been fully studied. The aim of this study is to find out the lymph node content of SCLNF with histological examination. Methods: Patients who required radical neck dissection or modified radical neck dissection due to cervical lymph node metastasis from head and neck cancer were included in this study. The SCLNF harvesting was performed as the first part of neck dissection. After flap harvesting, neck dissection was continued. The fresh SCLNF specimens were then sent for histological study. Results: Twelve SCLNFs were studied. The mean age of patients was 67.5 (range, 54-84) years. There were 10 males and 2 females. Seven flaps were harvested from the left side of neck, while five flaps were harvested from the right side of neck. The mean width, height, and thickness of SCLNF were 5.9 ± 0.6, 4.0 ± 0.5, and 1.8 ± 0.2 cm, respectively. The mean number of lymph nodes per flap was 8 ± 4.7 (range, 3-15). Conclusion: The lymph node content of SCLNF was confirmed. Its lymph node content is comparable to other lymph node flaps used in VLNT.
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Affiliation(s)
- Hin-Lun Liu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Joseph Chun-Kit Chung
- Department of Ear, Nose and Throat, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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15
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Correlation between Quantity of Transferred Lymph Nodes and Outcome in Vascularized Submental Lymph Node Flap Transfer for Lower Limb Lymphedema. Plast Reconstr Surg 2019; 142:1056-1063. [PMID: 30020232 DOI: 10.1097/prs.0000000000004793] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Vascularized lymph node transfer has shown promising results in the treatment of lower limb lymphedema, but little is known about the number of lymph nodes needed for the transfer to achieve optimal results. This study investigated the correlation between number of transferred lymph nodes in submental vascularized lymph node transfer and outcomes regarding limb circumference reduction and cellulitis incidence. METHODS Thirty-five patients who had received vascularized submental lymph node transfer to an ankle for lower limb lymphedema following gynecologic cancer treatment were included in the study. Limb circumference was determined by means of tape measurement preoperatively and postoperatively and was used to calculate the circumferential difference. Ultrasonography was performed postoperatively to determine the number of lymph nodes within the transferred flap. Patients were divided into groups A through C depending on the number of transferred lymph nodes: 1 or 2 (n = 10), 3 or 4 (n = 14), and 5 to 8 (n = 11), respectively. RESULTS The mean age of the patients was 60.0 ± 9.2 years. All flaps survived. The mean improvement of circumferential difference for the whole cohort was 19.8 ± 9.2 percent. Groups B and C both had significantly higher improvements in the circumferential difference than group A (p = 0.04 and p = 0.02, respectively), but when compared to each other, the difference was nonsignificant. All groups had significant reductions in the incidence of cellulitis postoperatively. CONCLUSIONS Submental vascularized lymph node transfer for lower limb lymphedema reduced the incidence of cellulitis, regardless of the number of transferred lymph nodes. The transfer of three or more lymph nodes provided significantly better outcome regarding limb circumference reduction than the transfer of two or fewer lymph nodes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Ho OA, Lin CY, Pappalardo M, Cheng MH. Comparisons of Submental and Groin Vascularized Lymph Node Flaps Transfer for Breast Cancer-Related Lymphedema. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1923. [PMID: 30656093 PMCID: PMC6326621 DOI: 10.1097/gox.0000000000001923] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 07/11/2018] [Indexed: 11/25/2022]
Abstract
Background: The vascularized groin and submental lymph node (VGLN and VSLN) flaps are valuable options in the treatment of lymphedema. This study was to compare outcomes between VGLN and VSLN transfers for breast cancer–related lymphedema. Methods: Between January 2008 and December 2016, VGLN and VSLN transfers for upper limb lymphedema were compared including flap characteristics, flap elevation time, complications, and limb circumference changes. Results: All flaps survived. Similar vein (2.6 versus 3.2 mm; P = 0.3) and artery diameter (2.1 versus 2.8 mm; P = 0.3) and number of lymph nodes (3 versus 4; P = 0.4) were found between VGLN and VSLN groups, respectively. Circumferential reduction rate was higher in VSLN than VGLN (P = 0.04) group. Vascular complication rate with salvage rate was not statistically different between the 2 groups. Donor-site complication and total complication rates were statistically higher in VGLN than VSLN flaps (7.7% versus 0%, P = 0.004; 46.2% versus 23.3%, P = 0.002). At a mean 39.8 ± 22.4 months, the circumferential reduction rate was statistically higher in VSLN than in the VGLN group (55.5 ± 14.3% versus 48.4 ± 23.9%, P = 0.04). Both flaps were effectively decreased in the episodes of cellulitis. Conclusions: Both VGLN and VSLN flaps are valuable surgical options in treating breast cancer–related lymphedema. However, the VSLN flap for breast cancer–related lymphedema is better in providing more significant improvements in limb circumference, a faster flap harvest time, decreased complication rates, and minimal donor-site iatrogenic lymphedema.
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Affiliation(s)
- Olivia A Ho
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Chia-Yu Lin
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Marco Pappalardo
- Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Italy
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
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Ishikawa K, Maeda T, Funayama E, Hayashi T, Murao N, Osawa M, Furukawa H, Oyama A, Yamamoto Y. Feasibility of pedicled vascularized inguinal lymph node transfer in a mouse model: A preliminary study. Microsurgery 2018; 39:247-254. [PMID: 30508286 DOI: 10.1002/micr.30394] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/31/2018] [Accepted: 10/05/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Vascularized lymph node transfer is becoming more common in the treatment of lymphedema, but suitable small animal models for research are lacking. Here, we evaluated the feasibility of pedicled vascularized inguinal lymph node transfer in mice. METHODS Twenty-five mice were used in the study. An inguinal lymph node-bearing flap with a vascular pedicle containing the superficial caudal epigastric vessels was transferred into the ipsilateral popliteal fossa after excision of the popliteal lymph node. Indocyanine green (ICG) angiography was used to confirm vascularity of the flap. ICG lymphography was performed to evaluate lymphatic flow at 3 and 4 weeks postoperatively. Patent blue dye was injected into the ipsilateral hind paw to observe staining of the transferred lymph node at 4 weeks postoperatively. All transferred lymph nodes were then harvested and histologically evaluated by hematoxylin and eosin staining. RESULTS In 16 of the 25 mice, ICG lymphography showed reconnection between the transferred lymph node and the afferent lymphatic vessels, as confirmed by patent blue staining. Histologically, these transferred lymph nodes with afferent lymphatic reconnection significantly regressed in size (0.37 ± 0.24 mm2 ) and showed clear follicle formation, whereas those without afferent lymphatic reconnection showed less size regression (1.31 ± 1.17 mm2 ); the cell population was too dense to allow identification of follicles. CONCLUSIONS We established a mouse model of vascularized lymph node transfer with predictable afferent lymphatic reconnection. Both the vascularization and reconnection might be necessary for functional regeneration of the transferred lymph node.
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Affiliation(s)
- Kosuke Ishikawa
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Taku Maeda
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Emi Funayama
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshihiko Hayashi
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Naoki Murao
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masayuki Osawa
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Furukawa
- Department of Plastic and Reconstructive Surgery, Aichi Medical University, Nagakute, Japan
| | - Akihiko Oyama
- Department of Plastic and Reconstructive Surgery, Fukushima Medical University, Fukushima, Japan
| | - Yuhei Yamamoto
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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18
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Schaverien MV, Badash I, Patel KM, Selber JC, Cheng MH. Vascularized Lymph Node Transfer for Lymphedema. Semin Plast Surg 2018; 32:28-35. [PMID: 29636651 DOI: 10.1055/s-0038-1632401] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Advances in our understanding of the lymphatic system and the pathogenesis of lymphedema have resulted in the development of effective surgical treatments. Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes into an extremity to restore physiological lymphatic function. It is most commonly performed by transferring combined deep inferior epigastric artery perforator and superficial inguinal lymph node flaps for postmastectomy breast reconstruction. For patients who do not require or are unable to undergo free abdominal breast reconstruction or have lymphedema affecting the lower extremity, several other VLNT options are available. These include flaps harvested from within the axillary, inguinal, or cervical lymph node basins, and lymph node flaps from within the abdominal cavity. This article reviews the lymph node flap options and techniques available for VLNT for lymphedema.
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Affiliation(s)
- Mark V Schaverien
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ido Badash
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, Keck Medical Center of USC, University of Southern California, Los Angeles, California
| | - Jesse C Selber
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ming-Huei Cheng
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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19
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Chang EI, Masià J, Smith ML. Combining Autologous Breast Reconstruction and Vascularized Lymph Node Transfer. Semin Plast Surg 2018; 32:36-41. [PMID: 29636652 DOI: 10.1055/s-0038-1632402] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Breast cancer patients are at risk for developing postmastectomy lymphedema syndrome of the ipsilateral upper extremity following treatment for breast cancer in the setting of an axillary dissection, postoperative radiation, and chemotherapy. For patients suffering from lymphedema who are also seeking breast reconstruction, combining an autologous abdominal free flap with a vascularized inguinal lymph node transfer provides patients the opportunity to have an aesthetic breast reconstruction as well as the potential to improve their lymphedema in a single operation. The present article aims to provide a description of the salient features of this approach including the preoperative preparation, the surgical technique, the postoperative management and complications, and a summary of the outcomes.
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Affiliation(s)
- Edward I Chang
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jaume Masià
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Mark L Smith
- Division of Plastic Surgery, Northwell Health System, Lake Success, New York
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20
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Pappalardo M, Patel K, Cheng MH. Vascularized lymph node transfer for treatment of extremity lymphedema: An overview of current controversies regarding donor sites, recipient sites and outcomes. J Surg Oncol 2018; 117:1420-1431. [PMID: 29572824 DOI: 10.1002/jso.25034] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 02/05/2018] [Indexed: 12/11/2022]
Abstract
As lymphatic microsurgery has become more common, vascularized lymph node transfer ascended to the forefront in many centers for the surgical management of advanced stages of lymphedema showing substantial clinical improvement. However, no consensus has been reached among experts regarding many details of the procedures, including patient selection criteria, type of treatment, donor, and recipient sites and postoperative evaluation of the outcome. Here, we will review these issues and provide the current results of this procedure.
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Affiliation(s)
- Marco Pappalardo
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan.,Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Ketan Patel
- Department of Plastic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
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21
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Tinhofer IE, Meng S, Steinbacher J, Roka-Palkovits J, Györi E, Reissig LF, Cheng MH, Weninger WJ, Tzou CH. The surgical anatomy of the vascularized lateral thoracic artery lymph node flap-A cadaver study. J Surg Oncol 2017; 116:1062-1068. [PMID: 28782246 DOI: 10.1002/jso.24783] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/03/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND One promising surgical treatment of lymphedema is the VLNT. Lymph nodes can be harvested from different locations; inguinal, axillary, and supraclavicular ones are used most often. The aim of our study was to assess the surgical anatomy of the lateral thoracic artery lymph node flap. MATERIALS AND METHODS In total, 16 lymph node flaps from nine cadavers were dissected. Flap markings were made between the anterior and posterior axillary line in dimensions of 10 × 5 cm. Axillary lymph nodes were analyzed using high-resolution ultrasound and morphologically via dissection. The cutaneous vascular territory of the lateral thoracic artery was highlighted via dye injections, the pedicle recorded by length, and diameter and its location in a specific coordinate system. RESULTS On average, 3.10 ± 1.6 lymph nodes were counted per flap via ultrasound. Macroscopic inspection showed on average 13.40 ± 3.13. Their mean dimensions were 3.76 ± 1.19 mm in width and 7.12 ± 0.98 mm in length by ultrasonography, and 3.83 ± 2.14 mm and 6.30 ± 4.43 mm via dissection. The external diameter of the lateral thoracic artery averaged 2.2 ± 0.40 mm with a mean pedicle length of 3.6 ± 0.82 cm. 87.5% of the specimens had a skin paddle. CONCLUSIONS The lateral thoracic artery-based lymph node flap proved to be a suitable alternative to other VLNT donor sites.
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Affiliation(s)
- Ines E Tinhofer
- Department of Anatomy, Medical University of Vienna, Centre for Anatomy and Cell Biology, Vienna, Austria
| | - Stefan Meng
- Department of Anatomy, Medical University of Vienna, Centre for Anatomy and Cell Biology, Vienna, Austria.,Department of Radiology, Hospital Kaiser-Franz-Josef, Vienna Hospital Association, Vienna, Austria
| | - Johannes Steinbacher
- Department of Anatomy, Medical University of Vienna, Centre for Anatomy and Cell Biology, Vienna, Austria
| | - Julia Roka-Palkovits
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Eva Györi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Lukas F Reissig
- Department of Anatomy, Medical University of Vienna, Centre for Anatomy and Cell Biology, Vienna, Austria
| | - Ming-Huei Cheng
- Division of Plastic Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial University Hospital Taipei, Taipei, Taiwan
| | - Wolfgang J Weninger
- Department of Anatomy, Medical University of Vienna, Centre for Anatomy and Cell Biology, Vienna, Austria
| | - Chieh Han Tzou
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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